After two resident deaths, Iowa care facility is named among the nation’s worst

After two resident deaths, a Mount Pleasant nursing home has been added to a federal list of the nation’s worst care facilities.

Arbor Court of Mount Pleasant is one of two Iowa nursing homes that Wednesday were named “Special-Focus Facilities” by the Centers for Medicare and Medicaid Services. They join several other Iowa care facilities already deemed eligible for inclusion on CMS’ periodic list of nursing homes that have recurring quality-of-care problems.

Iowa has 10 nursing homes on the list, but only two of the 10 are officially designated special-focus facilities that are operating under additional scrutiny from regulators. The others are considered “eligible” for that added level of oversight due to similar quality-of-care issues, but they’re not actually enrolled in the program.

The two Iowa facilities now deemed special-focus facilities are:

Arbor Court of Mount Pleasant — This 62-bed, for-profit home is owned by Judah Bienstock and Arbor Court Investments. It has a one-star rating from CMS for both health inspection results and quality-of-care measures. The federal government has fined the home seven times in the past three years. Since September 2021, those fines have totaled $272,024. The home has been considered eligible for special-focus status for 15 months.

Last December, the home was cited for a resident’s death after the woman was given an antibiotic and an anticoagulant medication that were contraindicated. The facility’s electronic system of checking residents’ health records issued a warning pertaining to the potentially dangerous interaction between the two drugs, noting they had the potential to increase the risk of internal bleeding.

According to state inspectors, the nursing staff didn’t acknowledge the warning and didn’t notify the woman’s physician. Days later, the woman was admitted to a hospital emergency room with a gastrointestinal bleed. She died while the hospital was attempting a blood transfusion.

In January 2022, the state cited Arbor Court after a resident of the home, Donna Lee Huffaker, fell to her death from a mechanical device that was being used to transfer her in and out of bed.

Aspire of Primghar — This 40-bed, for-profit home is owned by Bruce Wertham and Black Hawk Healthcare. It has a one-star rating from CMS for both health inspection results and staffing levels. The federal government has fined the home nine times in the past three years, with the penalties totaling $265,168. The home has been considered eligible for special-focus status for 19 months.

Last year, the home was cited for 26 violations of federal nursing home regulations related to a wide variety of issues, including abuse and neglect, professional standards, overall quality of care, treatment of pressure sores, frequency of physician visits, the use of unnecessary psychotropic drugs, medication errors, laboratory services, sanitary food service, staff qualifications, infection control, staff immunizations, and nursing services.

According to state records, one resident of the home was injured when her wheelchair rolled off the ramp on a vehicle that had transported her to an appointment. The resident reportedly rolled backward, then fell 3 to 4 feet to the ground and struck a building with her head. She was rendered unconscious, and made three trips to a hospital emergency room for rib fractures, severe back pain, muscle spasms and multiple bruises over her arms, hands, torso, legs and face.

More facilities eligible for special-focus status

The three other Iowa facilities that have just been added to the list of facilities considered eligible for special-focus status are:

Aspire of Gowrie — This 46-bed, for-profit home also is owned by Wertham and Black Hawk Healthcare. It has a one-star rating from CMS for both health inspection results and staffing levels. The federal government has fined the home six times in the past three years. The most recent fine, imposed last October, was for $196,247.

Granger Nursing & Rehab Center — This 67-bed, for-profit home is owned by Holdco Goldfinch, a limited liability company. It has a one-star rating from CMS for health inspection results and a two-star rating for staffing levels and quality-of-care measures. In the past three years, the federal government has fined the home once — a $57,469 penalty imposed in 2021.

Iowa City Rehab & Health Care Center — This 89-bed, for-profit nursing home is owned by Arboreta Healthcare Inc. and Greenside Healthcare Properties. It has a one-star rating from CMS for both health inspection results and staffing levels, and a two-star rating for quality-of-care measures. In the past three years, the federal government has fined the home once — a $5,000 penalty imposed in May 2022.

Other homes have long been eligible for ‘special-focus’ status

The five other Iowa care facilities considered eligible for special-focus status are: Cedar Falls Health Care Center, which has been on the eligibility lists for two months; Genesis Senior Living of Des Moines, which has spent 11 months on the list; Griswold Rehabilitation & Health Care Center, which has spent seven months on the list; New London Specialty Care, which has spent four months on the list; and Northern Mahaska Specialty Care of Oskaloosa, which has spent seven months on the list.

Three Iowa care facilities have dropped off the national list of special-focus facilities in recent months — but in each instance that was because the facilities either closed or changed ownership after bankruptcy.

The federal special-focus facilities list now is updated monthly by the CMS and includes homes deemed by the agency to have “a history of serious quality issues.”

Nationally, there are 88 nursing facilities on the list, with one or two slots filled by each state. Those homes are enrolled in a special program intended to stimulate improvements in their quality of care through increased regulatory oversight.

Because the number of special-focus facilities is capped, new facilities — even those that have earned CMS’ lowest ratings for quality — can’t be named a special-focus facility until other homes in that same state shut down or improve and “graduate” from the program.

That’s a process that can take four years or more. As a result, there are several homes in each state that are deemed eligible for special-focus status due to ongoing quality-of-care issues, but they are unable to benefit from actual enrollment in the program.

Iowa typically has 10 facilities on the list that are considered eligible for enrollment in the program.

Typically, all the homes that are deemed eligible for special-focus designation have about twice the average number of violations cited by state inspectors; they have more serious problems than most other nursing homes, including harm or injury to residents; and they have established a pattern of serious problems that has persisted over a long period of time.

This article first appeared in the Iowa Capital Dispatch.