Journalism in the Public Interest

What We Found Using Nursing Home Inspect

We’ve made it easy to search nearly 118,000 deficiencies found during government inspections at 14,565 nursing homes nationwide.


Update: We have updated Nursing Home Inspect with new data from the government, so the exact search result numbers cited here may no longer be accurate.

In February 2011, a nursing home resident in Michigan wandered away in a blizzard, unnoticed by staff. He was wearing only pajama pants, a sweater, canvas shoes and a knit cap. A technician driving to work found him half an hour later at a busy intersection, wet and covered with snow, government inspectors wrote.

Five months later, a resident at a different Michigan nursing home climbed out of a secured window in the home’s locked dementia ward, hitchhiked a ride and was picked up by police hours later in a restaurant some 65 miles away. Nursing home staff did not even realize he was missing, inspectors found.

Were these incidents, known as “elopement,” isolated? Or do they suggest a pattern? Until recently, no one could really say how often such incidents occur.

Now, ProPublica has an app for that.

Drawing on government reports posted online last month, today we are launching Nursing Home Inspect — a tool that allows anyone to easily search and analyze the details of recent nursing home inspections, most completed since January 2011. As of today, that includes nearly 118,000 deficiencies cited against 14,565 homes, but we will add more each month as new reports become available.

Users can search across all the reports by any keyword, such as elope — a feature the federal government’s official nursing home website doesn’t have. The results can then be sorted by both the severity of the violation and by state.

Although more elderly people are choosing to live at home or in assisted-living facilities, about 1.5 million people still live in nursing homes, according to the 2010 Census. Of those, more than 1.2 million were 65 and older.

For decades, federal auditors have flagged dangerous and neglectful conditions in U.S. nursing homes and faulted the government’s oversight. As the examples above suggest, the problems haven’t gone away.

Arguing that awareness is an answer, advocates for nursing home residents have long pressed oversight agencies to make inspection reports readily available to the public. But until last month, consumers, researchers and journalists had to file formal Freedom of Information Act requests to view them — or visit in person, because homes are required by law to make them available.

Having the reports searchable online will help identify problematic trends and encourage homes to make needed fixes faster, advocates say.

“It presents a tremendous opportunity to examine the scope of serious nursing home problems such as understaffing and misuse of antipsychotic drugs, and to see what, if anything, is being done about them,” said Michael Connors, an advocate with California Advocates for Nursing Home Reform.

Nursing home industry officials agree that inspection reports are valuable for consumers, but they say the reports leave out important information.

“One of our concerns is that it doesn’t acknowledge the things that the facilities are doing well,” said Lyn Bentley, senior director of regulatory services at the American Health Care Association, the industry trade group.

How Many Elopements?

Nursing homes are inspected on both a regular schedule and when there is a complaint. Inspectors typically work for state agencies paid by Medicare. If they find problems, known as deficiencies, they rank them on a scale of A to L, the most severe. The vast majority are either labeled D or E.

One regularly cited deficiency involves unsafe wandering, a well-known problem that can result from inadequate supervision. A report this year in the journal Annals of Long Term Care, citing earlier research, said up to 31 percent of nursing home residents with dementia wander at least once.

Nursing Home Inspect turned up hundreds of such cases.

A search for elope and variations returned 949 inspection reports that mention the term. Michigan had the most of any state — 84. (Users note: A hit on the word “elope” doesn’t always mean a resident wandered off, only that the word is included in a report. See our tips for interpreting search results.)

Hillcrest Nursing and Rehabilitation Community in North Muskegon, Mich., where the resident wandered away during a blizzard last year, was cited for deficiencies on three other occasions from May to October 2011.

Gary Vandenberg, a spokesman for the home’s parent company, Atrium Centers, said inspectors found no problems at Hillcrest during a follow-up review in November 2011. The chain provides elopement training at all its facilities, he said.

Jon Look, administrator of the Michigan home where the resident with dementia climbed out a window, said alarms have been added to every window and every door. No resident has wandered off since, said Look, who started in his role this June at the Iosco County Medical Care Facility in Tawas City, Mich.

