Long-term care advocates worry that nursing home quality has plummeted since the pandemic due to a perfect storm of problems.

Lillie Grier had always been sharp, but in her late 80s she started forgetting things.

The dementia progressed quickly, to the point where she didn’t recognize the Clarksville home she had shared since 1973 with her husband, Robert Grier, and where they had raised their two children. 

In 2021, Robert Grier made the difficult decision to move his wife of 60 years into the nearby Cloria Oaks Post Acute and Rehabilitation Center in Palmyra just outside of Clarksville.

It was the first time they had been separated.

Grier said he thought his wife would be safe. What he didn’t know was that Cloria Oaks had serious problems.

The troubled nursing home was among the worst in the nation for fines and deficiencies when it shuttered this year after the Centers for Medicare & Medicaid Services pulled payments for failing to follow health and safety codes. 

By the time it closed, Cloria Oaks had racked up more than $1.1 million in fines over a three-year period (the highest in the nation at the time) and was among the top five worst nursing homes for serious deficiencies, according to a database of CMS data complied by the nonprofit investigative news organization ProPublica.

It hasn’t been the only nursing home raising concerns since the pandemic. 

Tennessee has seen an alarming spike in serious deficiencies in nursing homes, leaving advocates worried that the quality of long-term care has plummeted, not only in the Volunteer State but nationwide.

From 2020 to 2022, the number of citations for the most serious federal deficiencies (those causing immediate jeopardy to resident health or safety) jumped 145% in Tennessee’s nursing homes, according to a report from the state’s Health Facilities Commission. 

Last year, the most serious deficiencies accounted for about 11% of all federal citations, up from 3% in 2018.

Of the nation’s top 10 nursing homes with the highest count of serious deficiencies, Tennessee has four on the list. Three are in Memphis. 

The state ranks fifth in the nation for delayed inspections, with 37% of homes going without an inspection for two or more years, according to the ProPublica data. Kentucky is top on the list with 76% of homes seeing delayed inspections.

Long-term care advocates say the increase in serious deficiencies is likely due to a perfect storm of challenges that grew worse as the pandemic swept though facilities. 

Staffing shortages, high employee turnover, a rise in the use of temporary staffing agencies, a shortage of inspectors and a backlog of complaint investigations have all impacted care, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care.

She said it’s a problem across the country.

“Ombudsman programs are saying conditions have really deteriorated since the pandemic, and many nursing homes have taken real steps backwards in the quality of care,” she said. “They’re saying things are worse now than they’ve ever been.”

‘This was completely preventable’  

At Cloria Oaks, Grier said the home seemed mostly OK on his weekly visits, though he did notice a smell in the facility and thought conditions could be a little cleaner.

In August 2022, he got a call from Cloria Oaks — something had happened to Lillie. 

A federal lawsuit filed by Grier against the nursing home in August alleges that Lillie was raped by another resident with a history of violent and sexually aggressive behavior. 

The man, who also suffered from severe cognitive impairment, had been sent to a psychiatric facility after he had sexually assaulted another male resident, but he was allowed to return to Cloria Oaks with the plan that staff would monitor him every 15 minutes, according to the suit. 

Despite the supposed regular checks, the man one afternoon forced himself into Lille’s room and was in there with her for over an hour with the door blocked before staff noticed, the suit alleges. 

The lawsuit says administrators didn’t document the sexual assault and failed to take witness statements and skin assessments. They had no documentation of the required 15-minute checks for the dangerous resident. 

As a penalty, the home was cited for the most serious violation of immediate jeopardy for failing to thoroughly investigate the incident and protect her, according to a CMS inspection report. 

A medical director later acknowledged that the alleged sexual abuse could have been prevented, and there should have been more staff supervision, according to the report. Police chose not to pursue the case due to the man’s severe dementia, the report said. 

Lindsay Cordes, a Nashville-based attorney representing Grier, said Lillie had no way of defending herself due to her dementia. Her mental and physical health deteriorated after the incident, and she died on March 12. She was 89.

Cordes said it’s unconscionable Cloria Oaks would accept a dangerous resident back into the facility and then fail to monitor that person. 

“This was completely preventable,” she said. “That to me is what’s really shocking.”

The nursing home’s network of limited liability corporation owners, as well as an Ohio resident Isaac Moskowitz, who is named in the lawsuit as an owner and is connected to several facilities in the region, did not respond to a request for comment.

