An Iowa nursing home with top federal nursing home ratings allegedly allowed a woman to die dehydrated and in severe pain.

According to the  Des Moines Register, the Iowa Department of Inspections and Appeals has recommended the Timely Mission Nursing Home in Buffalo Center, Iowa pay a $29,750 fine because Virginia Olthoff died on their watch on Feb. 27, 2018. The state agency is waiting to impose the fine in anticipation of the federal Centers for Medicare and Medicaid Services (CMS) beginning their own investigation.

CMS is the agency that currently indicates Timely Mission Nursing Home has been awarded the top-ranking of five stars for quality care of residents. At the same time, however, CMS handed Timely Mission only two stars for government inspection results. According to the CMS nursing home ratings scale, two stars means below average.

Nursing Home Ratings Gave False Sense of Security

Critics of the CMS nursing home ratings point out that nursing homes are allowed to submit their own data for inclusion in the ratings system, which allows the final rating to include unverifiable and biased opinions.

The adult children of Virginia Olthoff told the Des Moines Register they had no idea their mother hadn’t been eating or drinking very much for possibly as long as two weeks until they read the report by the Department of Inspections and Appeals. They said they were “heartbroken” to know their mother was in pain for a period of time.

According to the Des Moines Register, Virginia Olthoff was raised in Buffalo Center and moved into Timely Mission in 2002 at the age of 72. According to the Des Moines Register, staff observed Virginia experiencing severe pain and gave her Tylenol. Virginia allegedly was observed in tears, moaning, sometimes screaming. One nurse’s aide reported that when she alerted a nurse of Virginia’s advancing pain, the nurse did not react.

Nearly Three Hour Wait for Ambulance

Timely Mission staff allegedly found Virginia with sunken, dark eyes and cold, blue-tinged feet on the early morning of Feb. 27. When they tried to take her blood pressure and find her pulse, they were unable to obtain either. But an ambulance was not called to assist for hours.

An ambulance allegedly took Virginia to the hospital two hours and 45 minutes later, where a doctor told state inspectors it appeared Virginia had not been drinking any fluids for at least four or five days and most likely had received little fluid for several weeks. Virginia was in a coma when she arrived at the emergency room, the report says, but she awoke after being administered a liter of water. She was then sent back to Timely Mission, where she died later that day.

When a state inspector asked a nurse why staff waited nearly three hours to have Virginia transported to the hospital, the nurse allegedly said she didn’t think Virginia’s condition had deteriorated enough and said she and fellow staff members had to tend to other duties. However, the same nurse also allegedly admitted she thought Virginia appeared to be dying.

Less than an hour before Virginia died, another elderly woman died in her bed at Timely Mission. The nursing home has now been cited by the state of Iowa for inadequately addressing the needs of both women.

Despite its five-star nursing home ratings, Timely Mission reportedly received a $58,000 fine from CMS over purported abuse at the nursing home that occurred in the summer of 2017. One of the staff members purportedly became verbally and physically abusive to eight of the residents. Fellow staff members and residents accused the employee of using profanity and pulling on residents’ arms and legs.