“We’re charged with protecting our residents, and that is something we take very seriously certainly at this nursing facility,” Look said. At the same time, he said Michigan inspectors identify more problems at homes and levy higher fines than in other states — a contention federal statistics support.

Queries for other terms also returned hundreds of results.

A search for injuries produced 7,912 results. MRSA, a drug-resistant staph infection, yielded 514 entries. The word ignore is found 275 times, and entrapment, which can happen if a resident gets stuck in bed rails, brought 194 matches. (Again, not all the search results indicate a problem. See our tip sheet.)

States Aren’t All the Same

Nursing home industry officials caution against drawing conclusions from what’s in inspection reports. Echoing Look, they say that inspectors in different regions of the country have different thresholds for issuing a citation, and that could unfairly make one state’s homes appear worse than another’s.

“If an individual walks out the front door and turns around and walks back in, some states will consider that an elopement,” said Bentley, of the industry group. “In other states, it’s not considered to be elopement unless somebody leaves the building, leaves the grounds and there’s a negative outcome.”

To be sure, audits have found variation in how inspectors handle nursing home complaints. A report last year by the Government Accountability Office found that nationwide, of the nearly 50,000 complaints investigated in 2009, 19 percent were substantiated and resulted in at least one citation.

In 19 states, though, more than 30 percent of complaints resulted in at least one deficiency. And in five states, the proportion was less than 10 percent.

Advocates for residents say nursing homes should focus on fixing their own problems instead of pointing fingers at others. “It’s not a defense for facilities to say that other facilities have not been cited for this,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy in Washington, D.C.

If anything, Edelman said, auditors have found that inspectors cite too few problems and rate their severity too low.

Nursing Home Inspect allows users to more easily compare how one state’s K-rated deficiency, for example, stacks up against another’s.

Worries About Antipsychotics

For years, regulators, consumer advocates and officials in the nursing home industry have tried to keep an eye on problems by analyzing data about the number and types of violations found and their severity.

Federal officials have used such scope and severity data as part of campaigns to reduce the use of physical restraints and to encourage homes to cut back on antipsychotic drugs, said Thomas Hamilton, director of survey and certification at the Centers for Medicare and Medicaid Services (CMS).

Of particular concern is the use of antipsychotics to subdue residents with dementia, because the drugs can increase the risk of death in such patients.

But this data is nowhere near as detailed as the inspection report narratives, which were first released last month by CMS. Until recently, even internally, Medicare officials haven’t been able to search the text of all inspection reports to look for patterns, Hamilton said.

Advocacy groups are eager to dig into the reports.

Inspectors “don’t do a perfect job,” said Richard Mollot, executive director of the Long Term Care Community Coalition in New York. “They don’t do a consistent job. [But] they’re the only independent authority coming into nursing homes looking at this.”

Despite the value of these reports, CMS has not posted narratives from historical inspections. Only the most recent periodic survey report is online, along with complaint investigations from the past 12 months. As time goes on, CMS plans to have three years’ worth of reports for every home.

For privacy reasons, the reports released by Medicare do not include residents’ names and have been redacted to hide medications, diagnoses, room numbers and certain dates.

In many cases, CMS has also obscured residents’ gender, referring to everyone as female — even in cases in which gender may make a difference, such as sexual assault. Officials said they intend to change this in the near future and list the correct gender in the reports.

Advocates are pushing the government to redact less information from the reports so they can look at problems with specific medications.

“It’s really crucial for the public, and it’s really crucial for us, the people who do policy work,” Mollot said. “How are you going to know anything if the name of the drug is redacted?”

CMS’ Hamilton defended the current approach but said the agency will continue to review the information and work with advocates.

“As we make more information publicly available in searchable databases,” he said in a statement, “we must be careful to prevent various pieces of information from being combined in a way that would violate the privacy or confidentiality of those residents.”

Very nice.  It’s not really my field at all, but while data is great, accessible data is what people need.

This also shows why I’m not so worried about the FCC TV advertising database being hard to read.  We’ll deal with it…

(Also note that, when it comes to government spending, no matter how bad it gets, our government continues to mostly get one thing right:  As long as the project doesn’t get classified, the material is published and is part of the public domain.  In other countries, you need permission to work with government data, due to copyrights.)

