N.Y. Severely Undercounted Virus Deaths in Nursing Homes, Report Says

The state attorney general, Letitia James, said it’s likely that the Cuomo administration failed to report thousands of Covid-19 deaths of nursing home residents.

 

After the attorney general’s report was released, state health officials raised the number of Covid-19-related deaths connected to nursing homes by more than 3,800.Credit...Dave Sanders for The New York Times

By Jesse McKinley and Luis Ferré-Sadurní

ALBANY, N.Y. — For most of the past year, Gov. Andrew M. Cuomo has tried to brush away a persistent criticism that undermined his national image as the man who led New York through the pandemic: that his policies had allowed thousands of nursing home residents to die of the virus.

But Mr. Cuomo was dealt a blow when the New York State attorney general, Letitia James, reported on Thursday morning that Mr. Cuomo’s administration had undercounted coronavirus-related deaths of state nursing home residents by the thousands.

Just hours later, Ms. James was proved correct, as Health Department officials made public new data that added more than 3,800 deaths to their tally, representing nursing home residents who had died in hospitals and had not previously been counted by the state as nursing home deaths.

The state’s acknowledgment increased the overall death toll related to those facilities by more than 40 percent. Ms. James’s report had suggested that the state’s previous tally could be off by as much as 50 percent.

The findings do not change the overall number of Covid-19 deaths in New York — more than 42,000, the most of any state — but the recalculation in the number of nursing home deaths illustrates how unprepared the nursing home industry was in the first and deadliest weeks of the pandemic.

Mr. Cuomo, a third-term Democrat, had long dismissed the critiques of his policies governing those facilities as partisan attacks from the Trump administration and other Republican adversaries.

But the report by Ms. James, a fellow Democrat, casts a renewed light on the state’s decision to send nursing home residents who had been hospitalized with the coronavirus back to the nursing homes, a policy that Mr. Cuomo has defended as following federal guidelines.

At the same time, Ms. James’s assertion of an undercount of deaths gave credence to theories that the state may have intentionally played down the number of those deaths to avoid blame.

“This is shocking and unconscionable,” said Assemblyman Richard N. Gottfried, the Democratic chairman of the Assembly Health Committee. “But not surprising.”

The 76-page report, which included critiques of other policies promulgated by the Department of Health and of the behavior of nursing home operators, led to a scramble by Mr. Cuomo’s administration to rebut its assertions, including a lengthy response late Thursday afternoon from the health commissioner, Dr. Howard Zucker.

Dr. Zucker said that the state website had always been clear that deaths it listed did “not include deaths outside of a facility.”

“The word ‘undercount’ implies there are more total fatalities than have been reported,” he said. “This is factually wrong.”

He also asserted that the lack of data on hospital deaths of nursing home residents was due to concern and caution about the accuracy of data that nursing homes supplied — an issue also raised by the attorney general. “D.O.H. does not disagree that the number of people transferred from a nursing home to a hospital is an important data point,” he said.

The new data released by Dr. Zucker puts the total number of deaths connected to nursing homes at 12,743.

Ms. James’s findings would seem to put her in rare conflict with Mr. Cuomo; she was the governor’s preferred candidate after Eric T. Schneiderman suddenly resigned as attorney general in 2018, and she readily embraced Mr. Cuomo’s political backing.

Her report seemed certain to inspire more questions about the handling, oversight and performance of the state’s nursing homes in the early stages of the pandemic. Indeed, on Thursday, Mr. Cuomo’s critics in Washington and Albany had already seized on the attorney general’s report as evidence of his dishonesty, amid calls for Dr. Zucker to resign.

“This is now more than a nursing home scandal,” said Representative Elise Stefanik, a conservative Republican from upstate New York. “This is a massive corruption and cover-up scandal.”

Deaths in nursing homes and other long-term care facilities have accounted for about a third of the nation’s some 430,000 Covid-19 deaths. Federal and state authorities have made vaccinating staff and residents at such facilities a top priority, though that effort has been slower than hoped.

