On October 19, 2010, a Rockford, Illinois man was admitted to a local hospital. Emergency room staff found seven large bed sores on his body; some spanned several inches and had advanced to stage IV, the most severe. One wound, according to emergency room notes, was infected and covered his entire tailbone.
The man, identified in inspection reports only as "R1," had developed all of his wounds since arriving at Rockford Nursing & Rehab Center, a 67-bed facility in Rockford, Illinois. Bed sores — also known as pressure ulcers — are lesions that typically form when a patient has limited mobility, and her position isn't adjusted often enough. They can be extremely painful, and if left to fester can result in permanent loss of tissue, including muscle and tendons.
Resident 1 was far from the only victim of the poor conditions at Rockford Nursing & Rehab. The health reports describe a culture of verbal abuse and intimidation. Unexplained bruises were found on residents. Feces and urine were left on toilets and bathroom floors. An employee yelled at a resident for "pissing [him]self" and "cursed" at others "all the time." One resident reported not being given a shower for two weeks. When confronted by state inpectors, several staff members privately confessed that they were too intimidated to report bad employee behavior because some of the offenders were family members of their supervisors. "It's a scary place to work," one anonymous source said. "If you have concerns you can't complain because everyone is related."
We were able to track down these horror stories because Medicare had flagged Rockford Nursing & Rehab Center as one of the worst nursing homes in the country, a warning we found on our new mobile app, Sunlight Health. From there, we investigated Rockford further using Medicare's Nursing Home Compare database and the Illinois Department of Public Health website, which posts some of the actual inspection reports online.
What we found in Rockford Nursing's case was shocking. Reports filed by the state health department describe a steady stream of abuse and neglect that quietly continued at the facility in the nearly two years before Medicare officials put it on the list of bad nursing homes.
During a two-and-a-half year period ending in March, Rockford Nursing racked up a whopping 167 violations of federal nursing home standards, ranging from neglecting patients who couldn't eat or groom themselves to singling out residents who complained. In contrast, the average nursing home was dinged 34 times from roughly 2008 to 2011.
State health inspectors had to return repeatedly over that period to see if performance had improved. A litany of complaints by residents and family members also triggered extra visits: since September 2008, inspectors reported investigating complaints a full 49 times, according to the Illinois Department of Public Health website. Representatives from Rockford failed to respond to multiple requests for comment.
While Rockford Nursing & Rehab Center has a particularly bad record, it is by no means alone in having serious safety problems. Last year, according to a Sunlight analysis of Medicare data, inspectors flagged nearly 2,700 nursing homes for either hiring staff with a history of mistreating or neglecting residents, or failing to investigate suspected mistreatment or neglect. (Medicare counts both failures as a single category, so it's impossible to find out how many incidents of each occurred.)
Inspectors found nursing homes guilty of physically restraining residents for no medical reason over 1,100 times last year; on 2,400 occasions homes were found to be giving patients unnecessary catheters. Inspectors found that staff had allowed bed sores to form or persist over 2,700 times in 2010.
Medicare officials created a program in 1998 to separate out the worst of these facilities — the ones that improve just enough to avoid being banned from Medicare, but are still riddled with problems. These "Special Focus Facilities" (SFFs) are chosen from among the 15 homes in each state that did most poorly over the past three years, and are inspected twice as frequently as the rest. Less than one percent of the nation's nursing homes end up on this list.
Like Rockford Nursing & Rehab Center, a disproportionate number of these homes are for-profit: 88 percent, compared to 69 percent of all US nursing homes. Most are also part of a chain of facilities that are all under the same ownership.
While the Special Focus program certainly raises red flags for anyone looking for a nursing home, questions have been raised as to whether the facilities on the list are really the worst in the nation. In 2009, the GAO, using its own methodology, found that about half the homes with the most serious health and safety infractions were not in the program. Part of the problem, GAO found, was that Medicare pulls its list from the 15 lowest-performing facilities in each state. In reality, the worst of the bunch weren't distributed evenly across all states; some had far more than fifteen.
Unfortunately, only a fraction of what actually happened at Rockford Nursing & Rehab Center can be found on the web. In Illinois, only some inspection reports are published online; families must go to each individual home for the rest, or file a public records request and pay to have the reports copied.
And Illinois is among the better states when it comes to transparency for long-term care facilities. Most states don't post any inspection reports online. Last year's health care overhaul law requires that all states must begin doing so, but only a handful have complied so far.