Leg amputation and injuries at Waterloo care facility trigger $53,750 in fines

For the third time in three months, an Iowa nursing home has been fined for resident injuries that include broken bones and gangrene.

Between June 16, 2026, and Aug. 6, 2026, the Iowa Department of Inspections and Appeals investigated 14 complaints at Ravenwood Specialty Care, a 176-bed care facility in Waterloo, and imposed $53,750 in fines.

The first of the fines was imposed on June 16, when DIAL fined Ravenwood $7,750 for failing to assess and treat a male resident’s foot wound, which led to the man’s lower leg being amputated.

According to the state inspectors, a cognitively intact male resident who had lived at the facility since 2024 developed an open sore on his right foot in February 2026. By April 10, the foot was diagnosed with necrotic, dead tissue and was described by a foot care specialist as “very painful.” One toe was amputated at the time.

The wound continued to worsen and on April 27, another toe was amputated. By May 1, the resident was considered to be at high risk of a below-the-knee leg amputation.

On May 17, the resident was transferred to a hospital emergency room and diagnosed with sepsis, which is a  life-threatening infection, acute kidney failure and septic shock. Hospital staff reported the resident’s “foot appeared necrotic (due to) dead tissue,” with an “obvious gangrenous infection,” according to state inspectors.

The wound had split completely open, resulting in exposed bone, the inspectors reported. A below-the-knee amputation was performed the next day.

In addition to the $7,750 fine, the state also imposed a $6,250 fine for failing to intervene when another male resident of the home fell and broke his leg. The man reportedly told inspectors that he had fallen when he tried to walk to the bathroom without assistance, adding that he didn’t use his call light because “there’s no point in using it since it can take a couple of hours for staff to answer it.”

At the time of the June 16 inspection, the home was the focus of six separate complaints, three of which were substantiated.

More fines in June and August 

Two weeks after those fines were imposed, on June 30, the state imposed a fine of $5,750 for resident-safety violations, and then tripled that to $17,250 due to the recurring nature of the problem.

That penalty stemmed from an incident in which a female resident was hospitalized after a worker inadvertently injured the woman’s leg by improperly lowering the footrest of her recliner.

At the time, Ravenwood was the subject of four complaints, three of which were substantiated by inspectors.

On Aug. 6, inspectors returned to the home and imposed an additional $7,500 fine for resident-safety violations, which was then tripled to $22,500 due to the recurring nature of the problem. At that time, the home was the subject of six complaints, three of which were deemed substantiated.

The $22,500 penalty was tied to an incident involving a male resident who wandered from the facility sometime after midnight on July 29 — four days after his admission. The staff heard the door alarm sound but failed to perform a count of the residents, according to inspectors.

Inspectors reported that around 2:15 a.m., police spotted the man lying face down in the roadway next to the curb. The man was wearing socks and the top to a set of hospital scrubs and was taken by ambulance to a hospital. He was later treated for facial injuries, a large laceration to his head and a bruise on his forehead, inspectors reported.

According to the inspectors, the administrator at Ravenwood “acknowledged the facility did not have a door-alarm policy.” The missing-resident policy that had existed for the past eight years, since August 2018, lacked direction on how and when the staff was to respond to door alarms, inspectors reported.

It was in 2022 that Ravenwood was sued by the family of Michael Jensen, a former Wartburg College music instructor. According to the lawsuit, Jensen wandered away from Ravenwood, where he resided, on July 6, 2020. Four days later, inspectors reported, he was found in a ditch, submerged up to his chest in water. He was taken to a hospital and admitted to the intensive care unit for treatment of sepsis, hypothermia and  potential skeletal or heart-muscle damage. He remained in the hospital for 22 days.

DIAL subsequently fined Ravenwood $8,750 for the incident and because the home didn’t appeal the fine, the penalty was reduced to $5,687. The family’s lawsuit, which alleged negligence, breach of contract and dependent adult abuse, has been stayed pending the completion of arbitration proceedings scheduled for this month.

Ravenwood is operated by one of Iowa’s largest nursing home chains, Care Initiatives. The 176-bed home currently has a one-star rating of “much below average” on the Center for Medicare and Medicaid Services’ website. CMS has imposed no federal penalties on the home during the past three years, according to the site.

In May 2025, the family of the late Mickey Neal sued the owners of Ravenwood, alleging negligence and wrongful death. The lawsuit claims Neal was admitted to Ravenwood on March 15, 2024, and that two weeks later, on April 3, 2024, the staff found him on the floor of his room, incontinent and bleeding from a head wound. He was then transferred to UnityPoint Allen Hospital, where he died on April 7, 2024.

A trial is scheduled for July 13, 2027.