Charles…I live in a for-profit California Residential Care Facility for the Elderly.  Although there are regulations that protect the residents in these facilities, there is a serious lack of oversight.  These facilities charge outragious prices for what is termed “optional items and services.” In addition to basic room and board, these facilities can and do charge up to $1000.00 per month for medication management, continence management can cost up to $500.00 per month, bathing and dressing assistance 2 X per week can cost up to $1000.00 per month.  The monthly basic rate for room and board range from about $3000.00 per month for a single occupant that requires no optional services to $8000.00 per month for double occupancy with no optional services.  The paying resident or family member has no control over what the facility charges.  There is no standardized pricing structure in the regulations and the residents and their family members are unaware of the regulations that protect them.
Although many more of these facilities will be needed in the future some method of establishing basic and optioanl pricing for services and items needs to be develop by the regulatory agencies.

I would like to see an investigation into the pricing structure of these facilites at least in California. 

Thank you for your dedication in to revealing the problems associated with health care.  I have always respected your integrity and your sincere interpretation of the hazards associated with the U.S health care system.


Aug. 14, 2012, 1:47 p.m.

Excellent work. Such ongoing investigations which seek to expose wrongdoing and protect the rights of those who have no public voice sets an important example for aspiring journalists.

Great work.  My friend’s elderly parents were robbed by a home healthcare company. It turns out the alleged “CEO” only owned a website, and never registered the company with his secretary of state. Therefore he could not legally sell franchises, hire employees or bill Medicaid. This fraud is popular in Florida, and can be prosecuted by the U.S. attorney and the IRS.  This crime is ranked as one of the IRS’s dirty dozen scams.

I am an underwriter who has worked at insuring nursing homes for 12 years.  What I always find so disturbing is that people love to tell the stories of gloom and doom in any industry but they don’t seem to want to talk about the good things.  As the article state 1.5 million in nursing homes and they show 2 Michigan elopements and we are all supposed to be upset.  I am not saying that “bad things” don’t occurr in Nursing Homes, but in 2012 look around you in your community, “bad things” happen everywhere.  I am happy to be assisting our elderly community in whatever way I can.  Maybe the best solution would be for more people to spend more time with our elderly instead of looking for the “gotcha caughtchas”.  Just one persons thoughts!

Nina, are you honestly suggesting that the real problem in the industry is the customers expecting adequate treatment?  Or maybe it’s that we should sweep the “bad things” under the carpet?  As an underwriter, the latter philosophy can’t possibly be good for business, since you pay against those very bad things.

Keep in mind, I write software for a living.  I never hear from anybody, unless it’s an angry, frustrated complaint.  So I understand the emotion behind what you’re saying, but by the same token, if I don’t fail spectacularly at my job, one day (for example, it’s rare that I fail to notice whether my computer is on my desk…), that’s hardly cause for celebration or even interest.

Yes, people should spend time with their families.  But when you’re paid to do it for me and you screw it up, do not tell me it’s my fault for trusting you and pointing to all the other people who didn’t go missing for hours.

Oh John you have no idea.  Attorneys love the applications you are creating that is who will use this.  They will use it to make it look larger than it is.  Your example of the elopements.  No facility wants an elopement, they do there best to prevent them, when they occur they will find out what happened, and change their processess to make their best efforts to insure that it does not happen again.  You see there are “crazy nursing homes” out there, but unfortunately with all of the different methods for data collection most good and very good and sometimes even the “excellent” nursing homes can be made to look like poor operators.  We must remember people are not in a nursing home to receive 1 to 1 care.  They live there.  The state mandates the staffing and medicare mandates how much they receive.  Assisted Living is different, in a nursing home the buget tight. MOST facilities are doing the best they can with the staff available and the tools they have to work with.  So John, I understand your job and what you are hoping to do is help the public find good nursing homes, but really at the end of the day you will help attorneys build better cases when in many of those events the statistical data is flawed.  Then the defense attorney will need to prove to the jury that the information is flawed…... I can go on all day on that train but will stop here.  So John what I am not just suggesting but am saying out right, is the industry as a whole is providing more than adequate treatment that a nursing home is not the “Holiday Inn”.  I read surveys for a living .............. trust me the bad things are never swept under the carpet, but I know what I am reading and the general public does not without training understand the data the severity or lack there of and so applications such as yours can serve actually in a negative manner.  I am not trying to have a debate here I just wanted readers to see both sides.