But even as state officials in New York tackle vaccine shortages, the count of deaths in the state’s nursing homes remained a source of controversy. Mr. Cuomo had been accused of obscuring a more accurate estimate of nursing home deaths, because the state’s count only included the number of deaths at the facilities, rather than accounting for the residents who died at a hospital after being transferred there.

For its report, Ms. James’s office surveyed dozens of homes and found consistent discrepancies between deaths reported to the attorney general’s investigators and those reported to and officially released by the Health Department.

In one instance, an unnamed facility reported to the Health Department that it had 11 confirmed and presumed deaths on site through early August. The attorney general’s survey of that same facility, however, found 40 deaths, including 27 at the home and 13 in hospitals.

Another facility reported one confirmed and six presumed Covid-19 deaths to the Health Department, according to the report. The attorney general’s office, however, said the facility reported to its investigators that there were more than four times that number — 31 dead — by mid-April.

The attorney general’s report also scrutinized immunity provisions granted to health care providers codified by Mr. Cuomo in the state budget. The report said the protection of immunity may have prompted some nursing homes to make financially motivated decisions at the height of the pandemic, like admitting patients even when the facilities were facing staff shortages or were unequipped to care for them.

Indeed, Ms. James’s office is still investigating and weighing legal action stemming from complaints made to her office about shortcomings and neglect that may have placed residents at risk. Those include allegations of nursing homes that failed to isolate Covid-19 patients, maintain stockpiles of personal protective equipment, properly screen employees for the virus or ensure adequate staffing levels even before the pandemic.

The report also cast a critical eye on perhaps the governor’s most criticized decision since the beginning of the pandemic last year: a March 25 directive from the Health Department that ordered nursing homes to accept and readmit patients who had tested positive.

The Health Department responded in July with a report that sought to absolve the state from any blame resulting from the March directive. The report concluded that most of the patients sent back to nursing homes “were no longer contagious when admitted and therefore were not a source of infection.” The Health Department concluded that the virus was instead spread by employees who did not know they were contagious.

While acknowledging that Mr. Cuomo’s memo to nursing homes was consistent with federal guidance, the attorney general’s report said the governor’s policy “may have put residents at increased risk of harm in some facilities.” Under the policy, some nursing homes stopped testing residents for the coronavirus, a factor that might have obscured data reported by the facilities, the report found.

For its part, the Health Department also cited Ms. James’s findings on the March 25 memo, saying the report had found no evidence that the policy outlined in the directive “resulted in additional fatalities in nursing homes.”

Ms. James’s report also found a number of homes that “failed to comply with critical infection-control policies,” including failing to isolate residents who had tested positive for the virus or screen employees for it.

The state’s reporting of nursing homes deaths has been the focus of a lawsuit by a conservative economic think tank, the Empire Center for Public Policy, which has sued, seeking to force the Health Department to release more complete data. 

Last year, the Democratic-controlled Legislature held hearings partly in an attempt to pry the data from the administration, to no avail.

Dr. Zucker was supposed to testify next week during a state budget hearing, where lawmakers were expected to press him on nursing home deaths, but his appearance was recently pushed back to late February.

The Democratic chairman of the investigations and government operations committee in the State Senate, James Skoufis, who has accused the Health Department of stonewalling investigators, suggested on Thursday that he would use a subpoena to compel the release of data from Dr. Zucker’s office.

“The D.O.H. commissioner’s unresponsiveness to the Legislature’s many questions and concerns is insulting and unacceptable,” the senator said in a statement.

The attorney general asked 62 nursing homes — about a tenth of the state’s total — for information about on-site and in-hospital deaths related to the virus; investigators then cross-referenced that information with public reports of deaths issued by the Health Department. The deaths reported to the attorney general’s office at most of those facilities totaled 1,914, compared to the state’s much lower count of 1,229.

Ms. James said that her office was investigating those circumstances “where the discrepancies cannot reasonably be accounted for by error or the difference in the question posed.”

The attorney general said she was continuing to conduct investigations of more than 20 nursing homes across the state that “presented particular concern,” noting that “other law enforcement agencies also have ongoing investigations relating to nursing homes.”

