Utah's Nursing Homes: Compromised Care
Editor's note: This story originally ran in June.
Alvin Brewster has a hard time taking care of himself. He can't walk very well. His memory slips. But despite his health problems, he could still recognize the conditions he was living in.
"It was a dump," says Alvin, 66.
He's talking about Pine Ridge Care Center, a Salt Lake City nursing home that racked up the worst inspection record in Utah since 2000. Inspectors say the staff ignored bedsores and failed to investigate abuse complaints, including a 2005 case where a resident was forcibly dragged down the hall.
Chyreisse Bullock, Alvin's daughter, says the nurses and their aides rarely bathed her father and would leave him in soiled diapers.
"The staff really didn't care," she said.
Then two years ago, Walter Matjesich bought the place. Pine Ridge became Majestic Care. The staff was fired, the furniture replaced and Alvin is clean and much happier. Inspectors haven't found any major violations since the switch.
"It came down to ownership," Bullock said. "When this guy took over, I started to see dramatic changes."
A Salt Lake Tribune investigation of Utah's 91 nursing homes shows that ownership is probably the best predictor of quality care. But the public has no easy way to identify who owns the homes, particularly when names are changed to hide a troubled past.
Two groups - Quality Health Care and Infinia - operate five of the worst-performing facilities in the state, according to an analysis of inspection records from 2000 to 2007. Quality Health Care recently renamed two poor-performing homes, and Infinia's owners are working on a name change for all three of their Utah locations.
Such name changes are nearly impossible to track since the Utah Department of Health keeps incomplete ownership data, none of which is publicly accessible. That is not the only information that's hard to get. Only those who visit a nursing home can review its most recent inspection report.
The Tribune spent hundreds of hours mining data obtained through open records requests to compile an eight-year history of compliance for every nursing home in the state, focusing on cases where inspectors found a person was harmed.
These detailed reports document violations ranging from the mundane - missing caulk around a tub - to the severe - neglect resulting in death. And they show that for the most part, Utah's nursing homes are taking good care of the elderly and disabled.
In the last eight years, one-fourth of the homes were never cited for harming a resident and three-fourths had five or fewer "actual harm deficiencies." But a subset of homes had dismal track records loaded with medical errors, neglect and mismanagement.
Blame the patient: Pat and Craig Johnson stepped back from their four nursing homes in 2000, handing over the operations to a management company. They regret it.
"Everything went to hell. Our reputation went to hell. Care went to hell," Pat Johnson said. "We ended up coming back."
The couple, who own Quality Health Care, returned in late 2004 and voluntarily closed Oakview, a Provo nursing home that was in serious trouble with state inspectors. One resident was hospitalized for dehydration and another was repeatedly beaten by her roommate. Johnson said she closed Oakview because of financial difficulties, not the violations.
She now focuses on the three remaining homes - Castle Country in Price, Rock Canyon in Provo and Legacy in West Jordan.
Castle Country has by far the best track record of the three remaining facilities, but in 2006 the home was cited for a medical error resulting in a death.
In that case, a woman who had been fighting infections complained that mucus was making it hard to breathe. The nurse left to get some medication and when she returned, she found the woman unresponsive. Instead of trying to save the woman's life, the nurse called the family to ask what they would like her to do. The woman died.
More consistent problems have emerged at Rock Canyon. which is tied for the second most actual harm deficiencies since 2000, and Legacy, also in the top five.
The Johnsons renamed both homes this year. Rock Canyon used to be called East Lake and Legacy was South Valley. Pat Johnson said she changed the names at the request of her employees who wanted a fresh start. It was also part of a new business strategy that aims to reduce the deficiencies in state surveys.
"I can't take getting beat up by the state anymore," Johnson said.
She blames some of the problems on paperwork errors saying "we took care of the patient, but our documentation was crappy."
But she lays most of the blame on the mental health patients in her facilities.
"You can't chemically restrain them. They don't comply with their regimens of care. They can leave at any time. They are really hard patients to manage," she said.
Her new approach is to weed out tough patients before they ever enter her nursing home. Johnson said she is now interviewing families as much as they are interviewing her, hoping to avoid people with behavior problems.
