Medicare Nursing Home Compare Five-Star Rating System: A Fraud on the Public?

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Updated, October 21, 2013, 10:55 p.m. PDT

U.S. Supreme Court Justice Louis D. Brandeis, in the public domain. (Photo credit: Harris & Ewing Collection at the Library of Congress, Prints & Photographs Division, circa 1916)

What does it mean when a nursing home has a “five-star” rating on Medicare Nursing Home Compare website?

“We are a five-star-rated facility on the Medicare Nursing Home Compare website,” many nursing home administrators and owners proudly tell consumers searching for a nursing home where their loved ones will get high-quality care. John Sorensen—the president, CEO, and chairman of the board of Dana Point, California-based North American Health Care Inc.—even says on his personal website, “Thirty Four of its Thirty Five affiliated client facilities are five star rated and one is four star rated.” North American Health Care Inc. also advertises on its company website, “As of June 2013, Medicare awarded 34 North American Health Care Inc. client serviced facilities with their highest honor – a Five-Star Rating.”

But John Sorensen’s and North American Health Care’s statements lead to many questions:

• What does it mean when any nursing home operator advertises that Medicare has “awarded” it with the “honor” of a “five-star” rating?

• What message does a “five-star” rating evoke in a consumer’s mind?

• Would a close reading of the fine print on Medicare’s Nursing Home Compare website leave a consumer with the same message?

• Is the Nursing Home Compare website telling consumers that a “five-star” nursing home has a history of providing only excellent, high-quality care?

• How does Medicare calculate a nursing home’s five-star quality rating, which Medicare publishes on its Nursing Home Compare website?

• Does Medicare rely on all relevant nursing home inspection and complaint investigation data when calculating a nursing home’s quality rating?

• Or does Medicare systematically exclude some readily available, relevant information?

What is Medicare’s five-star rating system on the Nursing Home Compare website?

Before Elder Abuse Exposed.com answers the questions above and exposes the 16 secrets that Medicare and “five-star” nursing homes do not want you to know about the five-star rating system for nursing homes, let’s first understand what Medicare’s Nursing Home Compare is. It is a nationally promoted, frequently visited website managed by the Centers for Medicare and Medicaid Services (CMS), the U.S. government agency that administers the nation’s health insurance programs known as Medicare and Medicaid. Nursing Home Compare gives consumers access to a database of quality-of-care information on the more than 15,000 Medicare- and Medicaid-certified nursing homes in the U.S.

CMS says that the Nursing Home Compare website gives information about four separate star ratings (of one to five stars) for:

• A nursing home’s annual health inspections and complaint investigations within the past three years.

• A nursing home’s patient assessment data that supposedly indicate nine different quality-of-care performance measures.

• A nursing home’s staffing data that include staffing levels and staffing needs based on the patients’ care and resource needs.

• A nursing home’s overall quality rating, which is based on the nursing home’s other star ratings above: health inspections, quality measures, and staffing.

“Nursing homes with 5 stars are considered to have much above average quality,” CMS assures consumers searching for the best nursing homes, while also saying that “nursing homes with 1 star are considered to have quality much below average.” CMS’ explanation of its Nursing Home Compare five-star rating system conveys the message that there is a useful correlation between a nursing home’s star rating and the quality of care that a nursing home provides its residents.

But today, in part 1 of a three-part exposé, Elder Abuse Exposed.com is revealing the first four of 16 secrets that the Centers for Medicare and Medicaid Services and “five-star” nursing homes, especially in California, do not want you to know about CMS’ five-star rating system on Nursing Home Compare. Then within the next week or two, in part 2 and part 3 of the three-part exposé, Elder Abuse Exposed.com will expose the remaining 12 of the 16 secrets to see if there is truly a useful correlation between a nursing home’s star rating on Nursing Home Compare and the quality of care that a nursing home provides.

Secrets nos. 1–4 of 16 secrets Medicare does not want you to know about its five-star rating system on Nursing Home Compare

1. Nursing Home Compare excludes all deficiency citations and penalties that California nursing home inspectors have issued when referring only to state instead of federal law.

CMS’ Nursing Home Compare website misleads consumers searching the website for California nursing homes. CMS misleads California consumers by saying:

• Nursing Home Compare gives “detailed and summary information about deficiencies found during the 3 most recent state inspections and recent complaint investigations.”

