Death and two hospitalizations trigger $5,687 fine against nursing home

An intruder entered the Crestview Specialty Care nursing home in West Branch on April 5, 2023 and was later found partially undressed and in bed with a female resident of the home. (Photo via Google Earth)

An Iowa nursing home has been fined $5,687 for quality-of-care issues that resulted in one resident’s death and the hospitalization of two others.

In May, the Iowa Department of Inspections, Appeals and Licensing visited the Crestview Specialty Care facility in West Branch in response to nine separate complaints concerning resident care. Four of the complaints were substantiated.

The home was cited for four regulatory violations and fined $8,750. The fine was then discounted 35%, to $5,687, when the home declined to file an appeal.

According to state inspectors, Crestview Specialty Care failed to accurately assess residents’ condition and provide medical intervention when necessary. As a result, the inspectors allege, a resident suffered worsening gastrointestinal issues — which included stomach aches, abdominal tenderness and vomiting – for four days until he appeared to be struggling to breathe.

An ambulance was summoned and upon their arrival, the EMTs allegedly remarked “he looks terrible” and then determined the man was in acute respiratory failure and had a critically low blood pressure. Even after the administration of intravenous medications, the EMTs were unable to obtain a blood pressure reading.

The resident was transferred to a hospital emergency room where he was intubated and three liters of bowel obstruction were suctioned from his stomach. The hospital was unable to stabilize the resident, who died within six hours of arriving in the emergency room.

In a second incident, Crestview allegedly failed to intervene when a male resident was unable urinate for two days and showed signs of swelling caused by fluid retention. The man was eventually hospitalized.

In a third incident, Crestview allegedly failed to correctly transcribe a physician’s order for insulin, resulting in a resident’s hospitalization for diabetic ketoacidosis.

Crestview Specialty Care has a two-star overall rating on the five-star scale used by the Centers for Medicare and Medicaid Services.

Last year, an intruder allegedly spent four hours inside Crestview before the staff found him partially undressed in bed with a female resident.

According to state inspectors, some of the Crestview staff interacted with the man in the hours leading up to him being found in the resident’s bed. One worker had expressed concern that the man appeared to be homeless, another worker twice gave him directions to the victim’s room. A third employee heard the victim crying out, “Help me,” while she was being wheeled through the facility by the intruder.

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