Lee County facility cited for abuse, medication errors, quality of care

The Montrose Health Center in Lee County. (Photo via Google Earth)

A Lee County nursing home owned by a pair of Iowa developers is again facing sanctions for inadequate resident care.

The state of Iowa has proposed a series of fines totaling $44,250 against the Montrose Health Center in Lee County. The home was recently inspected and cited for violations related to: the abuse of residents; significant medication errors; the accuracy of resident assessments; the quality of resident care; the treatment of pressure sores; incontinence care; improper pain management; and inadequate staff training.

The 44-bed, for-profit facility is owned by developer Mark Holtkamp and his partner, Kevin Kidwell, a construction company executive. Holtkamp, Kidwell and the home’s administrator, Mallory Orton, could not be reached for comment.

As a result of the violations, the Iowa Department of Inspections, Appeals and Licensing has proposed, but held in suspension, a series of state fines totaling $44,250. That amount includes a $10,000 penalty for inadequate nursing services that was tripled to $30,000 due to it being the second time in less than a year that the home was cited for the violation.

Among the problems cited by state inspectors during their most recent visit to the home:

Resident abuse: The home failed to prevent physical altercations and abuse, including “multiple instances of one resident hitting another.” Inspectors reviewed the records of six residents and found instances of abuse involving three of them. The home has a total of 36 residents.

Quality of care: The home failed to provide the necessary care for a resident with a known history of respiratory failure. The woman had been short of breath for several days and on Jan. 14, 2024, asked to be taken to the hospital. On Jan. 17, the woman was increasingly agitated and showed signs of respiratory distress, telling the staff, “There must be something wrong with my oxygen concentrator, I’m not getting any air.” The next day, she was found unresponsive in a chair, with her head tilted down, no pulse and her lips blue in color. After the staff administered CPR, the woman opened her eyes and gasped for air, eventually becoming stable before being taken to a hospital. According to inspectors, another resident of the home was admitted to a hospital three days after an undocumented fall in the facility. At the hospital, she was diagnosed with a hip fracture.

Pain management: As an inspector watched, a registered nurse cleaned and dressed a serious pressure sore on a woman’s foot that was draining bright red blood. The woman “gasped, screamed, squeezed her eyes shut, and bit her tongue” but the staff didn’t pause or offer the woman any of her prescribed pain medication, instead advising the woman to “think happy thoughts.” The director of nursing later told the inspector the symptoms of pain that the inspector observed were acted out for the inspector’s benefit and that the symptoms “were a character thing.”

Nurse quit, citing ‘unsafe’ staffing levels

Since 2022, the Centers for Medicare and Medicaid Services has imposed $75,472 in federal fines against the Montrose facility. CMS, however, has a policy of not disclosing whether nursing homes have actually been paid.

In 2021, an administrative law judge ruled that a Montrose Health Center nurse was justified in quitting her job due to concerns that staffing levels in the home were unlawful and unsafe for residents. That case involved Kristin Pullins, who had worked for the home since 2018 as a full-time registered nurse. In early 2020, the home was purchased by Holtkamp and Kidwell.

According to the findings of an administrative law judge, after the home changed hands, staffing was allegedly cut back to leave one licensed nurse on staff, essentially doubling Pullins’ workload. Pullins complained about the staffing and was allegedly told by the home’s administrator, “Go find a job. You’ll come crying back in two weeks.”

Administrative Law Judge Sean Nelson ruled that although Pullins had voluntarily left her job, she was entitled to unemployment benefits.

“A reasonable person would find (Pullins’) working conditions intolerable,“ Nelson wrote in his decision, adding that Pullins “credibly described working conditions in which she feared she could not provide adequate care to all the employer’s residents. (She) also credibly testified to other incidents occurring at the facility that a reasonable employee could find as unlawful and unsafe.”

In 2020, the home was cited by the state for placing residents in immediate jeopardy by placing having COVID-free residents share rooms with residents who known to have tested positive for the deadly virus. The home also was alleged to have let workers who were known to be positive for COVID-19 care for residents who had yet to contract the virus.

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