LeadingAge reported that the GAO was asked to review federal oversight of elder abuse reporting, investigation, and law enforcement notification in both nursing homes and assisted living facilities. Both types of facilities often fail to report neglect and abuse.

The report highlighted specific federal requirements for reporting, investigating, and notifying law enforcement of elder abuse for nursing homes and state survey agencies.  For assisted living facilities, the report noted that there are no similar federal requirements as those are regulated by the states.  The Centers for Medicare and Medicaid Services (CMS), however, requires state Medicaid agencies to develop policies to ensure reporting and investigations of elder abuse in assisted living facilities.

In commenting on the report, the Department of Health and Human Services (HHS) reiterated its commitment to resident safety and acknowledged the distinct, and not directly comparable, oversight frameworks for nursing home and assisted living facilities.  This is a must read for all nursing home abuse and neglect attorneys.



McKnight’s had an article about the issues and problems at California Villa in Van Nuys, CA, an assisted living facility.  Staff members were unable to identify a veteran in their care when a case manager from the Department of Veterans Affairs visited, resulting in the case manager reporting that she had visited with the resident — four days after he had died, according to the U.S. Office of Special Council.

The incident is part of a larger issue with the care of veterans in assisted living, according to the office. The alleged incidents are examples of how VA  “compromised patient care” because they “failed to take action on repeated allegations of patient care deficiencies and employee misconduct” at assisted living facilities where veterans live. The VA investigation concluded that because veterans, not the VA, pay assisted living facilities, VA officials did not oversee those facilities as “vigorously” as they did other programs funded directly by the VA.

California Villa was approved to care for veterans by the VA Greater Los Angeles Healthcare System, according to the OSC. When a case manager visited in October 2017 looking to meet with a specific veteran, however, staff members referred her to the wrong resident, a VA investigation found. The resident she had come to see actually had died four days before her visit.

The VA investigation also “confirmed longstanding and well-known” issues at the home, including a general state of disrepair and a disorganized medication room, the OSC said. Between 2015 and 2018, several veteran residents experienced “serious” medication errors, according to investigators.

For instance, staff members did not provide physician-prescribed antibiotics to a 100-year-old veteran with sepsis, the report said. In another case, staff members allegedly did not update records related to physician-canceled prescriptions, resulting in a veteran receiving double doses of medication on two occasions. And in a third case, staff members allegedly did not provide medication to a resident who did not leave his room.

“I am shocked that such lax oversight of facilities providing critical care for vulnerable veterans ever occurred, and I commend these whistleblowers for coming forward to shine a light on this serious issue,” he wrote.

The VA has agreed to begin monitoring more closely the assisted living communities caring for veterans. Also, the VA agreed to make the community care program coordinator a full-time position, and the person in the role now will visit all VA-approved assisted living facilities every month, according to the OSC. All facilities also will be independently reviewed, too, the office said.

One of the problems I see as a nursing home abuse and neglect lawyer is with assisted living centers who treat the residents as hotel guests and not vulnerable adults who need supervision and assistance at times.  A recent article in InFORum sadly reminded me of that problem.

A state investigator has issued a finding of neglect and maltreatment against Hillcrest Terrace of Chisholm assisted-living facility after one resident allegedly raped another.  The report, concluded July 11 and posted by the Minnesota Department of Health, was forwarded to the Chisholm Police Department, the Chisholm city attorney and the St. Louis County attorney. The matter is being investigated by Chisholm police and she couldn’t comment further.

According to the report, the female resident states she was raped.  The male resident who allegedly raped her “had a history of touching other clients’ private areas to provoke them” along with a history of yelling, destroying property and impaired judgment when upset.

On June 17, the victim told the investigator that the male client struck her on the legs with a statue, pried her legs apart and raped her. She said she reported the incident to the staffer and asked her to call the police, but she was told to call the police herself.

According to the report, Chisholm police arrived about 7 that evening, collected evidence from the apartment and took the female client to the hospital for a sexual assault examination. Police then removed the predator from the facility, the report said. Hillcrest Terrace evicted him but he was allowed to return once to gather his belongings. The victim was kept in the nurses’ office during that time.

The employee on duty admitted that she had not been given vulnerable adult training, but her personnel file indicated that she had completed the training and received retraining two months before the incident. The staffer was placed on 90-day probation and assigned to a different facility where there always would be two staff members working, according to the report.  The investigator faulted the staffer, but also faulted the facility for not supervising the staffer and not providing retraining after the incident.

The Centers for Medicare and Medicaid Services, the federal office in charge of supervising the care at nursing homes, keeps a list of nursing homes that consistently don’t meet standards and agreed to release a monthly update to that list in June. The most severe offenders are then designated as Special Focus Facilities. This designation increases the frequency that a nursing home must be inspected and sets guidelines for where and how quickly a facility must improve.