Under normal circumstances, the attorney general’s office “would issue a report with findings and recommendations after its investigations and enforcement activities are completed,” Ms. James said in her report. “However, circumstances are far from normal.”

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N.Y. Severely Undercounted Virus Deaths in Nursing Homes, Report Says

NY data show nursing home deaths undercounted by thousands

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by MARINA VILLENEUVE, BERNARD CONDON and MATT SEDENSKY

ALBANY, N.Y. (AP) — New York Gov. Andrew Cuomo's administration confirmed Thursday that thousands more nursing home residents died of COVID-19 than the state's official tallies had previously acknowledged, dealing a potential blow to his image as a pandemic hero.

The surprise development, after months of the state refusing to divulge its true numbers, showed that at least 12,743 long-term care residents died of the virus as of Jan. 19, far greater than the official tally of 8,505 on that day, cementing New York's toll as one of the highest in the nation.

Those numbers are consistent with a report released just hours earlier by Attorney General Letitia James charging that the nursing home death count could be off by about 50%, largely because New York is one of the only states to count just those who died on facility grounds, not those who later died in the hospital.

“While we cannot bring back the individuals we lost to this crisis, this report seeks to offer transparency that the public deserves,” James said in a statement.

The 76-page report from a fellow Democratic official undercut Cuomo's frequent argument that the criticism of his handling of the virus in nursing homes was part of a political “blame game," and it was a vindication for thousands of families who believed their loved ones were being omitted from counts to advance the governor's image as a pandemic hero.

“It’s important to me that my mom was counted,” said Vivian Zayas, whose 78-year-old mother died in April after contracting COVID-19 at a nursing home in West Islip, New York. “Families like mine knew these numbers were not correct.”

Cuomo’s office referred all questions to the state health department. Several hours after the report, State Department of Health Commissioner Howard Zucker released a lengthy statement attempting to refute James' report but which essentially confirmed its central finding.

Zucker's figure of 12,743 nursing home resident deaths included for the first time 3,829 confirmed COVID-19 fatalities of those residents who had been transported to hospitals.

Those figures could be even higher, but the health department said its audit was ongoing, didn't break out deaths presumed but not confirmed to be caused by the virus, and omitted those in assisted living or other types of long-term care facilities.

Zucker, however, still took issue with James' characterization of his department's official tally as an “undercount.” He said “DOH was always clear that the data on its website pertains to in-facility fatalities."

James has for months been examining discrepancies between the number of deaths being reported by the state's Department of Health, and the number of deaths reported by the homes themselves.

Her investigators looked at a sample of 62 of the state’s roughly 600 nursing homes. They reported 1,914 deaths of residents from COVID-19, while the state Department of Health logged only 1,229 deaths at those same facilities.

Thursday's release backed up the findings of an Associated Press investigation last year that concluded that the state could be understating deaths by as much as 65%.

State Sen. Gustavo Rivera, a Democrat who has blasted the Cuomo administration for its incomplete death count, said he was “sadly unsurprised” by the report.

“Families who lost loved ones deserve honest answers,” Rivera said. “For their sake, I hope that this report will help us unveil the truth and put policies in place to prevent such tragedies in the future.”

Cuomo, who last fall released a book touting his leadership in dealing with the virus, has not been shy about using New York's lower nursing home death count to make the argument that his state is doing better than others in caring for those in such facilities.

“There's also no doubt that we’re in this hyper-political environment so everybody wants to point fingers,” Cuomo told CBS “This Morning” in October. “New York, actually, we’re number 46 out of 50 in terms of percentage of deaths in nursing homes ... it’s not a predominantly New York problem.”

The attorney general’s report also took aim at New York's controversial March 25 policy that sought to create more space in hospitals by releasing recovering COVID-19 patients into nursing homes, which critics contended was a driving factor in causing nursing home outbreaks.

James’ report said those admissions “may have contributed to increased risk of nursing home resident infection and subsequent fatalities,” noting that at least 4,000 nursing home residents with COVID-19 died after that guidance. But James’ report said the issue would require further study to conclusively prove such a link.

New York’s health department released a much-criticized report last summer that claimed the March 25 policy, which was reversed in May, was “not a significant factor” in deaths.

