Analysis finds clusters
of nursing home violations
by state, ownership
Gannett News Service
WASHINGTON — Where a nursing home is and who owns it can be
critical in determining the care given to America’s most frail
and vulnerable, a Gannett News Service investigation has found.
Nearly three-fourths of the most severe and repeated nursing home
patient care violations found in the past four years were concentrated
in a dozen states. Additionally, patients at homes owned by for-profit
companies fared worse in some ways than residents in government
and nonprofit nursing homes.
“There are many flaws in the long-term care system,”
said Thomas Scully, administrator of the Centers for Medicare and
Medicaid Services, which directs federal nursing home programs.
“We’re trying to look at them and fix them.”
The findings are the result of a four-month Gannett News Service
investigation. GNS interviewed dozens of people and analyzed four
years’ worth of federal data on inspections and patient well-being
at the nation’s 16,000 nursing homes.
The analysis revealed significant weaknesses in the safety net designed
to protect the nation’s 1.5 million nursing home residents,
weaknesses not apparent on a nursing home quality Web site the federal
government created. Star ratings for each Medicare- and Medicaid-certified
nursing home, the vast majority of nursing homes nationwide, can
be found by clicking the searchable database link at the top of
this page. The analysis also ranks each home’s inspection
results against peers in its home state.
— For-profit nursing homes accounted for 83 percent of the
more than 500 nursing homes with repeated, serious violations, yet
are only 65 percent of all Medicare- and Medicaid-certified nursing
— Patients at for-profit homes had, on average, higher rates
of infections and pressure sores than those the government and nonprofits
— Homes monitored by councils of residents’ family members
tended to have a higher use of physical restraints and a lower rate
of patients in pain.
Information about nursing homes and the care they provide is crucial
to thousands of Americans who each year must confront the difficult
decision of placing a loved one in a long-term care center.
As a nurse, Anne Smith of Salt Lake City is well aware of the troubled
past and present of nursing homes. When she needed care for her
88-year-old mother who was recovering from a heart ailment, she
asked the hospital discharge planner for help. The planner handed
her a list of 31 nursing homes in the area.
“I said, ‘Can you help me find a good one?’ and
she said she wasn’t allowed. And to tell you the truth, she
probably didn’t know which ones were good or bad,” said
Smith turned to a new consumer-oriented tool on the Internet, the
federal government’s Nursing Home Compare Web site, which
lists residents’ health status and inspection results for
all Medicare- and Medicaid-certified nursing homes.
The site is part of the federal government’s major new nursing
home initiative, which spent about $30 million to draw attention
to the Web project. It features inspection and patient health results
for every nursing home in the country.
Another $1 billion was pledged over three years to expand the role
of quality improvement organizations, staffed by health care professionals,
that work with nursing homes to lift the level of care delivered
to nursing home patients nationwide. With a list from the Web site,
Smith narrowed her choices, using proximity to her home and other
“It helped me go into the nursing home with this information
and ask them, ‘What is your strategy for caring for my mother
because you don’t look very good on paper,’” Smith
Consumer advocates who reviewed the GNS findings said they were
not surprised that the investigation found a substantial number
of repeat violations and links between poorer care and for-profit
They say nursing home residents continue to suffer from neglect
and abuse despite new quality and information efforts and years
of legislation and regulation intended to protect patients.
The National Citizens’ Coalition for Nursing Home Reform recently
published a book depicting in graphic, heart-wrenching detail the
neglect and pain 82 Texas nursing home residents suffered. The coalition
is the nation’s largest consumer advocacy group focused solely
on nursing homes.
— Lunnie C., 93, entered a Longview, Texas, nursing home suffering
from a handful of ailments that included coronary artery disease.
Twenty months later she was taken to the hospital suffering from
deep pressure sores, more commonly known as bedsores; dehydration;
malnutrition; and gangrene in her left foot. State inspectors found
the nursing home staff had ignored and neglected her.
— Kenneth E., 65, entered a Tyler, Texas, nursing home suffering
from Alzheimer’s disease. Less than two years later, he died
from pressure sore infections he developed there. State inspectors
found staff was negligent.
Incidents like these continue to occur despite government officials’
claims that care in nursing homes is improving, said Donna Lenhoff,
the coalition’s executive director.
