Karen Ellen Lambert believes that her mother, Mary Ellen Cross, was abused while at a nursing home and that it may have caused her death. (Sean Stipp | Tribune-Review)
Story by BRIAN C. RITTMEYER and JULIA MARUCA
Oct. 29, 2023
Mary Ellen Cross lived some of the best days of her life each December when she spent hour upon hour baking cookies and wrapping gifts, carefully crafting what she hoped would be the perfect, magical Christmas for her family.
The baking began weeks in advance, sometimes with her eclectic playlist featuring Frank Sinatra, Herbie Hancock and Snoop Dogg blaring in the background.
• Some fear patient care threatened as staffing shortages plague nursing homes
• List of nursing homes cited for abuse can be incomplete, arbitrary, experts say
• Nursing home rating system criticized over reliability, accuracy
When the big day arrived, everyone had something under the tree — even the dogs, her “granddoggers,” who received sweaters Cross crocheted.
Those good days turned bad in May 2021. Old age took its toll, and Cross couldn’t return home after a hospital stay, forcing her move to Mt. Lebanon Rehabilitation and Wellness Center, said her daughter, Karen Lambert.
In the next year, Cross, who was frail, confused and at times combative, fell 35 times. She suffered cuts and bruises, sometimes requiring hospital treatment, according to a lawsuit Lambert filed against the facility after her mother died March 14, 2022, five days after her last fall. Cross was 79.
Experts say stories such as Lambert’s are jarring signs of the nation’s deteriorating long-term care industry and unprecedented staffing shortages rendering it incapable of handling the “silver tsunami” of older Americans needing nursing home services.
It’s a crisis poised to worsen in Pennsylvania as the state’s already significant elderly population skyrockets, with the number of adults 85 and older expected to double by 2030, according to the Pennsylvania Health Care Association, which represents nursing homes.
Those concerns are borne out in a Tribune-Review analysis of state and federal health and safety reports for 168 nursing homes in a 17-county region of Western Pennsylvania, as well as in documents from public and private sources and interviews with those on the front lines.
Among the Tribune-Review findings:
• Eighty-nine of the 168 facilities — 53% — were rated as “below average” or “much below overage” in reports by the federal Centers for Medicare and Medicaid Services, the agency providing coverage via the two insurance programs.
• Twenty-one of the nursing homes — about 13% — also appear on a list, little known by consumers, of facilities flagged by federal officials for abuse or neglect, some resulting in severe injuries and death, records show.
• Federal officials won’t detail specific events that landed the nursing homes on the abuse list, but records indicate serious incidents at those facilities. Among them: a patient who died from a head injury after being dropped, a quadriplegic resuscitated after her ventilator was accidentally disconnected and a nursing assistant who permitted a patient with the mental capacity of a 7-year-old to perform a sex act with him
• A review of national records shows Pennsylvania has had more abuse-related federal enforcement actions, or penalties, than all but six states. Only Illinois, California, Florida, Missouri, Ohio and Texas have had more. The punishments are related to a range of health and safety deficiencies and can include fines, denial of Medicare payments and removal from the Medicare program.
• Although some of the nursing homes have carried “much below average” or “below average” ratings for extended periods and have been flagged for abuse, no Pennsylvania nursing home licenses have been revoked in the past three years, according to the state Department of Health.
“They put her through hell,” Lambert said about her mother. “If one other family doesn’t have to go through what our family went through, then it’s (the lawsuit) worth it.”
Although Cross’ death certificate indicates she died from end-stage dementia, Lambert’s attorney, Kristin Kennedy, contends the repeated falls contributed to her death.
Officials at the Mt. Lebanon facility didn’t return calls seeking comment. During two phone exchanges, an employee who would not identify herself said “we don’t do interviews” before hanging up.
It wasn’t until after her mother’s death that Lambert learned of the nursing home’s “below average rating,” its poor state inspection reports detailing numerous injuries to patients and a 2022 federal indictment of the facility. That indictment involved one of its co-owners and four management employees on charges they falsified staffing records and submitted fraudulent billings there and at Brighton Rehabilitation and Wellness Center, site of one of the nation’s deadliest outbreaks of covid-19.
