State: Intruder was in care facility four hours before entering resident’s bed

By: Clark Kauffman

An intruder allegedly spent four hours inside an eastern Iowa nursing home before the staff found him partially undressed in bed with a female resident.

According to newly released state inspection reports, the intruder – later identified by police as Michael James Beaver, 54, of West Branch – interacted with the staff at Crestview Specialty Care in West Branch on April 5 before being found in the resident’s bed.

During those hours, one of the workers expressed concern that Beaver appeared to be homeless. Another worker twice gave Beaver directions to the victim’s room, and one employee heard the woman crying out, “Help me” while being wheeled through the facility by Beaver.

Beaver has not been criminally charged, although he is currently facing a charge of indecent exposure for his alleged conduct in a public library two days before the incident at Crestview.

The nursing home’s owners, Care Initiatives of West Des Moines, did not respond to calls from the Iowa Capital Dispatch, but on May 9 issued a written statement that said the company “is committed to the health and safety of our residents and takes the April 5, 2023, incident at Crestview Specialty Care very seriously. We took immediate action to report the incident to the state and are working with state investigators to address the situation.”

The state inspectors’ reports provide a timeline of the events that occurred on April 5, according to the statements given to inspectors by the Crestview staff:

10:30 a.m.: A nurse aide saw a male stranger walking around the facility, appearing to look for someone.

11 a.m.: The aide saw the man pushing a female resident in her wheelchair and calling her “mom.” The resident — the same woman with whom Beaver would later be found in bed — was legally blind and was one of 26 residents at the home with cognitive issues.

11:30 a.m.: A second aide saw Beaver pushing the resident in her wheelchair. Beaver asked the aide where the resident’s room was and was told, “Down the hall, to the left and her name should be on the door.”

Noon: A third aide noticed the resident was at her table, eating lunch alone. Around that time, an aide approached the director of nursing and informed her there was a stranger who looked “a little dirty” sitting in a common area. The aide said the man had dirt on his face and clothing and, to her, appeared to be homeless. The director of nursing left her office, looked at the man later determined to be Beaver, and said he might be a family member of a resident.

12:30 p.m.: The aide who had contacted the director of nursing saw Beaver pushing the female resident in her wheelchair down a hallway, with the woman calling out, “Help me.” The aide said she thought nothing of it as the resident often said such things.

1 p.m.: At this point, and for some unspecified time afterward, the staff observed Beaver pushing the resident in her wheelchair throughout the facility. The aide who had previously given Beaver directions to the resident’s room saw him looking confused by the front door, so she gave him a reminder, saying, “Remember, I told you, her room is down the other way.”

2:40 p.m.: Two aides told the director of nursing “something weird” was going on in the resident’s room: A man is in bed with the resident, claiming to be “just cuddling” with her.

2:45 p.m.: The director of nursing and a registered nurse entered the resident’s room. The resident’s head was at the foot of the bed, Beaver was under the covers, but appeared to be shirtless with his pants pulled down. The resident’s one-piece jumpsuit was unzipped halfway in the back.

The director of nursing asked what was going on and Beaver replied that he was “just trying to help her sleep.” The director of nursing asked him why he wasn’t dressed, Beaver said he had his clothes on. The director of nursing replied, “Having pants around your ankles in not having clothes on.”

The staff removed Beaver from the resident’s bed at which point he zipped up his jacket and attempted to leave, saying, “I will get out of the way.” The director of nursing replied, “No, you will stay until the police come,” and the staff escorted him to the lobby.

Home cited for abuse and safety violations

Beaver initially told the staff he was a distant relative of the resident. Later, he reportedly said he was not related to her but had known her about 20 years prior. The resident’s nephew reported he had never heard of Beaver, but declined to have the resident sent to a hospital for an assessment.

The resident said nothing at the time but was reported to be anxious and tearful. When questioned a short time later, she had no recollection of the incident.

The police, who had picked up Beaver earlier in the day and dropped him off at a trailer park, took him to a local hospital for psychiatric commitment and evaluation.

The incident resulted in “possible distress for the resident,” state inspectors concluded, while noting that a physical assessment conducted at Crestview resulted in “no findings that the resident had been assaulted.”

The facility “took all precautions necessary to mitigate another similar incident of this type,” according to state inspectors. The home had placed residents in immediate jeopardy, the inspectors concluded, but they lowered the scope and severity of the violation after concluding the staff had immediately corrected the problem by locking the doors to the facility, educating the staff, creating a visitor’s log, and installing a doorbell at the front entrance for visitors to gain entry.

Prior to those changes, visitors had only to push a button near the front door to enter the building.

The Iowa Department of Inspections and Appeals imposed and immediately suspended two $6,500 fines against Crestview – one for failing to protect residents from abuse and one for failing to keep residents safe. With the state fines suspended, the federal Centers for Medicaid and Medicaid Services will consider what federal penalties, if any, will be imposed.

Court records show that two days before the incident at Crestview, Beaver was arrested and charged with indecent exposure at the Iowa City Public Library. According to the arrest report, video evidence showed Beaver entering the library, going to the computers on the second floor, taking off his sweatshirt and pants, placing a jacket over his genitals, and then spending four hours watching pornographic videos while reaching under his jacket and stimulating himself.

The day after he was arrested, he was released from jail on his own recognizance. District Associate Judge Jason A. Burns released Beaver on the condition that he not return to the library. The indecent exposure case is still pending.

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State: Intruder was in care facility four hours before entering resident’s bed