‘It was unbelievable, the filth’: State investigators find several violations at Platte City nursing home

PLATTE CITY, Mo. -- A Northland nursing home is under the microscope after multiple people reported health and safety violations at the facility.

Laura Spooner is grieving the loss of her aunt, Dee Feldman.

“She was a really special lady to us,” Spooner said.

But she said she is very worried about how her aunt spent her final moments in Hillview Nursing & Rehab in Platte City. She said the quality of care started to slip late last summer.

“It was 100 degrees out, and she was in somebody else's clothes. It was full-on sweat pants, and she was just totally red, soaked hair, just sweating,” Spooner said.

She said the family tried to give Hillview the benefit of the doubt. However, Spooner said things didn't get better.

Dee had dementia and needed help bathing and eating. Yet, in January, she was allegedly left in the shower alone. She fell, and a medical chart shows her entire body was bruised.

A few weeks later, Laura's daughter got a call that Dee wasn't doing well.

“She was bedridden," Spooner said. "Just two weeks prior, my daughter was in there, and she was sitting up in her wheelchair, and she was fine."

The family insisted Dee go to the hospital. The doctors there said her condition was dire.

“They found out she was severely dehydrated. She had to have five bags of fluid,” Spooner said.

Spooner flew in from Wyoming. After her aunt Dee was released from the hospital and sent back to Hillview, Spooner and her daughter stayed there around the clock.

“The conditions that we saw were just unbelievable,” she said.

She snapped photos of filthy and busted floors, dirty bathrooms, and she even caught an employee sleeping on the job, twice. She said it was on nights when he was the only CNA on duty for 66 patients.

“We couldn't find people to help as my aunt was choking on her own secretion. We were running down those hallways. It was unbelievable, the filth in that establishment,” Spooner said.

They also got Dee's patient logs, which show her aunt hadn't been bathed in 23 days. There's no record of her having dinner in weeks. The time stamps on meals are also off, including meals listed on days Dee was hospitalized.

“Every life matters. Every resident at Hillview Nursing Home matters," Spooner said. "I want family members to know they're not being taken care of. They're sitting in soiled pull-ups. Soiled pull-ups. And that should not be."

After a current resident, past employee, and Laura Spooner called the state’s nursing home neglect hotline, state inspectors visited. They issuing several citations for health and safety violations.

FOX4 spoke with the administrator of Hillview Nursing Home. She said:

“Patient safety is top priority. We are taking the concerns very seriously, with the issues brought from the state. We’ve thoroughly investigated and are promptly addressing those issues. We comply with state and federal patient privacy and employment laws and cannot discuss anything further about this matter.”

Hillview has 10 days to make a plan for improvements and report back to the state.

Documents show Hillview is tied to a company called Health Systems Incorporated. HSI has faced numerous wrongful death and personal injury lawsuits in Missouri at various facilities and was also part of a $30 million Medicare fraud case in 2014.

However, the party listed from Health Services Incorporated on state records told FOX4, “Health Systems, Inc does not have any ownership interest in Hillview Nursing & Rehab.”

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‘It was unbelievable, the filth’: State investigators find several violations at Platte City nursing home

State fines nursing homes over falls

Injury fatal for one resident, report says

by David C.L. Bauer

Two west-central Illinois nursing homes were among those fined by the Illinois Department of Public Health after one resident was injured and another died, according to the department’s quarterly report released Tuesday.

Aperion Care Jacksonville, a 113-bed skilled care facility at 1021 N. Church St., was fined $25,000 for failure to provide supervision and implement intervention for a resident to prevent multiple falls, according to the state.

Pittsfield Manor, an 89-bed skilled care facility at 610 Lowry St. in Pittsfield, was fined $25,000 for failure to provide supervision to prevent a fall, according to department records.

According to Illinois Department of Public Health documents, policies and requirements were not followed and that resulted in a resident falling, lacerating her head and suffering a fracture that required surgery and the pinning of her hip.

When the woman was admitted to the facility in 2018, it was determined she was at risk for falls, according to the state, but “the facility failed to implement effective interventions and provide supervision to prevent injury for multiple falls.”

At Pittsfield Manor, according to Illinois Department of Public Health documents, the facility also failed to provide supervision to prevent falling for a resident, resulting in her falling, hitting her head and being sent to the emergency room.

The resident suffered “a traumatic skull fracture, subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and subdural hematoma (a pool of blood between the brain and its outermost covering) that caused her death.”

The woman had been admitted to the facility in February and had been diagnosed with Alzheimer’s disease, a history of falls, unsteadiness, anxiety and vertigo.