Lambert cringes at stories such as that of nursing assistant Solomon Rivers, who was charged early this year with permitting a resident with the mental capacity of a second grader to engage in a sex act with him. In addition, state inspection reports say the victim was left to wander in and out of patients’ rooms, touching them, exposing himself and masturbating in public and private areas.
Like many others interviewed for this story, Lambert, of Pittsburgh’s South Side, said she knew nothing about how to research a nursing home’s background, that federal ratings of nursing homes existed or that state inspection results are available from the facilities.
On its Care Compare website, the Centers for Medicare and Medicaid Services publishes the latest state health inspection results for all facilities certified to receive reimbursement from the government-backed insurance programs.
It offers overall ratings for each nursing home on a five-star system, with five stars awarded to the best-performing sites.
It’s also where facilities flagged for abuse are identified with a red hand icon.
Officials at the Centers for Medicare and Medicaid Services often were slow in responding to inquiries for this story. They requested anonymity when providing information, communicated almost exclusively through emailed statements and ignored requests for in-person or telephone interviews.
In an email, a spokeswoman said, “Care Compare provides consumers and their families an easy way to understand nursing home quality to make meaningful distinctions between high- and low-performing nursing homes.”
Asking that her name not be used, she said that by adding the abuse icon in 2019, “we believe the … icon helps consumers make more informed decisions about their health care.”
Staffing problems at state agencies performing inspections on which the federal ratings are based cast some doubts on the accuracy, completeness and timeliness of what appears on the Care Compare site, U.S. Sen. Bob Casey said.
“For a lot of nursing homes, it’s been more than a year since they’ve been inspected,” said Casey, Pennsylvania’s senior senator.
More than half of the nation’s state agencies that inspect nursing homes are reporting staffing shortages, he said, noting that Pennsylvania is included in that group.
Some states have brought back retired inspectors to fill gaps, he said.
When questioned about Casey’s remarks and other issues raised in this story, a spokesman for the state Department of Health responded by email, saying only that there are 132 full-time inspectors for Pennsylvania’s 700-plus nursing homes. That’s down from 134 in 2019. In addition, the state now employs 12 retired inspectors. The spokesman did not directly address Casey’s concerns.
Even with the available information, there are no guarantees of quality care, one expert said.
“All things being equal, I’d want a five-star facility for my loved one compared to a one-star facility. But that doesn’t necessarily mean every five-star facility is great, and it doesn’t necessarily mean every one-star facility is terrible,” said Pittsburgh attorney Robert Daley, a partner in the personal injury firm of Robert Peirce & Associates, well known for handling nursing home litigation.
“Don’t just send your wife, your mom, your dad to a facility without seeing it. If you walk by an activity room and everybody seems to be having a good time, people are laughing and smiling, the place is clean and everyone has smiles on their faces, it’s probably a good place,” he said. “If you walk though another place and people are sitting in corners not doing anything and the activity room doesn’t have anything in it, maybe it’s not a good place.”
Lambert recalls feeling pressured to move her mother from the hospital.
“The hospital gave me very little time,” she said. “You had to pick where to send her, and you had ‘X’ amount of hours to do so. Every place we picked was full. I learned also that, prior to covid, they would have to make like three calls. After covid, they had to make like 70 calls to find a placement.”
It’s a painful quandary many face.
“Oftentimes, they’re rushed into it. They were in the hospital for a surgery … and they need to find a place for rehabilitation, and the hospital gives them a day or two to find a place,” said Ryan Duty, an attorney with the Pittsburgh office of the Senior Justice Law Firm.
A scarcity of nursing home beds is expected to grow exponentially unless dramatic change occurs, one expert warned.
Since the start of the pandemic, more than 450 nursing homes have closed nationwide, displacing more than 18,000 residents, according to Save Our Seniors, an advocacy group.
In Pennsylvania, 19 facilities have closed since 2021, according to the health department.
For Robert Wyner of Monroeville, learning that his mother’s Squirrel Hill facility, Charles Morris Nursing and Rehabilitation Center, would shut down in 2021 was “devastating.”
After two moves, Wyner’s 99-year-old mom landed at her current facility. Leaving the familiar surroundings, staff and friends at Charles Morris took an emotional toll on her, Wyner said.
