Man chokes to death in Iowa nursing home listed among the nation’s worst
A troubled Iowa nursing home that has been repeatedly cited for failing to provide residents with a safe environment has now been cited for contributing to a man’s death.
Since October 2022, the Aspire of Gowrie nursing home in Webster County has been cited by the state for 116 quality-of-care violations and been the focus of 26 complaints. Currently, it is one of two Iowa nursing homes on the federal government’s list of “special-focus facilities,” which are some of the worst care facilities in the nation.
The most recent incident at the Gowrie home involves a resident who choked to death on his dinner in early January. The staff at the home was aware the man was at risk of choking and had given him the Heimlich maneuver on three prior occasions: in December 2022, when he choked on French toast; in February 2023, when he choked on bread; and in March 2023, when he choked on a tortilla.
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According to inspectors, the man was to be given no bread, with the rest of his food cut into bite-sized pieces prior to being served. Despite that, he was allegedly served bread and uncut, bone-in chicken for his dinner on Jan. 5. A short time later, a certified nursing assistant who was working in the dining room saw the man choking and gasping for air. The CNA, who later told inspectors she didn’t know the Heimlich maneuver, summoned a nurse who tried to remove the food that was blocking the man’s airway and then performed CPR after he became unresponsive.
The man was rushed to a nearby hospital where the staff removed “a large piece of food” from his airway, according to inspectors, and later pronounced him dead due to a lack of oxygen caused by the aspiration of food.
According to the inspectors, the man’s diet card ― used by the staff to help prepare his meals ― stated “choking hazard ― bite-size food,” and “food cut into bite size.”
A review of personnel records indicated that after the death, a cook was given a written warning for failing to follow proper procedures in food preparation. She later told inspectors that she had relied on a “cheat sheet” for meal preparation, not the dietary cards, and the sheet omitted any information about the need to cut up the man’s food. The staff at Aspire of Gowrie was unable to locate the “cheat sheet” for inspectors.
Nursing home cited for many other violations
In addition to being cited for the resident’s death, Aspire of Gowrie was cited for numerous other violations, including a “strong, offensive urine odor” in one area of the building. A maintenance worker told inspectors he was aware of the smell but “the facility did not have the budget to buy the cleansers to get the smell out.”
The home also was cited for a failure to ensure all residents were seen by a physician once every 60 days; failure to ensure residents were given at least two showers per week; failure to respond appropriately to residents injured in falls; failure to respond appropriately to residents’ weight loss; and failure to offer or provide residents with their full meals and their nighttime snacks.
In addition, Aspire of Gowrie was cited for unsanitary conditions in the kitchen, with the inspector making note of a “thick coating of yellow grime” on shelving, garbage strewn on the floor, and grease and grime on appliances and the floor. The inspector also reported stained and dirty carpets in the hallways of the facility, as well as frayed, bunched carpeting that posed a tripping hazard for residents.
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Many of the violations had been cited during previous state inspections and inspectors concluded the home had failed to correct deficiencies related to nine of 21 previously identified areas of concern.
In total, the recent inspection resulted in 22 regulatory violations and $28,000 in state fines, all of which have been suspended by the state so the federal Centers for Medicare and Medicaid Service can consider imposing federal penalties in the case.
On four occasions within the past 17 months, Aspire of Gowrie has been cited for the same serious, Class I violation: failing to provide a safe environment for residents. The safety violations were tied to a failure to protect residents from sexual abuse; squirting glue, rather than eye drops, into a resident’s eye; inoperable door alarms to prevent residents from wandering away; and the Jan. 5 choking death.
In all, the state has proposed $107,000 in fines against the home during the past 17 months, all held in suspension. Federal records indicate the CMS has fined Aspire of Gowrie a total of $193,896 during those same 17 months.
Last year, Aspire of Gowrie had CMS’ lowest possible rating for overall quality, health care inspections and staffing levels. Currently, the home has no CMS ratings at all due to its status as a special-focus facility.
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CMS records indicate the home is a for-profit venture owned by Black Hawk Healthcare, a limited liability corporation, and that Bruce Wertheim of Beacon Health Management in Tampa, Florida, owns 100% of the company, and exerts managerial and operational control of the home. Wertheim could not be reached for comment.
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