• “Inspections about a complaint that result in a health deficiency citation are reported to CMS and included on this website.”

• Nursing Home Compare includes penalties, such as fines, imposed on a nursing home for serious deficiencies and for other deficiencies that a nursing home fails to correct.

These statements by CMS are very misleading to California consumers and could reasonably be considered falsehoods. The Nursing Home Compare website frequently excludes information on nursing homes’ deficiencies (in other words, violations of law or misconduct) that inspectors for the California Department of Public Health’s (CDPH’s) Licensing and Certification Program substantiate during complaint investigations. Nursing Home Compare also frequently excludes information on CDPH’s complaint investigations at nursing homes and any resulting deficiency citations and penalties that CDPH issues for even the most serious misconduct, including elder abuse leading to death.

Medicare’s Nursing Home Compare currently excludes much of California nursing homes’ violations due to the way CDPH inspectors have issued deficiency citations

Nursing Home Compare totally excludes much of California nursing homes’ substantiated misconduct, poor care, and deficiency citations due to a peculiarity in CDPH’s nursing home enforcement system and due to the way CDPH inspectors have issued deficiency citations. If CDPH inspectors issue a state deficiency citation for a nursing home’s misconduct that violates both California and federal law but choose to mention only California law in the citation, Nursing Home Compare will entirely exclude any information on the substantiated misconduct. Under these circumstances, Nursing Home Compare will also entirely exclude the nursing home’s deficiency citation because CDPH inspectors have chosen to refer only to California law in the citation and not to a parallel federal law.

Medicare’s five-star rating system totally excludes “state citations issued pursuant to California state statutes,” confirms CDPH and ProPublica senior investigative reporter

“State citations issued pursuant to California state statutes are not included in the federal 5-Star rating system developed by the federal Centers for Medicare and Medicaid Services,” Corey Egel, a spokesman from the CDPH’s Office of Public Affairs, confirmed in an August 9, 2013 email to Elder Abuse Exposed.com. “Beginning April 2012, CDPH began issuing both state and federal violations for the same investigation,” Egel said, adding that “a deficiency can have both a state and federal enforcement action, and only the federal will be included in the 5 star rating system.” Egel explained to Elder Abuse Exposed.com that “the 5-Star rating system is designed to include outcomes associated with federal investigations.”

Charles Ornstein—the Pulitzer Prize-winning senior reporter for the independent, public-interest ProPublica—also confirmed that CMS’ Nursing Home Compare excludes deficiency citations that CDPH has issued to California nursing homes while referring only to state law. Mr. Ornstein, who has collaborated with ProPublica colleagues to develop a reorganized, user-friendly version of CMS’ Nursing Home Compare, called Nursing Home Inspect, told Elder Abuse Exposed.com that CMS’ Nursing Home Compare and ProPublica’s Nursing Home Inspect only include deficiency citations that nursing home inspectors issue under federal law. Ornstein said that it would be difficult to correct Nursing Home Compare’s total exclusion of state enforcement actions against California facilities because of what Ornstein called a “quirk” in California’s nursing home enforcement system, which enables inspectors to cite nursing homes under either state or federal law.

Medicare’s Nursing Home Compare currently excludes most of California nursing homes’ misconduct that CDPH has substantiated during complaint investigations

Although Nursing Home Compare does include violations that CDPH inspectors have cited while referring to federal law during a nursing home’s annual inspections, Nursing Home Compare appears to exclude the vast majority of a nursing home’s misconduct that CDPH inspectors have found during complaint investigations. Elder Abuse Exposed.com members have looked at and studied countless state deficiency citations resulting from CDPH complaint investigations in California nursing homes. Elder Abuse Exposed.com has found that in most of these complaint investigations, CDPH inspectors have chosen to refer only to California law and omit any reference to federal law, thereby ensuring that Nursing Home Compare has excluded the nursing homes’ substantiated misconduct.

2. CDPH has not clearly explained why many nursing home citations have referred only to state law and are thereby excluded from CMS’ five-star rating system.