The state documented a series of falls that occurred although the resident was urged to use a call light to get staff assistance. In the days before the most significant fall, nursing home staff reported she required more assistance and complained more often of headaches and dizziness.

In June, the woman was taken from the facility for a dental appointment, according to the state’s report. A nurse’s aide and bus driver called a few hours later and said the woman had fallen and was taken to the emergency room, where she was diagnosed with a brain bleed. The diagnosis was that the woman would “likely soon pass related to the intracerebral hemorrhage.”

She died about three days later, according to the report. The cause of death was “blunt force trauma” resulting from “falling and striking head on ground.”

Both facilities were cited with type “A” violations of the Nursing Home Care Act and processed between October and December. An “A” violation pertains to a condition in which there is a substantial probability that death or serious mental or physical harm will result or has resulted, according to the Illinois Department of Public Health.


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State fines nursing homes over falls

LARA shuts down Southfield special needs group home due to violations, unsanitary conditions

By: Rudy Harper

SOUTHFIELD, Mich. (WXYZ) — A facility housing people with special needs suddenly shutdown Thursday. The home is located off Fairfax in Southfield.

Lisa Caruso made a desperate plea to find another home for her disabled uncle who is blind and mentally ill.

"There are a lot of very intelligent, good people who deserve a good life," Caruso said. "I just don't think they got it here."

Caruso said some residents are homeless after the sudden closure.

He said he was hired as a caretaker and hasn’t been paid in four weeks. He also told me, he cared for 12 people in the house at one time. Our full report airs in minutes on @wxyzdetroit pic.twitter.com/pQ7bHAGIhb

— Rudy Harper (@RudyHarperWXYZ) September 27, 2019

"I'm trying to get a hold of anybody to help me get medications from his home," Caruso said. "He has been locked out, although his rent has been paid."

Around 5 p.m., investigators with Michigan's Licensing and Regulatory Affairs (LARA) descended on the group home and posted violation notices.

The facility was licensed to care for people who are physically handicapped, developmentally disabled, mentally ill, traumatically brain injured, or suffer from Alzheimers.

Action News has obtained a report of major violations. Among the complaints, it states, a staff member punched a resident. There are also allegations of unsanitary conditions and an overall unhealthy environment.

My Beloved Group Home Special Investigation Report by WXYZ-TV Channel 7 Detroit on Scribd

Action News spoke with the staff member who is accused of punching a resident. He said the resident assaulted him and he accidentally punched the resident in self defense.

The owner of the facility is Theressa Nelson. She declined an on-camera interview Thursday evening, but denied the allegations via telephone.

LARA did not immediately return Action News' call for comment.

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LARA shuts down Southfield special needs group home due to violations, unsanitary conditions

‘I can see her spine’: Ohio nursing home cited after several complaints

COLERAIN, OH (FOX19) - A family is demanding changes at a Colerain nursing home after it says a loved one was hospitalized while in the home’s care.

The family made several complaints to the Ohio Department of Health about the Liberty Center of Colerain, which led to an on-site investigation. It claims a woman’s infected wound was left untreated and it nearly killed her.

Since that time the nursing center has been cited for several violations of state and federal regulations.

Elizabeth Smith-Burrell has been staying at the Liberty Nursing Center of Colerain for nearly two years. In October her health declined significantly after she developed a pressure ulcer on her lower back.

"If you have a weak stomach it'll make you cringe," said Michael Nowell, who is the cousin and legal guardian of Smith-Burrell.

Nowell showed FOX19 pictures of the wound on his 71-year-old cousin’s lower back, which are difficult to look at.

“The wound is probably 1 1/2 inch in diameter and 3 inches deep -- and at the base of the wound I can see her spine. I can see white bone, her spine,” said Nowell.

He says Smith-Burrell came to the Liberty Center of Center of Colerain after being partially paralyzed from a stroke. Nowell says that her doctor ordered a cushion to relieve pressure while sitting in her wheelchair. He also prescribed protein supplements to help her body heal and prevent bed sores. However, Nowell says the staff at the facility never followed through with the doctor’s orders.

“She a diabetic and when you have an eruption in your skin like that it could be deadly. This particular episode that’s she’s going through right now is very -- it’s got her close to death,” said Nowell.

Public records from the Ohio Department of Health list multiple violations at the Liberty Nursing Center of Colerain including: “The facility failed to initiate and consistently follow physician ordered treatments to prevent the development of avoidable pressure ulcers and/or promote the healing of three of five residents, which resulted in Immediate Jeopardy for two of five residents.”

The administrator of the Liberty Nursing Center of Colerain, Brenda White, said she was not able to discuss patient care but issued this statement: “We do provide quality care. We have a 5-star rating in our quality measure determined by Medicare and Medicaid Services.”

