Associated Press / news@whmi.com

The plea was desperate: Help!

Lorena Brown gasped for air on Sept. 12, 2022, turning blue, at the SKLD Muskegon nursing home.

Her roommate called for help from a nurse. The response: “Mind your own business.”

Using a washcloth, the roommate scooped vomit from the 68-year-old’s mouth, begging again for help, according to an inspection report based on interviews with Brown’s roommates and staffers.

No help came, and Brown died, according to the inspection report and other public documents.

The former foster parent and cosmetologist is one of nearly three dozen residents to die of suspected neglect or abuse at Michigan nursing homes in the past four years, according to a Bridge Michigan review of more than 3,100 state and federal inspection records and court documents.

Bridge’s investigation documented at least 5,915 cases of abuse, neglect, exploitation or quality of life and care violations among the 15,471 total citations for violations ranging from incomplete paperwork to poor care. In all, homes have been fined $21.5 million over the past three years and been denied a total of 6,451 days of Medicaid reimbursements.

While many of Michigan’s 420 homes provide exceptional care, the citations document severe staff shortages and conditions that include mold and gnats, odors of human waste, filth, rodents, flies, isolation and inactivity that left residents staring at walls.

Advocates say the conditions underscore failures of Michigan’s safety net — which were exposed by Brown’s death.

The administrator didn’t call the police or report the “sudden and unexpected death” nor the “allegation of neglect” to the state. The nurse continued to work at the facility, terminated only after state inspectors received a complaint and began an inquiry, according to reports.

Other states have passed laws in recent years to improve care for nursing home residents, but efforts to do the same for Michigan’s 34,000 residents have gone nowhere.

“We need to find a champion,” said Paula Cunningham, state director of AARP Michigan.

Bridge Michigan spent four months examining policies and practices of Michigan’s nursing homes, reviewing more than 45,000 pages of inspection reports of the state’s nursing homes, submitting dozens of requests for public records, reviewing more than 30 death certificates and speaking to nearly 100 family members, current and former staff, administrators, consumer advocates, researchers, policymakers and industry representatives.

The investigation found:

1. Michigan requires little staffing: The state mandates two hours and 15 minutes of care each day for each resident — far below the more than four hours a day that advocates say is needed. Staffing levels vary considerably from facility to facility — from the minimum to seven hours of care a day in a small number.

2. Staffers aren’t well trained: Michigan has some of the lowest training standards in the nation for nurse aides, about 100 hours. By comparison, the state requires 400 hours of training for manicurists and 1,800 hours for barbers.

3. Money to help is unspent: Michigan has a fund worth $35 million designed to improve care, but the money, collected in penalties for wrongdoing, is bound by so many rules and bureaucracy that administrators say it is nearly impossible to tap.

4. Public kept in the dark: When staffers are cited for wrongdoing, it’s difficult — if not impossible — for the public to know whether that person is still working. That’s because both residents and staff at nursing homes are not identified in state reports. Even nursing home leaders may not know of a nurse’s past wrongdoing, administrators told Bridge. Family members often don’t know that their loved one’s death or injury is part of an investigation.

5. For-profits fare worse: More than three-fourths of all nursing home beds are in for-profit facilities, which had 43% more citations per bed than nonprofit and government-run facilities, on average. Government-run homes have the fewest citations and most staffers, but there are only 39 in Michigan.

Abuse and neglect are indefensible, but the system works to identify and punish offenders, said Melissa Samuel, president and CEO of the Health Care Association of Michigan industry group.

“We’re not building widgets … and yes, mistakes are going to happen. And they happen in all the different settings,” she said.

Samuel said it’s “frustrating” that the media focuses on incidents of poor care.

“It’s not the positive story that people want to hear. It’s the ugly story, and I’m not going to defend it,” she said. “I just wish we’d spend more time talking about the good things they do and the good workers that are there.”

‘An incredible power base’
Despite federal and state reports indicating concerns about staffing and care, just one bill in the Legislature now addresses nursing home care.

It would allow cameras in nursing homes upon request — and its sponsor, Sen. Jim Runestad, R-White Lake, acknowledges it’s “dead on arrival.”

