Abuse, neglect, filth, death: 11 Tennessee nursing homes on federal list for persistently poor care
Unreported falls. Unexplained bruises. Untreated bedsores. An overdose of insulin — 25 times the prescribed amount. A resident discharged to a hotel without meds, money, food, a phone — or a long-term care plan.
These were violations at some of Tennessee’s 11 most poorly performing nursing homes.
400 ‘underperforming’ facilities
Last month, after U.S. Sens. Bob Casey, D-Pennsylvania, and Pat Toomey, R-Pennsylvania, of the Senate Special Committee on Aging released a report on the nation’s underperforming nursing homes, the federal Centers for Medicare and Medicaid Services agreed to release a public list of nursing homes that are candidates for its Special Focus Facility program, which get extra attention and inspections.
The names of facilities in the national program, for nursing homes with a documented pattern of poor care, have always been public, but resources for the program are limited. While nearly 400 nursing homes are candidates, a maximum of 88 are picked for the program — and the names of the facilities not in the program haven’t been public.
These nursing homes, which have a “persistent record of poor care” and make up about 2.5% of the 15,700 nursing homes in the United States, aren’t subject to extra inspections, and there’s no way to add them to the Special Focus Facility program without rolling another facility off — even if there’s an especially egregious incident or a law enforcement issue at the nursing home.
And CMS’ own “Nursing Home Compare” site for consumers doesn’t explain that they are Special Focus Facilities, instead using a yellow triangle symbol in place of the “stars” used to rate nursing home care.
Nursing homes that roll out of the SFF program — even if they’ve repeatedly been in it — aren’t specifically identified as such, although consumers can read through hundreds of pages of linked inspection reports to find that information. In addition, the study said, star ratings aren’t always updated to reflect the most recent inspections.
Tennessee nursing homes on list
The study cited examples of nursing home deficiencies in several states and listed every current SFF candidate in the country, including 11 nursing homes in Tennessee:
- Asbury Place, Maryville
- Bailey Park Community Living Center, Humboldt
- Brookhaven Manor, Kingsport
- Cornerstone Village, Johnson City
- Creekside Center for Rehabilitation and Health, Madison
- Dyersburg Nursing and Rehabilitation Center
- Greenhills Health and Rehabilitation Center, Nashville
- Life Care Center of Columbia
- Lauderdale Community Living Center, Ripley
- Rainbow Rehab and Health, Bartlett
- Westmoreland Health and Rehabilitation Center, Knoxville
Two — the former Brookhaven Manor and Lauderdale Community Living Center — are currently in the Special Focus Facility program.
Taken to hotel without money, meds
Brookhaven Manor entered the program in 2016. Additionally, it was investigated after it discharged a resident for openly breaking smoking rules, even though there wasn’t any documentation he had a clear understanding of those rules.
A state survey found Brookhaven discharged the resident, who had been admitted because of a traumatic head injury, without notifying either the state Long-Term Care Ombudsman or the TennCare CHOICES program, which was paying for his care. The survey said staff drove the resident to a hotel and paid for a three-day stay without ensuring he had money, food, his numerous medications or a phone. While staff later delivered medication — which the resident’s care plan indicated he wasn’t capable of managing on his own — the resident reported having only peanut butter crackers, candy and the hotel’s continental breakfast, no money for other food, and no phone to call out.
Brookhaven is now under criminal investigation by the Tennessee Board of Investigation for the incident.
At various times, Brookhaven also was cited by the state for failure to take steps to make sure a highly contagious bacterial infection didn’t spread from a patient in isolation; failure to prevent a bedsore in another resident; low staffing, bad oversight and too-slow response to help incontinent patients; and failure to make a urology appointment for a resident who needed one.
Now renamed Orchard View, the facility is under new management and ownership by New York-based Plainview Healthcare Partners, which specializes in turning around “troubled nursing homes,” administrator Norman Haley said. “The previous ownership sold the facility to Plainview Healthcare after its failure to maintain quality care and services to the residents that subsequently resulted in the facility having poor surveys and then becoming a Special Focus Facility.”
Since then, Haley said, the facility has had two surveys, both substantially better. Plainview put in place a “strategic plan to change the deficient care and services,” he said, and expects Orchard View to come off the SFF list with the next survey.
“We have made many changes and have yet some others to be made, but with these changes we can and will continue to provide what we believe is ‘not just one of the choices to receive great care, great services, and among great people — but the choice,’ ” Haley said.
Insulin overdose 25 times Rx
Several of the facilities on the list had been in the SFF program at least once. Many had incidents that were serious enough to cause the state to label them “substandard quality of care.”
Among the most egregious was Bailey Park in Humboldt, where an agency nurse “read the dosage wrong” and gave a diabetic resident 100 units of insulin instead of four — putting the resident in a coma.
In 2017, Bailey Park suspended a certified nursing assistant for “rough handling,” slapping and kicking a resident, a survey report said, but did not report the suspension to the state in a timely manner. In addition, the facility didn’t isolate several residents who had urinary tract infections caused by bacteria that produce enzymes that make it contagious and antibiotic-resistant, a survey noted. Four complaints in three years at Knoxville’s Westmoreland Health and Rehabilitation Center resulted in citations, the state said.