Nowell says he hopes the nursing home makes major changes to prevent a similar infection from happening to another patient.

“It’s really sad to have that happen to someone," he said.

Nowell is now reaching out to lawmakers in an effort to legalize cameras in private rooms in nursing homes.

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‘I can see her spine’: Ohio nursing home cited after several complaints

Editorial: It’s a scary time for seniors in nursing homes

Disgraceful is the word that sums up the number of violations that nursing homes in Connecticut are racking up — and troublesome is the White House’s effort to hide those violations under a new set of policies.

The Centers for Medicare & Medicaid Services, which oversees the nursing home industry, recently issued new guidelines that ease what the industry viewed as “overreaching, burdensome and punitive,” but advocates see as “dismantling the enforcement system and making it more difficult and less likely for any enforcement against facilities with serious deficiencies.”

Advocates have good reason to be concerned.

Connecticut issued 73 citations against nursing homes last year, with fines ranging up to $3,000, according to the Department of Public Health. To be fair, that is down from 96 the previous year.
But it is a persistent problem.

The federal government processed some hefty fines for 128 Connecticut nursing homes over the past three years, according to the CMS website, with Apple Rehab Rocky Hill being smacked with fines reaching more than $160,000; Advanced Center for Nursing and Rehabilitation in New Haven shelling out more than $75,000; and Orchard Grove Specialty Care Center in Uncasville fined nearly $50,000.

Nursing homes in Cheshire, East Haven, Hamden, Shelton, Torrington, also have been fined for violations due to lapses of care.

The violations have caused serious — and painful — injuries such as broken and fractured bones. Other violations include abuse and abusive behavior by staff toward patients; medication mix-ups and patients going up to six days without prescribed medications.

We believe these lapses in care highlight the need for more oversight — and we’re not sure how the industry thinks easing regulations is going to lead to less errors.

Those are not the kind of stats that leave seniors or their loved ones feeling confident about the safety and well-being of patients in these facilities.

And it is certainly something to think about in a state where seniors are a burgeoning population and turning 100 is becoming commonplace.

Connecticut has its own nursing home laws and regulations, and assesses fines against facilities that violate them. Under legislation passed in 2017, the limit for fines for each violation quadrupled to $20,000.

We do think that nursing homes have the intention to provide the best service possible for their patients — but we also believe they must pick up their game and do a better job.

Many seniors will have to go into nursing homes as their lives near the end.

They deserve to know they are going into a caring facility, not be in fear of entering one fraught with human error that is costing lives, serious injuries — and fueling fear among seniors.

Matthew Barrett, CEO of the Connecticut Association of Health Care Facilities, which represents more than 150 of the 224 skilled nursing facilities in the state, says the easing of regulations will allow the industry to deliver better services.

The industry has what it wants now, so there should be no excuses. Injuries should drop and better services should be provided. That is what the Connecticut Association of Health Care Facilities promises that less oversight will allow its members to do.

We’ll be watching — because right now, it’s a scary time for seniors in nursing homes.

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Editorial: It’s a scary time for seniors in nursing homes

How some Ohio nursing homes are putting the lives of society's most vulnerable at risk

Six months ago, News 5 Investigators began looking into the case of a local father, whose son had many questions about his dad’s health and experiences at a Strongsville nursing home. In the midst of our investigation, we uncovered eye-opening violations in Northeast Ohio’s most problematic nursing homes, with some including severe infractions that led to death. So we wondered how difficult it really was to get answers, and whether or not these facilities would own up to their past problems. What we found may surprise you.

‘I don’t believe I am the only one’

Donald Gallick Sr. was a man called hard-working. He was a man called helpful. He was also a man called “Dad” by his son, Donald.

“Always willing to do what needed to be done,” the younger Donald says of his dad. “He appreciated sports, a Buckeye fan…a hard worker, faced any challenge, very easy to talk to.”

But as he got older, Donald Gallick Sr. began having health issues. He suffered a minor stroke and it became difficult for him to drive or walk.

“One day, I came over, and he had tripped on a chair,” said the younger Donald, a lawyer who deals with healthcare fraud. “And I found him lying on the ground for the better part of a day.”

Now, the younger Donald can’t stop wondering, ‘What if?’, when it comes to whether or not his dad received the best care while he was in Falling Water Healthcare Center in Strongsville in 2013. He questioned how his father was treated there, but believes he didn’t get the answers he needed.

“I want to know, is this being treated?” he questioned. “What is actually the diagnosis? Is he going to walk again?”

