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SANTA FE, N.M. – Robert Pineda was a free spirit – a man who liked pickup trucks and painting. The certified public accountant decided to take up acting at age 50 and landed a role in the movie “All the Pretty Horses” with Matt Damon.
When Pineda, 68, checked into Casa Real, a local nursing home, after falling and breaking his kneecap in 2012, his daughter Suzette Lucero figured this was a bump in the road. Three or four weeks of rehab and he’d be out, she thought.
Two weeks after Pineda arrived, though, Lucero said she received a phone call saying her father was being taken to the emergency room.
“On the telephone, they sounded like this was not urgent,” she said.
When she arrived at the hospital, Lucero learned the truth: Her father had a stage-four bed sore, a pressure ulcer that had penetrated from skin to muscle. Worse, the wound was infected.
“For that [wound] to have penetrated that deeply, that was a straight-out case of neglect,” Lucero said.
Pineda wasn’t the only Casa Real resident to suffer. A 134-page complaint filed by the state of New Mexico in April 2015alleges residents at the nursing home went hungry because they couldn’t feed themselves, fell because they couldn’t get assistance, and languished for hours in soiled bedding and clothes.
Casa Real is one of seven New Mexico nursing homes named in the state’s complaint, along with their current and former owners, Preferred Care Partners and Cathedral Rock, Inc. (At the time Pineda was admitted to Casa Real, the nursing home was still owned by Cathedral Rock.)
The state alleges that the companies deliberately kept staffing levels dangerously low, all the while billing the government for services that were not provided and reaping millions in profits.
The civil suit comes as prosecutors, researchers and advocates across the country are questioning whether for-profit nursing home chains’ focus on the bottom line comes at the expense of the care residents receive.
“They didn’t meet their duty to provide adequate care,” New Mexico Attorney General Hector Balderas told America Tonight. “We believe it’s a model that favors profits over people.”
Since 2008, the seven nursing homes named in New Mexico’s complaint have generated more than $236 million in revenue, with almost 80 cents on the dollar coming from Medicare and Medicaid, the lawsuit says.
Preferred Care Partners, which purchased the nursing homes from Cathedral Rock in 2012 and is the 12th largest nursing home chain in the U.S., said in a statement that it “stands by the care it provides to New Mexico’s frail elderly and the dedication and commitment of compassionate staff who consider long-term care an honorable profession.”
A ‘terrifying’ experience
Tracy Murrell fell in love with working with the elderly as a nursing student. Since then, she’s considered long-term care an honorable profession.
Murrell worked as staff development coordinator at Santa Fe Care Center, one of the nursing homes named in New Mexico’s lawsuit. Murrell said she raised the problem of short staffing with higher-ups before leaving her job, in part because the issue was not addressed.
“You try to get as much as you can on your shift, and it’s not always possible to do everything. It’s just not,” said Murrell, who left in March 2013.
Short staffing led the Santa Fe Care Center and the six other New Mexico nursing homes to routinely ignore daily hygiene needs, such as showering, brushing residents’ teeth and shaving, according to the complaint.
A kitchen worker at Casa Real, a confidential witness in the complaint, said only one or two certified nursing assistants worked with the 55 residents in the dining room. As a result, the lawsuit claims, many of the residents who were unable to feed themselves went hungry and lost weight.
More seriously, the suit alleges residents’ call lights went unanswered, sometimes for an hour or more; the residents were not turned enough to prevent pressure ulcers; and without help getting to the bathroom, many fell unnecessarily.
A Santa Fe Care resident who spent two weeks at the nursing home last year, named only as “Confidential Witness #12” in the lawsuit, described the experience as “terrifying.”
“She complained to the floor staff about the lack of care, but she did not want to complain too much as she was afraid of retaliation,” the complaint says. She reportedly returned home after being sent to the hospital.
6 things to look for in a nursing home
Families often don’t have a lot of time to find a nursing home. A loved one is being discharged from the hospital and needs a place to go within days. Hospitals and families often pick the closest nursing homes, which are easiest to visit, but these may not be the best.
Here are tips on finding the right nursing home from Tony Chicotel, staff attorney with California Advocates for Nursing Home Reform; Carole Herman, founder and president of the Foundation Aiding the Elderly; and Tracy Murrell, a former state inspector in New Mexico:
• Visit at night or on weekends when staffing levels are usually at their lowest. “You take a look at a facility at its worst, essentially,” Chicotel said. Talk to residents, family members and certified nurse assistants (CNAs) to get their opinion of the facility and the services being provided.
• See if the men are cleanly shaven and the residents have their hair brushed or combed. “If you don’t have time to comb hair, there’s a problem,” Murrell told America Tonight. Also, she said, see if residents are dressed nicely or for the convenience of the staff like sweats.
• Smell the facility. A pervasive odor or urine or feces is a sign of understaffing.
• Notice if there is water available to the patients. “Dehydration is a very serious problem,” Herman said.
• Check the nursing home’s rating on Nursing Home Compare. Medicare gives nursing home one to five stars based on criteria including staffing levels and inspection results.
