List of nursing homes cited for abuse can be incomplete, arbitrary, experts say

A review of state nursing home inspection reports reveals no mention of two patients who died about a year ago at Quality Life Services-Chicora after being given fatal doses of insulin.

• Staffing shortages leave nursing homes overwhelmed, patients vulnerable, experts say

• Some fear patient care threatened as staffing shortages plague nursing homes

• Nursing home rating system criticized over reliability, accuracy

Registered nurse Heather Pressdee, who is charged in the killings, told investigators “she felt bad for their quality of life” and “hoped they would just slip into a coma and pass away,” according to a criminal complaint.

Facility inspection reports filed since the patients’ deaths offer details of incidents such as one in which a patient wandered outside the Butler County home, but no specific mention of the two fatalities or a third man who recovered after being given a toxic dose of insulin in August 2022.

Also not mentioned in inspection reports is what criminal investigators called a pattern of disciplinary actions against Pressdee, 41, of Harrison, for abusing patients and staff at 11 other care facilities that resulted in her firing or resignation.

The state inspection reports appear on the federal Centers for Medicare and Medicaid Services’ public-facing Care Compare website touted by a spokesperson as a top resource for consumers researching nursing homes. The reports also appear on the state Department of Health website where consumers are urged to review documents to a gain a picture of a facility’s quality of care.

But the Pressdee case is one example of why some experts say state inspection reports aren’t always an accurate or timely snapshot of what’s happening at such facilities.

As of this month, there still was no mention of the Chicora case on the federal or state sites.

“There was no specific complaint filed with the department that would have prompted an automatic survey/investigation,” said Mark O’Neill, a spokesman with the state health department, which conducts the inspections. However, he said, “the department received information in December 2022 that led to an immediate investigation and subsequent referral, with the assistance of the Department of State, to the office of Attorney General.”

Pressdee was charged May 24 by the state Attorney General’s Office with two counts of criminal homicide, one count of attempted murder and numerous related charges.

The ongoing investigation prevents details about the case from being released, said Mary Susan Tack-Yurek, chief quality officer for Quality Life Services.

“As a family-owned organization that prides itself on providing safe and compassionate care, Quality Life Services is shocked and devastated to learn that the charges brought against Ms. Pressdee by the Attorney General’s Office include alleged illegal activity that occurred at our QLS-Chicora facility” she said.

The company will continue to work with the Attorney General’s Office, she said.

Earlier this month, Pressdee was identified in a wrongful death lawsuit filed against Belair Healthcare and Rehabilitation Center of Lower Burrell that includes allegations she administered a deadly dose of insulin to Marianne Bower, 68, a resident with multiple sclerosis. Bower died Sept. 28, 2021, 15 months before the deaths of the two residents at the Chicora facility.

To date, allegations regarding Bower’s death are civil matters and no criminal charges have been filed against the former nursing supervisor in connection with that case.

Although inspection reports for some other facilities include details surrounding some residents’ deaths, reports for Belair from 2021 through 2023 make no specific mention of Bower’s case.

In their reports from that time frame, inspectors documented a “pattern” of staff failing to assess and monitor residents’ high blood sugar levels and report those elevated readings to physicians.

The lawsuit against Belair indicates that inspectors talked with Pressdee, who admitted she did not contact the physician for a patient with high glucose levels.

“Whenever we identify a patient-care issue or if state surveyors have a concern, we work diligently with our internal team and the state to address the matter in a plan of correction, employee training and other measures to ensure resident wellbeing and safety,” Belair spokeswoman Julie Beckert said in a statement. “We also work hard to communicate regularly with residents and families to ensure we are meeting their needs. We have processes in place to vet potential employees prior to hiring, and then we provide orientation and training upon hire and throughout their careers with us.”

An attorney representing the Bower family said the family learned only recently from an agent with the state Attorney General’s Office that Pressdee confessed to administering the lethal dose of insulin to Bower, who was not diabetic. Robert Peirce III, the attorney representing Bower’s son, Scott Hess of Buffalo Township, made the statement during a news conference announcing the lawsuit against Belair.

Officials from the Attorney General’s Office would not comment on Peirce’s statement.

The abuse flag

Federal officials have flagged Belair for abuse, according to the Care Compare website, but they would not disclose why that action was taken.

Belair’s profile on the website was updated in June based on a surveyor’s review of an event in October 2022, Beckert said. It did not involve resident harm, she said.

“When facility staff was made aware of the event, they promptly investigated and resolved the situation and self-reported to the Pennsylvania Department of Health. Belair is currently in compliance with all federal and state regulations,” she said. “We have used this as an opportunity to educate our team, learn from any mistakes and ensure we have appropriate systems and processes in place to provide quality care and maintain patient safety.”

An investigation regarding Pressdee is ongoing, according to officials with the state Attorney General’s Office.

Pressdee’s Chicora case unfolded just months before U.S. Sen. Bob Casey called into question the accuracy and timeliness of state inspection reports posted on the federal website, stating too much time elapses between inspections to give families a true snapshot of what’s happening at the facilities.

Those lapses also come into play with the federal government’s flagging of nursing homes for abuse, experts said. That action sometimes is arbitrary and often not used when circumstances clearly call for it, those experts believe.

Despite the deaths of the two patients, the Chicora facility is not currently flagged for abuse on the federal website, records show.

The most recent inspection at the Chicora facility did not warrant flagging it for abuse, adding that criminal charges and state actions often occur separately from federal action, a spokesperson from the Centers for Medicare and Medicaid Services said.

Because federal officials will not specify why a facility is flagged for abuse, it’s not known whether the Pressdee matter or a separate case in which a male nurse pleaded guilty in January 2022 to indecent assault of two patients played into the decision.

There sometimes is a lag between when abuse happens in a nursing home and when the abuse icon appears on the federal website, if it appears at all, said Ryan Duty, an attorney with the Florida-based Senior Justice Law Firm.

“The oversight from the (state) Department of Health is imperfect. Things aren’t caught all the time,” he said. “I have cases and clients where what happened to them qualifies as abuse, but the nursing home was never cited for it, even if the family complained about it to the Department of Health.”

It is unfair when facilities are flagged because of a “single, isolated incident,” said Zachary Shamberg, president and CEO of the Pennsylvania Health Care Association, which represents nursing homes.

“An isolated incident reported by a survey does not tell a complete story,” he said.

The association has seen the abuse icon remain on a facility for up to two years, Shamberg said.

“Even if a provider takes steps to fix that issue or to terminate an employee, that abuse icon may remain,” he said.

The Centers for Medicare and Medicaid Services’ one-through-five star rating system also can present a false image of a home’s quality of care, said Robert Blancato, national coordinator of the bipartisan 3,000-member Elder Justice Coalition advocacy group.

“If you get your rating in January, it’s good for the year. If in June your place starts falling apart, you’re still going to be listed as a five-star facility,” he said.

The Chicora facility currently carries a three-star rating, while Belair has a two-star rating, records show.

The federal website presents just of a sliver of information about what occurs in nursing homes, one expert said. That results in consumers receiving an inaccurate view of the quality of care.

“Not every fall that occurs in a nursing home you’re going to see in a survey. You’re going to see very few of them,” said Michael Collis, an attorney with the Pittsburgh office of Murray, Stone & Wilson law firm. “It’s the tip of the iceberg.”