(Griswold, Iowa) – A nursing home in Cass County (IA) could face sanctions for a woman’s death allegedly caused by the staff providing her with the wrong meal. According to a report in the the Iowa Capital Dispatch, the Iowa Department of Inspections, Appeals and Licensing recently cited the Griswold Rehab and Health Care Center in Cass County for failing to serve residents the appropriate prescribed diet. The agency proposed a $10,000 fine, which is being held in suspension while federal officials determine whether a federal penalty is warranted.

According to the agency, a female resident of the home had been prescribed a soft-textured diet due to issues with swallowing. On the evening of Aug. 28, the resident was served coleslaw that had not been minced as it should have been. Later, the staff noticed the woman was coughing continuously. Her lungs had gurgling sounds and her oxygen saturation level was in the 70% range – a dangerously low level since anything in the 80% range often requires immediate medical intervention.

About 21 hours later, a nurse aide noticed the woman was struggling to breathe and was coughing so hard that she had coleslaw coming out of her nose. The aide later told inspectors that after the director of nursing declined to assess the resident or check the woman’s vital signs, she approached a registered nurse who provided supplemental oxygen, called a physician, and sent the woman to the hospital. She was admitted for aspiration pneumonia, a condition that typically involves inhaling food or liquids into the lungs.

Two days later, the resident was reported to have died at the hospital of respiratory failure. Hospital x-rays showed the woman had aspirated an unidentified organism. The nursing home’s dietary manager later told inspectors she knew the woman should not have been served coleslaw, but her department had been “very low staffed” and she was serving meals by herself on the night in question with the help of a high school student. She told inspectors that an aide or nurse probably made a mistake and grabbed the wrong plate for the woman.

The facility was also cited for failing to adequately protect residents from abuse. A resident of the home told the staff he heard a worker tell his roommate 50 times to get dressed and then heard a slap and a thud against the wall, as if someone fell. The resident who fell was later treated for wounds to a finger, elbow and one knee, and later pointed out an aide and exclaimed, “She did it.” The aide denied any wrongdoing.

In addition to the citation for resident abuse, the home was cited for 10 other regulatory violations. In August 2022, the Griswold Rehab and Health Care Center was cited for failing to recognize that abuse had occurred and failing to protect residents from abuse. At that time, federal officials imposed a fine of $28,103.

The facility is owned by Griswold Care Center Inc., a for-profit company owned by Roger and Arlene Hinz. The facility has the lowest rating — one star on a five-star scale — from the Centers for Medicare and Medicaid Services with regard to both inspection results and overall quality.