BONDURANT, IOWA — A 77-year-old woman with Alzheimer's disease froze to death outside an Iowa assisted living facility after staff members and administrators ignored door alarms that sounded for hours, according to state inspection records and multiple news reports. Lynne Stewart died of hypothermia on January 21, 2022, after leaving Courtyard Estates at Hawthorne Crossing in Bondurant, a facility operated by Jaybird Senior Living of Cedar Rapids.
Stewart left her room on the evening of January 20, triggering the facility's door alarm system, according to reporting by KCRG. Temperatures that night plunged to approximately 11 degrees below zero. She was wearing only a sweater, pants, and shoes when she was found unresponsive outside the building nearly 15 hours later, covered in ice, as reported by 3 News Now. She was pronounced dead at a nearby hospital. The Polk County medical examiner determined the cause of death was hypothermia, according to a report from Yahoo News.
Multiple Staff Received Alerts, None Responded
State inspection records confirmed that multiple employees at various levels of the facility received alarm notifications throughout the night but failed to take action, according to the Iowa Capital Dispatch and corroborating reports.
The facility's night coordinator received continuous phone alerts from the door alarm system but made no effort to respond or investigate, as reported by the Waterloo-Cedar Falls Courier. Surveillance footage reviewed during the investigation showed that a certified nursing assistant walked around the facility for hours without checking on Stewart or resetting the alarms, according to reporting by The Gazette. Deposition transcripts revealed that top facility officials, including health care coordinator Jamie Haub, also received continuous alarm alerts for hours but neither responded nor directed anyone else to investigate, as The Gazette reported.
Four employees received written warnings for alarm response failures, according to 3 News Now. The facility's executive director and an on-call nurse also received alerts but did not respond.
Criminal Charges and Administrative Action
The case drew significant attention when Catherine Forkpa, 31, a certified nursing assistant who had been earning $13 per hour at the facility, was charged with second-degree murder — a charge carrying up to 50 years in prison — in connection with Stewart's death, as reported by the Waterloo-Cedar Falls Courier. Forkpa, who had immigrated to the United States from Africa in 2004 and had worked at the facility for seven months, ultimately pleaded guilty to the reduced charge of dependent adult abuse, according to the same report. Polk County prosecutors recommended a deferred judgment with two years of supervised probation.
Forkpa stated during the proceedings, "I know in my heart I would never do anything to hurt anyone," as quoted by 3 News Now.
The disparity in consequences drew scrutiny from advocacy groups. The Gazette reported that the case raised broader systemic questions about why a low-wage care worker faced a murder charge while facility management and administrators faced far lesser consequences for their roles in the alarm response failures.
Administrator Dwala Marie Lehman, 44, was charged with professional incompetence in 2023 and reached a settlement with the Iowa Board of Nursing Home Administrators, according to KCRG. Under the terms, Lehman must complete 10 hours of training on resident wandering, her license was placed on probationary status for one year, and she must file quarterly compliance reports. According to Yahoo News, Lehman has since taken a position at Edencrest at Green Meadows in Johnston, Iowa, and retained her nursing home administrator license subject to the probation conditions.
The facility itself was fined $10,000 by state regulators for failing to monitor residents and ensure dementia-specific training, as reported by KCRG. That fine was automatically reduced to $6,500 when the facility declined to appeal, according to Yahoo News.
Inadequate Dementia Training
A critical factor in the case was the facility's failure to provide adequate dementia-specific training to staff. According to 3 News Now, Forkpa had received only 4.75 hours of dementia training, falling short of the required 8 hours within her first 30 days of employment. Stewart had documented diagnoses of Alzheimer's disease, major depressive disorder, and anxiety disorder, according to Yahoo News, making proper dementia care protocols essential for her safety.
Federal and state regulations require assisted living facilities to provide staff with adequate training in caring for residents with cognitive impairments, including protocols for responding to elopement alarms and monitoring residents at risk of wandering.
CMS Inspection History
It should be noted that the CMS facility data available for this location does not reflect the assisted living regulatory framework under which Courtyard Estates at Hawthorne Crossing operated. Assisted living facilities in Iowa are regulated at the state level by the Iowa Department of Inspections, Appeals, and Licensing, rather than through the federal CMS nursing home survey and certification system. This distinction is important because assisted living facilities generally face less rigorous federal oversight than skilled nursing facilities, a gap that resident safety advocates have long identified as a concern.
Ownership & Operations
Courtyard Estates at Hawthorne Crossing was operated by Jaybird Senior Living, based in Cedar Rapids, Iowa, according to KCRG. The case also generated a related wrongful termination lawsuit filed by former resident assistant Sally Daniels, which settled in January 2025, as reported by The Gazette.
Resources for Families
Families with concerns about care quality at assisted living or long-term care facilities in Iowa can contact the following resources:
- Iowa Long-Term Care Ombudsman: 1-866-236-1430 - National Elder Care Hotline: 1-800-677-1116 - Long-Term Care Ombudsman Resource Center: https://ltcombudsman.org
If you believe a loved one is in immediate danger, contact local law enforcement by calling 911. Families can also file complaints with the Iowa Department of Inspections, Appeals, and Licensing, which oversees assisted living facility regulation in the state.
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