Journalism in the Public Interest

Nursing Home Inspect Update: More Homes, More Violations

Our Nursing Home Inspect news app now contains more than 134,600 deficiencies from nearly every nursing home in the United States. News organizations have identified many problems at homes in their communities.



Today, we are refreshing our Nursing Home Inspect app to include thousands more deficiencies found by government inspectors in nursing homes around the country.

Our tool, based on data from the U.S. Centers for Medicare and Medicaid Services (CMS), has already led to an impressive array of news stories.

The Shreveport Times reported that a resident with dementia at a Bossier City, La., nursing home went missing for more than 3½ hours last year before staff went looking for her. A worker found Hattie Mae Chambers “outside the facility lying in a fetal position near a fence, her white socks covered in grass,” the paper reported. “Blood was coming from her nose and mouth, and was pooled on the ground. The 57-year-old mother of three was dead. A police report later would reveal Chamber's body temperature was 118 degrees.”

The Columbus Dispatch wrote about a nursing home in Yellow Springs, Ohio, at which a worker last year “opened the door of a resident’s room and saw another aide on top of the resident, having sex. The worker shut the door and went to get a supervisor, leaving the partially paralyzed woman alone with her abuser. The abusive aide continued working for more than an hour before being ordered to leave, and was later fired.”

The Daily News of Los Angeles found that 125 residents at a local nursing home had to remain in rooms last year that reached up to 90 degrees after the air-conditioning had failed for days.

And the Contra Costa Times reported on an Oakland, Calif., home at which the owner yanked family pictures off a resident’s wall, “took away a crackers-and-jelly bedtime snack, and said the resident could not keep other food items relatives had left. Eyes welling with tears, the resident told an investigator how much it meant to have photos of relatives in the room. ‘Why did they do that to me?’ the resident asked.”

ProPublica has not done its own nursing home reviews. Rather, Nursing Home Inspect relies on the government, which first began publishing the narrative portions of inspections last month.

The CMS data cover all deficiencies identified during each home’s most-recent periodic review, known as a standard survey. It also includes complaint investigations from at least the past 12 months.

Nursing Home Inspect allows users to search all inspection reports by keyword to look for problems that may appear across the country. Results can be sorted by state or severity level. Our tip sheet offers suggestions about how to get the best search results.

In addition to adding more reports to its site last week, CMS stopped redacting residents’ genders in inspection reports — though it continues to redact information about residents’ diagnoses and medications.

As of today, the app includes 134,602 deficiencies from nearly 15,000 nursing homes. They represent 26,990 separate visits by inspectors.

The inspectors rated the majority of the deficiencies, nearly 57 percent, with a severity score of D, on a scale of A (least severe) to L (most severe). A “D” score signals an isolated instance in which the violation created the potential for harm, but in which no actual harm occurred.

The most common deficiency, cited 8,281 times, was a home’s failure to ensure that it was free of accident hazards and that each resident received adequate supervision and assistance to prevent accidents. The second most-common related to infection control. A recent blog post said nursing home inspectors have increasingly cited homes for the failure of their staffs to wash their hands.

Nursing home industry officials have cautioned that while the reports can be of value when choosing a home, they are only a snapshot and don’t highlight good practices in the home. The American Health Care Association, a nursing home industry group, has launched a program that each year recognizes homes that it says are working to improve the quality of care.

“...they are only a snapshot and don’t highlight good practices in the home.”

True, and these things should be called out (especially when it’s someone who wouldn’t ordinarily be called upon for help, like administrators or maintenance workers).

However, looking at all the Ford Pintos that avoided bursting into flame tells us what about the safety of the vehicle?  In what murder case would we enumerate the billions of people not killed by the defendant?  When your computer mangles your critical report, how much do you care about all the times it worked for me?

Jobs are, and I think must be, judged by the worst performance in recent history when choosing a product or service.  They don’t necessarily highlight bad employees (though they certainly could), but more usually a lack of resources, poor management, or some other, larger problem.  It doesn’t matter how friendly and helpful an orderly is, for example, if the boss has her working double shifts for extended periods of time.  As they say, a chain is as strong as its weakest link.

That said, when there’s improvement identified, that’s probably better than not having seen any problems at all.

Thank you for this report!  I have forwarded to many people asking them to do the same.

It sickens me that these kinds of abuses are STILL going on against the most vulnerable in our society. Where is the MANAGEMENT?!? 

This is one case where I support the trial attorneys.  Sue the hell out of these nursing homes that don’t hire decent people, because they’re too cheap!  And for not monitoring their every move…