"It was a bad business decision to take those kind of patients," she said.
The staff members at the nonprofit Disability Law Center in Salt Lake City are charged by the federal government to keep an eye on nursing homes. They bristle at Johnson's comments.
"Choosing patients to get a better survey is about as backwards an approach as you can take to providing these incredibly important services to this vulnerable population," said Eric Mitchell, community relations director for the center.
The Disability Law Center focuses its attention on troubled homes, conducting unannounced visits and sending tips to state inspectors.
Mitchell said owners, like Johnson, have tremendous influence on their homes, setting a tone that employees follow.
"When we work with the chronic violators, it is so obvious that they don't even like the people they are working with," he said.
Not out of the cellar: No Utah nursing home had more overall violations than Infinia at Granite Hills. The home, which specializes in mental health cases, also had the second-worst record of deficiences where a resident was harmed.
And like Johnson, Infinia owner Scott Robertson lays much of the blame on the residents.
"We take the kind of patients that won't go anywhere else - the complainers," he said.
The Disability Law Center agrees that Granite Hills "tends to be the dumping ground." But Eileen Maloney, an advocate for the center, said if Infinia markets itself as a company that can take care of those tough patients, then it should be able to follow the regulations.
Infinia's problems, though, stretch far beyond Granite Hills.
Its sister facilities - Infinia at Ogden and Infinia at Alta - also ranked in the 10 worst performing homes in Utah. The company owns two of the worst homes in Arizona and a failing home in Minnesota, according to health departments in those states.
The Alta facility received the most severe deficiency given in the last two years for forcing a woman to take a shower against her will. Robertson replaced the administrator and the director of nursing.
Since then, the new staff has worked to fill in gaps in the medical records of patients and correct accounting errors, Maloney said.
All of the violations have cost Infinia customers and cash.
The Infinia homes have been fined more than $200,000 since 2000. That equals about $4,000 per actual harm deficiency, though the nursing home chain was not fined in every case. Infinia at Granite Hills was fined more than any other home, racking up nearly $139,000 in penalties.
The government set the fine amounts 20 years ago, capping the worst offense at $6,500 if a home doesn't appeal, though some fines are assessed on a daily basis, adding up until the home fixes the problem.
That's an inadequate enforcement tool, said Janet Wells, public policy director for the National Citizens' Coalition for Nursing Home Reform.
"Often it is just the cost of doing business," she said.
Wells supports a move in Congress that would raise fines as high as $100,000 in the most severe cases.
Infinia's Robertson says that is ill advised. He thinks the fines as they are now only hurt residents.
"Who suffers because of fines and penalties? It comes out of the money that is supposed to go to patient care," he said. The state association that represents nursing homes complains that increased fines make it harder for facilities to improve, especially when they are underfunded by Medicaid and Medicare. The association agrees, though, that bad actors should be punished.
Robertson recognizes that his homes have had problems and said his company turned a corner a year and a half ago when a messy business relationship between Scott Robertson and his brother Jon ended.
Jon took control of five Kansas homes, all of which have been labeled low-performers, and Scott Robertson took the 14 other facilities.
Their split followed a bankruptcy, numerous bad inspection reports and a federal audit that determined the brothers failed to adequately staff Infinia at Granite Hills.
Infinia's problems in many ways were "a central leadership issue," Scott Robertson said, that started at the top and trickled down to lax administrators and nursing directors.
The problems compounded as a bad reputation drew more scrutiny from the state and the Disability Law Center.
"We have had historical issues with our three Utah facilities, without question," Robertson said. "But I think we are taking steps to improve the quality of the homes."
He said he has replaced top people and hired a company to conduct private inspections to root out problems. He has increased staff. And he is planning to remodel the buildings, which he leases.
He also has much larger changes planned for the future, including selling some of the homes outside of Utah, reducing the number of mental health patients and coming up with a new company name.
Disability Law Center staff may not like every change Infinia has planned, but they say the company has taken their concerns seriously and made improvements.
"There are some positive changes," said advocate John Inglish. "But by no means would I say they are out of the cellar."