Executive Summary
- Administrator Dwala Marie Lehman retains her license with one year of probation and mandated training following a resident’s death.
- Resident Lynne Stewart died of hypothermia after alarms indicating she had exited the building went unheeded for 15 hours.
- A staff member pleaded guilty to dependent adult abuse, and the facility paid a reduced state fine of $6,500.
- Civil lawsuits filed by the victim’s estate and a former employee were settled out of court.
BONDURANT, Iowa — The administrator of an Iowa assisted living facility, where an elderly resident froze to death in 2022, will retain her state license following a disciplinary settlement with the Iowa Board of Nursing Home Administrators. State records confirm that Dwala Marie Lehman, the administrator at Courtyard Estates at Hawthorne Crossing in Bondurant during the incident, reached an agreement with the board last month to resolve charges of professional incompetence.
According to state inspection reports, 77-year-old Lynne Stewart died of hypothermia on January 21, 2022. Stewart exited her room and the facility, falling to the ground just outside the door where she remained for approximately 15 hours. The Polk County medical examiner determined the cause of death was hypothermia, noting that the temperature was 11 degrees below zero that morning.
Investigators found that a series of recurring alarms were sent to Lehman’s phone and to staff inside the building after Stewart triggered the door alarm. State inspection records indicate Lehman received alerts regarding the exit door throughout the night. In deposition testimony cited by public records, Lehman acknowledged receiving the alerts but stated she could not recall if she contacted staff to investigate. When asked during the deposition if it was possible she neglected to contact staff about the alarm, Lehman replied, "It’s possible."
Under the terms of the settlement, Lehman’s license is placed on probationary status for one year. She is required to complete 10 hours of educational training focused on "resident wandering" and must submit a report detailing changes to her approach in such situations. Lehman currently serves as the administrator at Edencrest at Green Meadows in Johnston, another assisted living center.
Separately, Catherine Forkpa, the employee tasked with checking residents on the night of the fatality, faced criminal prosecution. Security footage revealed Forkpa did not enter the hallway where Stewart resided during the nine hours the door alarm was active. Originally charged with second-degree murder, Forkpa pleaded guilty to a reduced charge of dependent adult abuse and received two years of probation. The facility itself was fined $10,000 by state inspectors, an amount automatically reduced to $6,500 because the facility did not appeal.
Civil litigation surrounding the incident has also been resolved. A wrongful death lawsuit filed by Stewart’s estate against the facility’s owners, Abilit Holdings LLC, and management company Jaybird Senior Living was settled out of court in early 2024. A separate lawsuit by a former employee alleging wrongful termination was settled in January 2025.
Regulatory Oversight
This case highlights critical gaps in protocol compliance within assisted living environments, specifically regarding emergency alarm response and staff supervision. The disciplinary outcome for the administrator—mandated training rather than license revocation—underscores the specific boundaries of administrative liability as determined by state regulatory boards. Furthermore, the incident at Courtyard Estates mirrors a similar fatality at a sister facility in Spirit Lake just six weeks prior, raising broader questions about systemic operational oversight in senior care management. It is important to note that all individuals named in criminal or administrative complaints are presumed innocent until proven guilty in a court of law.
