State conducts emergency evacuation of nursing home, but won’t say why

The Aspire of Donnellson nursing home in Iowa was subject to a state-ordered evacuation this week, although state officials aren't saying why. (Photo courtesy of Lee County Assessor's Office; logo courtesy the State of Iowa)

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.