A Kansas program aims to reward good nursing home care, but critics say poor oversight remains
A Kansas program that awards nursing homes millions of dollars for providing thoughtful care doesn’t weed out those with a history of deficiencies. Critics say it’s just one way the state fails to adequately regulate the long-term care industry.
WICHITA, Kansas — By the time Tammy Near made it inside her longtime boyfriend Miguel Ornelas’ room at a Wichita nursing home — after the pandemic forced them to visit through a window for much of his 16-month stay — she’d already harbored questions about the care he got there.
It was still a shock to see him up close.
“He was laying in bed with nothing but a diaper on,” she said.
Ornelas is bedridden and cognitively impaired after a car hit him as he was crossing the street.
“He hadn’t been bathed in I don’t know how long,” Near said. “His toenails hadn’t been clipped, it looked like, in a year.”
“And he was laying in a puddle of urine and feces.”
When she looked in his closet for a clean pair of socks, she found them covered in mouse droppings.
“They just totally ignored him and neglected him,” she said.
Within weeks, she pulled him out of Advena Living on Woodlawn, also known as Orchard Gardens, and began caring for him around the clock.
She filed a complaint with the Kansas Department for Aging and Disability Services, or KDADS. Department spokesperson Cara Sloan-Ramos said the department cannot comment on an active complaint survey.
Advena’s owners declined comment on the complaint, but public records show the for-profit nursing home chain has been fined repeatedly for conditions that put its patients in peril.
Yet the nursing home operator, dogged by poor marks from regulators across Kansas, takes part in a program designed to make life better for the aging and ailing.
Officials say the Promoting Excellent Alternatives in Kansas, or PEAK, program aims to retool how nursing homes work — less institutional and more homelike. Through it, the state has doled out over $15 million in Medicaid payments over the last decade for providing “person-centered care.”
But critics say nursing homes getting those tax dollars notably fail to use it to hire more workers — one of the chief factors that contribute to substandard care.
“(Staff) are so rushed, they are giving the wrong medicines,” said Camille Russell, the state’s long-term care ombudsman. “They’re making these mistakes that can be life-threatening because there’s not enough of them.”
Six of Advena’s seven nursing homes participate in PEAK. And yet all but one are rated one-star for “much below average” by the Centers for Medicare & Medicaid Services. The last is rated two stars for “below average.” In the past three years, regulators found hundreds of deficiencies across the seven facilities, resulting in fines totaling more than $430,000.
'They just kept cutting back'
Larry Cundiff’s wife of 55 years, Phyllis, lived at Advena Living of Clearwater, also known as Clearwater Nursing & Rehabilitation, for over six years. Larry said the quality of her care declined markedly after Advena bought the Wichita-area facility in 2019 and continued up until her death this summer.
Afterward, Phyllis — who was bedridden after a stroke left her unable to move one of her legs — would frequently call him in tears. If she had slid down in her bed, he said, she’d often wait several hours for staff to respond to her calls for help. Cundiff said they sometimes ignored her calls entirely.
“She would call me at least once or twice a week,” he said, “bawling and crying.”
Many of the longtime nursing staff, he said, left after Advena took over.
“(Advena) just kept cutting back,” he said. “You’re just not able to take care of people properly.”
He said staff routinely brushed off his concerns, including when he asked about his wife’s leaking catheter or when he found a pool of urine beneath her bed.
Cundiff learned that the hospice nurses who visited a few times a week would more reliably complete basic care tasks than the nursing home’s staff. He wrote a letter to the facility’s administrator detailing the issues. Cundiff said he never got a response.
“You want someone to cherish your loved one the way you do. That’s how it was initially, but that’s not how it was the last couple of years,” said Lisa Cundiff, the couple’s daughter-in-law. After Advena took over, she said, “it lost the personal feeling.”
Elder care advocates say Advena’s documented failings offer evidence that the PEAK program doesn’t do enough to screen facilities before allowing them to participate in a program that’s often marketed as a proxy for high quality of care. Others say it’s emblematic of the state’s failure to regulate an industry where for-profit companies care for some of its most vulnerable people.
“There is a push to appease the business side of this industry versus the human service side of this industry,” Russell said. “The regulations that exist are not enforced. And it is primarily due to the fact that there are not enough resources to do so.”
She didn’t blame PEAK for a lack of regulatory oversight.
“But KDADS is the one that oversees and pays for that program,” Russell said. “So it is interesting that KDADS seems to be OK with homes that have serious deficiencies (participating).”
Rewarding 'person-centered care'
PEAK was established in 2002 to encourage nursing homes to move from a one-size-fits-all care model toward one that prioritizes resident preferences around things like meals and bedtimes.
A decade later, KDADS turned PEAK into a Medicaid pay-for-performance incentive program. The department contracted Kansas State University to administer it and began awarding nursing homes taxpayer money depending on their progress in certain core areas.
Program administrators look at factors including whether residents can decide what time they go to sleep and whether they’d rather take a bath or a shower. They encourage nursing home operators to schedule staff in a way that enables residents to form relationships with a small, consistent group of caregivers.
“It’s really about breaking down an old system that was based on a hospital or medical model approach to help to individualize care for people,” said Laci Cornelison, the program’s coordinator at Kansas State University.
Facilities entering the program can earn 50 cents per Medicaid bed per day. That increases to $3 at the program’s upper level. About 130 of the state’s more than 300 nursing homes currently participate — which reflects declines during the pandemic as many nursing homes struggled to meet certain requirements. At the program’s height, more than 200 facilities participated.
