Seven complaints, 16 violations at West Branch nursing home

By Clark Kauffman

A West Branch nursing home that has faced allegations of sexual assault and contributing to a resident’s death has been cited for 16 regulatory violations covering a wide range of recurring problems, from staffing shortages to infection control.

The Iowa Department of Inspections, Appeals and Licensing has proposed, but held in suspension, more than $16,000 in state fines against Crestview Specialty Care, a 65-bed nursing home that is part of the Iowa-based chain Care Initiatives. The department typically holds state fines in suspension while the Centers for Medicare and Medicaid Services determines whether a federal penalty is warranted.

The violations cited by DIAL include insufficient nursing staff; failure to provide the required nursing services for residents; hazards in the building; failure to protect residents’ rights; failure to provide a safe, clean, homelike environment; inadequate quality of care; failure to treat and prevent pressure sores, and inadequate infection control.

Of the suspended state fines, $10,000 is tied to the failure to treat and prevent the pressure sores of two different residents, while $6,750 is tied to the failure to assess and follow physicians’ orders for wound treatment.

Although DIAL’s database of care-facility fines indicates the proposed state fines total $16,750, the agency’s written citation indicates an additional $8,000 in fines was proposed and held in suspension due to three residents of the home falling out of the mechanical lifts used to transport residents in and out of bed. One of the three sustained a head injury, a bone fracture at the base of the spine and a leg fracture, according to inspectors.

Seven complaints, all substantiated 

State records indicate the inspection was precipitated by seven separate complaints that required investigation. All of the complaints were substantiated in that inspectors cited the home for specific violations related to each of the complainants’ allegations.

Regarding the allegations of too few staff, which is widely considered to be the single biggest contributor to poor quality care, inspectors reported that employees of the home openly acknowledged the issue.

Inspectors reported that one certified nursing assistant told them the homes did “not have enough staff scheduled on a routine basis.” As a result, she said, employees were not able to provide residents with all of the care they needed, according to inspectors’ reports. “It has been brought to management’s attention numerous times and nothing changes,” the aide allegedly told inspectors.

A registered nurse at the home told inspectors there was “definitely a lack of staff working at the facility at any given time,” adding that she had, on numerous occasions, informed the home’s director of nursing that residents’ needs weren’t being met but had never noticed any difference in the subsequent staffing levels, according to inspectors’ reports.

During the inspection itself, inspectors reported, a licensed practical nurse told them she had been unable to complete that morning’s treatment of residents’ wounds due to the fact that no medication aide had been scheduled to dispense the residents’ prescribed medications.

Another CNA reported that during the evening shift, she was often the only aide assigned to a hall that had 25 residents, despite the fact that some of the residents could only be transferred in and out of bed with the assistance of two or more employees to guard against injuries, according to inspectors’ reports.

On some occasions, she alleged, there weren’t enough employees on duty to get residents to the dining room for supper, so all of the residents were sent trays of food to eat in their rooms.

State records indicate that during Crestview Specialty Care’s last annual inspection, in November 2024, it was cited for some of the same violations, including insufficient nursing staff, failure to treat pressure sores and failure to provide the required nursing services for residents.

That year, Crestview Specialty Care was cited by inspectors for failing to accurately assess residents’ condition and provide medical intervention when necessary. As a result, the inspectors alleged, a resident suffered worsening gastrointestinal issues — which included stomach aches and vomiting – for four days until he 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.

Sexual assault lawsuit focuses on staffing

Currently, the family of the late Ruth Bartow is suing Crestview and Care Initiatives in Cedar County District Court. The lawsuit alleges that Bartow was admitted to Crestview in February 2023 with severe cognitive impairments, and that three months later, at 2:50 p.m. on April 5, the staff found an unauthorized male “visitor” in her room — 54-year-old Michael Beaver of West Branch.

Beaver was laying with Bartow in her bed “without any clothes on,” the lawsuit alleges. The Crestview staff escorted Beaver out of Bartow’s room to the front lobby and notified the police. Bartow was later found in her room crying, according to the lawsuit.

Beaver wasn’t criminally charged in the case as he was already subject to a civil commitment proceeding.

State inspectors later concluded Beaver had been seen walking around in the facility as early as 10:30 a.m. that day. At 11:10 a.m., and at 1 p.m., staffers noticed Beaver pushing Bartow in her wheelchair throughout the building but failed to intervene.

The lawsuit accuses Crestview and Care Initiatives of gross negligence and recklessness in the form of inadequate staffing, false advertising, and “inappropriately allocating excessive funds to itself, thereby draining the facility of the resources necessary to maintain sufficient and appropriately trained staff to supervise residents and prevent avoidable injuries.”

The lawsuit also seeks unspecified actual damages and punitive damages for breach of contract and dependent adult abuse.

Crestview and Care Initiatives have denied any wrongdoing and attempted to have the lawsuit dismissed due to the arbitration agreement Bartow’s guardian signed at the time of her admission. That agreement stipulates that any disputes over care issues are to be settled through private arbitration rather than through courtroom litigation.

Attorneys for Bartow’s family argued the arbitration agreement was part of 50 pages of admissions documents that were electronically signed in quick succession, with the arbitration agreement signed only 40 seconds after the admission agreement.

They also claimed the arbitration agreement was barred in cases such as theirs by the 2021 federal law known as the Ending Forced Arbitration of Sexual Assault and Sexual Harassment Act. Care Initiatives argued otherwise, saying the family’s claims were “based on an alleged failure to secure the premises — not a sexual assault.”

In May, Cedar County District Court Judge Elizabeth O’Donnell rejected Care Initiatives’ argument and found that the lawsuit revolved around a claim of sexual assault that wasn’t subject to mandatory arbitration.

A trial is now scheduled for May 17, 2027. 

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Seven complaints, 16 violations at West Branch nursing home