Grundy Center care facility where nurse quit over staffing issues has history of abuse

The Grundy Care Center in Grundy Center, Iowa. PHOTO VIA GOOGLE EARTH

GRUNDY CENTER – A judge has awarded jobless benefits to an Iowa nurse who quit her job at a care facility that has a history of issues with staffing and resident abuse.

State records indicate Jessica M. Nelson worked at the Grundy Care Center from February 2023 to January 2024, when she resigned her position as the interim director of nursing.

The facility’s previous director of nursing had left the facility the summer of 2023, after which, Nelson later told an administrative law judge, she began working very long shifts that sometimes exceeded 12 hours. On other occasions, she alleged, she was assigned to work a shift of less than 12 hours, but was expected to return to work within two or three hours to work an additional shift.

Nelson told the judge, who presided over a recent unemployment-benefits hearing, that she told her superiors she had concerns about her ability to drive safely during her commute to and from work and about her ability to properly perform all of her patient-care duties in a manner that wouldn’t jeopardize her nursing license.

She alleged she had refused the job of interim director of nursing but was assigned those duties anyway. She said that although she had the authority to have other nurses stay to the job to cover shifts, the other nurses would often threaten to walk off the job.

She also alleged that in December 2023 and January 2024, there were three instances in which she had to work without any opportunity to rest. According to Nelson, the home’s administrator, Robyn Beeken, was sympathetic but was unable to resolve the issue. Nelson alleged she spoke with the management at the Florida company that operates the home, but they suggested she fill shift openings by using a temp agency that rarely had nurses available.

On Jan. 20, Nelson was in Chicago when the home was short-staffed, which resulted in a floor nurse covering the majority of two 12-hour shifts. Nelson said she then had to drive back to Iowa from Chicago to work the evening shift on Jan. 21. She resigned the next day, effectively immediately, and applied for unemployment benefits.

The company that operates the care center, Arboreta Healthcare of Florida, challenged the application, which led to a hearing before Administrative Law Judge Alexis Rowe, who ruled Nelson had been subjected to intolerable working conditions.

Nelson, Rowe ruled, “quit the employment because there was an absence of meaningful responses to her concerns regarding the increasing frequency of excessively long shifts. (She) had reasonable concerns about her own safety and her ability to properly provide care for her patients should she be forced to work without proper rest. She had notified multiple people at the employer regarding her concerns.”

Man would ‘prey on female residents’

The 40-bed Grundy Care Center has the lowest possible rating from the federal government for overall care, inspection results and staffing levels. Last August, the facility was cited for 19 regulatory violations, including a failure to have competent nursing staff.

One nurse aide who was employed through a temp agency reportedly told state inspectors, “The facility does not give any training … You just figure it out as you go. There are no care plans on the wall, so I don’t know what (the residents) need because I do not have access to the computer to chart.”

The facility was also cited by the state for placing residents in immediate jeopardy by failing to protect them from abuse.

Inspectors reported that one of the home’s male residents had been seen entering female residents’ rooms and had been seen kissing or inappropriately touching three other residents who had diminished cognitive abilities. In one instance, the man was reportedly found in a woman’s room with his hands on her breasts and genitals.

According to inspectors, a registered nurse at the home stated that the man “would prey on female residents who are not able to say no and are not able to get away from him.” A medication aide at the relayed similar concerns to inspectors and said the man would “size up” newly admitted women and would target those with diminished capacity.

The state inspectors reported that Beeken’s predecessor as administrator and the vice president of clinical services acknowledged they had failed to prevent the abuse despite their knowledge of the man’s behavioral issues.

The facility was also cited for an 8% medication error rate, failure to provide residents with pain medication, using unnecessary psychotropic medications and issues with infection control. As a result of those findings, the home was fined $25,970 by the federal government.

In April 2023, the home was cited for failing to investigate abuse and failing to report abuse to the state. In that case, residents and employees had reported that a nurse aide had verbally abused a resident by getting in the woman’s face and telling her to shut up.

The home was also cited for resident abuse in September 2022 after a registered nurse allegedly threatened a resident who complained about not receiving his pain medication. The resident alleged the nurse told him, “I don’t appreciate what you’re saying about me,” and then said she was the only nurse working and that it would be his fault if she walked off the job and all the residents of the home were left without nursing care.

According to the Centers for Medicare and Medicaid Services, Arboreta Healthcare has ownership or management ties to 24 care facilities in five states. Over the years, CMS has fined the company a total of $1,252,289, according to the agency.

Officials at Grundy Care Center and Arboreta Healthcare did not return calls on Wednesday, March 20, from the Iowa Capital Dispatch.