James’ review also found that a lack of infection controls at nursing homes put residents at increased risk of harm, that homes with lower federal scores for staffing had higher fatality rates, and that a broad measure Cuomo signed in April shielding nursing homes and other health care providers from lawsuits may have actually encouraged homes to hold back on hiring and training.

“As the pandemic and our investigations continue," she wrote, “it is imperative that we understand why the residents of nursing homes in New York unnecessarily suffered at such an alarming rate.”

 

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NY data show nursing home deaths undercounted by thousands

New data show hundreds of thousands of elder abuse cases even with huge reporting gaps

Across the USA, solitude has become a deadly threat for hundreds of thousands of senior citizens living at home.

Last year alone, state adult protective services (APS) intervened in more than 142,000 cases to protect seniors at risk from what is clumsily termed “self-neglect” – seniors who have become too physically or mentally incapacitated to care for themselves and have no other care providers.

Overall, according to new federal data obtained exclusively by the New England Center for Investigative Reporting (NECIR), state-based APS agencies completed more than 713,000 investigations in fiscal year 2017. The agencies identified nearly 235,000 victims of abuse, including the self-neglect cases. About 10 percent of the total abuse victims counted were under age 50, because some states include abuse or neglect of younger adults with disabilities.

These numbers, part of an initial attempt by the federal government to track  maltreatment of seniors nationwide, understate the scope of the problem, and probably dramatically, according to the agencies compiling the data.

“The elder abuse data is not complete. It’s correct in terms of what’s reported, but there are so many cases that aren’t reported,” said Alice Page, an adult protective services and systems developer with the Wisconsin Department of Health Services.

“We're way behind in elder abuse reporting than, for example, in child abuse reporting. It's just a different system. There's much more emphasis and resources that have been put into child protective services than there have been into elder abuse or abuse of adults. And so we're sort of playing catch up.”

Elder abuse can range from physical or sexual assault against vulnerable seniors to financial scams to abandonment or neglect by caregivers. The most common threat is self-neglect: an elderly person unable to provide for their own clothing, shelter, food, medication or other basic needs, and having no one to provide care for them. It is a problem that is growing as the population ages.

States have operated under a federal mandate to collect data on child abuse for decades. There is no federal mandate to do the same for elder abuse and neglect.

“We have often referred to elder abuse as a silent issue. For decades people just didn't want to address it at all,” said Edwin Walker, deputy assistant secretary for aging at the Department of Health and Human Services, which is leading the effort to build the national database.

“In the mid-1970s, the federal government got in the business of charting out guidelines and parameters for addressing child abuse. But the federal government never did that for adult protective services or elder abuse.”

During the past several years, the Administration for Community Living has embarked on a voluntary effort with the cooperation of state APS agencies to compile a national database of abuse of seniors living at home. For the most part, abuse in nursing homes or other settings is managed by other agencies and counted separately.

A state-by-state breakdown of the data provided to NECIR shows obvious holes in the data.

For instance, the new totals do not include reports from six states – New Mexico, Oregon, Nevada, South Dakota, West Virginia and Wisconsin – for a variety of reasons.

West Virginia, for example, does not collect statewide data on maltreatment of seniors, leaving it to each county to keep their own tally. Wisconsin counts its data on a calendar year, not a fiscal year, and thus has not been able to produce reports for the time period the federal data system uses.

Oregon sent its data in late and was not included in this year’s report. Officials in Nevada and South Dakota said they have been gearing up to provide data for the new federal reporting system called the National Adult Maltreatment Reporting System (NAMRS) and expect to be included in next year’s report.

There are other anomalies – New York reported nearly 40,000 investigations of alleged abuse or maltreatment in 2017, but the federal data indicate New York had zero confirmed victims. That’s because New York’s law does not identify victims; instead the state determines when there is a level of risk to a senior that justifies the state providing services, which it did in 4,700 cases last year, according to the New York State Office of Children and Family Services.

States all have different standards for determining when abuse or neglect has occurred, meaning the same set of evidence may qualify as a “substantiated” abuse or neglect case in one state, but not in another. And the new report acknowledges “no two states reported on all of the same data elements.”

