An Iowa nursing home cited for regulatory violations that contributed to abuse, neglect and the death of a resident has been added to a federal list of the nation’s worst care facilities and fined more than half a million dollars.

The QHC Fort Dodge Villa in Webster County was cited in October for 18 federal regulatory violations and four state violations. The facility was recently added to the Centers for Medicare and Medicaid Services’ Special-Focus Facility List, which is a national list of care facilities with some of the worst records of regulatory compliance.

The Fort Dodge home, also known as the Villa Care Center, has about 75 residents, and now has the lowest possible overall rating from CMS, which evaluates care facilities’ performance based on inspectors’ findings, staffing levels and quality of care. It is one of two Special-Focus Facilities in Iowa that are run by QHC Management, of Clive, a company owned by Jerry and Nancy Voyna.

Officials at QHC Management said Friday that owner Nancy Voyna was not available for comment.

QHC Management operates eight nursing homes and two assisted living facilities that provide care for about 500 Iowans.

As a result of issues uncovered by state inspectors this past summer, the Fort Dodge home has been hit with federal fines for each day it has remained out of compliance with minimum health care standards. The daily fines, which once were accruing at almost $9,000 per day, so far total $685,740. State officials said Friday the final fine won’t be determined until the facility comes into substantial compliance with all government regulations.

In August, state inspectors visited the Fort Dodge home and subsequently issued a 199-page inspection report listing all of the regulatory violations found at the facility. Among the violations: failure to respect residents’ rights; failure to provide a safe, clean environment; failure to provide quality care; failure to prevent or treat pressure sores, and failure to ensure residents are free of medication errors.

Also, failure to employ sufficient nursing staff; failure to adequately prevent and control infections; failure to provide adequate COVID-19 testing and screening; failure to keep the home free of accident hazards; and failure to employ competent nursing staff.

The inspection was triggered by 10 complaints to the state inspections agency, all of which were substantiated.

Among the problems alleged by inspectors:

Resident death: On June 27, a resident of the home fell and struck his head. According to an aide who witnessed the fall, a nurse was nearby, on her phone, and did nothing to assist the resident and continued to talk on her phone even after the fall. Another aide interviewed about the fall told inspectors “the facility is a mess” compared to others she worked in, and that “the nurses don’t care” when resident issues are reported to them.

Although the resident who fell immediately complained of pain, no pain medications were given for 22 hours, and there was no indication of a complete assessment of the injury being performed. Shortly after the fall, the resident “screamed out in pain and could be heard as far as approximately 200 feet away when he was repositioned” in bed, inspectors reported. The resident “screamed, cried and begged for God to take his life,” the inspectors found. On July 2, five days after the fall, the resident died.

A staff nurse who saw the resident that day later told inspectors the man’s “hip was rotated all the way to his buttock” and one leg was significantly shorter, adding that the man’s condition would have been obvious to anyone who had performed an assessment.

Neglect: On Aug. 23, a resident was admitted to the home after surgical repair of an open compound fracture of his left ankle. The resident told inspectors that he waited more than an hour for assistance from the staff to get into bed. During that time, he said, he watched the staff congregate at the nurses’ station, using their phones and laughing.

When he attempted to put himself to bed, his wheelchair slid out from under him and he fell to the floor, then crawled to the bed and climbed in. None of the staff came to his assistance or evaluated his injuries, he said.

Another resident of the home told inspectors she fell on Aug. 30 while attempting to get into a taxi at the facility for a trip to bank. She said the staff saw her fall but was instructed not to help her, so she crawled across the parking lot and got into the taxi.

Physical abuse: A medication aide told inspectors she saw one resident of the home punch another resident while a group of nurses sat nearby using their phones. The aide said she had to threaten to call the state before her co-workers agreed to check the resident who was attacked. Another employee told inspectors that a nurse immediately assessed the resident.

Verbal abuse: A medication aide at the home backed up a resident’s complaint about two workers who were accused of bullying residents of the home. The aide said the two were verbally abusive to one resident, saying things such as, “You are going to do this right now or it’s not going to happen for you at all,” and spoke in vulgar, blunt tones.

COVID-19 screening: A dietary aide told inspectors she had a problem breathing through her COVID-19 mask so she typically placed it below her nose. She also reported that she had never had her temperature checked prior to working and had never been asked any questions about signs or symptoms of COVID-19 prior to entering the facility and serving food and drinks to residents.

Another dietary aide was seen by inspectors eating in the dining room, alongside two unmasked residents, with her mask pulled down below her chin. Inspectors watched as two nurse aides entered a resident’s room with their masks pulled down.

Later that day, another worker entered the building without being screened for COVID-19 and walked into the building with her mask below her nose. The home was also cited for failing to employ an infection prevention specialist as required.

COVID-19 testing: The home was cited for failing to maintain records of COVID-19 testing prior to July 13 of this year, and for repeatedly failing to test dozens of residents after positive COVID-19 cases were confirmed in the facility.

Resident discharge: The facility was cited for discharging a resident against medical advice without first making referrals to ensure someone would follow up with the man once he left the home and was in the community.

A nurse aide told inspectors that about a week after the man was discharged, she was driving to work and saw the man on the street where he flagged her down. She turned around and gave the man money to eat, later reporting that the man’s clothing was drenched in urine and soiled with feces and his motorized scooter was about to stop working.

“It was horrible to see him like that, he was definitely in the same clothes,” the aide told inspectors. “When he was at the facility, he was my favorite, respectful, never really did anything. I miss him.”

Medication errors: The home failed to give one resident four doses of prescribed medications for hypertension — a condition that increases the risk of stroke and heart attacks. The resident was rushed to the hospital after complaining of chest pain and becoming unresponsive. The resident was admitted to the hospital and diagnosed as having had a heart attack.

Residents’ rights: Inspectors noted that an infestation of bed bugs resulted in the staff throwing away one resident’s new leather recliner, which was not the source of the bugs.

Staffing levels: The home was cited for employing a director of nursing who often worked as a floor nurse, limiting her ability to oversee the staff. The director of nursing had worked 756 hours in one three-month period – an average of 63 hours per week.

Tuberculosis testing: The home’s administrator told inspectors the facility didn’t have any new physicals or tuberculosis tests for employees, adding that she wondered if the staff had stopped doing them once the company stopped giving pay raises.

Iowa’s Special-Focus Facilities both run by QHC

QHC Fort Dodge Villa is now on the nation’s Special Focus Facilities list. Typically, homes that are eligible for special-focus designation have about twice the average number of violations cited by state inspectors; they have more serious problems than most other nursing homes, including harm or injury to residents, and they have established a pattern of serious problems that has persisted over a long period of time.

The Special-Focus Facility List is updated quarterly by CMS and includes homes deemed by CMS to have “a history of serious quality issues.” Those homes are enrolled in a special program intended to stimulate improvements in their quality of care through increased oversight.