Two more facilities in Columbia and Myrtle Beach became the latest in South Carolina to be named on a congressional list of poorly performing nursing homes providing poor quality of care to their vulnerable residents.  Another one in Florence was officially flagged for the government to focus on.  Magnolia Manor in Columbia and The Retreat at Brightwater in Myrtle Beach were added to the list of candidates for the SFF program in July. Commander Nursing Center in Florence, which was a candidate for the program in June, was officially added as an SFF program.

Commander Nursing Center had 30 health citations at its most recent available inspection in July 2018, according to Medicare.gov, which periodically updates a nursing home database with health and safety information. South Carolina facilities typically average seven citations, the website states.  The facility was fined over $115,500 in 2018, records show.

Magnolia Manor had 25 health citations in a February 2019 health inspection and paid a $33,363 fine in 2017.  Manolia Manor-Columbia is owned and operated by the Fundamental chain which is a national for-profit chain with revenue over a billion dollars per year.  They have a long history of issues and problems ranging from fraud, short-staffing, and abuse and neglect.  As nursing home abuse and neglect lawyers for the last 20 plus years, Poliakoff & Associates have dealt with that awful chain often.

Riverside Health and Rehab in North Charleston was previously the only nursing home in the state designated as an SFF facility. They are also owned and operated by the Fundamental chain.  It shows the pattern of poor care provided at their facilities.

The Retreat at Brightwater had 16 citations in an April 2019 inspection and has not been fined in the last three years.

“It is outrageous that we continue to hear stories of abuse and neglect in nursing homes that do not live up to these high standards,” Casey said in a news release at the time. “Choosing a nursing home is a difficult and often painful decision to make. Individuals and families deserve to have all the information available to choose the facility that is right for them.”

On June 12, 2019, a report released by the Health and Human Services’ Office of the Inspector General revealed that Nursing Home Abuse remains largely unreported. The report estimates that one-in-five high-risk hospital emergency room Medicare claims for treatment provided during the 2016 calendar year were the result of potential abuse or neglect, including injury of unknown source, of beneficiaries residing in skilled nursing facilities (SNF).

The report revealed that nursing homes are failing to comply with regulations established by the Centers for Medicare and Medicaid Services (CMS). Under these regulations, SNFs are required to report incidents of abuse and neglect to Survey Agencies, who are then required to report the incidents to the CMS or local enforcement agencies. However, both SNFs and Survey Agencies have been failing to meet their federal requirements. Currently, the CMS may not be doing all they can to prevent abuse as it does not require all potential incidents to be tracked in the Automated Survey Processing Environment Complaints/Incidents Tracking System.

The Office of Inspector General (“The Office”) is urging CMS to take action since “preventing, detecting, and combating elder abuse requires CMS, Survey Agencies, and SNFs to meet their responsibilities.”

The Office suggests that CMS work with Survey Agencies to train SNF staff on identifying and recording all potential incidences of abuse or neglect. They also suggest that CMS require Survey Agencies to record and track all incidents of potential abuse or neglect in SNFs, as well as all referrals made to local law enforcement and other agencies. CMS concurred with these recommendations and stated they are creating a plan to ensure more accurate reporting in the future.

McKnight’s reported on an analysis that shows nursing homes where a majority of residents are black or Latino were more likely to receive a penalty in the first year of the Value-Based Purchasing Program. Nursing homes with more than 50% of residents who are black were nearly 25% more likely to be penalized by the Centers for Medicare & Medicaid Services compared to facilities with mostly white patients, according to the findings published July 1.  The study looked at how nursing homes that serve minority populations were impacted by fines and bonuses that were first doled out last October. About 85% of nursing homes with mostly Hispanic or Latino residents received a penalty, versus about 72% of white-majority homes.

“The patterns of performance among SNFs serving vulnerable populations underlie concerns about incentive-based approaches to quality improvement,” researchers from UMass reported in Health Affairs. “While SNFS that perform poorly should not be rewarded for delivering lower-quality care, it is concerning that vulnerable populations may be disproportionately affected by penalties.”

The data also strongly correlated penalties with high-Medicaid populations.  Most likely because they get less reimbursement so they spend less on staff.


New data from The Centers for Medicare & Medicaid Services (CMS) ranked North Carolina the 33rd worst state when it comes to the number of complaints at nursing homes. North Carolina families have demanded more regulation by state agencies after filing complaints on local nursing homes.

Fayetteville native Margie Whitehead said her family filed complaints on a Fayetteville nursing home in the past. “This can’t go on. It just can’t, “said Margie Whitehead. “I would find him wet, find him scratched up or find him scarred up. I would find him laying as I left him. Because I always would date and time his diapers when I put them on at night.” Whitehead took photos of her brother’s body when she was unsure of how he was cared for at the facility. CBS 17 blurred some the photos because of their graphic nature. The pictures  showed sores, bruises, and scratches on his face, back, and abdomen.

After taking her complaints to the nursing home staff, she contacted The NC Department of Health and Human Services (DHHS). The agency is over is N.C. Division of Health Service Regulation (DHSR). DHSR is the state department that specifically oversees nursing homes complaints.

