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Drowning, sex abuse among issues I-Team uncovers at problematic nursing homes

Nursing homes are in little-known federal program
Special Focus Facilities.png
Posted at 2:03 PM, May 25, 2022
and last updated 2022-05-27 11:20:57-04

KANSAS CITY, Mo. — What would you do if you found out your loved one was in one of the worst nursing homes in the country?

The KSHB 41 I-Team learned there is a federal program that specifically flags nursing homes with a long history of putting patients at risk.

The problem is, you might not have heard about it.

The KSHB 41 I-Team examined this program so that our viewers have the important information they need before deciding on a nursing home for their loved one.

Standing up for your loved one

As Arthur Williams’ health deteriorated over the last several years, his sister, Samantha Craven, focused all her attention on getting him better.

As a severe diabetic with neuropathy and blood pressure issues, he needed someone to be there for him, someone to fight for him.

"That's what I do in my family," Craven said. "I'm the one that does the fighting."

Arthur Williams family
Samatha Craven (right) felt it was her duty to stand up for her brother, Arthur Williams (bottom), when he had issues at his nursing home.

Craven took Williams in. He stayed in a room in her home. She did everything she could, including bringing his doctor and a nurse to the house. However, Craven had to make a tough decision when his health continued to get even worse. She called an ambulance although she knew her brother didn't want to accept help.

Craven worried she might lose the fight when her brother's nursing home, Ashton Court Care and Rehabilitation Centre in Liberty, rushed him to the emergency room in 2020.

"[The hospital] said that his potassium level was 10 times greater than it should have been. He was in kidney failure," Craven said. "His blood pressure was really low and they were going to have to admit him to ICU. “

As a licensed practical nurse, she says he could have died.

"He'd probably be gone within a day or two," Craven said.

Arthur Williams' family said he could have died in his nursing home because the staff didn't monitor his health issues.

Frustrated that the nursing home failed to monitor her brother’s health as his doctor ordered, Craven filed a complaint with the Missouri Department of Health and Senior Services in March 2020.

She was also concerned with the text messages Williams repeatedly sent her about his poor care. These texts detailed times when he said he would wait for long periods of time, sometimes more than an hour, for pain medicine and to be cleaned up.

"That’s the only way he gets treated," Craven said "He texts me and tells me what’s going on and I have to end up calling the facility and say, 'Hey, what’s up?'"

Her complaint triggered a state inspection in early 2021, which found residents were not being treated with dignity, several dietary deficiencies and failure to notify doctors when patients’ conditions changed. The state issued multiple citations against Ashton Court.

Taking a closer look

The KSHB 41 I-Team learned Ashton Court is part of a little-known federal program for nursing homes with a pattern of serious problems that can put residents’ health and safety at risk.

"I have never heard of such a thing, ever," Craven said, when the I-Team told her about the program.

It’s called the Special Focus Facility program. The Centers for Medicare and Medicaid Services, or CMS, created the program in 1998 to keep an eye on nursing homes that consistently fail to meet health standards.

During our investigation, we discovered there are 88 nursing homes in the program nationwide.

They are inspected twice as often as other homes and can continue to accept new residents.

Each state has a minimum number of slots for the program. Kansas has two special focus facilities. Missouri has three.

Life Care Center of Osawatomie, Osawatomie - 15 months in the program
Infinity Park Post Acute and Rehabilitiation Center, Overland Park - 10 months in the program

St. John’s Place, St. Louis - 42 months in the program, recently graduated
Riverside Nursing and Rehabilitation Center, Riverside - nine months in the program
Oakwood Estates Nursing and Rehab, Normandy - 10 months in the program

CMS says most of the nursing homes in the Special Focus Facility Program improve within 18 to 24 months after being selected and "graduate" from the program, with about 10% of them being terminated from Medicare and Medicaid.

A closer examination reveals there’s even a waiting list because there aren't enough resources to add all the problematic nursing homes to the program. Many of the same nursing homes show up on the published candidate list month after month.

Nationwide, 440 nursing homes are candidates for the Special Focus Facility Program.

According to the latest list published in April, there are 10 candidates in Kansas and 15 in Missouri, including Ashton Court.

Craven said she doesn't think she would have ever found out about the SFF program or the list.

"I’m thankful for whoever sent you guys to me about that, but I had no idea," Craven told us.

Recent inspections found Ashton Court is often understaffed, which caused residents’ wounds to go untreated, and left residents unable to get out of bed and going days without a bath. One resident also complained about sitting in their own feces for hours.

We also learned Ashton Court isn’t new to the program. CMS told us it was a Special Focus Facility from 2009 to 2012.

At the beginning of April, CMS and the state sent letters to Ashton Court threatening to cut their Medicare and Medicaid funding because of the persistent problems they found. The state spokesperson said Ashton Court is now back in compliance.

The I-Team called Ashton Court multiple times for comment. When no one answered the phone, we went there in person. The administrator said he’d tell his regional manager to call us, but no one has responded to our request for comment. We also contacted Ashton Court's parent company, Polaris Health and Wellness, for comment, but so far, we have not heard back.

The tip of the iceberg

The I-Team put other local nursing homes that have been in the program under the microscope. Here’s what we discovered:

An 88-year-old woman drowned in a bathtub in 2020 at the now-closed Grand Pavilion at the Plaza. According to a police report, the certified nursing assistant in charge of the woman’s care left her alone four times in less than an hour. The last time, the CNA was gone for 25 minutes and when she returned, she found the woman had died. At the time of her death, Grand Pavilion was a candidate for the Special Focus Facility Program. It went on to join the program in April 2021.