Self-neglect challenges

Still, experts in the field all agree that self-neglect is one of the most challenging issues in elder protection, and it dominates the work of Adult Protective Services units across the country.

“Self-neglect appears to be a very serious problem in our society not a new problem. But it is, as you've been picking up, approximately two thirds of the cases reported by APS nationwide,” said Holly Ramsey-Klawsnik, director of research for the National Adult Protective Services Association.

Ramsey-Klawsnik cautioned that the prevalence of self-neglect in state case files does not mean this is the most common form of adult maltreatment – only that it is the one most readily identified. “Self-neglect cases are so much more visible,” she said.

Neighbors or friends or social workers can tell when a senior’s house has fallen into disrepair, or an older person in the grocery store is unwashed or badly unkempt. It may be harder to tell if a senior has had money stolen from them by a caregiver or if they have been denied access to appropriate medical treatment.

Self-neglect cases also come with the underlying problem that adults are generally assumed to have autonomy and control of their decision-making, so it is hard for a government agency to know when to intervene, particularly if the elderly person rejects assistance.

Some people “just refuse to accept help for whatever reason,” said Cynthia Lien assistant professor of medicine at New York’s Cornell Medical Center. But she says there is also “a large population who just are incapable of giving up a coping mechanisms or repeat behaviors that they've developed over years,” even when those behaviors are no longer working. 

“That manifests in things like an unsafe home environment or hoarding disorders or refusing to see a doctor because maybe they had a bad interaction in the past with a physician and they just don't trust the health system. “

And people have a right to not take proper care of themselves, adds Alice Page from Wisconsin. 

“We talk about the dignity of risk in these cases,” she said. “All of us, there's risk to every decision we make, and some people just choose to live with more risk and accept the consequences. And if you give people choices that involve risk, that enhances dignity.”

But self-neglect is not simply an issue of risk for the senior individual making the poor decisions.

“We do know that self-neglect increases illness, increases emergency room use, increases hospitalization, increases nursing home use, increases hospice use and hastens mortality,” said Ramsey-Klawsnik. “Self-neglect is costing society a lot of money when they have to go to the E.R. and have no money to pay for insurance.” People who self-neglect are also at higher risk of other forms of abuse or exploitation.

Beyond that, a senior in an apartment who is hoarding or failing to take out the trash may be creating an unhealthy environment or a vermin problem for everyone else in the building.

Still, states struggle with how to intervene.

“We can't force somebody who's just making poor choices to do something," said Kathy Morgan of Washington State’s Aging and Long-Term Support Administration. “Although our investigators do a really great job of talking with people and trying to assist them with services or supports that may be able to put in place if they're willing to do that."

State assistance in self-neglect cases can range from referrals to Meals on Wheels or in-home care services to cognitive assessments that could lead to assignment of a guardian if the senior no longer has the capacity to make decisions on their own.

Soaring cases

While the data in NAMRS is full of gaps and aberrations, what is clear is that the number of abuse and neglect cases is soaring nationwide. 

• Washington state had about 19,000 elder abuse reports in 2012 and 49,000 reports in 2017, Morgan said.

• Massachusetts confirmed 7,100 abuse and neglect cases in 2015 and 9,800 in 2017.

• Ohio reported about 16,200 reports of abuse, neglect and exploitation of seniors in 2017, up from about 13,150 in 2014.

• Pennsylvania officials investigated 13,000 abuse reports in fiscal year 2014 and nearly 18,000 in fiscal year 2016. 

Part of this increase is simply a function of better reporting systems in the states, and more public awareness that elder abuse is a problem that should be reported to authorities.

But part is also because there are simply more seniors living in communities around the country, as Americans live longer, remain in their homes longer, and survive ailments that would have been fatal in prior decades.

“I think elder abuse is more prevalent,” Morgan said. “As our population continues to grow and is getting older – our 60 and older population, we’re going to continue to see these types of numbers.”

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New data show hundreds of thousands of elder abuse cases even with huge reporting gaps

Secret VA nursing-home ratings hid poor quality care from public

Nick Bonanno pushed his father, Russ Bonanno, down the hallway at the VA in Bedford.