A first incarnation died because Gov. Gretchen Whitmer did not sign legislation after it passed overwhelmingly in the Legislature. Its second incarnation died in committee.

Whitmer did not respond to multiple inquiries from Bridge about why she allowed the legislation to die.

The AARP’s Cunningham said a “quagmire of lobbyists” representing the nursing home industry has delayed change.

“They have an incredible power base, an incredible lobby base,” Runestad said.

The last major change to nursing home rules came in 2015, when lawmakers reduced mandatory annual inspections from once a year to once every three years.

That year, state Sen. Geoff Hansen, R-Hart, also authored a wholesale overhaul of regulations, removing the ability of state departments to pursue stringent requirements.

One of his top donors was the Health Care Association of Michigan, which gave $20,000 to his committees. Hansen told Bridge he acted because homes were getting hit with heavy fines and the “inspectors were not being helpful… they were just being the enforcers, not advocates (for patients.)”

Two major donors associated with the industry give heavily to both parties.

Favoring Democrats is the Healthcare PAC of the Service Employees International Union, which represents more than 30,000 nurse aides, and has given $708,000 to candidates, PACs, committees and parties since 2008.

Favoring Republicans is the Health Care Association of Michigan, which has donated $1.7 million since 2003 and spent $1.2 million on lobbying over that time.

State Rep. Carrie Rheingans, D-Ann Arbor, said Democrats don’t want to take on the Whitmer administration, and Republicans don’t want to upset business interests.

“There’s also just a lot of people who are OK with pretending like we’re never going to get old, and we’re never going to need care for months and years,” said Rheingans.

‘Somebody’s trash can’
Federal authorities have cracked down on flagrant offenders, such as the Detroit Nursing Center. Its owner, Villa Healthcare Management and related parties agreed to pay $4.5 million in July to settle a complaint alleging that six of its homes kept costs in check by hiring few staffers.

That hurt care for residents such as Morris Wilson, 69, who died in 2023 after a series of falls at the facility — also known as Imperial, a Villa Center — as well as medical errors and sepsis, according to a lawsuit.

After one fall, staffers waited four days to send him to a hospital, where X-rays revealed a fractured hip, according to a lawsuit filed by the family.

When he later died, the man had a pressure sore so big that a latex glove was found inside of it, covered by bandage and gauze, according to medical records connected to the family’s suit in Wayne County Circuit Court.

“My dad’s body was not somebody’s trash can,” said his daughter, Shanica League of Garden City.

Among other issues at the facility, some bedridden residents were moved only once daily, rather than the 12 times recommended to prevent bedsores, according to the 77-page complaint filed in US District Court in 2019.

Calls to Villa and its parent company weren’t returned, and the home — along with five others — admitted no responsibility in settling the suit.

The government alleged the homes defrauded Medicaid by billing for care that was never provided.

Other Michigan homes are able to stay within the law and still provide care far below optimal levels, according to advocates.

The U.S. Centers for Disease Control and Prevention in 2001 recommended 4.1 hours of care per day per resident. Michigan requires 2.25 hours — a level unchanged in 45 years.

In recent years, New Jersey, Pennsylvania, Virginia and others have passed laws increasing minimum staffing standards.

California and New Jersey have stepped up efforts to keep poor-quality homes from setting up shop. Minnesota has established a workforce standards board to help set work standards. In Connecticut, lawmakers are trying to require nursing homes to spend a certain amount of revenue — 80% — on direct care. Other states have similar requirements.

And Connecticut and California have pushed for more transparency in spending. In contrast, Michigan nursing homes report their finances through a dense process that remains opaque to an outsider. Advocates argue the process allows nursing homes to extract an unknown level of profits from tax dollars no matter the care of residents.

“It’s incredibly hard to know who’s providing care and what’s being hidden,” said Alison Hirschel, director of the Michigan Elder Justice Initiative, which this year released a report blasting four nursing homes chains for their ability to “ siphon away ” profits at the expense of resident care. Authors were careful: Federal and state reporting requirements didn’t reveal to what extent, if at all, that siphoning was happening.

That’s a problem, Hirschel later told Bridge.

“Families deserve transparency,” he said. “Right now, they don’t have it.”

The lack of transparency extends to inspections and discipline.

