Death at Care Initiatives-owned facility in Fonda. Second oxygen deprivation death at company-owned nursing homes in Siouxland since December.

By Clark Kauffman, Iowa Capital Dispatch
March 22, 2024

A nurse who allegedly failed to suction the airway of a U.S. Army veteran in an Iowa nursing home has been criminally charged in the man’s death.

Becky Sue Manning, 69, of Lake View, is charged with felony wanton neglect of a healthcare facility resident. According to prosecutors, Manning, a licensed practical nurse, refused repeated requests to provide physician-ordered care for a resident of the Fonda Specialty Care nursing home while working there in 2023 as an employee of the GrapeTree Medical Staffing temp agency.

Manning has yet to enter a plea in the case. She was arrested Thursday and released from jail on Friday on a $10,000 bond. Her lawyer could not be reached for comment Friday night.

According to state inspection records, Marvin “Pete” Jacobs, 87, died Feb. 19, 2023, while sitting in his room at Fonda Specialty Care. Jacobs had undergone a tracheostomy, and because his airway tended to become clogged, the staff kept a suctioning machine by his bedside.

On that afternoon, an aide later told inspectors, Jacobs was sitting in his recliner when another worker said Jacobs appeared to be “in trouble” and instructed her to get a nurse right away. Jacobs was pointing at his neck, gasping for air, and mouthing that he could not breathe, the aide told inspectors.

The aide said she left the room to get the only nurse on duty — alleged by prosecutors to be Manning — and was absent for a few minutes. The worker who remained in the room later told inspectors Jacobs grew “really pale” and was gasping, so she, too, left the room and approached Manning and said, “Would you please suction him? He needs to be suctioned.”

When Manning entered the room, Jacobs was pale, but soon turned purple and then blue, the aide later reported. Manning allegedly took his vital signs and told the aide Jacobs was having a heart attack. The aide explained to Manning that Jacobs had been signaling he couldn’t breathe, at which point Manning allegedly said, “Just a minute,” and left the room. The suctioning machine sat idle on Jacobs’ nearby dresser.

According to inspectors, the nurse alleged by prosecutors to be Manning told inspectors the “staff wanted me to suction him (and) I told the staff no. I was told that I would not have to do anything with the tracheostomy.” Manning allegedly said she first left the room to get supplies so she could check Jacobs’ blood pressure, pulse and oxygen levels and that when she returned, he was clammy and had an irregular pulse.

“I told the staff that I needed to go back to the nurses’ station and find out if the resident was a full code or DNR,” Manning allegedly told inspectors, referring to do-not-resuscitate orders that some residents have in place.

She reportedly told inspectors that while she was checking on that, one of the aides approached her and said she was needed right away in Jacobs’ room. “I went back into his room and he had no blood pressure, no pulse, and no respirations. I pronounced him deceased,” Manning allegedly told inspectors.

Manning reportedly acknowledged to inspectors that her fellow workers had each told her Jacobs needed his airway suctioned and that he had been pointing to his neck and mouthing that he couldn’t breathe. According to the inspectors, she allegedly said that despite her colleagues’ comments, it never occurred to her to suction Jacobs’ airway.

Pocahontas County prosecutors allege that no fewer than four workers asked Manning to suction Jacobs’ airway and that the staff had alerted Manning to the fact that Jacobs was asking to be suctioned and that, in their professional opinion, he needed to be suctioned right away.

Prosecutors also allege Manning prevented the staff from calling 911 when it became apparent Jacobs couldn’t breathe.

The Iowa Department of Inspections and Appeals fined Fonda Specialty Care $10,000 for the death, then reduced that penalty 35%, to $6,500, due to the lack of an appeal in the case.

In its written response to DIA’s findings, the facility’s owners, Care Initiatives of West Des Moines, said it does not admit to any statements, findings or conclusions by the state inspectors and added that it “will continue to provide care and services” for respiratory patients, including airway suctioning.

Jacobs grew up in northwest Iowa, was the varsity catcher of the 1953 Auburn Tigers state baseball championship team, and was a 1954 graduate of Auburn High School. From 1955 to 1957, he served in the U.S. Army while stationed in Korea. After his discharge, he and his wife, Darlene, raised three sons in northwest Iowa. Over the years, he worked as a farmer and served as a partner and owner of the Mill City Loader Corporation.

Care Initiatives owns eight healthcare facilities in northwest Iowa and 11 facilities within 100 miles of Sioux City. The facilities they own are:

• Correctionville Specialty Care, Correctionville.
• Westwood Specialty Care, Sioux City.
• Kingsley Specialty Care, Kingsley.
• Cherokee Specialty Care, Cherokee.
• Odebolt Specialty Care, Odebolt.
• Lyon Specialty Care, Rock Rapids
• Sibley Specialty Care, Sibley
• Fonda Specialty Care, Fonda
• Odebolt Specialty Care, Odebolt
• Dunlap Specialty Care, Dunlap
• Avoca Specialty Care, Avoca

Another death caused by lack of oxygen at a Care Initiatives-owned facility

Another Care Initiatives-owned facility was found responsible for contributing to a resident’s oxygen depletion death in January. Odebolt Specialty Care in Sac County was fined $8,500 by the Iowa Department of Inspections, Appeals and Licensing. The staff at the nursing home neglected to replace a resident’s depleted oxygen tank, resulting in a woman’s death, according to state inspectors.