World War II veteran Rosario “Russ” Bonanno was facing worsening dementia when his family took him last year to the Department of Veterans Affairs nursing home in Bedford. He had been in assisted living, but after six years, some family members thought he needed more specialized care.

Within days after Bonanno arrived, his son Nick said the 94-year-old was “dazed, confused, disheveled” as staff began medicating him. And he wasn’t the only resident who looked drugged. “Everyone looks like a zombie,” Nick said.

What Nick and his family didn’t know was that the Bedford facility ranked among the worst of 133 VA nursing homes across the country, in part for giving so many residents antipsychotic drugs.

The agency has tracked detailed quality statistics on its nursing homes for years but has kept them from public view, depriving veterans of potentially crucial health care information. Nearly half of VA nursing homes nationwide — 60 — received the agency’s lowest ranking of one out of five stars as of Dec. 31, 2017, according to documents obtained by USA Today and The Boston Globe.

The VA finally made some of its ratings public last week after receiving questions from the Globe and USA Today about all the secrecy. VA officials claimed that President Trump wanted to release the ratings all along and blamed the Obama administration for not making them public earlier.

Statistics the VA has not released paint a picture of government nursing homes that scored worse on average than their private sector counterparts on nine of 11 key indicators last year, including rates of antipsychotic drug prescription and residents’ deterioration. In some cases, the internal documents show, the VA ratings were only slightly worse. In others, such as the number of residents who are in pain, the VA nursing homes scored dramatically worse.

The worst-performing VA nursing homes in the ratings were scattered across 32 states, including Pennsylvania, which had five one-star facilities, as well as Texas and California, which had four each. The VA facility in Bedford and another in Brockton were the only one-star nursing homes out of six in New England.

But VA officials argued that the nursing home system overall “compares closely” with private nursing homes despite caring for typically sicker residents.

VA spokesman Curtis Cashour called it “highly misleading” to compare pain levels at the VA to private nursing homes because VA residents have more challenging medical conditions.

The VA quality tracking found that its nursing home residents were five times more likely to report being in pain than private nursing home residents.

Cashour added that 60 VA nursing homes have improved their ratings over the last year, while only one had a “meaningful” decline.

“We are committed to continuous improvement efforts in all of the [VA nursing homes] and demonstrating performance that is as good [as] or better than private sector facilities,” Cashour said.

The VA’s hospitals have drawn intense criticism for repeated scandals with veterans’ health care in recent years, including preventable deaths, but the agency has largely operated its nursing homes with scant public scrutiny. VA nursing homes serve 46,000 veterans annually in 46 states, the District of Columbia, and Puerto Rico.

Internally, the agency has long monitored care at its nursing facilities through quality indicators and unannounced inspections, and, since 2016, through star rankings based on the indicators. But until now, it has kept all of these quality measures from the public.

Under federal regulations, private nursing homes are required to disclose voluminous data on the care they provide. The federal government uses the data to calculate quality measures and posts them on a federal website, along with inspection results and staffing information. But the regulations do not apply to the VA.

The VA has “got this whole sort of parallel world out there that’s hidden,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care. “I still can’t get over that this information is not available to people who are looking for a veteran’s home; that’s just unacceptable.”

VA spokesman Cashour blamed the Obama administration for resisting making quality data public. “But under President Trump’s leadership,” he wrote in a June 12 statement, “transparency and accountability have become hallmarks of VA.”

However, the VA’s decision to release the quality data came after first asking USA Today and the Globe for more time to answer questions about the secret ratings. Then the VA released the quality ratings while the reporters waited for answers.

The agency did not release the more detailed information that underlies the star ratings, such as rates of infection and injury.

Alex Howard, a transparency advocate and former deputy director of the Sunlight Foundation, said the VA should release all the data immediately — and on an ongoing basis. He said the underlying information is critical to understanding what the stars mean..

“There shouldn’t be a gap between the reality of how we’re treating people under the government’s care and public understanding of it,” said Howard. “This is not a situation where we’re concerned about some matter of national security, this is simply being honest about how well things are going.”