Elder Abuse Exposed.com asked CDPH if there was a rule permitting CDPH inspectors to refer only to California law in nursing home deficiency citations

When CDPH spokesman Corey Egel said that CDPH inspectors can initiate a state or federal enforcement action against a nursing home for a particular violation and that “only the federal will be included in the 5 star rating system,” Elder Abuse Exposed.com promptly followed up with an email to CDPH. In the following August 14, 2013 email, Elder Abuse Exposed.com asked CDPH if there was any rule requiring CDPH inspectors to cite either California or federal law for a nursing home’s violation. Elder Abuse Exposed.com also asked CDPH if there was a rule permitting CDPH inspectors to choose to cite only California law in a deficiency citation, thereby ensuring that CMS’ five-star rating system will exclude the nursing home’s misconduct and any penalties.

From: Elder Abuse Exposed.com
Sent: Wednesday, August 14, 2013 6:47 PM
To: Corey.Egel@cdph.ca.gov
Subject: Re: Medicare’s Nursing Home Compare’s database

Dear Corey Egel:

We have a quick follow-up question for you.

On the basis of what authority could CDPH nursing home inspectors issue a deficiency statement for negligent failure to comply with a nursing home patient’s care plan solely pursuant to California law (e.g., Title 22, Section 72311(a)(2)), instead of federal law (e.g., 42 CFR 483.20(k))? By issuing a deficiency statement solely pursuant to California law, nursing home inspectors can thereby (perhaps unintentionally) ensure that the care plan failure does not appear on CMS’ Nursing Home Compare website.

Please assume for the purposes of our question that the alleged misconduct is prohibited by both the state and federal regulations that we cited above.

Thank you very much for getting back to us at your earliest convenience. We really appreciate your help!

Regards,

Elder Abuse Exposed.com

CDPH responded to Elder Abuse Exposed.com’s question with an incomprehensible email written in bureaucratese by CDPH nursing home regulatory expert

After Elder Abuse Exposed.com followed up with an August 20, 2013 email, CDPH responded with an August 21, 2013 email that did not clearly answer Elder Abuse Exposed.com’s question. Elder Abuse Exposed.com’s question to CDPH in the August 14, 2013 email above was about CDPH inspectors who have chosen to cite only California law for a nursing home’s misconduct, thereby ensuring that CMS’ Nursing Home Compare has excluded the misconduct. But CDPH’s largely incomprehensible response in an August 21, 2013 email was the following:

CDPH Response: The California Department of Public Health’s (CDPH) change from the state process to using the federal process in April 2012, was to ensure that federal enforcement actions were taken and reflected in a facility’s CMS 5-Star rating along with state enforcement activity. The federal government uses an enforcement scheme (known as “scope and severity”) where violations are rated on a scale of A–L (“A” being the lowest level and “L” being the highest). Since April 2012, CDPH now cites a skilled nursing facility for violations of federal regulations and assigns the appropriate scope and severity rating. This scope and severity deficiency will be reflected on the facility’s record and also reflected on its 5-Star rating. If the violation also meets the state statutory definition of a state citation, the facility will receive an additional state sanction (see Health and Safety Code 1423 and 1424 for CDPH’s authority and definition of citations).

Both Elder Abuse Exposed.com and the CDPH spokesman had difficulty interpreting the CDPH regulatory expert’s incomprehensible bureaucratese

After receiving CDPH’s August 21, 2013 response, Elder Abuse Exposed.com spoke to CDPH spokesman Corey Egel on the phone and told him that CDPH’s response was very difficult to understand. Elder Abuse Exposed.com said that its legal staff had translated the first sentence in CDPH’s bureaucratese (above) as follows:

In April 2012, the CDPH changed from citing state law to citing federal law when citing federal law is possible in nursing home citations and statements of deficiencies. The purpose of CDPH’s change was to ensure that violations of both federal law and California law were reflected in a nursing home’s five-star rating on CMS’ Nursing Home Compare.

Mr. Egel could neither definitively confirm nor reject Elder Abuse Exposed.com’s interpretation of the first sentence in CDPH’s August 21, 2013 email. Elder Abuse Exposed.com told Mr. Egel that CDPH appeared to use the jargon “federal process” or “federal action” to refer to a deficiency citation that refers to federal law. Elder Abuse Exposed.com also said that CDPH appeared to use the jargon “state process” or “state action” to refer to a deficiency citation that refers to California law.

Is CDPH reluctant to respond to a government watchdog’s clear and understandable question without wearing down and confusing the watchdog with incomprehensible jargon?