A festering problem  

In the throes of the COVID-19 pandemic, all but essential staff were locked out form nursing homes, leaving residents isolated while longtime problems in some places festered. 

The state’s long-term care ombudsman program, which advocates for nursing home residents and helps to investigate complaints, detailed the concerns in its 2022 report.

“When ombudsmen reentered long-term care facilities, they encountered serious issues such as inadequate, poorly trained facility staff, poor infection control practices, ongoing disease outbreaks and generally poor care,” the report said.

Residents’ family and friends saw similar concerns and appealed to the ombudsman for help. 

In all, the program saw its largest ever number of complaints last year with 3,705, up from 1,932 in 2021. The most common complaints included abuse, neglect and care quality. 

And as the number of complaints have skyrocketed, the Tennessee Health Facilities Commission, which last year took on oversight of the state’s 313 active nursing homes from the Department of Health, remains buried in a backlog of investigations.

In a report this year, the HFC said it has a backlog of 1,197 overdue complaint investigations and has resorted to hiring contract agency surveyors to help free up its own staff to address a backlog of facility recertifications. The agency is using $1.7 million in existing funding for the extra contract work.

The HFC declined to answer a list of questions from The Tennessean regarding the concern over quality of care and an increase in serious deficiencies. But in its report, it detailed similar problems noted by the ombudsman. 

From March 2020 through November 2021, surveyors, due to a pandemic executive order, were suspended from in-person investigations for all but the most serious complaints.

“When surveyors returned to surveying in-person, high level scope and severity and immediate jeopardies were found in buildings,” it noted.

As a result of the “many immediate jeopardies,” five nursing homes, including Cloria Oaks, have been decertified and shuttered since 2022, as well as multiple voluntary closures.

Moreover, the agency said it has seen a 61% increase in complaints since it adopted a new incident reporting portal in October 2022. It expects a total of more than 6,500 complaints by the end of this year. 

Smetanka, with the long-term care advocacy group, said serious problems have increased as a growing number of facilities rely on temporary healthcare staffing agencies. 

Nursing homes have long struggled with staffing shortages, but the problem was especially bad in the pandemic as people left for better-paying jobs with less stress.

Smetanka said temporary staffing agencies do not have the same level of training for adequate nursing care.

“These folk didn’t know what they were supposed to be doing,” she said. “We’ve had several residents say they don’t want (the staff) even touching them because they don’t know how to turn them properly. They don’t know how to work the equipment.” 

Last year, Tennessee nursing home facilities were expected to spend over $100 million on temporary staff, up from $9.8 million in 2019, according to a state Comptroller report.

State Long-Term Care Ombudsman Teresa Teeple in an email said the turnover is a major concern.

“Residents tell us that often it’s not about whether there are enough staff applying, but if the home can keep the good staff they have,” she said. “This points to the need for nursing home leaders to treat staff better and make the jobs better so staff stay. Consistency in staffing is critical for achieving good resident care.”

Accountability for nursing home owners

Cordes, the attorney representing Grier, said more needs to be done to hold bad nursing home owners accountable. 

The homes are often owned by a complicated web of limited liability corporations, making it tough to determine who’s at fault in a lawsuit, she said. Also, Tennessee does not require the homes to carry insurance, so recovery for damages can be minimal, she added.

The Biden administration has been pushing to increase transparency for nursing home ownership, as well as minimum staffing requirements.

Most of the nation’s nursing homes would be required to boost their staffing levels under new federal regulations proposed in September, according to a USA Today report.

Cordes said she hopes to see accountability on behalf of Lillie Grier and her family. 

“Nothing is ever going to change what happened to Lillie, but we hope to bring awareness to this really horrible problem and spur some action,” she said. “These types of things are going to keep happening until these nursing homes are held accountable.”

Sitting in his Clarksville home on a recent afternoon, Grier, a veteran who served two tours in Vietnam as a paratrooper, prefers to remember the happy times with his wife. 

Born and raised in Nashville, Lille worked as a waitress and was also a military wife while her husband served for many years in the U.S. Army. The family moved to Clarksville in the 1970s to be near Grier’s base at Fort Campbell. 

She was active in her church and loved to talk about God, her husband said.

“She was a good wife and mother,” he said. 

At 86, Grier doesn’t talk much these days, but when asked why he chose to file a lawsuit, his answer comes quick and clear.

“I want other people to know what’s going on,” he said, “and I hope they won’t have their loved ones in the same situation.”

Reach Kelly Puente at kpuente@tennessean.com.

Check the quality of a nursing home in your area

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