Secrets over Seniors

How to uncover injuries and death within an under-regulated system

Investigations in 2023 exposed widespread trouble

Washington Post’s “Memory Care Inc.” examined instances where residents wander off into the heat or cold and die

Senior living is a big business

The New York Time’s “Dying Broke” investigated the many hidden fees that assisted living centers benefit from while their residents struggle

Dying for Care

• First story in series highlighted the influence of corporate landlords on finances and, ultimately, care quality.

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• Second wave of the project explored why most nursing homes fail to meet minimum recommendations for staffing levels even though the government has collected daily data on it for years and the research is decades old.

People get hurt; families pay the only consequences

The Arizona Republic’s “Bitter End” series exposed how hundreds of vulnerable seniors contend with violence in the very places that promise to keep them safe.

Big Local News and Rural News Network

It’s a big system, but local and hyperlocal coverage matters!

Why YOU should cover senior care

• More demand: Baby boomers are aging
• Original reporting: Assisted living is regulated by the states, so you may find unique challenges
• Opportunity for Impact: both Republicans and Democrats in Arizona have said protecting seniors is a bipartisan issue after our series
• “Comfort the Afflicted”: Residents are often discounted because their memories are failing; very few people listen to them

Why YOU should cover senior care

• Too much room for failure: Employees have little to no protection, limited training
• Big spending: Congress debates spending $90 billion annually on Medicaid/Medicare (plus funding for inspections and oversight)
• The press may be someone’s only option: States have shield or tort laws that block families from suing
• News pegs /changes incoming: There may be some federal action that makes rules for assisted living, as there are for nursing homes
• President Biden has proposed expansive reforms for nursing homes

Some basics

Follow this link!

Some more basics: Inspections

Nursing homes

• Feds require state surveyors to check compliance at least every 15 months
• No matter the state, surveyors are following the same guidebook
• State surveyors may also visit nursing homes after receiving complaints

Assisted Living

• States determine how frequently inspections happen, and what surveyors look for (get familiar with your states’ rule books!)
• Inspections may also be triggered by complaints
• These inspections may be done by a completely different team than the one that surveys nursing homes

• Every deficiency a surveyor thinks they can prove is assigned an “ftag,” which is a code that corresponds to the particular federal rule violated.
• 880 is infection control
• 725 / 726 is sufficient and competent staff
• <<<<< Each ftag also is given a “scope and severity code” that is a letter signifying how many people were affected and how serious the incident was.
• That code determines whether a “Plan of Correction” must be filed by the nursing home. That is simply documentation filed by the nursing home to the state to show a problem has been fixed. Sometimes, state survey agencies accept paperwork as proof of change. Sometimes, they do follow-up in-person inspections to check for changes.
• It depends on who is president, but findings of “actual harm” or “immediate jeopardy” automatically triggers a fine. For a variety of reasons, these citations are rarely issued.
• Some presidents have those fines accrue DAILY until a problem is fixed. Some presidents have had that be a one-time fine.
• Nursing homes often appeal these high-level citations to be reviewed through the “Federal Independent Dispute Resolution” process. This is a HUGE hassle for surveyors, who have to present their detailed evidence of the violation. Because inspection agencies are often understaffed, this is a huge time suck.

Nursing home deficiencies explained

Ownership: Nursing homes

https://www.usatoday.com/story/news/2023/02/13/nursing-home-care-compare-gao-report-ownership-congress-cms/11230607002/

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https://www.newyorker.com/news/dispatch/when-private-equity-takes-over-a-nursing-home

• Building: Who owns it?
• Operator: The company providing medical services and the “face” of the nursing home.
• Related Parties: Other companies or businesses operating inside the nursing home that often have financial ties to the operating company or its parent company.

pharmacy

therapy

consultant

operator

Holding Company

Holding Company

Holding Company or Independent Manager

Ultimate Owners

(a family, private equity firm, real estate investment trust, etc.)