The fact that Elder Abuse Exposed.com’s legal staff, paralegal staff, and an intelligent and attentive CDPH spokesman were all unable to definitively interpret CDPH’s August 21, 2013 email suggests that the CDPH bureaucrat who wrote CDPH’s response is either unable or unwilling to provide clear and understandable answers to clear and understandable questions. Because Elder Abuse Exposed.com’s experience with CDPH managers and regulatory experts indicates that they are usually quite intelligent, it appears as if CDPH may be reluctant to respond to Elder Abuse Exposed.com’s August 14, 2013 question without resorting to incomprehensible jargon. CDPH bureaucrats may be unwilling to respond to Elder Abuse Exposed.com without relying on the head-spinning gobbledygook that can wear down government watchdogs who request explanations. For example, the last sentence from CDPH’s August 21, 2013 email says the following:

If the violation also meets the state statutory definition of a state citation, the facility will receive an additional state sanction (see Health and Safety Code 1423 and 1424 for CDPH’s authority and definition of citations) [emphasis added].

Elder Abuse Exposed.com looks forward to CDPH’s explanation of its incomprehensible jargon in its August 21, 2013 email

Mr. Egel told Elder Abuse Exposed.com that a technical expert who had left work for the day had written CDPH’s August 21, 2013 response, which Mr. Egel had forwarded to Elder Abuse Exposed.com. Mr. Egel said that he would solicit more information from the CDPH technical expert to clarify the meaning of the August 21, 2013 email.

Elder Abuse Exposed.com looks forward to hearing the CDPH regulatory expert’s explanation because after researching Health and Safety Code §§ 1423 and 1424 and other resources, Elder Abuse Exposed.com’s legal and paralegal staff have been unable to find a “state statutory definition of a state citation” in California. Elder Abuse Exposed.com believes that it is unlikely that the definition exists. In addition, the word violation is obviously not equivalent to a document known as “a state citation.” Therefore, “the violation” to which CDPH refers in CDPH’s unintelligible, jargon-filled sentence above cannot logically meet “the . . . definition of a state citation,” which is a document.

Elder Abuse Exposed.com asked CDPH why CMS’ five-star rating system totally excludes a 2013 class “B” citation CDPH issued to a North American Health Care client nursing home in California

Elder Abuse Exposed.com also told Mr. Egel that a class “B” citation that CDPH issued on March 7, 2013, to North American Health Care’s client facility Cottonwood Healthcare Center, in Woodland, California, called into question a key statement that CDPH made in its August 21, 2013 email. Elder Abuse Exposed.com said that the March 7, 2013 class “B” citation, which referred only to California law and not federal law, seemed to be inconsistent with what appeared to be CDPH’s statement that since April 2012, CDPH inspectors have been issuing deficiency citations referring to federal law before referring to California law for each nursing home violation. Elder Abuse Exposed.com also said that the March 7, 2013 class “B” citation, which CMS’ five-star rating system totally excludes, seemed to be at odds with what appeared to be CDPH’s statement that CDPH inspectors have been referring to federal law first for each violation to ensure that CMS’ five-star rating system includes all state and federal nursing home violations.

Mr. Egel said he would soon respond to Elder Abuse Exposed.com about the March 7, 2013 class “B” citation, which he kindly did by sending the following CDPH response in an August 23, 2013 email to Elder Abuse Exposed.com:

CDPH Response: The violation date for this citation was November 2, 2010. For investigations beginning April 2012 and beyond, CDPH uses the federal process with dual enforcement and the facility receives both a federal and a state sanction (see Health and Safety Code 1423 and 1424 for CDPH’s authority and definition of citations).

CDPH’s response about 2013 class “B” citation issued to North American Health Care client facility confirms that CMS’ five-star rating system excludes most misconduct substantiated during complaint investigations at California nursing homes

CDPH’s August 23, 2013 email response confirms that CMS’ misleading Nursing Home Compare five-star rating system currently excludes the majority of deficiency citations and penalties that CDPH inspectors have issued to California nursing homes during complaint investigations. CDPH’s August 23, 2013 email also confirms that the Nursing Home Compare five-star rating system will continue to exclude for a number of years the majority of California nursing homes’ misconduct that CDPH has found during complaint investigations:

• According to CMS, Nursing Home Compare has a three-year look-back period for information on nursing homes’ deficiency citations and penalties resulting from both routine annual inspections and complaint investigations. In other words, when Elder Abuse Exposed.com was doing research for this three-part exposé in late August 2013, CMS’ Nursing Home Compare five-star rating system included nursing homes’ deficiency citations and penalties from about August 2010 until August 2013.

