Report: Nursing home owner balked at hiring more staff before evacuation order

The Aspire of Donnellson nursing home. (Photo courtesy of Lee County Assessor's Office)

The Iowa nursing home that underwent an emergency evacuation last month was so short-staffed that workers had to call 911 on occasion for assistance and the director of nursing worked a 34-hour shift with few breaks, according to state records.

The records also indicate that hours before the Aug. 26 evacuation order was given at the Aspire of Donnellson nursing home in Lee County, about a dozen of the home's 31 residents were transferred to the care facility owners' other Iowa homes, leaving 18 or so residents in the dementia unit. Hours later, those remaining residents were evacuated due to an unresolved fire-safety issue.

At the time, Beacon Health Management, the home's Florida-based owner, said the evacuation was triggered by a problem with the electrical panel that controls the fire alarms and sprinklers.

Two weeks after the evacuation, on Sept. 9, the federal Centers for Medicare & Medicaid Services took the rare step of terminating Medicare funding for the home, effectively shutting off the home's primary source of revenue. The agency said only that it did so because the home had failed to come into substantial compliance "with certain Medicare and Medicaid participation requirements." The home has yet to reopen.

State inspectors were at the home in August to investigate a backlog of eight complaints.

Owner cites 'financial health' when asked about staffing

As a result of the August inspection, state officials recently published a 195-page report detailing 42 state and federal regulatory violations, many of them related to staffing shortages. The records show that while the home was decertified by CMS and its license to operate was revoked by the state, no fines for the 42 violations were imposed.

According to the inspection report, the home's former administrator told state officials she had been working weekends and cooking meals for residents to deal with staff shortages, adding that "there were months and months of emails begging for help" – presumably referring to written appeals for assistance she had sent to Beacon.

The inspectors reported that the former administrator said she had been told by Beacon's management that she could not hire more staff without additional residents being added to the home.

State inspectors reported that they contacted the chief operating officer at Beacon and asked him whether he had prevented the Donnellson home from hiring additional staff until more residents were recruited.

According to the inspectors, the executive responded that he had, in fact, questioned whether the home was overstaffed, adding that he felt the number of nursing hours allotted to the home per day was "a key performance indicator that helps skilled nursing facilities monitor their financial health."

The chief operating officer also indicated he had repeatedly notified the Iowa Department of Inspections Appeals and Licensing that because the company owed "a large amount of money to a temporary staffing agency" it was having a hard time securing more temporary workers.

A spokeswoman for Beacon Health Management did not immediately respond to requests for comment on the matter Thursday.

'No staff on the evening shift,' so 911 is called

During the August inspection, a nurse who worked at the home tearfully told inspectors she was "exhausted" and felt like she had post-traumatic stress disorder due to the stress, anxiety and worry that situation might cause for her nurse licensure. She reportedly told inspectors she had "worked multiple days and did not remember the last time" she completed the necessary assessments of residents' needs, adding that the staff had called 911 for help on Aug. 24 due to the fact that were "no staff on the evening shift."

Another worker told inspectors of a separate incident that resulted in EMTs being summoned to the home. A resident, she said, "started puking up blood and, when calling 911, a different resident fell up front, so two ambulances were called at the same time."

The home's director of nursing allegedly told inspectors she had been on duty for 34 hours just before the inspectors arrived, with only "a couple two- or three-hour breaks." She allegedly stated that "corporate was calling and texting people" in an effort to get workers from sister facilities owned by Beacon to come to the Donnellson home. She allegedly "explained it was an ongoing battle and was (getting) worse and worse," the inspectors reported.

One certified nursing assistant, or CNA, told inspectors the staffing shortage was so bad that all the staff could do was "make sure people didn't get out of the building" by wandering away, inspectors reported. An aide who sometimes worked with only the home's administrator to assist said she didn't feel safe in the facility. Another worker told inspectors the home was so short-staffed residents went without showers for a more than a week.

A CNA allegedly told inspectors that on Aug. 23 she had worked "by herself for the whole building from 2 p.m. to 6 a.m." – although the inspectors' report goes on to say there was also one nurse on duty for at least part of that time.

A licensed practical nurse told the inspectors that the home sometimes had only one employee working in the dementia unit and when it had two it had to rely on "a kid from the kitchen."

The home's activities director told inspectors the home's administrator had "forced" management staff to work in the dementia unit to make up for the lack of licensed caregivers. "I did what I was told to do, not by my own free will," the activities director reportedly told inspectors.

