Special oversight of the nation’s worst nursing homes still leaves residents at risk

Residents have been abused, neglected and ignored under the government’s watch. Oversight weakened because of COVID-19.

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(InvestigateTV) - Last fall, a Virginia nursing home evicted a wheelchair-bound resident against his will and left him on the lawn of his sister’s house where he remained for hours without food, water, medication or access to a bathroom.

The staff of a Vermont nursing home ignored a patient’s infected foot for so long that it became infested with maggots.

At an Iowa nursing home, two residents died because of medical neglect in the same month. One of them had been left in a soiled diaper for days.

State and federal inspectors cited each of these nursing homes for egregious failures, federal records show.

The violations also occurred while they were under heightened scrutiny by government regulators.

These nursing homes had amassed so many serious violations over a 3-year span that they were placed in the Special Focus Facility program, which provides additional oversight to up to 88 of the worst nursing homes in the country.

The program, run by the Centers for Medicare and Medicaid Services, requires that these poor-quality facilities be inspected every six months – about twice as often as other nursing homes.

Typically, it takes about 18 months to bring a troubled nursing home into compliance, CMS director Seema Verma wrote in a letter to two Pennsylvania senators last year.

But one out of every five nursing homes in the program as of August remained on the list for more than 18 months because they had not improved their quality of care enough to meet the lowest standards set by CMS, an InvestigateTV analysis of CMS nursing home data has found.

Center for Medicare and Medicaid Services Director Seema Verma responded to questions about the Special Focus Facility program to Pennsylvania's senators including how long it should take nursing homes on the list to improve.
Center for Medicare and Medicaid Services Director Seema Verma responded to questions about the Special Focus Facility program to Pennsylvania's senators including how long it should take nursing homes on the list to improve. (Source: Illustration: Jamie Grey, InvestigateTV)

The program is supposed to give CMS extra enforcement tools and penalties to force these facilities to improve. But CMS has not levied financial penalties against more than 15% of them.

One nursing home that graduated from the program in April had 57 substantiated complaints since 2017 but wasn’t fined during that time.

CMS removed the Grove at North Huntingdon in Pennsylvania from the SFF program four months after the nursing home was cited for failing to properly monitor a resident who frequently groped female residents and staff. It did not respond to a request for comment.

Once a nursing home graduates from the SFF program it remains on the list for several months but is not subject to the extra oversight and is not counted among the reserved 88 SFF slots. As of August, there were 28 nursing homes that had graduated in the previous four months.

Crest Nursing Home in Butte, Montana has been on the SFF list for three years and never has been fined.

In May 2019, a patient at Crest suffered unnecessarily when the staff failed to provide basic life support to him, an inspection report says. The patient aspirated food into his lungs and died because staff didn’t suction him.

During its time in the program, Crest has not shown improvements in its quality of care, records show. The nursing home did not respond to requests for comment.

“It’s not doing what it was intended to do,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, a nonprofit organization that pushes for nursing home reforms. “We don’t treat these problems seriously.”

Nursing homes take a spotlight because of the pandemic

The coronavirus has shone a bright light on the nation’s 15,700 nursing homes, where 1.3 million senior citizens and adults with disabilities live.

COVID-19 has claimed an estimated 50,000 long-term care residents and sickened thousands of others, according to CMS. Even top-rated, five-star nursing homes were no match for the voracious virus.

The pandemic also put nursing homes on lockdown and left residents without their advocates: their families, friends and state-funded watchdogs.

In the past three years, the concerns of these advocates have led to the discovery of more than 1,600 substantiated complaints against facilities on the SFF list, the data shows.

These nursing homes have on average four times as many substantiated complaints as all other facilities in the country, the data shows.

For more than five months this year, these troubled nursing homes did not receive the heightened oversight because CMS halted routine inspections of all long-term care facility due to COVID-19.

In March, CMS said inspectors would only check on facilities’ infection-control practices and respond to complaints that threatened the health and safety of residents.

Many other potential violations may have been ignored during that time including identifying hazards that lead to falls, medication errors or kitchen cleanliness.