“It’s devastating to have to move a loved one who needs care into another facility. … She was getting such good care where she was,” Wyner said. “(It was) like the world was going to end.”
“We are in no way prepared for what will happen in 10 years or what will happen over the course of the next year,” said Zachary Shamberg, president and CEO of the Pennsylvania Health Care Association. “We’re going to see more backlogs in hospitals. … We’re going to see more and more seniors in Pennsylvania become homeless if nursing homes are forced to close their doors.”
About 27% of Pennsylvania’s population will be 60 or older by 2030, an increase of almost 28% from 2012, according to U.S. Census figures.
Reversing unprecedented staffing shortages will be essential in serving that population, Shamberg said.
A survey by Shamberg’s group this year showed that more than 50% of nursing home officials had beds they couldn’t use because they didn’t have enough staff and that on any day more than 2,000 people in the state were on nursing home waiting lists.
A lack of competitive pay versus other health care jobs and the grueling, physical demands of long-term care add to the problem, experts said.
The annual median wage for registered nurses working in general/surgical hospitals is $90,600, according to the U.S. Bureau of Labor Statistics. The median salary for registered nurses working in nursing homes is $77,190.
Certified nursing assistants working in hospitals earn a median salary of $37,820 a year, while those in nursing homes earn $35,160 a year.
Experts say reports of abuse and neglect often are linked to staffing shortages.
“These people have a lot of needs in terms of their activities of daily living and daily function: bathing, going to the bathroom, showering, eating. All the things we take for granted, a lot of nursing home residents can’t do for themselves anymore,” Duty said. “When those needs are not met, that’s neglect and that’s a form of abuse.”
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Many inspection reports cite patients suffering serious injuries while being moved by one worker instead of two as prescribed in their care plans.
Duty said he has had clients with fractures from falls, pressure sores that extended to the bone and infections that could have been prevented.
Although many facilities on the abuse list have one-star (well below average) or two-star (below average) overall federal ratings, a few have three-star and four-star (average and above-average) ratings, records show.
That was the case at Longwood at Oakmont, which has a four-star rating.
A report details an incident at Longwood in which a resident’s leg was caught under a bed while she was being transferred from a wheelchair to the bed. The resident suffered a broken leg when only one worker was moving her instead of two, as outlined in her care plan. The employee was terminated, the report states.
At Oakwood Heights of Oil City, with a three-star rating, state inspectors detailed an incident in which a resident died from “complications of blunt force trauma to the head” five days after she fell while an aide was tending to her.
“We take these matters very seriously and fully investigate any situation in which abuse may have occurred or been alleged. In addition, we ensure that all team members receive ongoing education regarding identification, reporting and prevention of abuse and neglect,” according to an emailed statement from Presbyterian SeniorCare, which operates Longwood at Oakmont and Oakwood Heights.
Inspection reports offer graphic details about other life-threatening incidents.
At Cranberry Place, a nonprofit facility operated by UPMC Senior Communities that carries a one-star rating, a September 2022 report details an incident in which a quadriplegic’s ventilator was accidentally disconnected. The patient became unresponsive and had to be resuscitated.
UPMC oversees three homes — Canterbury Place, Cranberry Place and Seneca Place — that were flagged for abuse or neglect.
“We address any and all incidents that might compromise our residents’ care and comfort and adhere to all government self-reporting requirements and regulations,” UPMC spokeswoman Ashley Trentrock said in an emailed statement. “We review the training and educational needs of staff on an ongoing basis to prevent situations that could potentially lead to any harm to the residents in our care.”
The Allegheny County-operated John J. Kane Regional Center in Ross, which carries a two-star rating, recently was flagged for abuse, records show.
Dennis Biondo, director of the county’s four Kane centers, said the abuse flag stems from a resident injured in a fall while being moved improperly. A report notes the employee involved was fired but does not indicate the facility’s correction plan.
A spokeswoman for the Centers for Medicare & Medicaid Services said correction plans are available upon written request.
Platinum Ridge Center for Rehabilitation and Healing in Brackenridge, which carries a one-star rating, also has been flagged for abuse, the result of a November 2022 incident, administrator Matthew Tack confirmed.
