An Iowa nursing home that implemented an emergency evacuation last month was so short-staffed that staff sometimes had to call 911 for help and the director of nursing worked 34-hour shifts with few breaks, according to state records.
Records also show that just hours before an evacuation order was issued at Aspire of Donelson nursing home in Lee County on Aug. 26, about a dozen of the home’s 31 residents were transferred to the owner’s other facilities in Iowa, leaving about 18 residents in the dementia unit. Hours later, the remaining residents were evacuated due to unresolved fire safety issues.
At the time, Beacon Health Management, the Florida-based owner of the home, said the evacuation was caused by a malfunction in the electrical panel that controls fire alarms and sprinklers.
On September 9, two weeks after the evacuation, the federal Centers for Medicare and Medicaid Services took the unusual step of terminating Medicare funding for the facility, effectively cutting off its main source of revenue. The Centers said only that it did so because the facility had not substantially complied with “certain Medicare and Medicaid participation requirements.” The facility has not yet reopened.
State inspectors visited the facility in August to investigate eight outstanding complaints.
When asked about staffing, the owner cited “financial health.”
As a result of an August inspection, state officials recently released a 195-page report detailing 42 violations of state and federal regulations, many of which were related to staffing shortages. The facility was decertified by CMS and had its operating license revoked by the state, but no fines were levied for the 42 violations, records show.
The facility’s former manager told state officials that she worked weekends and cooked meals for residents to deal with staffing shortages, according to the inspection report, adding that “emails asking for help had been sent for months” — likely a reference to a request for assistance she sent to the Beacon.
Inspectors reported that a former manager said she was told by Beacon management that she couldn’t add staff unless the facility saw an increase in residents.
State inspectors reported they contacted Beacon’s chief operating officer to ask whether the Donelson facility had prevented the hiring of additional staff until it had increased occupancy.
Inspectors said executives responded that they had doubts about whether the facility was, in fact, overstaffed, adding that they felt the number of nursing hours per day allocated to the facility was “a key performance indicator that helps care homes monitor their financial position.”
The COO also said the company had repeatedly notified the Iowa Department of Inspection, Appeals and Licensing that it was having difficulty finding temporary workers because it owed “significant amounts of money to temporary employment agencies.”
A spokesman for Beacon Health Management did not immediately respond to a request for comment on the matter Thursday.
Called 911 because “there is no staff on the night shift”
During the August inspection, a nurse working at the home tearfully told inspectors she felt “exhausted” and had post-traumatic stress disorder from stress, anxiety and worry about the situation that might affect her nursing qualifications. “I’ve worked days on end and can’t remember the last time I completed a required assessment of a resident’s needs,” she told inspectors, adding that staff called 911 for help on August 24 because “there was no staff on the night shift.”
Another staff member told inspectors about a separate incident that resulted in paramedics being called to the facility: “A resident started coughing up blood so we called 911 and then another resident collapsed out front so two ambulances were called at the same time,” she said.
The facility’s director of nursing reportedly told inspectors that she had been working 34 hours prior to their arrival and had “only taken a couple of two- or three-hour breaks.” She reportedly said “corporate headquarters had been calling and texting people” to try to get staff from sister facilities owned by Beacon to come to the Donelson facility. Inspectors reported that she “explained that this was an ongoing battle that was getting worse and worse.”
According to the inspectors’ report, one certified nursing assistant (CNA) told inspectors that the facility was so understaffed that all staff could do was “keep people from leaving the facility.” Aides, who sometimes only worked with the facility’s administrator, said they didn’t feel safe at the facility. Another staff member told inspectors that the facility was so understaffed that residents had not been able to shower for more than a week.
One CNA reportedly told inspectors that on Aug. 23, she was “working alone for the entire building from 2 p.m. to 6 a.m.,” but the inspectors’ report went on to say that a nurse was also on duty during at least part of that time.
A registered nurse told inspectors that sometimes there was only one staff member working in the dementia ward at the facility, and when there were two she had to rely on the “kid in the kitchen.”
The home’s activities manager told inspectors that home managers had “forced” administrative staff to work in the dementia unit to make up for a shortage of qualified caregivers. “I just did what I was told, I didn’t do it of my own volition,” the activities manager reportedly told inspectors.
Sexual abuse, violent attacks, death of residents
An inspection led the facility to make a medication error that may have contributed to the resident’s death. The resident’s doctor had instructed the facility to withhold antiplatelet medication after she fell and injured her head on Aug. 9 because the medication can interfere with blood clotting and increase bleeding.
But the facility continued to administer the drugs, inspectors allege. Within days, the resident was rushed to the hospital, where he was diagnosed with a brain hemorrhage and died a few days later.
