Jan. 17, 2013: This article has been updated to reflect more recent numbers from the ProPublica database and to clarify exactly how many nursing homes are within the city limits of Pittsburgh.
Jan. 7, 2013: A correction has been made to this article.
Richard VanHalanger, 83, was independent when he walked into the Cedars of Monroeville nursing home in 2006 for two weeks of rehabilitation before heart surgery.
He drove. He attended church. He played golf.
By the end of two weeks at the home, his daughter, Valerie Warning, said he had lost both strength and pride because of the staff’s actions:
Nurses and aides had used restraints to keep her father in a wheelchair and routinely disconnected call bells he could use to signal for help, she said. Instead of walking with him to the restroom, they forced him to wear diapers and left them soiled, leading to rashes and sores.
After five months in the home, VanHalanger was admitted to the hospital for pneumonia and died a week later.
A lawsuit alleging that VanHalanger received insufficient care by an untrained staff at Cedars was settled last year and his family was awarded $250,000; the nursing home denied any fault and said the allegations were “unfounded.”
“It’s still hard on me because I made the decision to put him in that home,” Warning said.
Richard VanHalanger, at age 83, with his grandson, Chris Warning, at Chris's graduation from Gateway High School in May 2006. (Photo courtesy Valerie Warning)
Pennsylvania, with the fourth highest percentage of people 65 and older in the United States, has an extensive network of senior care facilities. As families find their parents or grandparents needing care, they are thirsty for information about nursing homes, which cost an average of $8,000 a month in the state, and their services and deficiencies.
This summer, the U.S. Centers for Medicare and Medicaid Services (CMS) answered the calls of elder advocates to publish online the full text of federal nursing home inspection reports. So far, it has uploaded inspections for about three years.
PublicSource analyzed that newly available information with the help of a program developed by Manhattan-based ProPublica.
It learned that Pittsburgh’s nursing homes – those within the official city boundaries -- have a higher average rate of deficiencies than those in the more populous Philadelphia.
In roughly three years of inspections, 18 nursing homes in Pittsburgh were issued 255 deficiencies. That’s an average rate of 4.72 violations per nursing home each year.
Philadelphia nursing homes have an average rate of 3.28 deficiencies per nursing home annually. Inspectors reported 403 violations for Philadelphia’s 41 nursing homes.
The data for both cities was for August 2009 until October 2012.
The 36 nursing homes in Pittsburgh and its suburbs garnered a higher number of deficiencies than the 41 homes in Philadelphia.
Inspectors assigned 479 deficiencies to the Pittsburgh-area nursing homes within the three years examined, giving it an average rate of 4.44.
The national average is six to seven deficiencies per inspection, according to CMS. (The deficiencies are graded A through L, with the worst problems receiving the L grade.)
Neither Pittsburgh nor Philadelphia nursing homes had a violation higher than a G, which meant no residents were in immediate jeopardy. A G deficiency means “actual harm occurred,” but it was an “isolated” incident.
However, six nursing homes in Allegheny, Westmoreland and Lawrence counties – all in southwestern Pennsylvania -- accounted for the majority of the state’s worst violations, which meant residents in those homes were in “immediate jeopardy.”
To be sure, Pennsylvania fares well in comparison with many other states. Its facilities have fewer serious deficiencies than 45 states, according to a ProPublica analysis of the federal data.
Nursing homes in Pennsylvania are required to have the most recent inspection report on hand when the public asks for them and the narratives have long been available online, but people who need the information don’t always know what’s available and the state databases are difficult to navigate.
Warning, for example, said she was never informed that the inspection reports from the Pennsylvania Department of Health were online when she was looking for a place for her father.
“I was shown and told only what would sell me on putting my father there,” she said.
Information that family members can access and understand helps to protect the elderly, said Karen Chenoweth, an advocate with the Philadelphia-based Center for Advocacy for the Rights and Interests of the Elderly (CARIE).
“We are giving our most vulnerable loved ones to them and trusting they will do the best for them and not their profit margin,” said Chenoweth, who supervises online counseling services for CARIE. “We need the information out there for everyone to scrutinize their actions.”
Problems in Western Pennsylvania
The Cedars of Monroeville, where Warning’s father lived, was one of six nursing homes in southwestern Pennsylvania that made up the majority of the state’s most severe violations.
The five other facilities – located in Allegheny, Westmoreland and Lawrence counties -- were Caring Heights Community Care & Rehab Center in Coraopolis, Edison Manor Nursing & Rehabilitation Center in New Castle, West Haven Manor in Apollo, Mountainview Specialty Care Center in Greensburg and Latrobe Health and Rehabilitation Center in Latrobe.
Cedars received one K rating in the past three years, according to the PublicSource analysis. In June 2010, a steam table that contained water as hot as 185 degrees was regularly left simmering in a kitchen open to seven cognitively impaired residents, the inspection report stated.
The facility was fined more than $10,000 for that deficiency and another violation, according to the Medicare website. It corrected the hazard.
The Mountainview Specialty Care Center in Greensburg and the Latrobe Health and Rehabilitation Center in Latrobe earned grades of L in May 2011 and May 2012, respectively.
