By Billy Kobin, Louisville Courier Journal
Six Kentucky nursing homes, including two Louisville facilities, have been named in a U.S. Senate report on nursing homes with a “persistent record of poor care.”
Pennsylvania’s U.S. Sens. Pat Toomey, a Republican, and Bob Casey, a Democrat, released the names of nearly 400 nursing homes nationwide with poor safety records that, until Monday, had not been publicly identified.
The Kentucky nursing homes included in the list are:
- Klondike Center, Louisville
- Springhurst Health and Rehab, Louisville
- River Haven Nursing and Rehabilitation Center, Paducah
- Woodcrest Nursing and Rehabilitation Center, Elsmere
- Mountain Manor of Paintsville, Paintsville
- Twin Rivers Nursing and Rehabilitation Center, Owensboro
Complaints at the Kentucky nursing homes include residents not receiving their medication on time, a staff member allegedly sexually assaulting a patient, and unlocked medication carts sitting unattended in hallways.
Toomey and Casey released the names after questioning why the Centers for Medicare and Medicaid Services only publicly shares a smaller list of about 80 nursing homes that investigators frequently check on to resolve documented issues.
Those facilities are designated as “Special Focus Facilities” and identified on the federal Nursing Home Compare website with a small yellow triangle.
They can be cut off from Medicare and Medicaid if they fail to make improvements.
Owensboro’s Twin Rivers Nursing and Rehabilitation Center is the only Kentucky facility designated as one of “Special Focus Facilities,” according to the report that was shared with the Senate Special Committee on Aging.
The expanded list of about 400 nursing homes that Toomey and Casey revealed Monday includes “Special Focus Facility candidates” that have a “persistent record of poor care.”
These additional facilities, however, are not deemed “Special Focus Facilities” because of limited resources at the Centers for Medicare and Medicaid Services, according to the report.
Federal budget cuts in 2014 limited the number of nursing homes the agency can put in the oversight program, Medicaid Services Administrator Seema Verma said in a May letter to Casey.
But Toomey and Casey described the “SFF” candidates as “nearly indistinguishable” from the smaller group of about 80 nursing homes.
According to the report, the only parties that know if a nursing home is a SFF candidate are Centers for Medicare and Medicaid Services, the state in which the candidate is based and the facility itself.
SFF candidates do not face additional oversight and are not “subject to more rigorous enforcement actions, additional disclosure or reporting requirements,” the report states.
In addition, CMS does not have a way to add a candidate to the more rigorous SFF program “if a particularly egregious incident occurs,” according to the report.
The senators’ report also found the Centers for Medicare and Medicaid Services has failed to consistently update the Nursing Home Compare site and include “detailed information or context” on the SFF program.
“There is no information on Nursing Home Compare explaining the reason for a facility’s participation in the program, the length of time it has been in the program or whether it has improved,” the report stated.
About 1.3 million Americans are nursing home residents, cared for in 15,600 facilities, according to the Centers for Disease Control and Prevention.
In April, CMS identified about 3% of them as problematic in one of two categories, according to the report, after Casey and Toomey requested the list of problematic nursing homes one month before.
“When a family makes the hard decision to seek nursing home services for a loved one, they deserve to know if a facility under consideration suffers from systemic shortcomings,” Toomey said.
Problems at Louisville nursing homes
Representatives with Klondike Center and Springhurst Health and Rehab did not immediately return requests for comment.
On the federal Nursing Home Compare website, Klondike Center, 3802 Klondike Lane, received a rating of “Much Below Average.”
Among the complaints against Klondike Center detailed in federal reports is a failure by staff in May 2018 to immediately notify a resident’s doctor when needed medication was not available to treat the resident.
The resident “had periods of confusion and an elevated ammonia level during the time when the medication was not administered,” according to the report.
Klondike Center’s failure to have “an effective system in place” to ensure physicians were notified when residents did not receive their medications “has caused or is likely to cause serious injury, harm, impairment or death to a resident,” the report noted.
In August 2018, a resident accused a male staffer at Klondike Center of sexual assault. Investigators determined the facility did not remove the alleged perpetrator from his role to “prevent the potential for further abuse.”
Klondike Center also failed to train staff on abuse prevention after the allegation, according to the report.
The nursing home was hit with a $13,627 fine in November 2018 and a $104,878 fine in October 2017, according to records.
Springhurst Health and Rehab, 3001 N. Hurstbourne Parkway, also received a one-star rating on Medicare.gov and has received numerous complaints in the past few years.
In January, investigators said a medication cart was left unlocked and unattended with two drawers open in the middle of a hallway.
Investigators also described in undated incidents how open food items with no dates or labels and expired food and drinks were found in Springhurst Health and Rehab.
A walk-in freezer had no thermometer and chemicals were stored in areas where food was prepared, according to reports.
Springhurst Health and Rehab has received 23 health citations, according to its Nursing Home Compare page, well above the average of 5.3 citations given to facilities in Kentucky and 7.9 given nationwide.
The nursing home was hit with fines of $250,023 in May 2018 and $88,021 in May 2017, according to the Nursing Home Compare website.
River Haven Nursing and Rehabilitation Center in Paducah also was mentioned among cases of nursing home neglect and abuse in the Senate report.
One resident at the facility who suffered from a burn wound and was receiving treatment that included a skin graft did not have their “dressing changed or showers administered as ordered,” according to the report.
State investigators at the Paducah facility found the individual “lying in bed with a large amount of green drainage on (their clothing) and a pool of green drainage on the bed sheets,” the Senate report said.
The resident told investigators they were not sure the last time their clothing had been changed.
“As evidenced by this report, oversight of America’s poorest quality nursing homes falls short of what taxpayers should expect,” the senators concluded.