‘I was told how good it is — by VA, of course’

After 38 years of marriage, Leslie Roe made the gut-wrenching decision to place her husband in a nursing home.

Earl James “Jim” Zook, 72, was suffering from dementia and had taken to wandering away from their home in Coosada, Ala., and she worried she would lose track of him.

So Roe moved Zook, a Vietnam-era Navy veteran, into a VA home an hour away in a rural, wooded swath of Tuskegee. She said VA staff put a bracelet on his wrist warning he was a flight risk and placed him in a secure ward.

But just three months after Roe checked Zook into the Tuskegee facility, staff lost track of him. Zook simply walked out into the woods; Roe said she was told there was a faulty door.

She had no idea that the facility ranked among the worst VA nursing homes in the country last year, scoring only one out of five stars in the agency’s rankings. She had to rely on what the VA said.

“I was told how good it is — by VA, of course,” Roe said

The VA assigns stars based on 11 indicators that can be tip-offs to larger problems with overall quality. For example, high rates of falls or bed sores may indicate understaffing or neglect.

The Tuskegee nursing home scored worse than private nursing home averages on eight of the 11 criteria as of Dec. 31, 2017, including rates of residents being in pain, receiving antipsychotic drugs, and contracting urinary infections.

Ironically, this year, the Tuskegee nursing home improved from one star to two stars. But that was too late for Zook.

He hasn’t been seen since he walked out of the Tuskegee facility in January 2017. Searches by helicopter and with tracking dogs turned up nothing.

“We finally declared him legally dead,” Roe said earlier this year. “Because there was no way he could have lived without his medication.”

“Anybody that deals with VA, I feel sorry for them,” she said.

Cashour said that after Zook’s disappearance, which he called an “unanticipated outcome,” the VA implemented more safety measures, including adding GPS to an alarm system that notifies staff if patients leave the facility.

Kelsey Cronin

Nick visits his father several times a week to push him around the building in his wheelchair along with throwing a ball around.

‘They break their spirit’

The VA has relied for more than a decade on an outside company, Wisconsin-based Long Term Care Institute Inc., to conduct inspections of VA nursing homes and report back to the agency.

The VA banned the public release of institute reports after the Pittsburgh Tribune-Review in 2009 published the findings from one report detailing “significant issues” at the VA nursing home in Philadelphia, including poor resident grooming and pest control. In one case, a patient’s leg had to be amputated after an infection in his foot went untreated for so long his toes turned black and attracted maggots.

The VA said the reports are internal quality-assurance documents “protected” from disclosure under federal law. However, in their announcement last Tuesday releasing the nursing homes’ star ratings, VA officials said they would also release the long-term care reports. They didn’t say when.

Such reports might have been helpful to Bonanno, the WWII veteran whose family moved him from a private assisted-living facility to the Bedford VA last April as his dementia worsened.

An inspection report obtained by The Boston Globe shows reviewers from the Long Term Care Institute found several instances of neglect at the nursing home in April 2017. They saw a veteran lying in bed covered only by a urine-and-feces-stained sheet. They saw another veteran struggling to eat, using his hands to shove food in his mouth after trying unsuccessfully to maneuver food onto a spoon. Staffers were nearby, the report said.

By then, inattentive patient care in Bedford had already proven to be fatal to one resident. Vietnam veteran Bill Nutter died in 2016 while an aide who was supposed to check on him hourly allegedly played video games on her computer and didn’t check on him at all. She later resigned, and Nutter’s family has sent a demand letter to the VA seeking $10 million in damages.

Bonanno’s family would learn about the conditions the hard way.

His son said Bonanno, a happy-go-lucky retired mechanic, would always wake up early for breakfast. But for the first few months in the Bedford facility, he was fast asleep when his son arrived after 11 a.m. for a visit. According to Nick, the staff woke him up at 6 a.m. to put him back to sleep.

They gave him an antipsychotic drug and a sedative, Nick said.

“They medicate them until they break their spirit and make them passive. I guess it’s easier for the staff to deal with them,” Nick said. “In six years in assisted living, he’d never been medicated during the day.”