• However, according to CDPH’s August 23, 2013 response above, CDPH inspectors will supposedly issue deficiency citations referring to both federal law and California law for each nursing home violation, but only if CDPH started investigating the violation after March 31, 2012.

• CDPH inspectors did not actually start issuing deficiency citations referring to both California and federal law for each nursing home violation until some indefinite time after April 1, 2012, because of the time, sometimes considerable, that passes between the beginning of a complaint investigation and CDPH’s issuance of a citation. For instance, in the case of the March 7, 2013 class “B” citation that CDPH issued to North American Health Care’s client facility Cottonwood Healthcare Center, almost two years and three months passed between the beginning of CDPH’s investigation on December 14, 2010, and CDPH’s issuance of the class “B” citation, referring only to state law, on March 7, 2013.

• If CDPH inspectors had started the same Cottonwood Healthcare Center complaint investigation on April 1, 2012, when CDPH said it started using “the federal process with dual enforcement,” and took the same amount of time (almost two years and three months) before issuing the class “B” citation to Cottonwood, CMS’ Nursing Home Compare would still not even mention the deficiency citation. In fact, CMS’ five-star rating system on Nursing Home Compare would continue not to mention Cottonwood Healthcare Center’s deficiency until CDPH issued a citation referring to both federal and state law in late June 2014.

• Because CDPH inspectors very recently started issuing citations referring to both federal and state law, the majority of California nursing home citations and penalties resulting from complaint investigations and issued during Nursing Home Compare’s three-year look-back period currently refer only to California law and not federal law.

• As a result, CMS’ Nursing Home Compare five-star rating system, which only includes citations and penalties referring to federal law, currently disregards most of the misconduct that CDPH inspectors have substantiated during complaint investigations at California nursing homes.

3. Even with CDPH’s “dual enforcement” after April 2012, CMS’ five-star rating system will likely continue to exclude serious misconduct by wealthy, politically connected nursing homes in California.

Even if CMS’ Nursing Home Compare eventually includes all California nursing home citations and penalties resulting from both annual inspections and complaint investigations, CMS’ five-star rating system will likely continue to exclude the most serious misconduct by wealthy, politically connected nursing homes in California:

• Before CDPH supposedly started using what it has called “the federal process with dual enforcement” on April 1, 2012, CDPH inspectors could issue nursing home citations referring only to California law and not federal law and thereby ensure that Nursing Home Compare would exclude the citations.

• But now that CDPH has claimed that its inspectors will be issuing dual citations, referring to both state and federal law, CDPH inspectors will likely continue doing what U.S. Senator Charles Grassley (R-Iowa) has found through his many Senate hearings and investigations of what he has called a “seriously corrupted” and “broken” nursing home inspection and enforcement system. In other words, many well-intentioned CDPH inspectors who may feel pressured by supervisors, high-level bureaucrats, and state lawmakers will likely increase the practice of understating or downgrading the most serious nursing home misconduct, including blatant elder abuse leading to death. (For more on Senator Grassley’s findings, see secret number 16 in the upcoming part 3 of this three-part exposé.)

• By downgrading nursing home citations even more so in the new age of “dual enforcement,” many conscience-stricken CDPH inspectors who may feel that the pressure from above prevents them from doing the right thing will continue to ensure that Nursing Home Compare excludes most of the higher-level violations by wealthy, politically connected nursing homes in California.

4. CMS’ Nursing Home Compare excludes state enforcement actions against even “five-star” nursing homes in California.

Research of state enforcement actions against California nursing homes rated “five stars” by Medicare reveals some facilities with history of higher-level violations

Because North American Health Care’s president and CEO, John L. Sorensen, says on his personal website, “Thirty Four of its Thirty Five affiliated client facilities are five star rated and one is four star rated,” Elder Abuse Exposed.com decided to do some research. Elder Abuse Exposed.com looked at deficiency citations that CDPH inspectors have issued to some of these “five-star-rated” nursing homes but that are excluded from CMS’ Nursing Home Compare. Elder Abuse Exposed.com found that CDPH inspectors have issued citations to some of these “five-star-rated” nursing homes for various alleged violations of law, including class “B” citations and even a class “AA” citation in 2007 for a death-related violation. (California Health and Safety Code § 1424 defines the most serious citation under state law, a class “AA” citation, as “violations that meet the criteria for a class “A” violation and that the state department determines to have been a direct proximate cause of death of a patient or resident of a long-term health care facility.”)