More and louder outcries are necessary to initiate tighter controls for those in charge of the most vulnerable to abuse. Not only is abuse and neglect rampant in nursing homes but ProPublica should also add in occurrences of abuse of the elderly in “so called” assisted living communities. Further, rampant in the U.S. is professional fiduciary (PF) abuse. My mother is currently under the extreme control of a professional fiduciary and his attorney who has 13 such fiduciaries. Mom has received no clothes, shoes, dentistry, hair or nail care, and even had her dog removed her from her. Alzheimer patients connect and feel secure when their pet is with them. The PF has placed her in a assisted living facility that charges month to month rent for the room where she sleeps and meals, feedings, bath, etc is all charged ala carte. Court investigator made note of a huge bruise on her cheek but says the facility says she likes to walk independently and must have run into something and in response the court investigator says in her once yearly report, “the facility advised her conservator immediately,” as if a phone call makes it okay to allow a late stage alzheimer patient to roam unattended and obtain a bruise from who knows where or what. Someone knows. By the way the fiduciary’s attorney provides lectures and luncheons for court investigators in the area and mom’s PF has the facility filled with his conserved, which gives him leverage to obtain compliance of alienating mom from family, as the facility and professional fiduciary and his attorney all withhold information from myself and mom’s sisters. I am simply in the way as sole beneficiary of the trust that is feeding them as long as mom is alive. What is happening to my mom is not uncommon in the Bay Area. They are currently fine-tuning their protocol in anticipation of the huge wave of baby boomers that began the whole trust wave of popularity. Pro Publica, please do some investigation on professional fiduciaries and assisted living facilities in San Francisco. And note who initiates elderly laws into legislation and notice that “pro” professional fiduciary and attorney bills are passed , whereas “pro” elderly bills are vetoed, is it not the American Bar Association that creates elder laws? Are they not the ones that prosper most from employing professional fiduciaries. Let’s delve a little deeper and see what I have seen over the 4 years as I fight for mom. By the way my fight has cost me my career, education, family, and I am $50,000 in debt to my own family trust, my inheritance plus my inheritance has dwindled from over 2 million to $600,000 in payment to attorneys and professional fiduciaries that are harming my mom. Oh, sorry I forgot to add my $50,000 indebtedness to the now dwindling $600,000 inheritance.  Sincerely, “Conserving Frances”

Lauren, I’m no expert in the field (I’m a computer guy at a corporate job, and my mother is spry and living on her own), but my limited experience is that many of these sorts of problems are due to management, and have much less to do with who’s hired.

When a person is tired or stressed, their reactions and their abilities to reason abstractly both slow down.  So even a brilliant doctor, after he’s worked a couple of double shifts and getting yelled at by the boss, is someone you don’t want diagnosing you or holding a scalpel.  That’s not who’s at a nursing home, but the same applies to a bus driver, a waitress, or nearly any other job.  Stressed people do lousy work.

Unfortunately, it’s probably non-trivial to mandate to corporate America that stressed-out employees should be sent home (on the company dime) to recuperate, if only because no home has a mass of “reserve employees” to help the patients when your star is sent on walkabout…

Pearl Stendzis

Sep. 2, 2012, 10:42 a.m.

I don’t know how it is today but I worked at a few nursing homes years ago and we were notified when inspections were forthcoming and thats when supplies were plenty and everything was ship shape until inspections were over then it was back to the way it was then supplies were at a miminal.Sometimes staff was also.We had an assignment that was overloaded and it made it hard to give the patients the the best care they needed.I .It was like an assembly line. I remember doing a whole floor alone that meant one bed change per shift which should have been 2 bed changes.I also remember my first day at one nursing home when I was handed a tray of pills to pass out. I was only a nurses aide and didn’t know any of the patients.They had no name bracelets and you had to go by the names on the beds or rely on the sanity of the patient.I hope today that has changed.

My experience with nursing homes and their patients suggests that homes run by non-profits provide better care and demonstrate greater respect for their residents than do their for-profit contemporaries. Like other segments of our health care system in this country, the profit motive appears to often overpower other considerations.

Nursing Home Neglect Attorney St Louis

Sep. 3, 2012, 5:17 a.m.

According to me nursing home are not good. If we are not care our parents means we are not a human. Our parents care us our childhood to younger age and when we young we leave him alone, It’s not a good thing. He is not a man whose leave her parents alone.

How sad it is to see our parents (Elderly) abused in this manner.  My mother was in a nursing home for 8yrs.  She was very fortunate to have a loving family that would check on her daily.  But, there were numberous occasions that we would have to come to her defense (rescue) due to neglect by the staff.  During her 8yrs. in the nursing home they had three (3) directors, which would try to pacify the family by taking actions in which the outcome was not much different from before. .  .  this may not apply to all nursing homes, but it seems like to me that they don’t really care about their clients are simply just warehousing them.  I, on numerous occasions, have told Nurses and CNA (Certified Nurse Assistant) if they are in for the money they are in the wrong field.  I have also noticed the lack of supervision by shift supervisor and the failure to entry proper enteries into medical log.  How sad this hascome.  Our elderly possess so much history that could be shared w/staff and other visitors.  Lets treat then with some form of dignity and respect.  It could be you Parent, Child etc. or even you who one day be in a nursing home.  KARMA- - - This is in reference to the “San Luis Care Center located in Alamosa, Colorado”.

Elder Abuse Attorney St Louis

Sep. 15, 2012, 2:57 a.m.

More violation, i hate this and i really want to change this situation specially violation but i have no power for this act and daily i am burning in the fire of violation…...

This article is part of an ongoing investigation:
Nursing Homes

Nursing Homes

Our Nursing Home Inspect tool allows anyone to easily search and analyze the details of recent nursing home inspections, as well as penalties imposed on each home over the past three years.

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