• The operating company, which holds the license, submits Annual Cost Reports to CMS, which are supposed to detail the money coming in and out of the nursing home.
• It’s supposed to name related parties, but often doesn’t.
• Academics and regulators have found problems with facilities changing their operations so the snapshot looks better, but doesn’t reflect typical operations (like staffing).
• CMS is collecting more detailed ownership data for the first time and has published statistics on the country’s largest ownership groups. (Impact!)

Ownership: Assisted Living Facilities

• Assisted living facilities, unfortunately, don’t have to report their ownership to CMS. So their ownership structures can be harder to probe!
• Like nursing homes, the buildings of a facility aren’t always owned by the same people/company that operate a facility. Operators are generally the ones making hiring decisions, creating facility policy and handling the day-to-day function of facilities…
• …But that doesn’t mean the company that owns the real estate is absolved when things go wrong.
• AZ case study: Heritage Village

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CMS: There’s data for pretty much everything on nursing homes

• Provider info: basic details of ratings and ownership
• Ownership: Lists most people/entities that own a nursing home -- but not always other related businesses (More coming soon!)
• Payroll based journal data: every row is represents hours worked by core nursing home staff (RNs, LPNs, CNAs, therapists, clinicians, etc.) per facility -- per DAY
• Health deficiencies: every row is a single deficiency found during inspections (more on these later)
• Penalties: federal fines associated with compliance periods. IMPORTANT NOTE: they are are not linked to any one deficiency or even one survey. That requires a FOIA.

LINK TO NURSING HOME DATA: https://data.cms.gov/provider-data/topics/nursing-homes

CMS: Data on resident variables

• The MDS Frequency Report tells you a lot about how nursing home patients feel and what they’re dealing with in your state.
• Questions cover a variety of things including diagnoses, daily activities, demographics, cognitive abilities and mood
• This is useful for quick stats in your story. For example, if you’re writing about residents with dementia, you can use this to say what percent of nursing home residents not only have that - but to what degree it affects them.

https://rb.gy/42iphh

ProPublica’s

Nursing Home Inspect

• A good place to start as you scout potential stories, or if you don’t have time to wait for responses to record requests.
• Find copies of inspection reports and see quick summaries of basic nursing home fines, COVID data and raw staffing levels.
• Recently updated to include CMS’ expanding data on ownership.
• SEARCH ALL INSPECTION REPORTS BY KEYWORD!

Assisted Living Data

• The National Post Acute and Long Term Care Study surveys assisted living facilities: https://www.cdc.gov/nchs/npals/questionnaires.htm
• Example of questionnaire: https://rb.gy/1vgjpj
• State licensing documents
• Most states require assisted living facilities to report resident injuries / abuse. You should be able to get those reports, or even databases on them.
• Colorado, for example has a dashboard that shows you occurences https://cdphe.colorado.gov/find-and-compare-facilities

ALF inspection report availability (as of 2022)

States that post inspection reports online for consumers to search

• Idaho
• Michigan
• Minnesota
• Missouri
• Nevada
• New Mexico
• North Carolina
• Oklahoma
• Oregon
• Pennsylvania
• Rhode Island
• Texas
• Vermont
• Washington
• Wisconsin
• Wyoming
• West Virginia
• New Hampshire
• Arizona

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States that said they do not

• Alaska
• Arkansas
• Louisiana
• Maine
• Maryland
• Mississippi
• Nebraska
• Ohio
• South Carolina
• Tennessee
• Utah
• New Jersey

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… if they’re not on either list then their health department didn’t answer that question

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State licensing boards

• State health departments license facilities and inspect them, but they don’t always license or regulate the managers that run the facilities.
• States should have disciplinary and licensing records on hand for managers, which would be separate from citations you find on the facility (both NHs and ALFs)
• Arizona case study: there were stories about a facility cited for severe Covid-19 violations. But then there was another layer: the manager had felonies for fraud and no healthcare experience.

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Get creative

Check your state law and see what assisted living facilities are required to report and to which agency.