But government watchdogs and elder care advocates say the program is flawed, rewarding nursing homes with taxpayer money for what many would consider to be common-sense standards of care.
“This probably should be a best practice for all facilities — not just those that are wanting to receive an award through the PEAK program,” said Dan Goodman, executive director of Kansas Advocates for Better Care.
Russell, the state ombudsman who also sits on the PEAK advisory board, said the program doesn’t do enough to address the most pressing issues in the industry.
“It did a lot of good, early work,” she said. “It just hasn’t evolved.”
Both Russell and Goodman said the program’s heavy reliance on checklists and metrics can be counterproductive to the ultimate goal of person-centered care: listening and responding to residents.
“You are the only one that knows what gives you a reason to live and get up in the morning,” Russell said. “The answer to providing quality of life and person-centered care is knowing the person individually — planning and supporting around their life goals. And that can’t be done with more tasks and more checklists.”
Russell also said the program’s system for evaluating nursing homes doesn’t weight resident input heavily enough.
Cornelison said the PEAK advisory board, at the suggestion of Russell and others, is exploring ways to make resident feedback a bigger part of the evaluation progress.
But critics say the program, which is one of the state’s few tools for improving the quality of nursing home care, is woefully inadequate.
They say, for instance, it doesn’t address a crisis of care inside nursing homes driven by the industry’s longstanding reliance on bare-bones staff levels — a crisis that data shows is worse in for-profit chains like Advena. Person-centered care isn’t possible, they say, when homes are struggling to meet residents’ most basic medical and hygiene needs.
Nursing home operators say they can’t find enough people willing to do the often demanding work of caring for the elderly. Critics say that’s because of low pay and untenable working conditions. The tension is unique to neither Advena nor Kansas.
Still, Russell says the issues with PEAK exemplify the state’s failure to hold nursing homes accountable.
“Things can’t keep happening like this,” she said. “Because it may be somebody else today living in those nursing homes, but it’s me tomorrow. It’s you tomorrow. We all will suffer.”
'Please help us'
Willie and Michelle Novotny, Advena’s owners, declined to comment on the complaints about their Wichita and Clearwater facilities.
“As an organization, we are committed to quality care,” they said in an email. “We would welcome the chance to meet with any current or former residents and their family members to ensure we have the opportunity to resolve things moving forward.”
But evaluations by regulators document a host of deficiencies at the two facilities.
The Wichita home was cited for 38 deficiencies in the past three years, resulting in a $25,638 fine and two Medicare payment denials. Staff failed to adequately monitor a male resident accused of sexually abusing a female resident, evaluators found, leading to alleged abuse of a second female resident. They also found issues with bedsores, medication administration, cleanliness and cockroaches.
The Clearwater home was cited for 53 deficiencies in the same period, prompting $132,090 in fines and one Medicare payment denial. In interviews with evaluators, workers said chronic and severe understaffing even before the pandemic prevented them from bathing residents and administering medications on time.
“Things are terrible,” one resident told evaluators, saying showers were given “only if you beg for one.”
“Please help us. No one else seems to care,” said another resident. “What if there was a fire? There’s no one here to help us all get out. We would all burn to death.”
A former director of nursing at the facility said in written testimony to the state Legislature that when she was hired in February 2020, several months after Advena acquired the facility, many residents hadn’t been bathed in more than five weeks.
While Advena’s evaluation record is checkered, it’s not an anomaly in Kansas. Over a third of the state’s Medicare-certified nursing homes had at least one serious deficiency in the past three years — one of the highest rates in the country. And yet the average fine Kansas homes received was lower than the U.S. average.
KDADS records indicate Advena’s Wichita location is currently not receiving PEAK incentive payments due to deficiency surveys. The Clearwater location currently receives 50 cents per Medicaid bed per day.
The agency said participating in PEAK doesn’t necessarily mean a facility has met all required criteria to receive incentive payments.
“By being listed as ‘participating,’ the facility may have shown interest in, is engaged in, and/or is attempting to become eligible for the program,” Sloan-Ramos, the KDADS spokesperson, said in an email.
Cornelison, the program coordinator, said that PEAK is not just a rewards program but one that’s also intended to boost the quality of care.
“We do want homes that don’t have good quality in our program so they can learn how to improve their quality,” she said.
Low-performing homes would continue to receive PEAK incentives, she said, unless their payments are denied in accordance with federal guidelines.
But elder care advocates and those with experience working in PEAK-participating homes said they were skeptical that the money does much to improve nursing home care.
“Many of us who’ve been around this a while doubt that (nursing home operators) actually invest this money into staffing,” said Dave Kingsley, a retired University of Kansas Medical Center professor who researches the nursing home industry.
Russell said one of the problems is that facilities joining the program can begin to receive money before implementing any changes — creating a skewed incentive structure.
“Why do nursing homes that sign up get any per diem reimbursement until they meet a sufficient amount of these core measures?" she said.
Darcey Kozisek, a retired licensed practical nurse, worked at the Good Samaritan Society in Ellis, Kansas, when the facility joined the PEAK program. She described traveling with the home’s administrator to visit a PEAK mentor home — the program’s designation for top performers — in Inman, Kansas.
“On the way down to Inman, the administrator told me, ‘I get … more (from) Medicaid if we get in this program,’” Kozisek said. “It wasn’t, ‘We’re going to be a better place for our residents to live in.’”
Good Samaritan Society did not respond to a request for comment about the encounter.
Rose Conlon reports on health for KMUW and the Kansas News Service. You can follow her on Twitter at @rosebconlon or email her at firstname.lastname@example.org.
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