The app is a very good idea while the article about a couple of AWOLs in MI is pointless. There’s plenty of liability (costs) to keep these guys competent, but there’s always going to be some who either think they can sneak by or get in and out quickly with a profit - hence the need for some type of vigilance.

With the stressful interactions dealing as they do with the severely ill this industry (which I’m not in) probably has the highest concentration of living saints.

Nina, I have no connection to the tool or ProPublica, other than a reader.  I just want to clarify that.  This was done by journalists (good ones, in my opinion) who were researching the data involved.

Now, I sympathize with budgets, but you know what competent people do when they don’t have the resources to do a job?  They don’t sign a contract promising to do the job.  If “the best they can do” is lose a patient in their care, they should get out of the business.  I don’t mean that in some vindictive way, I mean that as a simple benchmark:  No matter what the field, if you can’t do the job with the resources at hand, don’t.

And if the data is as flawed as you say (without giving a single example, I note—just, this is a terrible idea for some reason), an attorney should be able to find someone as smart as you (or even you) to pick it apart.

You also assume that the ProPublica app somehow makes this data substantially more accessible to someone looking to win a court case.  Considering that it’s public data on the Medicare website, I find that very hard to believe.  I also hate to break it to you that the reports are pretty darn easy to read, with little interpretation required.  Perhaps you’re looking at the wrong data?

Overall, this reminds me of the FCC rules for the TV stations to post their advertising information.  We were told that it shouldn’t happen, because the data was inconsequential and some ignorant layperson (as opposed to the master race of elites who can read a spreadsheet) would be confused by it and destroy humanity or something.  They didn’t have any interest in debate, either.  People like that never do, because they know they sound less reasonable the longer they talk.

John I am not going to debate the subject with you further.  It appears that you are in attack mode and I if I did not make clear earlier was in an industry defense mode.  I not only work in insurance in the industry but a large number of my friends work in the industry, including my own RN daughter who is an ADON at a facility.  I know from which I speak and apologize to any reader following this post that I do not unfortunately have the time to discuss the industry at length and all the hard working people who serve our elderly every day.  Hope you all have a most wonderful day!

John I am not going to debate the subject with you further.  It appears that you are in attack mode and I if I did not make clear earlier I apologize I was in an industry defense mode.  I not only work in insurance in the industry but a large number of my friends work in the industry, including my own RN daughter who is an ADON at a facility.  I know from which I speak and apologize to any reader following this post that I do not unfortunately have the time to discuss the nursing home industry at length including all the hard working people who serve our elderly every day.  Hope you all have a most wonderful day!

Randall L. Scheel

Aug. 15, 2012, 3:56 p.m.

The public need only to access and then go to “Nursing Home Compare” to get totally transparent information/data based on rigorous government quality inspections.  ProPublica is merely being redundant and inflaming the consumer.

Nina, you’re the one attacking, claiming doomsday for the ability to (more easily) search for problems, dismissing them because they’re in the minority.  You even blamed me, personally, for some sort of vague destruction, after deciding that I was either Charles or Lena.

I’m trying to be clear, and I apologize if I come off as aggressive for it.  The fact of the matter is that apologists for various industries often drop into comments (here and elsewhere) to loudly decry an article with some handwaving about how shining a light on abuses and errors will cause the collapse of civilization.

They don’t want to engage in debate, just “balance” facts with what amount to scare tactics, never contradicting facts.  I know there are a lot of good people in every industry, which is why it’s all the more important to direct focus on the bad apples, to make them better or drive them away.

Id love to talk about the good… Ive just seen alot more bad. I believe most of michigan homes are bad….the good one seem to “cherry pick” and my fiance has seen most the bad.  hw is a complicated case… they have nearly killed him literally more than once. I and he would love to help fix us were to sign up to help….he has been in many over time. for physical rehab. they are Bad.

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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