Anthony Rushke told Bridge he was never informed that the state investigated the 2022 death of his mother, Cindy, after her care was delayed when a nurse mixed her up with another resident at Optalis Health and Rehabilitation St. Francis in Saginaw.

She died 41 hours after entering the home for what her family thought would be a short stay. When a nurse found Ruschke struggling to breathe at 4 a.m. in her room, he mistook her for a hospice resident in a nearby room, according to state reports.

Instead of life saving measures, the nurse turned up Ruschke’s oxygen tank and left to tend to another patient, reports indicate.

Ruschke was dead by the time the nurse returned. Another staffer was told to clean the body for the family and headed to the resident in hospice.

“I’m not dead yet,” the hospice resident said, according to reports.

Eventually, after sorting out the mix-up, staffers tried CPR on Ruschke.

By then, her body was cold, reports indicate.

Inspections don’t reveal names of staff or residents, Bridge tracked down Ruschke’s family and others through death certificates, medical examiners records and obituaries.

Anthony Ruschke said he didn’t know details of his mother’s final hours until he was contacted by Bridge — or that the facility was fined $39,231 and cited for failing to report the nurse to the Michigan Bureau of Professional Licensing.

“There’s nothing about this that makes sense,” the Coopersville man said.

’A terrible place to be’
The way the federal regulatory system is set up, it’s tough to compare Michigan to other states, said Richard Mollot, executive director of the Long Term Care Community Coalition that operates the consumer website nursinghome411.com.

Michigan doesn’t stand out as particularly good or bad in nursing home care, safety or staffing, he said. “You don’t want an average nursing home. That’s a terrible place to be,” Mollot said.

To be certain, even critics agree that countless Michigan nursing homes provide quality care.

Moreover, “there are wonderful staff in even the poorest performing homes,” said Alison Hirschel of the consumer advocacy nonprofit, the Michigan Elder Justice Initiative.

Even in cases in which inspectors meted out citations linked to death, it’s not clear that the deaths, themselves, were the clear result of wrongdoing.

Boulevard Temple in Detroit, for example, was cited in 2023 on claims its staff failed to perform CPR or call 911 when they found a resident who was unresponsive. But the same report, in which the facility also was cited for filth and understaffing and ultimately fined $14,518, also notes the resident was in hospice care with brain tumors.

Optalis of Grand Rapids was cited 10 months later on claims a nurse failed to perform CPR on a resident. The nurse who found the resident told investigators that the woman’s body was pale and she’d apparently “been dead for a while,” the report stated. The nursing home was fined nearly $7,800.

In the case of Brown, who choked on her vomit in Muskegon, it’s equally unclear whether medical intervention would have made a difference. The county’s medical examiner wasn’t contacted; an autopsy was never performed.

That’s not unusual. Pathologists are often never consulted after deaths — and even when they are, it is difficult to determine whether preexisting conditions or wrongdoing killed residents, said Dr. Stephen Cohle, longtime medical examiner in Kent County.

“People in nursing homes are generally elderly and have a lot of disease,” he said.

But families of patients like Brown said they deserve more information when things go wrong.

Bridge contacted the woman’s niece, Kesia Malone, who said she had no idea about the confusion of Brown’s final moments.

It’s “mindboggling” and sad, Malone said.

“It’s like stripping a Band-Aid off a wound,” she said.

The SKLD facility, now part of the Optalis nursing home chain, did not respond to repeated requests for comment.

Bridge’s investigation found that, in each case involving the death of a resident, state inspectors alleged errors in care from staffers and sometimes nursing home leadership. Sometimes, the issues involved missing or unclear paperwork; other times staff covered upwrongdoing.

In all, Michigan nursing homes were cited 290 times in that five-year period for medication errors; 549 times for failing essential care for pressure wounds, Bridge found.

Such incidents can be avoided, and they’re not acceptable, said Samuel, of the Health Care Association of Michigan.

“There are bad things that can happen, but the flip side of that is that every day in nursing facilities, there are thousands and thousands of positive actions and outcomes, people who go home, people who see receive wonderful quality of care, people who have no family and they’re in the facility, and that’s their family,” she said.

This story was originally published by Bridge Michigan and distributed through a partnership with The Associated Press.