FARGO — Five North Dakota nursing homes performed poorly in routine inspections and are among 435 facilities in the nation that federal officials have on a watch list that could place them under added scrutiny.

The nursing homes falling under the regulatory spotlight were highlighted in a recent U.S. Senate report that disclosed for the first time nursing homes around the country that are in jeopardy of being considered “special focus facilities,” a designation requiring added inspections and possible financial penalties if they fail to correct serious deficiencies.

These are the five nursing homes in North Dakota on the candidate “watch list” for possible federal status as “special focus facilities”:

  • Western Horizons Care Center in Hettinger

  • Dunseith Community Nursing Home in Dunseith

  • Richardton Health Center in Richardton

  • Minot Health and Rehabilitation in Minot

  • Knife River Care Center in Beulah

A sixth North Dakota nursing home, Trinity Homes in Minot, was designated as a special focus facility, but was removed from that status after it resolved serious deficiencies. Notification was sent by state officials in a letter dated June 28. The state must have one special focus facility, so another will be chosen to replace Trinity Homes.

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There are more than 15,700 nursing homes in the United States, and 0.6 percent, a maximum of 88, are selected for the “special focus facilities” program. The names of those nursing homes are made public as a matter of routine.

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'Uncovering poor care'

But the public was not told about serious concerns about resident care and protections involving the other 435 nursing homes, including the five in North Dakota, that represent 2.5 percent of the nation’s long-term care facilities, Sens. Bob Casey, D-Pennsylvania, and Pat Toomey, R-Pennsylvania, said in their report, “Families’ and residents’ right to know: uncovering poor care in America’s nursing homes.”

“Despite being indistinguishable from participants in terms of their qualifications for enhanced oversight, candidates are not publicly disclosed,” the senators wrote in their report. “As a result, individuals and families making decisions about nursing home care for themselves or for a loved one are unlikely to be aware of these candidates.”

By law, nursing homes in the “special focus facilities” program must be inspected no less than once every six months. That compares to a general requirement that inspections must be given at least once every 15 months and on average 12 months statewide.

The North Dakota Department of Health performs the nursing home inspections for the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services, or CMS.

'A motivational tool'

Trinity Homes, which was subject to $24,703 in fines for deficiencies, has corrected the problems and soon will “graduate” from the special focus facilities program, said Bruce Pritschet, director of health facilities for the state health department.

“They’re ready to come off that list, and we’re ready to select another one,” he said. “That’s just a paperwork issue.”

The number of nursing homes in the special focus facilities program is based on the number of nursing homes in each state; North Dakota has 80 long-term care facilities.

The added scrutiny and pressure to correct deficiencies does help nursing homes to improve their performance, Pritschet said.

“I wouldn’t say it’s just more monitoring on their part,” he said. “They have to up their game.” If not, they could face civil penalties, including withholding of federal payments.

“It’s a motivational tool,” Pritschet said. “Either you improve or you have to pay the penalties.”

The health facilities division that Pritschet administers has 18 nursing home inspectors, although two of those positions are vacant, he said.

In general, conditions in nursing homes today are better than when Pritschet started three decades ago. “Generally speaking — I go back 30 years in this area — they’re a lot better now than they used to be.”

The added oversight is effective in bringing deficient nursing homes into compliance, Pritschet said. “It does seem to work,” he added. “They do improve their performance.”

Staffing levels and training underlie many of the deficiencies inspectors find, he said. “We look at staffing in every survey. It’s something that’s on our radar all the time.”

Maintaining a qualified nursing home staff can be difficult, especially in rural areas, Pritschet said. “There’s struggles around the state,” he said.

Frustrated with the process

Shelly Peterson, president of the North Dakota Long Term Care Association, the industry group for nursing homes, said a flaw of the federal rating system for nursing homes is it does not enable state-by-state comparisons. Instead, it ranks nursing homes within each state.

"Our lowest still could be the highest in another state," she said. "When you rank high to low, there's always going to be a highest and lowest. We're frustrated by that process."

The association works with its members to adopt best practices and offers training programs, Peterson said. "I believe they're all committed to doing the very best," she said.

Josh Askvig, state director for AARP North Dakota, said consumers can use better information to help them evaluate the quality of nursing homes.

“I think it’s often hard to evaluate the federal reports,” he said. Too often, that leaves consumers in the dark.

“Anything we can do to improve transparency would be helpful,” Askvig said. “Consumers have a right to know what kind of care they or their loved ones would receive in a certain facility.”

AARP ranks North Dakota's long-term care services 37th in the nation overall, and 13th for quality of life and quality of care.

Another safeguard for nursing home residents is an ombudsman program provided by the North Dakota Department of Human Services. The ombudsman program, which acts as an advocate for nursing home residents and investigates complaints, had 206 nursing home visitations related to complaints, according to the program’s 2018 annual report.

Of those, 25 percent involved resident care; 19 percent involved residents’ autonomy, choice, preference, rights or privacy; 8 percent concerned environment; 3 percent involved staffing; and 3 percent involved abuse, gross neglect or exploitation, the report said.

“As an independent advocate for residents of long-term care facilities, the North Dakota Long-Term Care Ombudsman Program believes that facility residents have a right to quality care in a safe environment, and that all nursing facilities should be held accountable for compliance to the health and safety standards," said Karla Backman, the ombudsman.

"For consumers to make informed decisions, it is important they have access to the information showing how individual facilities meet the standards.”