Some Georgia nursing homes have a problem. More of them than the public knew.
Last week, the U.S. Senate released the names of nursing homes that have been on a troubling watch list. Up to now they've been kept private. The list is of "candidates" for a program giving special focus to troubled nursing homes.
The only reason they’re candidates and not special focus facilities already is that the federal government says it doesn’t have enough resources to focus on all the homes that need it, according to the Senate report. It can only handle 88 nationwide. The other 400 candidates for the list remain candidates until a space opens up, though their need for oversight is indistinguishable from the others, the report said. Yet the candidates’ names were still kept secret until last week.
Their inspection reports are listed along with all other nursing homes on the federal government's Nursing Home Compare website, at https://www.medicare.gov/nursinghomecompare/search.html.
The facilities are judged in six categories: health inspections; fire safety inspections; staffing; quality of resident care; penalties; and an overall rating. They’re given one to five stars, with five being the best. All Georgia candidates for the Special Focus list had one star as an overall rating when The Atlanta Journal-Constitution looked them up this week.
Tony Marshall, the president of the Georgia Health Care Association, a nursing homes advocacy group, pointed out that the star ratings focus on a limited list of items and can miss good things happening in a nursing home.
For example, two of the Georgia facilities have been given four out of five stars for quality of residents’ care. Other issues dragged down their overall marks, such as health inspections or a low number of staff. It’s a tough hiring market across the state, Marshall said.
The inspection reports show just one moment in time, he added, and don’t note any improvement that’s happened since then.
“Our membership certainly support having increased levels of transparency,” Marshall said. “We would also encourage individuals to actually visit the centers, talk to the center staff. There’s a lot of different ways to measure a building.”
Indeed, some of the nursing homes on the watch list have been sold this year to new owners, people hoping to clean up operations. One of those under new management is Pinehill Nursing Center, which Marshall said is working to fix its problems.
When the Senate did its work, Pinehill was Georgia’s only nursing home with a spot on the Special Focus list. As of now, a second Georgia center has been named a Special Focus Facility, Clinch Healthcare Center in Homerville. Clinch has now renamed itself River Brook Healthcare Center.
An additional eight homes are “candidates” and would go on the Special Focus list if space opens up.
For many of the details listed below, inspectors say they’ve worked with the facilities who have agreed on fixes or already made them.
CANDIDATES FOR SPECIAL FOCUS FACILITY
Brentwood Health and Rehabilitation, Waynesboro
Had three stars out of five for quality of residents’ care and one for the health inspection rating.
Detail: An inspection report states: “It was determined that the facility failed to provide supervision to prevent accidents.”
East Lake Arbor, Decatur
Had three stars out of five for quality of residents’ care and one for the health inspection rating.
Detail: In September, inspectors watched staff fail to sanitize glucometers, devices that measure blood sugar, before and after use with several patients. Staff said they didn’t remember receiving training on how to clean it.
East Lake Arbor said in a statement that the facility changed hands at the end of 2019 and has improved.
LaGrange Health and Rehab
Had four stars out of five for quality of residents’ care and one for the health inspection rating.
Detail: A patient had signed an advance directive upon admission, but when asked directly, she gave uncertain answers about whether she would want to be resuscitated and said she couldn’t remember signing it. Inspectors asked the doctor whether the patient was competent to sign the directive at the time, and the doctor said she must have been since she was allowed to sign it. In the end, the advance directive wasn’t properly filed, and staff said they didn’t realize she had it so they said they would have resuscitated her anyway.
Northeast Atlanta Health and Rehabilitation Center on Johnson Ferry Road
Had four stars out of five for quality of residents’ care and one for the health inspection rating.
Detail: In an October inspection a resident stated she frequently went to bed without eating dinner, due in part to being served food she did not like. Residents were supposed to be offered meal choices, but some didn’t get to choose if they didn’t make it to the dining hall. The facility’s report has improved since its May 2017 inspection, when it was given 23 citations.
Pleasant View Nursing Center, Metter
Had two stars out of five for quality of residents’ care and one for the health inspection rating.
Detail: Last year staff failed to meet a state requirement to report a patient’s abuse by another patient. When the patient was abused again four months later, and then again, they reported those incidents.
Pruitthealth — Blue Ridge
Had one star out of five for quality of residents’ care and one for the health inspection rating.
Detail: A patient fell and broke an ankle. The facility failed to determine the root cause of the fall, to put measures in place to try to prevent further falls or to document a resulting updated care plan. The patient fell again two days after returning from the hospital, then nine days later, then five days after that, then again the following month.
Westminster Commons, Atlanta, near Piedmont Park
Had four stars out of five for quality of residents’ care and one for the health inspection rating.
Detail: Some patients had advance directives, which generally mean a person does not want to be resuscitated; but the facility’s official tally indicated it had no advance directives for patients. One patient’s was misfiled in the clinical record.
Windermere Health and Rehabilitation Center, Augusta
Had one star out of five for quality of residents’ care and one for the health inspection rating.
Detail: No health deficiencies found in the last inspection, conducted in February. That’s an improvement since February 2018, when inspectors found 11 health deficiencies, including that the facility’s doctor didn’t know he had a new patient admitted for six days. It had 15 fire safety deficiencies though, compared with a national and state average of less than three.
SPECIAL FOCUS FACILITIES
Pinehill Nursing Center, Byromville
No star ratings were available because it’s on the Special Focus list.
Detail: During an inspection in December a strong odor of urine permeated the building. Housekeeping reports alleged that during late shifts urine was being left in some bathrooms after patients urinated and stooled on the floor. The facility needed to replace the floors, but it wasn’t getting done as top managers cited the need for approval or price quotes or reports.
Another detail: In June 2018 a resident climbed out her window and staff didn’t know where she was. Two nursing assistants found her half an hour later standing on railroad tracks with a train approaching, shaking and covered in grass. They ran to get her off the tracks and got her to their car as the train sped by.
River Brook Healthcare Center, appears under original name of Clinch Healthcare Center, Homerville
No star ratings were available because it’s on the Special Focus list.
Detail: Confusion arose about whether a patient was staying at the facility or looking to move. The data coordinator said she “misunderstood and thought that all the resident specific focus, goals and interventions would also populate from the online system, but they didn’t.” She had not gone back to see which care plans had been properly updated.
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