Mountainview’s failing grade came because the facility left gates and doors unlocked at all times, leaving 117 residents vulnerable, according to the inspector’s report.
The center implemented a locking system the day after the report.
“We are dedicated to providing our residents with high quality, compassionate care and to providing peace of mind to their families and caregivers,” Mountainview Administrator Kris Hoke wrote in an email to PublicSource.
The 107-bed Latrobe center was given a D grade in November 2011 for a dirty frying pan and for failing to help a resident move closer to the table.
But just six months later, the home received an L after inspectors uncovered nearly $77,000 in unpaid bills for essential services such as food, medical supplies, and water.
The center now makes payments directly rather than through its corporate office, according to Department of Health records. The Latrobe facility did not respond to multiple calls requesting comment.
The availability of the inspection reports gives a broader perspective on the ratings on the Medicare website.
For example, the Latrobe center has below-average ratings from CMS in all categories but its staff, which is rated above average. But, consumers could read a detailed June 2011 inspection report for more information.
Help in the search for the right nursing home
The Pennsylvania Department of Health allows consumers to search for nursing homes by city, county and zip code as well as facility size and ownership. Visit their site.
Consumers may contact a local Area Agency on Aging to learn about the facilities in their communities. Find the nearest agency.
Medicare’s “Nursing Home Compare” program features a five-star ranking scale and the information behind the ratings, such as staffing, inspections and other quality measures. Visit their site.
News website ProPublica.org created “Nursing Home Inspect” so consumers can search the details of inspection reports, a feature the government website does not have. Visit their site.
At that time, the center was cited with a D for failing to report an allegation of physical abuse to the Department of Health. The report stated that a nurse’s aide was accused of throwing a resident into bed, causing him to hit his head on a cement wall, and tossing a diaper into the face of another resident and telling him “he could change himself.”
There was no determination of whether the allegation was true in the report.
Every nursing home in the state is visited by a long-term care ombudsman at least once a year and more often if it is considered troubled, said Wilmarie Gonzalez, the director of the Advocacy and Protection Bureau at the Pennsylvania Department of Aging.
She suggests taking the time to contact the nearest Area Agency on Aging to speak with an ombudsman about nursing home choices.
“They can talk about conditions and what homes might meet particular needs,” she said. That information about the quality of care is “going to be what makes your loved one feel safe and protected.”
Some nursing home officials and experts said that inspection grades can be misleading and shouldn’t be the only measure of a facility.
A G grade in one instance was issued when a resident went missing for a half-hour and was found cut and bruised at the bottom of a concrete stairwell with his wheelchair on top of him; at another nursing home, mouthwash and a disposable razor left on the sink of a shared bathroom constituted a G.
Inspections -- also referred to as surveys by the industry -- provide a sometimes biased glimpse of nursing facilities, said Ron Barth, president and CEO of LeadingAge PA, a Mechanicsburg-based trade association that represents not-for-profit senior service providers.
“We have a really broken survey system,” he said. “The survey really depends on the surveyor, the day and the mood the surveyor is in.... It really doesn’t do a good job of assessing quality. What it does do a
good job at is playing ‘gotcha.’ ”
Looking for trends in deficiencies may prove helpful, Barth said, but the best research comes from visiting the facilities.
“See for yourself,” Barth said. “Talk to the residents, visit at meal time, look at how much staffing they have. Are people occupied or are they sitting around looking lost?”
Watching for mistakes
Valerie Warning picked Cedars of Monroeville for her father because doctors recommended its rehabilitation program, she said. She thought it would provide relief.
Instead, she said she felt compelled to stay at the facility at all hours because of instances such as when her father was given his roommate’s medication or when she felt there was a disconnect between his treatment and what was stated on his chart.
An April inspection at Cedars yielded four deficiencies. Of them, the reports show a resident got a blood-clotting medication that was not prescribed for him and another’s care plan was not updated.
The facility re-educated its nurses on medication procedures and each care plan was reviewed, according to the Department of Health.
“The most recent inspection reflects the current status of compliance with regulations,” wrote John Silvestri, Cedars’ lawyer, in an email. “Any issues raised by prior inspections, that were appropriately raised, were corrected.”
Warning said any transparency is helpful.
“I didn’t go after Cedars for a financial gain,” she said. “I wanted them to be exposed for what they did. There were, and I bet there still are, so many other families that complained, but they were afraid because they couldn’t be there like I was.”
Ultimately, Warning felt responsible, in a way, for her father’s death.
“This was a time for me to show the appreciation for everything he did for me, and that’s why I still feel guilty,” she said.
Correction: A previous version of this story incorrectly stated the rate of nursing home violations in Pittsburgh.
Reach Halle Stockton at 412-315-0263 or firstname.lastname@example.org.
Nursing Home Violations
A 10-county region in southwestern Pennsylvania contains 142 nursing care facilities. Click on a nursing home in your area to learn how many violations it has received and to view the inspection reports, which explain how the rules were broken. Reports refer to mandated annual inspections and complaint investigations conducted by the state Department of Health; the reports have been compiled by Medicare.gov and news website ProPublica.org.
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Sources: Centers for Medicare and Medicaid Services and ProPublica.
Map by Alexandra Kanik