CMS’ Nursing Home Compare falsely states that “five-star” nursing homes with histories of many complaint inspections and fines in past three years have had no complaint inspections or fines

For example, according to CMS’ Nursing Home Compare website on August 19, 2013, Cottonwood Healthcare Center had an “overall rating” of five stars. Relying on CMS’ five-star rating of this facility, the Cottonwood Post-Acute Rehab website advertises on its homepage that “Cottonwood Post-Acute Rehab is a 5 Star Rated Facility by Medicare.” CMS’ Nursing Home Compare also claimed that Cottonwood Healthcare Center had “no complaint inspections” between July 1, 2010, and June 30, 2012, and had only one complaint inspection (on August 3, 2012) between July 1, 2012, and June 30, 2013. Finally, Nursing Home Compare falsely claimed, and still claims, “This nursing home has not received any fines in the last 3 years.”

But according to CDPH nursing home data on Cottonwood Healthcare Center, since July 1, 2010, CDPH inspectors have imposed many fines and substantiated many complaints and facility self-reported incidents during inspections at North American Health Care’s client facility Cottonwood Healthcare Center. In fact, CMS’ Nursing Home Compare profile of Cottonwood Healthcare Center and CMS’ calculations of Cottonwood Healthcare Center’s health inspection star rating and overall star rating have totally excluded the following substantiated complaints, facility self-reported incidents, and state enforcement actions against Cottonwood Healthcare Center:

Penalty Issue Date: 7/2/2010
Penalty Number: 030007346
Penalty Category: Patient Care
Class Assessed: B
Violation Date: From: 8/10/2008 To: 8/10/2008
Violation Code(s): 72311(a)(2), 72315(b)
Associated Complaint(s): CA00159708
Total Amount Due: $1,000.00
Total Balance Due: $1,000.00
Appealed: Yes

Penalty Issue Date: 7/20/2010
Penalty Number: 030007388
Penalty Category: Patient Care
Class Assessed: B
Violation Date: From: 11/29/2008 To: 11/29/2008
Violation Code(s): 72315(b)
Associated Complaint(s): CA00170767
Total Amount Due: $1,000.00
Total Balance Due: $0.00
Appealed: No

Penalty Issue Date: 7/20/2010
Penalty Number: 030007389
Penalty Category: Abuse/Facility Not Self Reported
Class Assessed: B
Violation Date: From: 10/8/2008 To: 10/8/2008
Violation Code(s): 1418.91(a), 1418.91(b)
Associated Complaint(s): CA00235529
Total Amount Due: $600.00
Total Balance Due: $0.00
Appealed: No

Intake Received Date: 8/25/2010
Intake ID: CA00240692
Allegation Category: Quality of Care/Treatment
Sub Categories: Resident Safety/Falls
Investigation Finding: Substantiated

Intake Received Date: 9/14/2010
Intake ID: CA00242742
Allegation Category: Admission, Transfer & Discharge Rights
Investigation Finding: Substantiated

Intake Received Date: 10/12/2010
Intake ID: CA00245653
Allegation Category: Infection Control
Investigation Finding: Substantiated

Intake Received Date: 11/2/2010
Intake ID: CA00248164
Allegation Category: Resident/Patient/Client Abuse
Sub Categories: Employee to Resident
Investigation Finding: Substantiated
Enforcement Action: Issued
Issue Date: 3/7/2013
Original Penalty Amount: $500.00

Intake Received Date: 2/11/2011
Intake ID: CA00258819
Allegation Category: Infection Control
Investigation Finding: Substantiated

Intake Received Date: 2/24/2011
Intake ID: CA00260440
Allegation Category: Quality of Care/Treatment
Sub Categories: Resident Safety
Investigation Finding: Substantiated

Intake Received Date: 3/10/2011
Intake ID: CA00261908
Allegation Category: Resident/Patient/Client Abuse
Sub Categories: Other
Investigation Finding: Substantiated

Intake Received Date: 3/14/2011
Intake ID: CA00262170
Allegation Category: Quality of Care/Treatment
Investigation Finding: Substantiated
CDPH Deficiency Statement Issued to North American Health Care Client Facility Cottonwood Healthcare Center (September 13, 2011)

