The administrator of an assisted living center, accused of incompetence in an incident that resulted in an elderly resident freezing to death outside the facility, will retain her state license subject to 10 hours of educational training.
According to state records, Dwala Marie Lehman was the administrator at Courtyard Estates at Hawthorne Crossing in Bondurant in January 2022 when 77-year-old Lynne Stewart froze to death after leaving her room, exiting the facility, and then falling to the ground just outside the door.
Between the time Stewart left her room — triggering a recurring series of alarms sent to Lehman’s phone and to workers inside the building — and the time Stewart’s body was found outside, almost 15 hours passed during which no efforts were made to locate Stewart, according to state inspectors.
In 2023, the Iowa Board of Nursing Home Administrators initiated an investigation of the matter. Last month, it charged Lehman, 44, with professional incompetence. At the same time, the board and Lehman settled the disciplinary matter with a formal agreement.
The agreement stipulates that Lehman must complete 10 hours of educational training on the topic of resident wandering, after which she must write a report stating “what she has learned and how she has changed her approach” to such situations.
The agreement also stipulates that Lehman’s nursing home administrator’s license will be placed on probationary status for one year, during which time Lehman is to file quarterly reports with the board documenting her compliance with the agreement.
As a result of Stewart’s death, state inspectors fined Courtyard Estates $10,000, alleging the facility had violated state regulations for dementia-specific assisted living centers by failing to have its staff monitor residents. The center was also accused of failing to ensure that all workers have at least eight hours of dementia-specific training within a month of being hired.
Because Courtyard Estates didn’t appeal the fine, the penalty was automatically reduced by the state to $6,500.
Lehman currently serves as the administrator at the Edencrest at Green Meadows assisted living center for people with dementia, located in Johnston. The Iowa Capital Dispatch was not able to reach Lehman for comment Wednesday.
Murder charge and a plea bargain
State records indicate an employee of Courtyard Estates reported for work about 5 a.m. on Jan. 21, 2022, and noticed that a computer showed one of the door-alarms in the building was activated.
The worker told inspectors she immediately dropped everything and searched the area, eventually finding Stewart lying on the ground, unresponsive, just outside one of the exit doors, with various items frozen to her body. The temperature outside that morning was about 11 degrees below zero.
Employees brought Stewart inside, covered her with blankets and called 911. Stewart was wearing a sweater, pants and shoes, but no coat, hat or gloves, according to state inspectors.
An ambulance crew arrived and took Stewart to a nearby hospital. Just before 9 a.m., the county sheriff arrived at the home to investigate the matter and informed the staff that Stewart was dead. The Polk County medical examiner’s report listed the cause of death as hypothermia, according to inspectors.
Although the staff was to have made hourly, visual checks on Stewart, the inspectors’ review of video captured by the facility’s in-house camera system on the night of her death reportedly showed the employee tasked with checking on residents, Catherine Forkpa, never ventured down the hall where Stewart resided.
According to county investigators, Stewart’s door alarm was activated for nine hours before her body was found. Forkpa was initially charged with second-degree murder but later pleaded guilty to a reduced charge of dependent adult abuse and was sentenced to two years of probation.
Lehman testifies in case
In October 2023, transcripts of two depositions in Forkpa’s criminal case were made public briefly on Iowa Courts Online before a judge ordered them sealed from public view.
The records indicate one of the individuals who gave deposition testimony was Lehman, who acknowledged the alarm on the door to Stewart’s room was triggered at 4:32 p.m. on Jan. 20, and wasn’t deactivated until 7:15 a.m. the next day — almost 15 hours later — around the time Stewart’s body was found.
State inspection records indicate screenshots of Lehman’s phone show that by 9:44 p.m., Lehman was receiving phone alerts about a separate alarm on the building’s exit door, and that she continued to receive those alerts every five minutes throughout the night.
Lehman testified she couldn’t recall whether she contacted the staff at Courtyard Estates to have them check on Stewart after the alarms were triggered.
“Would you agree that when somebody — a resident, a geriatric patient — walks out of your facility and freezes to death, that that’s a pretty, that’s a pretty significant event, right?” public defender Matthew Sheeley asked.
“Yes,” Lehman replied.
“And the events of that day — what you did the day before and what you did the day that this unfortunate event occurred — those events are pretty significant and you’d kind of remember what was happening during those days, right?” Sheeley asked.
“I would,” Lehman said.
“I’m just going to ask you,” Sheeley continued, “is it possible you saw these notifications and you ignored them?”
“No,” Lehman replied.
Sheeley pointed out that police and state-inspection reports suggest Stewart’s door was in alarm mode for roughly 17 hours and that during that time Lehman appeared to have made no effort to respond to it or have others look into the situation.
“I’m asking you, having heard that now, whether it’s possible that you failed or neglected to contact the staff about the alarm to Lynne’s door?” Sheeley asked.
“It’s possible,” Lehman said.
The court records also indicate that Courtyard Estates’ former health care coordinator, Jamie Haub, gave sworn, pretrial testimony in the case. In her deposition, Haub testified that while she was at home the night of the incident she received continuous alerts on her phone about door alarms and failed to respond because she was with her family and, later, went to bed.
“It sure sounds like that there were a lot of people that were ignoring things,” Sheeley said. “Is that fair?”
“Yes,” Haub replied.
“Would you agree that Ms. Lehman ignored things, too?”
“I would agree with that, yes,” Haub replied.
Lawsuits settled out of court
Jaybird Senior Living is the Cedar Rapids company that managed Bondurant’s Courtyard Estates at Hawthorne Crossing at the time of Stewart’s death. Jaybird also managed Keelson Harbour Senior Living, an assisted living center in Spirit Lake, where 95-year-old Elaine Creasey froze to death six weeks earlier, in December 2021.
Jaybird is a for-profit company headed by CEO Kevin Russell, a former lawyer and investment banker from Rancho Santa Fe, California. In recent years, Jaybird has managed 40 senior-living communities in Iowa and more than two dozen others in Wisconsin, Minnesota, Illinois and Kentucky.
In April 2023, Sally Daniels, a former resident assistant at the Courtyard Estates sued the facility’s owners, Abilit Holdings LLC, and Jaybird Senior Living, alleging she was unfairly fired after Stewart’s death.
In her lawsuit, she alleged she was fired despite having no responsibility for residents in Courtyard Estates’ memory care unit where Stewart lived. Daniels also alleged she was the worker who first alerted others to the fact that Stewart was missing. The defendants in the case denied any wrongdoing. Court records show the lawsuit was settled out of court in January 2025.
In January 2024, Stewart’s estate sued Abilit Holdings and Jaybird Senior Living for wrongful death. Court records show that several weeks later, the case was settled out of court with the defendants never having filed a response to the allegations.