• Look at the percentage of the nursing home’s residents who receive antipsychotics. The figure is listed under the quality measures for each nursing home on the Medicare site. Lower staffing often results in higher uses of these powerful drugs, which can stupefy residents and make it easier to care for them.
Children and spouses regularly pitched in to provide loved ones with basic needs at the nursing homes named in the lawsuit. But sometimes, their best efforts were not enough.
One confidential witness stayed for hours at Santa Fe Care Center to help his mother eat meals and drink water. While attempting to go to the bathroom alone, though, she fell, and according to the complaint, died three days later.
In Las Cruces, another confidential witness said she often found her husband at Sagecrest Nursing and Rehabilitation Center in a urine- or feces-soaked diaper, according to the complaint. Before she could transfer her husband – a stroke victim – to a different facility last year, Sagecrest called to say her husband had choked to death.
“There was an incredible amount of suffering due to inadequate care,” Balderas said.
Murrell said the nursing homes were run like any other business.
“They want to make a profit,” Murrell said. “They don’t see the residents day-to-day. They don’t interact with them. They don’t provide care to them. They rely on other people to do that. So they’re up there in their offices, and what they’re looking at is financial statements.”
Murrell, who has worked as a state inspector in New Mexico, added: “There’s enough profit out there even if you staff adequately. Nobody does it, though.”
‘Quality is secondary’
The number of for-profit nursing homes have been creeping up for years and now make up more than two-thirds of the 15,600 nursing homes in the United States.
Nursing homes have become popular investments for real estate funds, family trusts and others. From 1998 to 2008, the Government Accountability Office found private investment firms purchased 1,876 nursing homes [PDF].
“Their mission is to make money for investors, and the quality is secondary,” said Charlene Harrington, a professor emeritus at the University of California, San Francisco, who has studied nursing home finances.
In her research, Harrington found that for-profit nursing homes have significantly lower staffing levels than nonprofits and more deficiencies in the care they provide.
“Nursing homes are very labor intensive,” Harrington said. “The primary way to make money is to cut staffing.”
The largest for-profit chains give residents only 34 minutes a day with a registered nurse, compared to 51 minutes a day at nonprofit chains, according to Harrington’s research [PDF].
“RNs are the most important part of the nursing home staffing because they’re the ones that can assess the residents. They provide the treatments,” Harrington said. “They do the planning and the care management, so if you don’t have enough of them you’re going to have all kinds of quality problems.”
At the seven facilities in New Mexico, America Tonight found registered nurses spend 35 minutes per resident per day, according to figures filed with Medicare. That’s a third less than the state average. The facilities also average twice as many health deficiencies.
Unlike many other states, New Mexico does not have specific staffing requirements. A state Department of Health spokesman said by email the state focuses on quality of care and patient outcomes rather than strict staffing ratios.
The star system
A recent Kaiser Family Foundation report on the nation’s nursing homes found for-profit chains were twice as likely as nonprofits to receive poor marks on the federal government’s Five-Star Quality Rating System.
For-profit nursing homes are also overrepresented on the federal Special Focus Facility list of the nation’s worst nursing homes.
In New Mexico, the seven nursing homes named in the complaint scored poorly in five-star ratings, averaging 1.4 stars, roughly halfway between “below average” and “much below average.”
One of them, Sagecrest Nursing and Rehab in Las Cruces, is among the 83 nursing homes on the Centers for Medicare & Medicaid Services’ Special Focus Facility list, dubbed the “hall of shame” for nursing homes nationwide.
Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform, said nursing homes have little financial incentive to provide residents with good care.
“Whether you’re a five-star facility or a one-star facility, you’re still going to get the same — virtually the same — Medicaid reimbursement and Medicare reimbursement,” Chicotel said. “The government is going to pay you, regardless.”
‘Why my father is dead’
After Pineda’s trip to the emergency room with a severe pressure ulcer and blood infection in August 2012, he never returned to Casa Real. He didn’t go home either.
Lucero, his daughter, kept a journal of her father’s decline:
Aug. 21, 2012: Pineda admitted to the hospital.
Aug. 22, 2012: Pineda underwent his first operation. Operations followed on Aug. 30, Sept. 9 and Sept. 14, to close his wound and insert a colostomy bag, with Pineda in pain much of the time.
Oct. 9, 2012: Congestion that started a week earlier became so pronounced Pineda almost went into respiratory failure. This was the last day he spoke. Pineda was placed on a ventilator the next day.
Dec. 1, 2012: A week after Pineda’s 69th birthday, with family around him, he was removed from the ventilator and died.
“It’s shocking and horrific what my father went through,” said Lucero. She and her two brothers sued Casa Real and reached an undisclosed settlement last year.
“My father was a Type 2 diabetic. He had some issues. My father didn't pass away from complications from diabetes. My father did not pass away from complications from gout or acid reflux or obesity or anything of that,” Lucero said. “My father passed away as a direct result of the bedsore that was received from the neglect at Casa Real for the 14 days that he was there. That is why my father is dead.”