Staff told Nick that his father was “agitated” and needed the medication — a contention Nick disputes.

Cashour said many of the veterans at Bedford live with “chronic mental illness” related to their military service and require psychotropic medication “to reduce distress and manage behavior.” After the veteran is stabilized, he said, the VA works to reduce the use of these drugs.

Nick’s brother, Russ, who lives in Indiana, said that he and his sister, who also lives outside of Massachusetts, believe that their father’s overall health has improved and he is properly medicated.

“My sister and I both agree he’s getting care that’s high quality and appropriate for his needs,” he said.

Still, Nick said as their father became more and more groggy, he participated in fewer activities; he went from walking with help to sitting in a chair for hours, doing nothing.

“There are ways to care for people with dignity and allow them to be themselves,” said Nick, who plays catch with his father indoors, using a small rubber ball, when he visits several times a week.

“I was lucky to have Dad in a place that was pretty good for six years. It was a huge drop-off in the way they provide care at the VA versus a private facility.”

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Secret VA nursing-home ratings hid poor quality care from public

Conditions at state institutions unacceptable

It’s a track record that can’t be tolerated.

Data compiled from 2016 inspections of Washington’s four state-run residential habilitation centers (RHCs)--including Rainier School in Buckley--detail shocking accounts of abuse and neglect toward developmentally disabled residents.

The 2016 reports read like documents from the 19th century when people with Down syndrome, autism, or other disabilities were isolated in asylums and often neglected.

The state’s own surveyors reported 257 allegations of injuries with origins unknown, 25 accident allegations, and 16 reports on the misuse of seclusion and restraints both physical and chemical.

In November of 2016, a staff member at the Rainier School sexually assaulted a female resident. An investigation revealed later that several other residents had allegedly been raped by the same staff member. The accused awaits trial in the Pierce County jail.

Employees at Rainier School said training on how to identify sexual trauma in nonverbal adults was never administered.

At that same institution, in the span of less than two years, two residents choked to death, and a man nearly drowned during a lake trip. A staff member left him alone on a dock strapped into his wheelchair. When he fell into the water, he was unable to free himself.

The report also detailed how staff at the Lakeland Village facility near Spokane withheld food to “manage” behavior. The plan called for staff to “only provide diet supplements” if they saw the resident come out of his room.

Nurses at other facilities worked with expired licenses.

In 2015 and 2016, federal experts found so many violations, ones that included leaving residents strapped to toilets or exploiting them financially, they froze federal funding for new admissions. The Developmental Disabilities Administration, which oversees operations, is given 11 months to get back into compliance.

Washington is one of only 13 states still operating large institutions for people with developmental disabilities. Oversight authority lies with the Washington State Department of Social and Health Services and The Centers for Medicare & Medicaid Services (CMS).

Surveys are conducted every 15 months; when an infraction occurs, the facility in question responds with a “Plan of Correction,” an inadequate method of accountability considering the ongoing problems with safety and substandard therapeutic conditions.

Don Clintsman, a top DSHS official charged with overseeing the state RHCs, said corrections have been implemented. He also mentioned the facilities are crumbling. “Some of the buildings are 50, 60 and 70 years old.” He’d like to see real investment coming from the state Legislature.

Disability Rights Washington is entreating the public for help, calling for a panel, one that includes both state officials and concerned citizens.

Reisha Abolofia, author of No Excuses: shining a light on abuse and neglect of people with developmental disabilities in Washington institutions, says lawmakers and public officials are aware of the report’s findings. To her knowledge, no special investigations have been assigned.

“People with disabilities are viewed as less than human,” says Abolofia. It’s the only answer she can give for why state officials have not done more.

Sue Elliott, executive director of the Arc of Washington says, “Washington ranks 42nd in the nation for how we treat our DD (developmentally disabled) residents.”

This kind of treatment wasn’t acceptable in the 19th century, and it isn’t acceptable now.

But until Governor Inslee and the state Legislature take concerted action, more than 800 of our most vulnerable citizens remain at risk.

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Conditions at state institutions unacceptable