Long-term care ombudsman says she’s not ‘comfortable’ disclosing issues
By: Clark Kauffman
For the second time in two years, residents of the Aspire of
Donnellson nursing home in Lee County have been relocated after an
emergency evacuation at the facility.
On Christmas Eve in 2022, the home’s 50 residents were evacuated with
the assistance of the fire department and more than a dozen other
agencies after a water line burst and flooded the building. The facility
didn’t reopen until October 2023.
On Tuesday, with state inspectors on site to investigate a complaint,
the 46-bed home was evacuated again – although state officials aren’t
saying why.
A spokesperson for the Iowa Department of Inspections, Appeals and
Licensing, which oversees nursing homes in the state, said the
investigation of the complaint, along with the home’s scheduled
recertification inspection, had been underway on Tuesday when
“deficiencies were identified, including a life-safety issue, requiring
the facility to implement their emergency plan and safely relocate their
16 residents to other health facilities.”
The spokesperson did not identify the life-safety issue or indicate
where or how the residents were relocated, or when they might return.
She said that once DIAL finishes its inspection, it will write a report
that outlines the agency’s findings and then publish it to the DIAL
website.
Iowa Long-Term Care Ombudsman Angela Van Pelt, whose office is
responsible for independent oversight of DIAL and for protecting
residents’ rights related to evictions, indicated that while her office
wasn’t at the home when the evacuation occurred, DIAL kept her office
informed of the situation as it unfolded.
Van Pelt said DIAL shared with her a list of “issues” that gave rise
to the evacuation. She said one of the issues was tied to some form of
infection-control problem, but she declined to elaborate.
Van Pelt said she doesn’t know what DIAL will ultimately decide to
disclose with regard to its findings and so she’d rather not share the
information she has.
“We’re not the regulator,” she said. “So for me to release that
information, publicly is — you know, I’m not overly comfortable doing
that.”
Aspire of Donnellson has the lowest possible quality ratings on the federal government’s Care Compare website. It has been awarded one star, on a five-star scale, for both its inspection results and its staffing levels.
According to the Centers for Medicare and Medicaid Services, the home
was last subjected to federal fines in 2022, when $30,544 in fines were
imposed. It has been six years since any state fines were imposed,
according to state records.
Officials at the home and at the Florida office of the home’s
corporate owner, Beacon Health Management, did not respond to calls and
emails Thursday. Beacon operates nine Iowa nursing homes, all of which
carry the Aspire name.
Aspire of Donnellson and Beacon are currently being sued for wrongful
death by the family of Jo Anne Walter, a former resident who died in
July 2021, allegedly as a result of a fall at the home. The company has
denied any wrongdoing, and a trial is scheduled for May 13, 2025.
Last year, the family of Marjory Chaney sued the home and Beacon for
negligence, alleging the home failed to treat her pressure sores until
the wounds were so serious she had to be treated at a hospital emergency
room and then transferred to hospice care. The home has denied any
wrongdoing, and a trial is set for Sept. 30, 2025.
Home was the focus of complaints and violations
Almost immediately after the Donnellson home reopened in October
2023, it was the focus of complaints. In November of that year,
inspectors from DIAL investigated seven complaints and substantiated six
of them. The home was cited for 11 regulatory violations, although no
fines or penalties were imposed.
In April 2024, inspectors from DIAL visited the Donnellson facility
again, this time to investigate a backlog of 10 complaints. Nine of the
10 complaints were substantiated.
While there, the inspectors cited the home for 30 state and federal regulatory violations – an unusually high number — and proposed, but then held in suspension, $15,700 in fines.
The violations included failure to meet overall quality of care
standards, failure to treat pressure sores, failure to have sufficient
nursing staff, failure to avoid significant medication errors, failure
to meet infection-control standards, and numerous failures related to a
lack of staff training.
Some of the suspended fines were tied to allegations that the home
had failed to attempt cardio-pulmonary resuscitation on two residents,
both of whom died.
In the first of those two cases, according to state reports, a male
resident of the home was found in his bed at 5:15 a.m. on Jan. 18, ashen
colored with no pulse or respirations. The aide who found him later
told inspectors the man was still warm when found. According to the
inspectors, the aide had checked on the man after noticing his light was
on, suggesting he was up or at least awake.
After noticing the man wasn’t breathing, the aide summoned a nurse
and asked whether they should initiate CPR. The aide allegedly told
inspectors the nurse never answered and instead called the family to
report the man was dead.
The nurse told inspectors that he had not been “exactly sure” about
the resident’s code status which would indicate whether attempts to
resuscitate him should be made, according to state reports. He
acknowledged, however, that it was later determined the man was “full
code,” indicating CPR should have been attempted.
Eleven days after that incident, a female resident of the home was
found unresponsive in bed at about 10 p.m. The woman’s guardian and
family were notified, and a funeral home was summoned to pick up the
body. Although the resident was “full code,” no one on staff had
attempted CPR, according to state reports.
Earlier this year, the Iowa Board of Nursing Home Administrators
charged Tara Behrendsen of Eagle Grove, who ran the Aspire of Gowrie
care facility in Webster County in 2022, with violating the standards of
her profession. Behrendsen voluntarily surrendered her license.
The Gowrie home had been cited for 114 regulatory violations over the course of 19 months.
Full Article & Source:
State conducts emergency evacuation of nursing home, but won’t say why