Intake Received Date: 3/16/2011
Intake ID: CA00262452
Allegation Category: Resident/Patient/Client Rights
Investigation Finding: Substantiated

Intake Received Date: 3/17/2011
Intake ID: CA00262668
Allegation Category: Infection Control
Investigation Finding: Substantiated

Intake Received Date: 6/27/2011
Intake ID: CA00274133
Allegation Category: Quality of Care/Treatment
Sub Categories: Resident Safety/Falls
Investigation Finding: Substantiated

Intake Received Date: 6/30/2011
Intake ID: CA00274641
Allegation Category: Admission, Transfer & Discharge Rights
Investigation Finding: Substantiated

Intake Received Date: 8/2/2011
Intake ID: CA00278016
Allegation Category: Quality of Care/Treatment
Investigation Finding: Substantiated
CDPH Deficiency Statement Issued to North American Health Care Client Facility Cottonwood Healthcare Center (August 12, 2011)

Intake Received Date: 8/11/2011
Intake ID: CA00279187
Allegation Category: Resident/Patient/Client Abuse
Sub Categories: Resident to Resident
Investigation Finding: Substantiated
CDPH Deficiency Statement Issued to North American Health Care Client Facility Cottonwood Healthcare Center (October 3, 2011)

Intake Received Date: 9/19/2011
Intake ID: CA00283627
Allegation Category: Resident/Patient/Client Rights
Investigation Finding: Substantiated

Intake Received Date: 11/14/2011
Intake ID: CA00289873
Allegation Category: Quality of Care/Treatment
Investigation Finding: Substantiated
CDPH Deficiency Statement Issued to North American Health Care Client Facility Cottonwood Healthcare Center (November 23, 2011)

Intake Received Date: 11/21/2011
Intake ID: CA00290468
Allegation Category: Quality of Care/Treatment
Investigation Finding: Substantiated

Intake Received Date: 6/4/2012
Intake ID: CA00312867
Allegation Category: Resident/Patient/Client Abuse
Sub Categories: Employee to Resident
Investigation Finding: Substantiated
CDPH Deficiency Statement Issued to North American Health Care Client Facility Cottonwood Healthcare Center (August 3, 2012)

Intake Received Date: 11/30/2012
Intake ID: CA00334716
Allegation Category: Physical Environment
Investigation Finding: Substantiated

Penalty Issue Date: 3/7/2013
Penalty Number: 030009770
Penalty Category: Patient Rights
Class Assessed: B
Violation Date: From: 11/2/2010 To: 11/2/2010
Violation Code(s): 72315(b)
Associated Complaint(s): CA00248164
Total Amount Due: $500.00
Total Balance Due: $0.00
Appealed: No
CDPH Class “B” Citation Issued to North American Health Care Client Facility Cottonwood Healthcare Center (March 7, 2013)

Intake Received Date: 4/22/2013
Intake ID: CA00351931
Allegation Category: Resident/Patient/Client Abuse
Sub Categories: Employee to Resident
Investigation Finding: Substantiated

In an interview with CNA 1 on 5/3/13 at 10:30 a.m., she stated, “I came in that morning (4/18/13) and Resident 1 told me she had been beat up the night before. . . . I then went and told the nurse.”

In a telephone interview with Licensed Nurse (LN) 1 on 5/3/13 at 1:10 p.m., she stated, “[The] administrator said there were allegations of abuse. There was nobody else to talk to. This is really new to me. I tried to follow orders I was given [by the administrator]. . . . I did not contact the Medical Doctor [MD]. I was just told to do the head to toe assessment. I didn’t know the [abuse] protocol. Followed the administrator’s orders of the head to toe assessment. I did endorse it to the next shift nurse [LN 2].”

In a telephone interview with LN 2 on 5/3/13 at 1:20 p.m., she stated, “[The administrator] called me into his office after I clocked in 4/18/13 and I told me what happened. I didn’t call the [MD] or write a care plan.”