“We’re tremendously worried. Absolutely worried for the residents,” said Edelman before CMS said on Aug. 17 that routine inspections could resume.

About 15% of the SFF nursing homes were not inspected as part of the targeted inspections between early March and July 31, according to an InvestigateTV analysis of CMS data.

More than 90% of SFF nursing homes on the list in August have not had a regular 6-month survey. One in five hasn’t been inspected in a year or more.

The SFF category “has just gone by the wayside during this pandemic,” Edelman said. “They are treated just like all the other facilities.”

Even before the coronavirus pandemic halted routine inspections, these poor-performing nursing homes struggled to provide a safe and healthy environment for their residents even with the heightened oversight triggered by their SFF designation.

In the past three years, residents have died because negligence in some of those homes or suffered horrible injuries because of staff failures, inspection records show.

Many of the most serious violations largely are discovered because someone lodged a complaint against the nursing home.

“Those who have done so much for us and for our nation deserve quality care,” said Sen. Bob Casey, a Democrat from Pennsylvania who has long pushed for nursing home reforms and transparency. “We have not done a good job across the board of protecting nursing home residents.”

Families unaware of nursing home troubles

For some families, they didn’t know the troubled histories of these nursing homes until it was too late.

That was the case for Beth Themm.

Her father, Charles Themm, was sent to Touchstone Healthcare Community in Sioux City, Iowa in mid-May after a two-week hospital stay. The hospital made the arrangements for him to move to there to rehabilitate after a fall.

“He was supposed to be at Touchstone just for rehab, just to get him a little bit stronger and then he was supposed to go home,” Ms. Themm said. “That never really happened like we were hoping.”

With visitation halted because of COVID-19, Ms. Themm and other family members were unable to see him in person and were often left in the dark about his condition.

When the family would call for an update, the staff often would answer the phone then immediately hang up, she said. Other times, when they did answer, they would give vague responses to her questions.

Ms. Themm got her father a cellphone so she could talk to him directly. But she said the staff wouldn’t help him charge it.

“He didn’t have a phone available in his room that we could call the room,” Ms. Themm said.

After a six week-stay at Touchstone, Mr. Themm’s condition deteriorated. He was sent home for hospice care.

When Ms. Themm, who is a surgery technician, saw her father the day that he was sent home, she said she was horrified.

His hands and feet were dirty. His hair was so full of dandruff that cradle cap was forming. Food was matted in his clothing. He had been wearing the same hospital gown for a week.

“I had started oral care as soon as he got there and when I opened his mouth to start putting in the swabs to do oral care, I pulled out chunks out of his mouth that looked like cloves of garlic, and this man had not been eating,” Ms. Themm said.

The medics who were transferring him to his home refused to move him until his soiled diaper had been changed, she said.

“There are no words. I don’t know how another person could do that to someone else,” Ms. Themm said. “I work in healthcare, I’m on the end of saving lives and I do that every day and how someone can do that to another human being and treat them with no care. . . I have no words.”

Mr. Themm died on July 2 two months shy of his 78th birthday.

Beth Themm, left, takes a selfie with her dad, Charles, on Father's Day. Within weeks, Mr. Themm's family gathered to say their final goodbyes after his condition deteriorated while residing in an Iowa nursing home.
Beth Themm, left, takes a selfie with her dad, Charles, on Father's Day. Within weeks, Mr. Themm's family gathered to say their final goodbyes after his condition deteriorated while residing in an Iowa nursing home. (Source: Family-Provided)

On Aug. 26, Themm’s family received a letter notifying them that Iowa state inspectors had substantiated their complaint that Mr. Themm received sub-par care while at Touchstone.

“I would not recommend this facility to anyone looking for elder care or after-surgery care. I am ashamed they treated him this way,” Themm said. “They shouldn’t be in business. Absolutely not. No, not one bit.”

Beth Themm’s family isn’t alone in their experience at Touchstone.

Gayle Evans has similar feelings about Touchstone after her mother was there two years ago.

She described the care her mother received as “neglect” and “incompetent.”

Evans’ mother was sent to the nursing home by a hospital to recuperate after surgery to repair a broken back and pelvis.