“When I called the state department, they told me they had to actually see the event taken place. Although I had pictures and showed them pictures, they told me they had to actually see it for themselves. They had to actually be present when things happened,” said Whitehead.

But Whitehead decided to speak out about her brother, after our story on another family at Whispering Pines. In April 2019, Tracey Ervin contacted CBS 17 after documenting her mother’s living conditions at the Whispering Pines. She recorded cell phone video from inside of the facility.  “This is the fourth day in a row that I’ve been coming in here and finding findings,” Ervin told the staff. “You can already see right, urine!”

“I’m angry. I’m frustrated….all the above and then more,” she explained to CBS 17.

“Hold people accountable for what they do. They have to be held accountable for what they do,” said Whitehead.

WSPA recently reported on one of the scarier facts about the nursing home industry:  Nursing facilities fail to report thousands of serious cases of potential neglect and abuse of Medicare beneficiaries even though the federal government requires such reporting.

Auditors with the Health and Human Services inspector general’s office investigated incidents where the patient was taken straight from a nursing facility to a hospital emergency room. Scouring Medicare billing records, they estimated that in 2016 about 6,600 cases reflected potential neglect or abuse that was not reported as required. Nearly 6,200 patients were affected.

Mandatory reporting is not always happening, and beneficiaries deserve to be better protected,” said Gloria Jarmon, head of the inspector general’s audit division.

Overall, unreported cases worked out to 18% of about 37,600 incidents in which a Medicare beneficiary was taken to the emergency room from a nursing facility in circumstances that raised red flags.  CMS agreed with the inspector general’s recommendations to ramp up oversight by providing clearer guidance to nursing facilities about what kinds of episodes must be reported, improving training for facility staff, requiring state nursing home inspectors to record and track all potential cases and monitoring cases referred to law enforcement agencies.

Neglect and abuse of elderly patients can be difficult to expose. Investigators say many cases are not reported because vulnerable older people may be afraid to tell even friends and relatives much less the authorities. In some cases, neglect and abuse can be masked by medical conditions. Investigators found that nursing facility staff and even state inspectors had an unclear and inconsistent understanding of reporting requirements.

The nursing facilities covered by the report provide skilled nursing and therapy services to Medicare patients recovering from surgeries or hospitalization. Many facilities also play a dual role, combining a rehabilitation wing with long-term care nursing home beds.



The Berkshire Eagle investigated Sweet Brook Rehabilitation & Nursing Center in Williamstown, Ma.  The troubled nursing home may have its license to operate revoked following a new federal report detailing how staff failed to prevent multiple incidents of physical and sexual abuse among residents with cognitive impairments.

In February, the nursing home was added to the federal government’s list (Special Focus Facility) of the worst-performing facilities in the country. The addition to the list meant Sweet Brook was in “immediate jeopardy” of losing funding.

The federal report details multiple incidents of alleged abuse between December 2018 and February, according to the Eagle, including a Feb. 7 incident where a resident reportedly held the hand of a “severely cognitively impaired” resident over their exposed genitals, forcing the person to sexually gratify them.  That incident and several others occurred in a day room referred to as “the man cave,” the Eagle reported.

The report showed “no documentation” that the facility had staff supervise the “man cave” while residents were inside, according to the newspaper.  Neither party had the mental capacity to consent, a social worker said.

Reports of other incidents reported at the home can be found on the CMS website. One incident report details a resident being left to sit in a soiled adult undergarment for long periods of time.

According to Medicare, the nursing home has faced two fines in the past three years including a $288,267 fine on Sept. 11, 2017 and a $5,355 fine on April 11, 2017.

The Centers for Medicare and Medicaid Services announced that it will post a monthly list of underperforming nursing homes. CMS said that roughly once a year, it performs a health and safety survey of all nursing homes that care for Medicare and Medicaid patients. More than 500 facilities are identified with significant health and safety issues, but less than 20 percent are subject to additional oversight.  CMS maintains the list of facilities that perform poorly on the survey, but only public discloses which nursing homes are receiving the oversight. That’s despite the two groups “being indistinguishable” in terms of quality, according to the report.

Dr. Kate Goodrich, CMS’s chief medical officer, said this lack of surveillance is due to funding limitations and an increase in the number of long-term care facilities.  “That has made it challenging … to do all the work that is necessary to oversee these nursing homes,” said Goodrich. “But we do believe that if we had an increase in our budget, that we would be able to have more robust oversight with this increase in our workload.”

CMS selects facilities for the Special Focus Facility program, which provides additional oversight, with input from state officials. The federal agency said it asks a state which of several nursing homes most needs additional surveying, which occurs every six months.

CMS said the best way to evaluate a facility’s quality is its online comparison tool for nursing homes, which bases rankings on not only the health survey, but also on staffing levels and performance measures. It is possible for a nursing home to have a low survey score, but still rank well due to higher numbers in the other two categories.