An Iowa nursing home resident was allegedly left in a vegetative state after the facility ignored her screams of pain and her pleas to be taken to a hospital, according to state records.
State inspectors say another resident of the same southern Iowa care facility was evicted last August when the staff dumped his belongings outside and wheeled him out the exit door with nowhere to go.
The allegations against Windsor Place Senior Living Campus in Sigourney could result in federal fines. A state fine of $9,500 fine is being held in suspension while the Centers for Medicare and Medicaid Services considers a federal penalty.
The inspectors’ findings come at a difficult time for Windsor Place, which has been managed by a company now mired in receivership. That company, which has managed several care facilities in Iowa, allegedly owes $15.1 million to creditors and, according to court records, it is in “dire” financial shape.
The most serious allegation against Windsor Place is tied to its treatment of a female resident of the home in November. State records indicate the woman, who was once a nurse, was up earlier than usual on the morning of Nov. 29, 2022, and was complaining of a severe headache. The administrator, Aimee K. Crow, who also happened to be the charge nurse on duty, allegedly told a nurse aide the resident had already been given pain medication.
Later in the day, the aide reportedly told Crow the resident was complaining her headache had worsened and that it was causing “excruciating” pain. The woman was asking to be sent to a hospital. The aide later told inspectors Crow took no action and “seemed more interested in cleaning and organizing the medication room.”
At 8:30 a.m., several of the facility’s aides allegedly approached the marketing director at Windsor Place and told her Crow was doing nothing about the resident’s pain or her request to go to the hospital. The marketing director later told inspectors she then raised the issue with Crow, but no action was taken and Crow never saw or assessed the resident that day.
‘She was like a vegetable’
By noon on Nov. 29, the resident was even more agitated, grabbing her head and screaming in pain, and yelling that someone needed to take her to the hospital, according to inspectors. Two of the woman’s fellow residents spoke to Crow, allegedly telling her the woman was crying, was in pain, and was asking to be sent to the hospital. Two employees told Crow the woman was yelling, “I was a nurse, I know they can help me … This is not normal.” Nothing was done, the workers later told inspectors.
Later that afternoon, according to inspectors, the marketing director went back to Crow and reported that the woman’s speech was garbled and she was showing signs of confusion. Another aide reportedly talked to Crow several more times, asking her to check on the woman. The aide later told inspectors she felt “helpless” when Crow failed to act.
Another worker told inspectors the administrator appeared dismissive of the employees’ concerns, telling them the woman “complains, but she is fine.”
The next morning, when one of the aides reported for work, she checked on the woman and found her “soaked in urine from her shoulders to her knees,” according to state reports. The woman was unresponsive, unable to talk, couldn’t see out of her right eye and couldn’t move her right side.
Crow was allegedly standing nearby and listening as one of the aides informed a colleague of the woman’s condition. Crow reportedly told the two workers she had ordered a urinalysis and that the woman was “fine.”
One of the aides later told inspectors of the woman’s condition that morning. “There was nothing in her eyes, she was like a vegetable,” the aide reported. Two days before, on a Monday, the aide said, the woman “was up, independent and in the dining room talking, and normal – and by Wednesday, she was vegetable.”
The inspectors’ written report indicates the woman most likely suffered a stroke, pointing out that federal guidelines advise health care provider that “during a stroke every minute counts. Fast treatment can lessen the brain damage that a stroke can cause.” The report doesn’t indicate whether the woman survived the incident or was transferred elsewhere.
When interviewed by inspectors, Crow reportedly acknowledged that staff members had come to her about the resident having a “headache,” but said no one ever told her the woman wanted to go to the hospital. She acknowledged she never assessed the woman’s condition, consulted a physician or notified the resident’s family of the situation.
Resident evicted with nowhere to go
As a result of the state’s investigation into that incident, inspectors cited Windsor Place for several other violations, including the eviction of a male, wheelchair-bound resident who had nowhere to go.
The man told inspectors that when he moved into the home, he was told he could have his own room. Later, Crow insisted he share a room with someone else. The home’s social worker told inspectors that when the man objected, the administrator yelled at him, wouldn’t let him speak, and kept saying, “You are getting a roommate, or you are leaving against medical advice. What’s it going to be?”