The nursing home, which is owned and operated by the West Des Moines nursing home chain Care Initiatives, allegedly failed to provide adequate oxygen for the female resident diagnosed with congestive heart failure and who required supplemental oxygen. The inspections department alleges the staff repeatedly failed to monitor the woman’s vital signs and failed to check her oxygen tank to ensure she could breathe.

Inspectors’ reports indicate that when workers at the home approached the woman to take her to lunch on the morning of Dec. 20, they found her unresponsive with an empty oxygen tank nearby. The reports state the woman’s oxygen saturation level ranged from 12% to 45%. Anything below 88% typically calls for immediate medical intervention.

The woman was transported to a hospital where she was diagnosed with an anoxic brain injury, a condition caused by a lack of oxygen. The hospital transferred the woman by air to a larger hospital where she died a few days after admission.

According to the state inspectors, the woman’s clinical record at Odebolt Specialty Care indicates the staff there failed to check and record the woman’s oxygen saturation levels in the days leading up to her hospitalization, a period in which she had displayed erratic behavior, odd facial expressions, and signs of lethargy — all potential signs of oxygen deprivation.

Workers later told inspectors they had not checked the resident’s oxygen tank to see whether it was switched on or the oxygen tank was depleted. The director of nursing reportedly told inspectors that she expected the staff to check whether the oxygen supply was functioning but added that she “didn’t know for sure what kind of education” the staff had on the use of the device.

Two nursing assistants allegedly told the inspectors they didn’t recall receiving any education or training on residents’ use of oxygen concentrators and tanks.

State inspectors also cited Odebolt Specialty Care for repeatedly failing to assess and treat a wound on the leg of another resident last May, resulting in the wound growing or “tunneling” into her flesh.

A nurse practitioner from a local hospital later told inspectors the wound was “horrible” with tunneling throughout the full length of the leg, adding that the woman had been admitted to Odebolt Specialty Care with a wound vacuum and specific instructions for the staff to periodically change the wound dressing. The nurse practitioner allegedly said she knew no one at the nursing home had changed the dressing as it still had the original date markings on it.

State inspectors concluded the home had assessed the wound only twice: on the day of the woman’s admission and, 19 days later, the day of her discharge. The inspector’s report gives no indication as to whether the resident survived or was hospitalized.

It’s not clear why the investigation of the May 2023 incident didn’t take place until December 2023. State records indicate that when the inspectors visited the facility in December, they were responding to a backlog of four separate complaints, all of which were substantiated.

That’s not all. There was an alleged rape of a female resident at the Correctional Specialty Care facility.

An Iowa nursing home resident was evicted and dumped at a homeless shelter after complaining that an employee of the home raped her, according to state records.

State inspectors say a female resident of Correctionville Specialty Care in Woodbury County complained in October that a male certified nurse aide had forced her to perform a sex act on him and had sent her a video of him pleasuring himself. The woman allegedly provided law enforcement officials with a copy of the video.

The care facility retaliated against the woman, state inspectors allege, by evicting her from the home on short notice and then dumping her at a homeless shelter with no notice to the shelter and without her medical records.

Despite the allegation of sexual abuse, the home’s corporate owners then failed to prevent the man from going to work in other Iowa care facilities they owned, placing him in close contact with other vulnerable, elderly Iowans, inspectors allege.

The company, Care Initiatives of West Des Moines, is also accused of retaliating against a worker who confronted the administrator about the need to report the alleged rape to authorities.

As a result of the state’s findings, the home’s residents were deemed to be in immediate jeopardy. The state has proposed $45,500 in state fines, although those penalties have yet to be imposed. It’s not clear whether criminal charges have been filed in the case.

In a written statement, Care Initiatives said it investigated the “allegations of inappropriate behavior between a team member and a prior resident. We take these matters very seriously and are actively cooperating with the Department of Inspections, Appeals & Licensing as well as area law enforcement in their investigation.

“Additionally, we launched an extensive internal investigation into this matter and have taken immediate action to ensure the safety of our residents. Involved parties are no longer employed by Care Initiatives.”

The company said some form of “additional action” has been taken to protect residents and that its “top priority is the care and well-being of our residents, and we do not tolerate any behavior that compromises their trust and confidence.”

Read more about the Correctionville Specialty Facility and the alleged rape story here.

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Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing.

Iowa Capital Dispatch is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Iowa Capital Dispatch maintains editorial independence. Contact Editor Kathie Obradovich for questions: info@iowacapitaldispatch.com. Follow Iowa Capital Dispatch on Facebook and Twitter.