In Arizona, for example, resident abuse/neglect/exploitation must be reported to Adult Protective Services (which keeps most of what it does secret) OR police. So we looked to police reports to track resident injuries that the state would never know about. 400 addresses and 40 jurisdictions later, we had a pretty good picture of what happens out there.

Think of all the ways government (and people) interact with senior living beyond monitoring health care.

• 911 calls
• Campaign finance filings
• County property records
• State business filings
• SEC business filings (especially the 10k)
• Investor reports and quarterly calls
• Company websites (and their archived versions) - you might find some damning videos or promotional material
• Shift work apps
• Facebook groups, Yelp reviews, Google reviews, etc. In some cases, you can find pictures of what the inside of the facility looks like based on what reviewers post.
• Be weary if you see a rash of very positive reviews posted in a short period of time after negative reviews were posted and find out if the positive posters work for the facility.

Who can you talk to? How?

Who are the people (aka sources) to interview?

• Ombudsmen (state employees who are supposed to watchdog nursing homes on behalf of the public and families)
• Resident advocacy organizations, if there is one in your state
• Academic researchers
• Industry associations
• Investors
• Elected officials
• Inspectors (usually won’t talk, but the State Survey Agency director might)
• Operators (but also talk to their owners, related companies, landlords and investors!)
• Administrators (licensed by the state to run a nursing home)
• Current and former staff members! - RNs, LPNs, CNAs, social workers, therapists, etc. and their union, if they have one.
• Current and former residents + their families!

TIPS FOR INTERVIEWING FAMILY WHO LOST SOMEONE

• Give them a lot of time and space. Before starting in with your questions about the bad thing that happened, ask them about their loved one (who they were, what they liked to do, personal anecdotes of memories) - not only because it’s important to include these details in our stories but your source will feel much more comfortable knowing their loved one is not going to be portrayed as a one-dimensional victim or a number. This helps readers understand what is lost with their death.
• Make sure they understand your timeline. If you’re working on a long project, be sure to tell them at the beginning that the story won’t publish for x number of months. And check in with them throughout – meet them for lunch or coffee periodically and just talk about life stuff. A lot of these folks have been ignored and are suffering trauma and you want to make sure you’re not giving them similar vibes while they wait for your project to publish. You also don’t want every time you talk to them to be about ‘the incident.’
• Explain your process and why you’re doing what you’re doing. Most people do not understand how journalists do their jobs or why they’re asking the questions they are asking. Demystify this. Invite them to ask you questions. Explain up front how you will bolster their story with other sources and do fact checking with them at the end to get everything right.
• Multimedia and documents: Ask them for photos, audio (like voicemails), little videos, documents (medical records, emails to the nursing home), etc. they might have of their loved from their life and from their time in medical care. (Check our our video about a woman who was killed in a facility. We used audio of her voice.)

Tips for interviewing Facility Directors

• Talk to a variety of facility directors. In addition to calling the facility or facilities where you have found problems, you should also call facilities where you have not found problems. Try to get tours of their buildings, understand how they do things and tell them what you’re finding. This can allow you to see how things should be done, and also find sources to explain how the system works. It’s always fascinating to hear their take on your findings. Do they defend the facility with issues? Or do they identify where things went wrong?
• Do your homework. If you’re calling a facility about the “solutions” side of things, make sure you have exhausted every single possible avenue to find problems there so you’re not just highlighting a facility that never got caught by government inspectors. For nursing homes, start with CMS data and state inspection reports and the manager licensing board, as well as police calls for service and incident reports, lawsuits and even consumer reviews.
• When contacting a facility where you’ve found problems, identify who the manager is and look up their background. Manager licensing records will give you extra insight to whether they’ve personally had troubles at other places before or if the issue at hand seems to be a one-off for them. Knowing these things can help shape your interview questions that may help them open up or just understand that you know the whole picture.