Ohio Nursing Homes: Is your family affected? Check our interactive map here.

Donald Gallick Sr. passed away at another facility in 2014.

“…This was my experience,” he said. “And I don’t believe I am the only one.”

The Gallicks’ story is one of many, as numerous nursing homes in Northeast Ohio have racked up thousands in fines and low ratings by the Centers for Medicare and Medicaid Services (CMS).



(Click to Continue)

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How some Ohio nursing homes are putting the lives of society's most vulnerable at risk

She believed her mom died peacefully. Two years later, a nurse wrote to say what really happened

Family had been kept in the dark about mother's final moments at Kindred Hospital Sugar Land

Manuela Chapa, on her 85th birthday in 2012.

The package came in January: An anonymous letter and a stack of government records, stuffed in a yellow envelope with no return address and mailed to her late mother's home in Damon.

Cris Chapa ripped it open and began to cry.

She thought of the day, March 12, 2015, when medical staff at Kindred Hospital Sugar Land sat her down in a waiting room. They'd said there was nothing anyone could have done. Led her to believe her 87-year-old mother's death had been the inevitable result of her bout with pneumonia.

The stranger's letter told a different story:

Her mother hadn't died peacefully, it said. Instead, a doctor had attempted a procedure without Chapa's knowledge or legal consent, and it had gone badly. Blood poured from a tube in her mother's neck. Soaked her hospital gown. Caused her heart to stop.

Why hadn't anyone told her what happened? Why didn't anyone tell her three months later, when the state sent someone to investigate? Why didn't anyone tell her a few weeks after that, when the federal government cited the hospital for violating her mother's rights?

For nearly two years, Chapa and her family had been kept in the dark. Until now.

She didn't know it then, but the stranger who'd written the letter had mailed duplicates to two of her siblings. Chapa's hands shook as she studied the documents, looking for clues to who'd sent them, but found only an email address.

That night, she logged onto her computer and typed a message: "Can you call me?"

***

Linda Patton read the email twice, unsure how to respond. She'd been hesitant to contact Chapa in the first place, even anonymously. She'd already lost so much.

This wasn't the life she'd hoped for when she accepted a job as a nurse practitioner at Kindred Hospital Sugar Land in September 2014. She knew it had been a risk leaving Houston Methodist Hospital for a less-prestigious facility, but Kindred had offered her a more senior position and an opportunity to mentor young nurses, which was her passion.

Patton noticed problems right away, she said. On daily rounds, she'd quiz nursing staff on what medications patients were taking. What side effects they should be looking for. Basic stuff. Routinely, though, nurses didn't know the answers, and some seemed agitated by her attempts to educate them.

"That just kind of shocked me," Patton said.

She hadn't realized her new hospital had a history of mistakes. In the three years leading up to her first day at Kindred, the federal Centers for Medicare and Medicaid Services had cited the facility for 10 separate violations of state rules governing patient care.

Among the citations, obtained by the Houston Chronicle through a public records request: Kindred nurses weren't adequately trained or supervised. Patients had been unnecessarily restrained. Others had suffered infections after staff mishandled contaminated materials or failed to properly wash hands. Administrative safeguards weren't in place to prevent future mistakes.

In 2012, according to one citation, a patient in Kindred's intensive care unit became disconnected from a breathing machine and was left to die, even as an alarm sounded, alerting staff of the problem. One staffer who heard the beeping said she didn't know what it meant.

J. David Cross, the chief executive officer of Kindred's Houston-area district, defended the hospital's quality of care, noting that the facility exceeds national benchmarks for complication rates.

"We take seriously any issues brought to our attention by regulatory authorities, and work with them to address any concerns," Cross wrote in an email to the Chronicle. "We share the same goal — to provide quality care to our patients."

Patton was troubled by the problems she saw but felt she'd begun to make progress. Some nurses had become receptive to her on-the-job training, she said, and hospital leadership initially seemed to appreciate her efforts to instill a more professional culture.

She'd been there seven months when Cris Chapa brought her mother, Manuela, to the hospital with pneumonia.

Patton checked on her daily and saw her condition grow worse over the course of two weeks. The illness put a strain on her frail heart. Her lungs began to fail. So did her kidneys.

Before leaving for the day on March 12, 2015, Patton checked in on Chapa once more. It seemed clear to her that she might not recover.

Patton assumed doctors would soon be meeting with the woman's family to discuss their options.

***

The next morning, as she arrived at work, a respiratory therapist grabbed Patton by the arm and pulled her aside: "Oh my God, Linda," she said. "It was terrible."