The social worker told inspectors the facility summoned a sheriff’s deputy to escort the man outside after a maintenance worker stacked the man’s belongings outside the door in trash bags.
The man, who was insulin dependent, told inspectors he wasn’t given any medications and had nowhere to go. He said he called his nephew and got a ride to his ex-wife’s home where he fell down the steps and was taken by ambulance to a local hospital.
The hospital kept him for two days and then arranged for him to return to Windsor Place where he was placed in a small room that he described as so cluttered he couldn’t get to the bathroom. Later, he was moved to another room and assigned a roommate.
The director of nursing at the time of the incident later told inspectors she was uncomfortable with what had happened and had voiced her concerns to the corporate office. She and the home’s social worker each told inspectors that as soon as Crow started at the facility in June 2022, she insisted that Medicare- and Medicaid-dependent residents share rooms to better accommodate the private-pay residents who typically pay more for their care. Residents who objected, the social worker said, were given 30-day eviction notices.
Crow told state inspectors she was the niece of the man who was evicted. Asked if she remembered why she felt it was necessary for the man to share a room when there were vacant rooms at the facility, she allegedly said she couldn’t recall the reason as it was “a long time ago.”
State inspectors also spoke to the county deputy who had helped evict the man. The deputy reportedly confirmed his role in the matter and told inspectors he didn’t feel it was right that a nursing home could force a resident “onto the streets” with no place to go.
The inspectors cited Windsor Place for multiple violations related to the eviction, alleging the home had “badgered and coerced” the man into leaving so his discharge could be labeled voluntary and against medical advice.
No state fines were imposed for any of the violations related to that incident.
Although the eviction took place in August 2022, it was only recently investigated by the Iowa Department of Inspections and Appeals. Two months before that eviction, Trinity Hospital in Bettendorf discharged a homeless, 81-year-old, wheelchair-bound veteran to the street with no phone, nowhere to spend the night and no transportation. Hours after he was forced to leave the hospital, motorists spotted the man in his wheelchair trying to merge into traffic on Interstate 74. No fines were imposed in that case.
Crow declined to comment Monday when asked about the findings of state inspectors. State records show Crow earns $92,500 per year at Windsor Place and has been an Iowa-licensed nursing home administrator since 2009. In addition to her role at Windsor Place, Crow is also the administrator at Keota Health Care Center.
Iowa workforce records show Crow, 40, was fired from Ridgewood Nursing and Rehabilitation in 2009 where she worked as a charge nurse. She was accused of telling an aide, “Do what you want,” in response to a request for direction on how to handle an issue. Also, she was alleged to have shared confidential information about corrective action taken against an employee.
Crow’s nursing home administrator’s license is in good standing with no public record of discipline. In the past six years, the Iowa Board of Nursing Home Administrators has levied public sanctions against a licensed nursing home administrator on only two occasions.
According to the Iowa Board of Nursing, Crow’s nursing license is active and has no public record of discipline.
Company now in receivership
Federal records indicate the 41-bed Windsor Place has CMS’ lowest possible rating on all three quality measurements used by the federal agency: health inspections, staffing levels and overall quality.
According to court records, Windsor Place and several other Iowa care facilities are operated by a network of affiliated businesses based in Chicago. In July of last year, each of those care facility operators was sued by sued Propco, which is a group of New York investors who own the Iowa care facilities and lease the property to the operators. Propco is alleging the Iowa facilities owe at least $15.1 million in unpaid rent.
According to Propco, the Chicago-based operator of the Iowa facilities is insolvent and had informed Propco last year that it was in “a dire financial position” with only enough cash on hand to operate the care facilities for 40 days. As a result of that lawsuit, a court-appointed receiver was put in charge of overseeing the facilities’ cash flow. The receiver then appointed Mission Management Communities, a Florida company, to run the Iowa care facilities.
A representative of Mission told the Iowa Capital Dispatch on Monday the company had no comment on the findings of state inspectors.
Earlier this month, the receiver in the Propco case told the court that two prospective buyers for the chain had toured some of the care facilities but “no acceptable offers to purchase” have been made.