Tips for interviewing residents

• Visit them at the facility. Getting invited by a resident may be your only way into the building. Find out what the facility’s visitation policy is; as long as the resident is allowed to have anyone visit them you’re fine to sign in as their visitor. But be honest if an employee asks you how you know the resident.
• Be careful about interviewing other residents while you’re there. Depending on their cognitive abilities (dementia, for example) they may not understand why you’re there or that they’d be quoted in a story. If you do end up finding more residents to talk to it is important to follow up with them and their families so no one’s surprised to see their name in the news.
• Ask the resident about themselves; they are more than their condition. Some nursing home and assisted living facility residents suffer daily indignities and chances are, if you’re there talking to them, that’s why you’re there. This is similar to the general rule about interviewing families: no one wants to feel like a statistic.
• If you take pictures in the facility during a resident visit, consult with your photo department and legal teams. Lots of legal and ethical questions to cover there.
• Be open to interviews by text message or email. Often, this is easier (or the only option) for people with disabilities or other speech challenges, which also means you get more authentic and real responses. Requiring people to use their voice to talk will exclude important perspectives from your work.

Making an impact

Impact from the Bitter End

• The governor launched an investigation into a facility we exposed for rampant problems and said senior living reforms would be a top priority
• Two bills passed in the AZ House of Representatives that would require transparency, stiffer fines and training requirements particularly for memory care units
• The state health department began investigating more cases and issuing more citations
• The board that licenses facility managers started investigating more managers
• U.S. Senators asked the GAO to study how medicaid and medicare dollars are spent on assisted living, citing The Bitter End, The New York Times and Washington Post stories

Impact from USA TODAY and BLN/RNN collaboration

• White House called us to learn more about Real Estate Investment Trusts, as did members of a NASEM committee, leading that ownership player to be specifically mentioned in reports, congressional hearings and now-enacted regulations.
• CMS has proposed numeric staffing level requirements for the first time. Industry says they can’t meet them. Resident advocates point to loopholes. We’ll keep covering the issue.
• Some local partners report that state legislators are newly interested in creating or updating state-level staffing requirements
• People feel HEARD and learn about SOLUTIONS they can advocate for – not just another tragic without hope.

Making an impact

Things that helped the team at The Republic or USA TODAY

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1. Make a power and information needs map. Who has the authority to make change and what motivates them to do so? What information do different kinds of readers need to be empowered by your story? Too often we limit our thinking to government. What about investors?

Making an impact

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2) Doubling down: The Bitter End began as a four-story drop. But then, every month to every other month, the team released a folo story. Hammering down on the issue undoubtedly helped ensure the public and its lawmakers couldn’t forget about the horrors unearthed.

Making an impact

3) Helping everyday people find workarounds: Investigations that unearth troubling truths about the institutions people depend on are necessary.

But what is an everyday person supposed to do when you tell them that people just like their family members are being ill treated within the facilities they have to rely upon for care?

Even while you’re continuing to report in the hopes of impacting systemic change, it’s important to give your audience workarounds for the problems you just unearthed. People still have to use assisted living facilities and nursing homes — how can they do so in an informed manner? How can they best protect their loved ones under the circumstances as they are?

Making an impact

4) Present clear solutions.

“Those series of articles definitely heightened the awareness of the potential and the actual abuses going on,” said Republican state Rep. Selina Bliss, who is co-sponsoring one of the recently-introduced bills. “We knew they were out there — we just didn't know how to put an end to them or stop them. So the article series, I have to admit, was very well done and did bring attention to this very difficult matter.”

This was not by accident. We built a clear roadmap for reforms into our published work, which started with pinpointing them early on within our reporting process and reporting those out just as we reported the problems.

Making an impact

5) Empower other reporters to cover these issues with nuance.

These institutions require expertise to cover well, which can be a barrier to more coverage that communities need. Help each other learn the wonky regulations and systems. There are more stories to cover than reporters, and the public deserves all of it.

Contact us!

Caitlin McGlade: cmcglade@gannett.com | X or Insta: @caitmcglade

Sahana Jayaraman: sahana.jayaraman@gannett.com | X: @SahanaJayaraman

Jayme Fraser: jfraser@gannett.com or jaymef@EqualAccessPublicMedia.com

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