A new study finds that nursing home workers often do not change their gloves when they should. Wochit
‘Extremely painful’ fractures
In one instance, a resident at Westmoreland, the former Brakebill Nursing Home, slid out of bed while a CNA was changing her sheets, but the CNA didn’t report it, a state survey said. Only when the resident — who one nurse described as “not a complainer” — screamed in pain over her swollen, bruised knees was she taken to the hospital. X-rays showed fractures in both knees, the survey said.
“She was in extreme pain at the time of admission,” it noted. “The fractures were extremely painful, and they were repaired for palliative reasons.” The resident, who had other health issues, has since died.
Asbury Place, in Maryville, had seven residents with multiple falls — one with nine falls in a year, including a fracture; another with nine falls in four months; another with four falls in two months. After each fall, a state survey report said, staff failed to put in place interventions to prevent more falls — putting residents in immediate jeopardy and labeling the facility “substandard quality of care.”
Medication error rate 65%
Creekside Center for Rehabilitation and Health in Madison had a medication error rate of 65%, including failing to complete blood glucose testing for nine residents; failing to give seven residents insulin as directed; failing to give three residents cardiac and blood pressure medication correctly; failing to give three residents antidepressant and anti-anxiety medication as directed; and failing to follow guidelines for one resident’s wound vac.
The federal threshold for medication errors in nursing homes is 5%.
Lauderdale Community Living Center was cited for a medication error of 7% or greater, stemming from staff giving insulin incorrectly in conjunction with meals. It was cited for poor hand hygiene and poor infection control also — specifically, failure to rinse syringes and properly clean glucometers, putting diabetic residents in immediate jeopardy.
Greenhills Health and Rehabilitation Center in Nashville, in addition to leaving dried food on the tables and routinely running out of clean towels and washcloths for residents, failed to protect residents from being hurt by two residents with violent tendencies, surveys said. The state cited it for being dirty, failing to prevent resident falls, and admitting a resident without assessing mental status because the facility didn’t get an interpreter, among other issues, and labeled it “substandard quality of care.”
Wheelchair flipped off van gate
At Dyersburg Nursing and Rehabilitation Center in 2017, according to a state survey, a resident who was blind and had both legs amputated at the knee had his wheelchair flip backward off the gate of a transportation van he was getting in to be taken to a medical appointment. He landed on the concrete on his head, suffered a hemorrhage, went into a coma and died in the hospital. The nursing home defended sending him to the appointment without an escort by noting they’d done it 59 times before without an issue, the survey said.
Cornerstone Village in Johnson City put residents in immediate jeopardy by unnecessarily or unsafely using restraints, including on some residents who then were at risk for injury as they tried to free themselves, a survey said. In addition, incontinent patients had to wait an hour for call lights to be answered, so that soiling themselves was unavoidable, a survey said.
Staffing issues, bedsores common
Nursing homes with serious deficiencies often had trouble staffing, one using as many as six agencies. Medication errors were common, as were bedsores — lack of preventing them and inadequate care for them. Several had residents with excessive weight loss, but it’s a different matter that half of them were on their personalized medical weight loss program.
When asked for comment on this story, only Orchard View and Life Care Centers of America responded.
Consumers can view these reports, which are public record. But they may not have the choice to avoid poorly performing facilities, especially in rural parts of the state, wrote Trudy Lieberman for the Rural Health News Service.
“Oversight of America’s poorest quality nursing homes falls short of what taxpayers should expect,” wrote the senators, who pledged to advocate for “increased transparency into consistently under-performing facilities and a robust Special Focus Facility program that has the tools it needs to oversee these nursing homes.”
But Life Care Centers of America President Beecher Hunter said the list is not new and doesn’t change his company’s commitment to safety. Life Care operates or manages more than 200 facilities in 28 states; five, including the one in Columbia, Tennessee, are SFF candidates.
“The public always has access to information such as this to help them select care facilities,” Beecher said. “We support making relevant, transparent information available, so they can make informed care decisions for their loved ones. Survey data is always available for review in all of our facilities as well.
“While there are challenges in any profession, including health care, we love serving our residents and patients across the country.”
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Filed under: General Problems
The same thing in New Mexico. The nursing home company hired family members at the agency that was supposed to provide oversight. The local newspaper covered for the horrific behavior, and got our AG to ignore the situation for years. These companies just pay off the right local officials. A local hospital dumped near death patients there in order to get a 4 star rating from CMS. The nursing home would then ignore them for 24 hours, or more until they died in shock.
The same local hospital silenced their physicians, to ensure the profits. The nursing home, put all of the patient in diapers. They forced patients to sit in their own filth for days, so they could profit from the UTI’s and infections. Medicare will pay a lot of money for the treatment of infections. The AG refused to investigate and claimed it was a staffing issue.
I have seen “assisted living” personally. I watched my aunt DIE in a”assisted living”. facility. WE, my wife and I chose to take time to move in with my Mother to take care of her the best we could and to help ease her demise the best we could in February, 2019. Not easy! What do you do?