Sexual abuse, violent attacks and a resident death

As a result of the inspection, the home was cited for a medication error that may have contributed to a female resident's death. The resident's doctor had ordered the home to withhold the woman's antiplatelet medication in the aftermath of a fall and a head injury on Aug. 9, since the drug can prevent blood from clotting and increase bleeding.

The home, however, continued to administer the drug, inspectors allege. Within a few days, the resident was taken to a hospital and died several days later after being diagnosed with a brain bleed.

The inspectors also noted there was no working fax machine in the building to send or receive physician orders, pharmacy orders or lab-test results. The director of nursing admitted the lack of a fax machine had created patient-care issues and said she didn't know whether the nurses who weren't in a management position had access to a secure, work-related email address that could use used in lieu of a fax machine.

The home was also cited for staff-on-resident abuse, and for failing to prevent and report several instances of resident-on-resident sexual abuse and violent physical abuse.

Earlier this year, after a male resident was found in bed with a female resident, workers raised concerns the female resident might be pregnant. They contacted the woman's doctor to obtain an order for a pregnancy test and the physician allegedly refused or failed to respond.

Later, two workers went to a store and bought a pregnancy test, collected a urine specimen from the woman, and performed their own test, one of the nurses told inspectors, to "get everyone to shut up about it." The test indicated the woman was not pregnant.

During the inspection, state officials called the home's corporate owners to report that the home's residents were in immediate jeopardy as evidenced by the fact that the home was planning to use unlicensed "support" help – which could include kitchen, maintenance or housekeeping staff – to assist residents due to the lack of licensed or certified caregivers on the payroll.

By the end of the inspection, the home was cited for 12 separate conditions that each had placed residents in immediate jeopardy, including a lack of resident assessments and interventions, a lack of pain management, resident abuse, insufficient staffing levels, a lack of competent staff, significant medication errors, inadequate nursing home administration and building safety issues.

Beacon official first proposed an evacuation

At 6 a.m. Aug. 26, the day of the evacuation, the Donnellson home had no workers on hand to monitor the 17 residents in the home's east and west halls, according to state inspectors.

At 6:10 a.m. that day, a worker sent a text message to Beacon's regional nurse consultant asking for assistance. Minutes later, the director of nursing told inspectors "she did not know where to start" in terms of addressing residents' needs. Within the hour, the home's administrator entered the building and attempted to answer a resident's call light but could not locate the resident's room, inspectors reported.

Minutes after that, the regional nurse consultant arrived and with the assistance of another worker they were, after several minutes, able to locate the room where the resident had switched on their call light.

Twenty minutes later, the administrator was informed another CNA had quit and so a temporary-staffing agency was sending a worker who had to travel 90 minutes to reach the home.

Two hours later, at 9 a.m., company officials informed the state that the temporary worker who was lined up to work that morning "called off and did not show up to work," inspectors reported. The company's regional vice president told the state "she had no idea what else to do but to start evacuating residents and it would not be a popular decision with her corporation representatives above her but she felt she had no choice as they could not meet resident needs with the current staffing levels," inspectors reported.

It was then decided to move 13 of the home's 31 residents to the home's sister facilities while keeping the remaining residents in the dementia unit. Beacon operates nine Iowa nursing homes, all of which carry the Aspire name. Later that day, all of the remaining residents were evacuated.

The August incident was the second evacuation of the Donnellson facility in recent years. On Christmas Eve in 2022, the home's residents were evacuated with the assistance of the fire department and more than a dozen other agencies after a water line leading to the sprinkler system burst and flooded the building. The facility didn't reopen until October 2023.

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 at that time.

Governor opposes federal staffing mandates

According to data from CMS, 14% of Iowa's 422 nursing facilities were cited for insufficient staffing in fiscal year 2023. That's more than double the national average, which was 5.9%.

Only five other states – Hawaii, Michigan, Montana, New Mexico and Oregon — had a worse record of compliance with the sufficient-staffing requirement. Iowa's neighboring states of Nebraska, South Dakota, Wisconsin and Missouri had no more than 2% to 6.8% of their facilities cited for insufficient staffing in 2023.

Over the past year, the Biden administration has called for the approval of a new rule that would establish, for the first time, specific minimum staffing levels for care facilities that collect taxpayer money through Medicare or Medicaid. That proposal has faced stiff opposition from industry lobbyists and many state and federal Republicans, including Gov. Kim Reynolds.