Inspectors also found that the building had no fax machines for sending or receiving doctor’s orders, pharmacy orders, or test results. The director of nursing acknowledged that the lack of a fax machine created problems for patient care and said she was unsure whether non-management nurses had access to a secure, work-related email address that could be used instead of a fax machine.
The facility was also accused of failing to prevent and report staff abuse of residents, as well as several cases of resident-on-resident sexual abuse and violent physical abuse.
Earlier this year, staff raised concerns that the female resident may be pregnant after a male resident was discovered sharing a bed with her. Staff contacted the woman’s doctor and obtained a pregnancy test, but the doctor allegedly either refused or was unresponsive.
The two nurses then went to a store, bought a pregnancy test kit, took a urine sample from the woman and ran their own test, one of the nurses told inspectors, “to keep everyone quiet.” The test showed the woman was not pregnant.
During the inspection, state officials called the facility’s corporate owner and reported that residents at the facility were being put at immediate risk due to the fact that the facility was planning to hire unlicensed “support” helpers (including kitchen, maintenance and housekeeping staff) to assist residents because they were not on the payroll of licensed or certified caregivers.
By the end of the inspection, the facility was cited for 12 separate situations that put residents at immediate risk, including lack of resident assessment and intervention, lack of pain management, resident mistreatment, understaffing, lack of qualified staff, serious medication errors, inadequate nursing home management and building safety issues.
Beacon officials were the first to suggest evacuation.
State inspectors said that as of 6 a.m. on Aug. 26, the day of the evacuation, Donelson Home did not have staff members supervising the 17 residents living in the home’s east and west halls.
At 6:10 a.m. that day, staff texted Beacon’s regional nursing consultants, asking for assistance. Minutes later, the director of nursing told inspectors she “didn’t know where to start” to address the residents’ needs. Within the hour, the home’s manager entered the building and tried to answer the residents’ call lights but was unable to find the residents’ rooms, according to the inspectors’ report.
A few minutes later, a local nursing consultant arrived and, with the assistance of another staff member, was able to locate the room where the resident had activated their call light a few minutes later.
20 minutes later, management was informed that another CNA had quit and a temp agency would send a worker who would take 90 minutes to arrive at the facility.
Two hours later, at 9 a.m., a company executive told the state that a temporary worker scheduled to work that morning “cancelled and did not show up to work,” inspectors reported. The company’s regional vice president told the state that “we didn’t know what to do other than to begin evacuating residents, a decision that was unpopular with our superiors, corporate representatives, but we felt we had no other choice because our current staffing levels were not enough to meet the needs of the residents,” inspectors reported.
The decision was then made to move 13 of the home’s 31 residents to the home’s sister facility, and leave the rest in the dementia unit. Beacon operates nine nursing homes in Iowa, all of which bear the Aspire name. All remaining residents were evacuated that same day.
The August incident marked the second evacuation at the Donelson facility in recent years. Residents of the facility were evacuated with the assistance of the fire department and more than 10 agencies on Christmas Eve 2022 after a water main feeding the sprinkler system burst, flooding the building. The facility was not due to reopen until October 2023.
The Donelson Home became the target of complaints almost immediately after it reopened in October 2023. In November of that year, DIAL inspectors investigated seven complaints and substantiated six of them. The Home was cited for 11 regulatory violations, but no fines or penalties were imposed.
In April 2024, DIAL inspectors again visited the Donelson facility, this time to investigate the 10 outstanding complaints. At that time, 9 of the 10 complaints were substantiated.
Governor opposes federal staffing mandate
According to CMS data, 14% of Iowa’s 422 nursing homes have been cited for staffing shortages for fiscal year 2023, more than double the national average of 5.9%.
Only five states — Hawaii, Michigan, Montana, New Mexico and Oregon — performed worse than Iowa in complying with adequate staffing requirements. Iowa’s neighbors — Nebraska, South Dakota, Wisconsin and Missouri — had between 2% and 6.8% of facilities facing staffing shortages in 2023.
The Biden administration has spent the past year seeking approval of new rules that would establish for the first time certain minimum staffing levels for nursing homes that collect taxpayer money through Medicare and Medicaid, a proposal that has faced stiff opposition from industry lobbyists and many state and federal Republicans, including Gov. Kim Reynolds.
Last November, Reynolds and 14 other Republican governors sent a letter to President Biden complaining that the nursing home industry was facing staffing shortages, especially in rural areas. They predicted that minimum staffing levels would “force more than 80% of facilities nationwide to hire additional staff,” forcing many facilities to close.