Doctors ordered her to be on 24-hour-a-day bed rest but allowed her to use the bathroom with staff assistance.

But during those six weeks, Evans’ mother fell about seven times and the staff downplayed the incidents, she said.

The first time her mother fell, Evans remembers Touchstone calling to notify her, but the third and fourth time, she received no call.

“At one time, after I had been told by my mom about her falling, I went and talked to the administrator and once again, she tried to downplay it as no big deal and assured me that it would never happen again,” Evans said.

She said that her mother’s calls for help to the bathroom went unanswered at least a dozen times.

Other times, they would take her to into the bathroom then never return to help her back to bed.

Even Evans’ personal doctor called the nursing home to complain about her care, her daughter said.

Evans visited her mother almost every day during her 3-month stay.

“I can say that it did not appear to be the cleanest facility,” Evans said.

The bathroom reeked of urine and the floor of her mother’s room was dirty with food debris, she said.

“I do believe that management did not hold staff accountable for not doing their job,” Evans said.

Neither Ms. Themm nor Evans knew that Touchstone was a Special Focus Facility.

Touchstone Executive Director Timothy Cook said in a written statement to InvestigateTV that the nursing home’s mission is to provide compassionate, quality care.

“We very much appreciate the comments from family members about the care their loved ones received at Touchstone. While it is difficult to hear, we view these comments as constructive criticism that we will use to help us improve,” Cook wrote. “It is important to note that more recent feedback assessments from residents showed positive ratings for the work our staff does. Nevertheless, we will continue to address the issues the families raised, and we consider this as an opportunity to enhance our delivery of care and daily operations.”

InvestigateTV told Touchstone about the comments made by Themm and Evans. It did not respond specifically to their complaints.

Nursing home reforms still leave residents at risk

Use the map below to explore facilities in the Special Focus Facility program. Hover over each dot for more details. The darker the dot, the longer the facility has been in the program. Data Source: CMS.

These Special Focus Facility nursing homes on average have four times as many substantiated complaints as all other facilities in the U.S. and collectively have paid more than $9.5 million in fines. The Centers for Medicare and Medicaid Services revises the list each month and assigns designations based on facilities’ most recent inspections. Newly added: have had a record of poor care for at least three years. Improving: made “significant” strides in quality of care. Not improved: failed to improve even after being named an SFF. Graduated: sustained significant improvement for 12 months but still may have problems with quality of care. No longer in Medicare and Medicaid: terminated from the reimbursement program after an inability to comply with health and safety requirements.

Touchstone Healthcare Community is the only nursing home in Iowa in the SFF program.

Congress created the program as part of nursing home reforms in 1987. It was designed to provide additional oversight and additional penalties for nursing homes with a persistent record of poor care.

Because of federal budget constraints, the program is limited to only 88 nursing homes even though hundreds of others have equally poor records.

Each state has a limited number of slots ranging from one to six. States with the most nursing homes receive the most slots. Twenty-nine states have just one; California and Texas – states with the highest numbers of nursing homes each have six.

Inspections triggered by complaints, which often uncover the most serious violations, are not included in the formula to select nursing homes for the program.

For example, CMS data shows that a nursing home in Michigan has 132 substantiated complaints in the past three years, yet it is not an SFF. Nor is a facility in Williamsburg, Virginia with 102.

On average, the 15,400 nursing homes that receive Medicare and Medicaid funding have had less than five substantiated complaints in the past three years.

“We need to make sure that if there are poor performers that consistently underperform and don’t provide quality care that there is more intensive focus on them in terms of the frequency of inspections,” Sen. Casey said.

But no additional resources or education are provided to these nursing homes to help improve conditions for the residents.

Facilities in the program are flagged as a Special Focus Facility on the public Nursing Home Compare website, where consumers can read inspection reports, check staff levels and examine other key metrics.

But few know that exists or how to interpret the results. Advocates have long criticized using the word “special” in the program’s title.

Special, Edelman said, usually means to people that something is good.

Casey and Sen. Patrick Toomey, R-PA, also criticized the CMS website in their 2019 report.

“It lacks detailed information or context on the SFF program,” they wrote. “There is not information . . . explaining the reason for a facility’s participation in the program, the length of time it has been in the program or whether it has improved.”

