Nursing home administrator surrenders her license

The former administrator at one of Iowa’s most troubled nursing homes has agreed to surrender her license.

In a rare disciplinary action, the Iowa Board of Nursing Home Administrators earlier this month 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. At the same time the charges were publicly filed, the board agreed to accept Behrendsen’s decision to resolve the case by voluntarily surrendering her license.

The board action has no immediate practical effect as Behrendsen’s license expired in December 2023. However, in order to have her license reinstated, Behrendsen will now have to show that such action would be in the public interest.

The board’s charges were based in part on an October 2022 state inspection at the 46-bed Aspire of Gowrie. That inspection resulted in citations for failing to provide residents with a safe environment; failure to prevent inappropriate sexual activity between residents; failure to ensure the staff was trained spotting and reporting dependent adult abuse; and failing to ensure all workers were subjected to a background check; failure to ensure the staff was skilled and competent; and failure to ensure a nurse was on duty at least eight hours per day.

Two months later, the facility was cited for additional violations, including failure to correct the previously cited deficiencies and failure to provide the staff with personal protective equipment as they cared for residents diagnosed with COVID-19.

Between January 2017 and March 2023, the Iowa Board of Nursing Home Administrators publicly sanctioned only three administrators, despite state inspectors citing care facilities for numerous violations tied directly to the administrators’ actions. The violations were tied to physical abuse, unwarranted evictions, falsification of records and patient dumping.

Facility cited for death, fined $197,230

Since Behrendsen’s departure from Aspire of Gowrie in January 2023, the home has continued to be cited for violations. Currently, it is one of two Iowa nursing homes on the federal government’s list of “special-focus facilities,” which are some of the worst care facilities in the nation. Aspire of Gowrie has been on the list for seven months.

The most recent incident at the Gowrie home involves a resident who choked to death on his dinner in early January. The staff at the home was aware the man was at risk of choking and had given him the Heimlich maneuver on three prior occasions.

In addition to being cited for the resident’s death, Aspire of Gowrie was cited for numerous other violations, including a “strong, offensive urine odor” in one area of the building. A maintenance worker told inspectors he was aware of the smell but “the facility did not have the budget to buy the cleansers to get the smell out.”

The home was also cited for a failure to ensure all residents were seen by a physician once every 60 days; failure to ensure residents were given at least two showers per week; failure to respond appropriately to residents injured in falls; failure to respond appropriately to residents’ weight loss; and failure to offer or provide residents with their full meals and their nighttime snacks.

Since October 2022, Aspire of Gowrie has been cited for 114 quality-of-care violations and been the focus of 26 complaints. Federal records indicate that in the past three years, the Centers for Medicare and Medicaid Services has fined Aspire of Gowrie a total of $197,230.

On several occasions in the past two years, Aspire of Gowrie has been cited for the same serious, Class I violation: failing to provide a safe environment for residents. The safety violations were tied to a failure to protect residents from sexual abuse; squirting glue, rather than eye drops, into a resident’s eye; inoperable door alarms; and the Jan. 5 choking death.

Last year, Aspire of Gowrie had CMS’ lowest possible rating for overall quality, health care inspections and staffing levels. Currently, the home has no CMS ratings at all due to its status as a special-focus facility.

Federal records indicate the home is a for-profit venture owned by Black Hawk Healthcare, a limited liability corporation, and that Bruce Wertheim of Beacon Health Management in Tampa, Florida, owns 100% of the company, and exerts managerial and operational control of the home.

Court records indicate that in 2021, Beacon purchased the 10-facility Pearl Valley chain of Iowa nursing homes for $24.2 million. The entity that brokered the deal said the homes were generating $35 million in annual revenue, with cash profits totaling $3.5 million per year.

At the time, a state nursing home regulator named Todd Frank was recruited by Beacon to head the company’s Iowa operations. Court records indicate Frank then left his $89,000-per-year job as deputy administrator of the Iowa Department of Inspections and Appeals’ Health Facilities Division to join Beacon at an annual salary of $150,000.