Review of the Nurse’s Notes dated 4/18/13 at 9:39 p.m., indicated an entry by LN 1 “Head to toe assessment done.” There was no reference to the Resident 1’s allegation of abuse in the Nurse’s Note. [Emphasis added. Excerpts from following August 22, 2013 deficiency statement:]

CDPH Deficiency Statement Issued to North American Health Care Client Facility Cottonwood Healthcare Center (August 22, 2013)

Intake Received Date: 5/8/2013
Intake ID: CA00353838
Allegation Category: Resident/Patient/Client Rights
Sub Categories: Resident Not Treated with Dignity/Respect
Investigation Finding: Substantiated

Intake Received Date: 5/28/2013
Intake ID: CA00356052
Allegation Category: Quality of Care/Treatment
Sub Categories: Resident Safety
Investigation Finding: Substantiated

Intake Received Date: 7/1/2013
Intake ID: CA00360317
Allegation Category: Pharmaceutical Services
Investigation Finding: Substantiated

Intake Received Date: 7/1/2013
Intake ID: CA00360317
Allegation Category: Quality of Care/Treatment
Sub Categories: Water Not Offered To Resident
Investigation Finding: Substantiated

Nursing Home Compare’s false statements about California nursing homes’ enforcement and complaint investigation histories can be considered a fraud perpetrated on unsuspecting California consumers

In light of all the preceding fines, substantiated complaints, and substantiated facility self-reported incidents during inspections at North American Health Care’s “five-star” client facility Cottonwood Healthcare Center since July 2010, it is hard not to consider CMS’ statement on Nursing Home Compare that “this nursing home has not received any fines in the last 3 years” as an unjustifiable falsehood that consumers may have relied on to their detriment. In other words, this statement by CMS on Nursing Home Compare can be considered a fraud under California law that is perpetrated on unsuspecting consumers searching for a nursing home for their elderly, disabled, and sick loved ones.

North American Health Care’s “five-star” client facility Cottonwood Healthcare Center was hit with the most severe penalty under state law, a class “AA” citation, and a $90,000 penalty in 2007

In addition to the many state enforcement actions above against North American Health Care’s “five-star” client facility Cottonwood Healthcare Center, CDPH hit Cottonwood Healthcare Center in January 2007 with the most severe penalty under state law, a class “AA” citation, and a $90,000 penalty. CDPH issued the class “AA” citation to Cottonwood Healthcare Center after the death of an 89-year-old female patient who died, according to the citation, after becoming severely dehydrated, infected, and mentally altered for many days. In the class “AA” citation, CDPH investigators said, “The Department determined that the above violations presented an imminent danger or substantial probability that death or serious harm would occur, and were a direct proximate cause of the death of Patient A.”

According to the following CDPH nursing home data on August 19, 2013, Cottonwood Healthcare Center appealed the class “AA” citation and had a total amount due of $32,500:

Penalty Issue Date: 1/5/2007
Penalty Number: 030002916
Penalty Category: Patient Care
Class Assessed: AA
New Class Assessed: A
Violation Date: From: 3/20/2005 To: 3/20/2005
Violation Code(s): 72311(a)(1)(A), 71315(h), 72523(a)
Associated Complaint(s): CA00041684
Total Amount Due: $32,500.00
Total Balance Due: $0.00
Appealed: Yes
CDPH Class “AA” Citation Issued to North American Health Care Client Facility Cottonwood Healthcare Center (January 5, 2007)

While referring only to California law and not federal law, CDPH inspectors issued the class “AA” citation to North American Health Care’s client facility Cottonwood Healthcare Center in January 2007. That was almost two years before CMS launched its five-star rating system on Nursing Home Compare in December 2008. But even if CDPH inspectors had started investigating the same death-related violations listed in the class “AA” citation anytime after December 2008 and before April 1, 2012, when CDPH claimed it started using “the federal process with dual enforcement,” CMS’ five-star rating system would still disregard this highest-level state enforcement action against Cottonwood Healthcare Center. As a result, consumers who rely solely on CMS’ Nursing Home Compare for information about Cottonwood Healthcare Center do not see any mention of the state law violations and corresponding state enforcement actions listed above against the “five-star” Cottonwood Healthcare Center, regardless of the severity of the violations. That means that California consumers are getting a false and misleading message from CMS’ Nursing Home Compare website.

Continue to part 2…

Please return to Elder Abuse Exposed.com’s blog within the next week or two to read part 2 and part 3 of this three-part exposé, “Medicare’s Nursing Home Compare Five-Star Rating System: A Fraud on the Public?” In part 2 and part 3, Elder Abuse Exposed.com will continue to reveal the remaining 12 of the 16 secrets that the Centers for Medicare and Medicaid Services and “five-star” nursing homes, especially in California, do not want you to know about CMS’ five-star rating system on Nursing Home Compare.

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