That case settled.

In 2018, A 57-year-old man at Redwood of Independence had a urinary tract infection that went untreated and he developed sepsis that caused gangrene in his genitals. He died a short time later. Redwood was in the program as recently as March of this year.

That case settled.

Also at Redwood, an elderly woman was sexually assaulted in 2017 by a male resident, whom staff was supposed to check on every 15 minutes. According to the police report, the home did not notify her family for several hours and failed to call authorities for nine hours. She died a month after the assault.

A wrongful death lawsuit is pending for that case and a settlement hearing is set for June.

"It is definitely the tip of the iceberg," Camille Russell, Long-Term Care Ombudsman for Kansas, said.

The Ombudsman's office is not affiliated with any nursing home. They advocate for nursing home residents' rights, take complaints and help resolve complaints.

Russell hears similar stories of abuse and neglect at special focus facilities all too often.

We asked her if any of the cases we found surprised her.

"Sadly, no, not at all," Russell said.

Russell says her office receives nearly three times as many complaints about special focus facilities than other nursing homes.

Russell also says while special focus facilities make up only four percent of all nursing homes in Kansas, they account for about 16% of the complaints her office receives. And, she said, about 23% of all gross neglect complaints come from special focus facilities.

"A considerably higher number of complaints come from special focus facilities of all types," Russell said. "More serious complaints. Retaliation, abuse / neglect. So, they take up a lot more of everyone's resources and are providing a lower quality of care and a lower quality of life."

Putting the program into focus

CMS publishes a list of each month of homes in the program, but it’s tough to find.

If you’re starting on CMS’s home page, it takes a bit of searching. You have to navigate through four different pages and click on specific links that the average person may not know to click on. Then on the Nursing Homes page, you find a link that says "SFF Posting with Candidate List" and it'll take you to the list - that is, if you know what "SFF" means in the first place.

Or, to make it easier, you could Google the words, "Special Focus Facility list" and it'll bring up the most recent list.

Sarah Stand Up

The candidates are not flagged on CMS's Nursing Home Care Compare website, so you may not know the nursing home you're looking at is a part of the overall SFF program.

The Care Compare website shows a yellow triangle indicating a home is in the program but it doesn’t provide a link to the list.

"It does concern me," Russell said. "It makes me think that perhaps that’s something we should have on our website, the list."

The I-Team also learned nursing homes are not required to tell residents and their families if they’re in the program.

"You know, they should be. And not only that, but probably there should be a sign on the front door," Russell said.

The only reason Russell could think of for not advertising that information for all to see is to protect the residents' dignity.

CMS declined to talk to the I-Team on camera but told us it “expects” nursing homes to inform residents if they’re in the Special Focus Facility program.

CMS also said it can deny funding for new admissions to homes in the program and even kick them out of the Medicare and Medicaid program if problems continue for six months.

But we discovered nursing homes can stay in the program much longer, such as the Dr. Guy Gorman Senior Care Home in Chinle, Az. that's been a candidate for 93 months, or nearly eight years.

Who's accountable?

"It makes me feel like I have no control," Craven said.

Back in Lawson, Missouri, and armed with this new information, Craven has a message for anyone considering moving a loved one into a special focus facility.

"I would not send anybody there, ever," Craven said.

Her brother is now in another nursing home, one not on the list, but she still worries about the thousands of other vulnerable people living in special focus facilities right now.

"I want to see that those things are taken care of, that those policies are in place and those regulations are followed, and those people are taken care of the way they should be," Craven said.

The I-Team called Ashton Court multiple times for comment. When no one answered the phone, we went there in person. The administrator said he’d tell his regional manager to call us but no one has responded to our request for comment. We also contacted Ashton Court's parent company, Polaris Health and Wellness, for comment but so far, we have not heard back.

We also reached out to local senators on the federal committee that has oversight over CMS.

A spokesperson for Kansas Senator Roger Marshall told us “it would seem probable that Medicare beneficiaries and their caregivers are not aware of the SFF program,” and said the list should be easier for consumers to find. The spokesperson said Marshall and his staff will reach out to CMS on ways to improve education about the program.

In February, the Biden Administration announced it would crack down on unsafe nursing homes.

"Despite the tens of billions of federal taxpayer dollars flowing to nursing homes each year, too many continue to provide poor, sub-standard care that leads to avoidable resident harm," the announcement said.

The Administration is calling on Congress to give $500 million to CMS, a 25% increase, to fund inspections at nursing homes.

It also calls on CMS to overhaul the Special Focus Facility Program by making requirements "tougher and more impactful" and allow the program to inspect more facilities in a timely manner. The facilities that do not make any improvements will face bigger penalties, including termination from the Medicare and Medicaid program.

The KSHB 41 I-Team also exposed issues with CMS's COVID-19 "generally accurate" vaccine data, another problem Biden's announcement highlighted. You can see that story here.


Families have a variety of resources to look at when choosing a nursing home for a loved one:

  • Visit the nursing home in person. Make sure the staff knows your name and you know theirs.  
  • Talk to the people who live there, and their families.  They will tell you what's going on.
  • Ask to see inspection reports, staffing reports and vaccination reports. Find out who enforces these protocols.  
  • Look at survey inspection reports to see how compliant the facility has been over the last three inspection cycles. 
  • Call Kansas Advocates for Better Care. In Missouri, you can call VOYCE.
  • Call your local long-term care ombudsman office. They are the federally and state authorized advocate for nursing home residents.  
  • Call your area agency on aging center.
  • Your local Alzheimer’s Association may be able to point you to facilities they've worked with and approve.