The therapist had been in the room the afternoon before, when Dr. Yassir Sonbol, an interventional cardiologist, tried to insert a catheter in a major vein in Chapa's neck, in the hopes of starting dialysis.

 The treatment might have eased the burden on Chapa's kidneys — but it also came with risks.

On his first attempt at inserting the line, according to medical records and witnesses, Sonbol couldn't get the catheter to stay in the vein. So he tried again on the right side, but this time, the wire got stuck, and Sonbol struggled to get it out.  (Click to Continue)

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She believed her mom died peacefully. Two years later, a nurse wrote to say what really happened

State: Nursing home’s failure to ‘provide adequate care’ led to beating death

BUFFALO, N.Y. (WIVB) — The New York State Department of Health cited Emerald South Nursing and Rehabilitation Center for failing to provide adequate care to its residents, specifically, the 84-year-old dementia patient who beat Ruth Murray to death last August.

Those are regulations are in place to keep residents, like the 82-year-old Murray safe.

Instead, the department of health says the nursing home’s negligence is the reason Murray was attacked after wandering into the man’s room on Aug. 26.

As a result of its investigation, the state leveled its stiffest fine — $10,000 — against the facility.

News 4 is not naming Murray’s attacker because he was never charged with a crime.

Mike Scinta, of the Brown Chiari law firm, represents the Murray family.

“What we see here is they failed both residents,” Scinta said. “They failed not only Ms. Murray, who suffered the fatal injuries, but they also failed the attacker because he was supposed to be watched as well every 15 minutes, which clearly did not happen.”

A News 4 investigation into Murray’s death found Emerald South repeatedly violated state and federal regulations, which led to the facility’s one-star rating.

But the vast majority of residents at the home on Delaware Avenue receive Medicaid or Medicare, and former employees say the facility has a heads-in-beds approach — keep the rooms full and the money flowing.

An investigation into the beating death of Murray by the department of health found multiple deficiencies.

“This family has been devastated by the manner in which their mother died,” Scinta said. “And to see a report like this, and to know that there’s ongoing systemic problems in the facility, it makes them very angry and very frustrated with the fact that this facility can do this time and time again.”

The department of health found Emerald South did not ensure each resident received adequate supervision to prevent accidents. As one example, they failed to check on Murray’s attacker every 15 minutes, which was part of his care plan.

The department’s investigation found the CNA (Certified Nurse Assistant) who was assigned to Murray’s attacker on the day of the beating was out of the building running an errand for her team leader, and the next time she laid eyes on the man was after the incident.

“The facility chooses to under staff itself,” Scinta said. “They don’t have enough hands on deck to take care of the residents, and in turn what happens is things get missed or ignored, and simply not done. And people aren’t protected. Because of their failures, Ms. Murray is now dead.”

When it came to reporting the fatal beating to authorities, Emerald South failed three as well, the state report showed.

The department of health wasn’t notified about the incident until Aug. 28th, two days after it happened — when the report said they should have been notified within 24 hours.

Buffalo attorney Richard Sullivan represents Emerald South, but has not returned repeated calls for comment about the state’s investigation or the impending lawsuit by attorneys representing Murray’s family.

Willie Faulkner lived across the street from the 84-year-old man.

Faulkner cared for his neighbor, and was ultimately one of the reasons why he was sent to Emerald South after he could no longer care for himself.

“That’s not the type of facility that I would go to if I had to go to one,” said Faulkner, who visited his neighbor and other residents at Emerald South.

It’s a place Faulkner says he remembered all too well for all the wrong reasons.

“The day that I went in, he was in the room with nothing,” Faulkner said of his visit with his neighbor. “He didn’t have anything. There was nothing on the bed. He may have had a pillow behind him, but it didn’t have a pillow case on it. It didn’t have no sheets on the bed, no nothing on the bed. No dresser.

“There was nothing. Bare walls and a bed. And his robe from the hospital,” he added.

There were other deficiencies about the facility’s care of Murray and her attacker, some of which were not connected with the violent incident.

The state found Emerald South had no documented evidence of an admission agreement for Murray’s attacker, which is a state requirement.

The department’s investigation led them to the nursing home’s business office, where a female employee told the investigator Murray’s attacker’s agreement “fell to the wayside,” and that she was “very busy because she was working for both buildings.”

“We know that this is pervasive throughout the facility because of their failure to staff the facility and their failure to follow the care plans, other residents are affected, and other residents in that building are at risk,” Scinta said.

“They want heads in beds, and they want to keep their facilities full, and that’s the way they operate their business,” he said. “But in doing that, in exchange of that, they have to have enough people there to properly care for these individuals.”

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State: Nursing home’s failure to ‘provide adequate care’ led to beating death