The public never found out that inspectors cited another New Jersey nursing home, Rehab at River’s Edge, for failing to protect a fragile resident who fell seven separate times, at one point fracturing her foot.
And the public never found out that a resident at the Golden Living Center nursing home in Morgantown, W.Va., crashed to the ground and died after staff mistakenly removed the safety rails from his bed.
In all three of those cases, the state inspectors’ findings were upheld by a federal judge.
Mr. Blum, the C.M.S. official, didn’t say why such citations had never appeared on Care Compare. He said the agency was working to fix the problem. (The three homes declined to comment or didn’t respond to requests for comment. Golden Living is under new management.)
Dr. David Gifford, the chief medical officer of the American Health Care Association, which represents the nursing home industry, said the group’s members believed the appeals process should be faster and more transparent. He said Medicare should not post the results of inspections that are in dispute.
Found on the Pavement
On paper, Hilltop Rehabilitation, a sprawling ranch-style nursing home in Weatherford, Texas, seems like a place where little ever goes wrong. On Medicare’s rating website, the facility has won the highest scores on its health inspections for four years straight, not incurring a single serious infraction.
What’s missing from that picture, though, is what happened to Alan Hart’s mother, Laverne.
In 2014, he placed the 87-year-old retired children’s book author, who had dementia, at Hilltop because he was having trouble caring for her on his own.
Mr. Hart said it broke his heart to move her, but he thought she would be in good hands at the five-star nursing home, which planned to keep her on a supervised, locked floor.
The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
The result, prosecutors said, was that Brookdale “has been awarded higher star ratings than it deserved.” They added, “The chain’s manipulation has allowed Brookdale to attract prospective patients and their families to its facilities by misleading them about its quality of care.”
Prosecutors also accused Brookdale of illegally evicting or transferring residents so that the chain could “fill its beds with residents who will bring in more money.” In one instance highlighted in the suit, prosecutors said Brookdale discharged a 78-year-old resident who suffered from heart and kidney disease without removing his catheter.
The lawsuit seeks civil penalties and an injunction to prevent future unlawful conduct. Under California law, civil penalties are up to $2,500 per violation. In this case, where the violations are committed against seniors or people with disabilities, the law provides for an additional penalty of up to $2,500 per violation.
A Brookdale spokeswoman didn’t immediately respond to a request for comment.
The Times previously reported that a Brookdale facility in Lexington, Ky., told Medicare in 2017 that every resident got an average of 75 minutes of care each day. In reality, nurses at the Brookdale Richmond Place facility spent an average of less than 30 minutes a day with patients. Brookdale received five stars for staffing. Absent the inflated numbers, it probably would have received only one or two stars.
A former Brookdale nursing assistant said in a deposition last year that her supervisors had told her to falsify residents’ medical records to make it look as if they received more care than they did.
Heather Hunter, a spokeswoman for Brookdale, told The Times, “We have detailed policies in place to ensure compliance with C.M.S. reporting rules, and we are not aware of any instance where inaccurate or false information was submitted by any of our communities outside of the confines of the C.M.S. rules.”
President Biden nominated Mr. Becerra, whose office brought the case against Brookdale, for secretary of health and human services, which oversees C.M.S. The Senate has not yet voted on the nomination.
The pandemic laid bare the flaws in the government rating system.
The state health inspections do little to penalize homes with poor records of preventing and controlling infections. From 2017 to 2019, The Times found, inspectors cited nearly 60 percent — more than 2,000 — of the country’s five-star facilities at least once for not following basic safety precautions, like regular hand washing. Yet they earned top ratings.
In San Bernardino, Calif., inspectors wrote up Del Rosa Villa for four different infection-control violations. It kept its five stars. Ninety residents at the 104-bed facility have contracted the coronavirus, and 13 have died.
Del Rosa Villa officials didn’t respond to requests for comment.
Life Care Centers of Kirkland, Wash., the first nursing home in the United States to have documented coronavirus cases, was found in 2019 to have weak infection controls, despite its five stars. State inspectors wrote it up for failing to “consistently implement an effective infection control program.”
Thirty-nine of the facility’s residents have died from Covid-19. The home has 190 beds.
Leigh Atherton, a Life Care spokeswoman, said that citation was the only lapse in infection control that inspectors had identified over 32 previous visits. She said the home quickly fixed the problem.
If the rating system worked as intended, it would have offered clues as to which homes were most likely to have out-of-control outbreaks and which homes would probably muddle through.
That is not what happened.
The Times found that there was little if any correlation between star ratings and how homes fared during the pandemic. At five-star facilities, the death rate from Covid-19 was only half a percentage point lower than at facilities that received lower ratings. And the death rate was slightly lower at two-star facilities than at four-star homes.
A facility’s location, the infection rate of the surrounding community and the race of nursing home residents all were predictors of whether a nursing home would suffer an outbreak. The star ratings didn’t matter.
The Biden administration on Wednesday published revised guidelines for nursing home visits during the pandemic, allowing guests the freedom to go inside to see residents regardless of whether the visitors or the residents have been vaccinated.
The new recommendations, released by the Centers for Medicare & Medicaid Services with input from the Centers for Disease Control and Prevention, are the first revision to the federal government’s nursing home guidance since September. And they arrived as more than three million vaccine doses have been administered in nursing homes, the agency said.
The guidance was also the latest indication that the pandemic in the United States was easing, with Covid-19 cases continuing to decrease across the nation, though the seven-day average remains at more than 58,000. The C.D.C. on Monday released long-awaited guidance for Americans who have been fully vaccinated, telling them that it is safe to gather in small groups at home without masks or social distancing.
About 62.5 million people have received at least one dose of a Covid-19 vaccine, including about 32.9 million people who have been fully vaccinated with Johnson & Johnson’s single-dose vaccine or the two-dose series made by Pfizer-BioNTech and Moderna.
raced through tens of thousands of long-term care facilities in the United States, killing more than 150,000 residents and employees and accounting for more than a third of all virus deaths since the late spring. But since the arrival of vaccines, new cases and deaths in nursing homes have fallen steeply, outpacing national declines, according to a New York Times analysis of federal data.
The eight pages of recommendations, which are not legally binding, did come with suggested limits, saying that “responsible indoor visitation” should be allowed at all times unless a guest is visiting an unvaccinated resident in a county where the Covid-19 positivity rate is higher than 10 percent and less than 70 percent of residents in the nursing home have been fully vaccinated. The guidance also says to limit visits if residents have Covid-19 or are in quarantine.
Federal officials said in the new guidance that outdoor visits were still preferable because of a lower risk of transmission, even when the residents and guests have been fully vaccinated.
So-called “compassionate care” visits — when a resident’s health has severely deteriorated — should be allowed regardless of vaccination status or the county’s positivity rate, the guidance said.