A female resident overheard two nursing assistants making fun of her because she is blind, according to a state report. The woman then soiled herself but told the workers she didn’t want them to touch her. One of the workers jerked her blanket away, ripped open her disposable brief and roughly threw her from one side to the other so abruptly that the woman thought she was going to roll off the bed, the report indicates.
Tack said the worker was from a staffing agency and “we told the agency she’s no longer welcome back here.”
They are stories all too familiar to Margaret Barajas, the state’s long-term care ombudsman, who manages about 350 local ombudsmen — some paid, some volunteer — who visit nursing homes to act as advocates for residents.
Many of those patients are desperately ill and alone, with no family to visit or look out for them, she said.
“We often hear people feel like chores. You hit your call bell button, and somebody calls, and they’re hurried. ‘What do you want now?’ ” she said. “What it really does is it projects on that resident that they’re helpless and they’re really kind of a nuisance.”
All states are responsible for inspecting and certifying that nursing homes meet the requirements to receive payment from Medicare or Medicaid for their patients. These certifications are subject to approval by the federal Centers for Medicare & Medicaid Services, which, based on the inspections, rates the facilities on a five-star system as follows:
★★★★★: Much above average
★★★★: Above average
★★★: Average
★★: Below average
★: Much below average
Based on those inspections, CMS also flags nursing homes for incidents of abuse or neglect. As of October 2023, there are 21 Southwestern Pennsylvania nursing homes on that list:
Arbutus Manor, 207 Ottawa St., Johnstown 15904
Overall rating: ★★
Belair Healthcare and Rehabilitation Center, 100 Little Road, Lower Burrell 15068
Overall rating: ★★
Canterbury Place, 310 Fisk St., Pittsburgh, 15201
Overall rating: ★★
Cheswick Rehabilitation and Wellness Center, 3876 Saxonburg Blvd., Cheswick 15024
Overall rating: ★★
Cranberry Place, 5 St. Francis Way, Cranberry 16066
Overall rating: ★★
Harmar Village Health and Rehabilitation, 715 Freeport Road, Cheswick 15024
Overall Rating: ★
Hempfield Manor, 1118 Woodward Drive, Greensburg 15601
Overall rating: ★★
Jefferson Hills Healthcare and Rehabilitation Center, 448 Old Clairton Road, Clairton 15025
Overall rating: ★★
John J. Kane Regional Center — Ross, 110 McIntyre Road, Pittsburgh 15237
Overall rating: ★★
Longwood at Oakmont, 500 Route 909, Verona 15147
Overall rating: ★★
Mt. Lebanon Rehabilitation and Wellness Center, 350 Old Gilkeson Road, Pittsburgh 15228
Overall rating: ★★
Mt. St. Macrina Manor, 520 W. Main St., Uniontown 15401
Overall rating: ★★
Oakwood Heights of Presbyterian Care, 10 Vo Tech Drive, Oil City 16301
Overall rating: ★★★
Platinum Ridge Center for Rehabilitation and Healing, 1050 Broadview Blvd., Brackenridge 15014
Overall rating: ★
Quality Life Services of Mercer, 8221 Lamor Road, Mercer 16137
Overall rating: ★★
Seneca Place, 5360 Saltsburg Road, Verona 15147
Overall rating: ★★
Squirrel Hill Wellness and Rehabilitation Center, 2025 Wightman St., Pittsburgh 15217
Overall rating: ★
Townview Health and Rehabilitation, 300 Barr St., Canonsburg 15317
Overall Rating: ★★
Transitions Healthcare — North Huntingdon, 8850 Barnes Lake Road, North Huntingdon 15642
Overall Rating: ★★
Twin Lakes Rehabilitation and Healthcare Center, 227 Sand Hill Road, Greensburg 15601
Overall rating: ★
Uniontown Healthcare and Rehabilitation Center, 129 Franklin Ave., Uniontown 15401
Overall rating: ★★★
To search for information about a specific nursing home, visit the Medicare website.
Brian C. Rittmeyer and Julia Maruca are Tribune-Review staff writers. You can contact Brian at brittmeyer@triblive.com and Julia at jmaruca@triblive.com.