During the past three years, inspectors have substantiated 51 complaints against Touchstone, the Iowa nursing home. It is among seven SFF nursing homes with more than 50 complaints – 10 times the national average of all nursing homes in the U.S.

During the complaint-driven investigations at Touchstone, records show that inspectors have discovered that:

· The facility failed to report last December an incident in which a resident’s pain medication disappeared after a staff member took custody of it. The nursing director told investigators that she had suspicions about that staff member because “she smelled of alcohol during work hours.”

· During a 30-day period in 2018, one resident fell five fives breaking an ankle during one episode and his hip during a second. Inspectors said the nursing home failed to provide adequate monitoring to prevent falls. After the fifth fall, he underwent surgery to repair his hip. He died days later after developing respiratory problems. A nurse told inspectors that there was nothing in the resident’s file that instructed the staff “to watch the resident closer.”

· In the fall of 2018, inspectors arrived to investigate complaints of lack of proper care to eight patients. One had such a severe infection at the site of his catheter and on his buttocks that his primary care doctors said he had been in a soiled diaper for “several days.” One resident with diabetes died because staff failed to address his rapidly declining blood sugar. A second died of respiratory failure when staff didn’t adequately address her complaints that she had difficulty breathing.

The facility has been fined four times for a total of $138,811 during the nearly 34 months it has been an SFF.

“We are aware of the matters identified in the state reports and have made major progress and taken specific actions to make improvements. Some of the issues mentioned were administrative in nature, and we were able to resolve them very quickly,” said Cook, the nursing home’s executive director in his statement to InvestigateTV. “We continue to strive to elevate our care levels and service. We are grateful for the dedication our staff has shown in working on a daily basis to implement our action plans to improve care.”

CMS’ August report shows that Touchstone’s quality of care is “not improving.”

Few consequences for troubled nursing homes

During the two years that Pines Rehab & Health Center has been an SFF, it has not shown improvement.

CMS has fined the 60-bed facility of Lyndonville, Vermont twice for a total of $22,358.

It has had 13 inspections in the past three years that have unearthed serious failures.

Last March, a resident died because the staff ignored the seriousness of his bloody stools. Last fall, a staff member was “physically abusive” with a woman who has dementia and refused to get up off the floor, leaving bruises on her arms and around her ribcage. And, in September 2017, inspectors found a patient whose foot was infected with maggots.

Pines Rehab did not respond to requests for comment.

More than a third of the SFFs have not shown improvement, including nine of them that have been cited for abuse since 2017.

A nursing home in California that has been in the program for almost five years has not shown signs of improvement has been fined $16,490, the data shows. There is no time limit on how long a nursing home can remain on the SFF list.

“Not much happens to them,” Edelman said. “The fines now are even lower. We don’t treat these problems seriously.”

Collectively, these 28 facilities that haven’t shown improvement have been fined $3.3million – an average of about $117,000 per facility. Edelman said that for nursing home operators, these fines are considered nothing more than the cost of doing business.

Five of them haven’t been fined at all.

The nursing home with the highest fines is showing improvement, according the August SFF report.

Envoy of Westover Hills in Richmond, Virginia evicted an amputee against his wishes, humiliated him and left him on his sister’s lawn last fall. The nursing homes has been fined five times for a total of $706,416. The nursing home did not respond to requests for comment.

In 2017, the Trump administration changed the fine structure so that nursing homes weren’t fined on a per day basis but rather per incident. Financial penalties dropped, according to a 2019 analysis by Kaiser Health News.

The most severe sanction in CMS’ toolbox – terminating them from Medicare and Medicaid funding – is rarely used.

Since April, CMS’ report on SFFs noted that four nursing homes were no longer participating in the Medicare and Medicaid funding programs. Three of the four appeared to have permanently closed.

One, located in Seattle, Washington, had been an SFF for nearly three years.

Its departure from the program opened a slot for one of Washington’s other nursing homes with records of persistent poor care to become a Special Focus Facility. The state has five candidates.

Those facilities have been targeted for months for extra scrutiny.

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