“These are severe breakdowns in the provision of health care
services and in the provision of basic human decency,” she
said. “There are a lot of nursing homes that are giving a
lot of bad care.”
Federal officials, nursing home administrators and others representing
the industry said recent reforms, especially the Nursing Home Compare
Web site, have helped improve patient care.
“Getting people talking about quality, measuring poor quality,
making people aware of quality is a big first step,” the Medicare
agency’s Scully said.
“Long after we’re all gone, this is going to have a
huge impact on the health care system — if we can manage to
slowly turn around quality measures and public accountability,”
Few states had most problems
Nearly three-fourths of severe and repeated violations of federal
patient care standards from 1999 to 2003 were at nursing homes in
12 states. They are, in descending order: Texas, Illinois, Arkansas,
Washington, New Jersey, Kansas, Missouri, Indiana, Oklahoma, North
Carolina, Mississippi and Tennessee.
The violations included failing to protect patients from mistreatment,
hiring staff without conducting criminal background checks, and
allowing patients to be abused and physically punished.
In some cases, problems were isolated. But in others, dangerous
conditions were widespread.
Government regulators, the nursing home industry and consumer advocates
disagree on whether nursing home quality has improved or slipped
in recent years. The theory behind the Bush administration's $1
billion quality improvement effort, barely 6 months old, is to encourage
nursing homes to improve care for patients by offering them guidance
from teams of experts and by holding their violations records up
to public scrutiny. The program has not yet produced measurable
Some states such as Florida and Washington have gone beyond federal
requirements by enacting their own reforms, but those, too, are
so recent that results are not conclusive.
Terry Watters, a Maryland ophthalmologist who compiles nursing home
information, said it is important to know which homes are cited
repeatedly for severe violations.
“This means somebody is not doing their job,” said Watters,
who founded the nursing home watchdog group Member of the Family.
Scully — whose agency sets nursing home care standards, payment
and enforcement policies — said concentrations of repeat offenders
in certain states do not necessarily mean those states have more
problem nursing homes.
in some states, due to different secretaries of health, different
state legislatures, different funding, and different cultures, you
may have more aggressive or less aggressive inspections,”
Federal health quality measures can be similarly misleading.
The New Underwood Good Samaritan nursing home in New Underwood,
S.D., recently reported 71 percent of its patients in pain. That’s
seven times the average for all nursing homes nationwide.
Administrator Ron Kortemeyer said his nursing staff records and
treats pain precisely as the Centers for Medicare and Medicaid Services
recommend it be done, and the high number for his nursing home indicates
strong oversight, not poor care.
“It is our understanding we’re doing it correctly,”
Kortemeyer said. “Which suggests others are not.”
Officials with the trade association representing for-profit nursing
homes argue that the inspection process is so inconsistent —
from state to state and even within the same state — that
any attempt to make comparisons or draw conclusions is misleading.
“The statistics are easily subject to misinterpretation,”
said Alan DeFend, vice president for public affairs of the American
Health Care Association. “Drawing sweeping conclusions could
present readers with an incorrect picture of reality.”
DeFend said providing consumers with the information is helpful
but focusing on violations and attempting to rate nursing homes
give consumers false information.
DeFend’s group represents 12,000 for-profit and nonprofit
nursing homes and other long-term care centers. It spent $305,000
lobbying Congress last year, and its political action committee
made more than $800,000 in campaign contributions in the 2001-2002
election cycle, according to watchdog group PoliticalMoneyLine.
Quality data not all as they appear
Tom Patton of Richmond, Va., faced a difficult choice last year.
His 80-year-old mother, Elaine, was living in St. Petersburg, Fla.,
and had been diagnosed with lung cancer on top of the emphysema
she had been struggling with for years. Patton decided to move his
gravely ill mother to a nursing home closer to him in central Virginia
but, like many people in his situation, was overwhelmed.
“I began frantically searching for a nursing home here not
knowing the first thing about where to start,” said Patton,
a home builder. “All I had was the Yellow Pages, newspaper
ads and word of mouth.”
Patton, 55, found his way to the federal Web site, downloaded information
about his local nursing homes and began visiting them before he
settled on one.
“It was by process of elimination,” he said. “Quality
of care was most important.”
Medicare director Scully said he is encouraged by the early experiences
of people like Patton.
“It’s going to take a while” for people to understand
what’s available, Scully said. “We’re just in
the first steps.”
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