A Georgia nursing home is under investigation after a woman fell, suffering bleeding in her brain and permanent brain damage. This is not the first time that Shepherd Hills Nursing Home has been under the microscope of investigators. The facility has a lengthy history of citations and allegations of nursing home abuse and neglect.
The most recent resident death now has lawmakers looking into the facility because it is funded by taxpayer dollars. The Centers for Medicare and Medicaid Services (CMS) requires facilities to meet certain standards in order to receive reimbursements. Some lawmakers are questioning why Shepherd Hills has continued to receive millions of dollars in reimbursements even though they have routinely been cited for substandard care.
Resident Death Raises Alarm
Frances Palmer moved into Shepherd Hills Nursing Home in 2018. During her time there, she suffered three falls that caused injuries to her. The second fall happened in September 2019, which prompted her husband to file an incident report with the local police department. In the report, he alleged that the staff was abusing her. The report was sent to Adult Protective Services (APS).
After the fall, Palmer’s husband requested padding around his wife’s bed. The facility refused, saying that she might trip on it. Palmer’s husband argued that at least then she would land on something soft if she fell. Eleven days after he made the request, Palmer fell again. This time, she suffered numerous bone fractures in her face and bleeding in her brain. The brain damage was permanent.
Mr. Palmer believes that Shepherd Hills is responsible for his wife’s death. State inspectors are investigating to determine if Shepherd Hills staff contributed to her death. With a lengthy list of complaints and citations, investigators are working with the Department of Community Health (DCH) to address the situation.
Shepherd Hills Has a Long History of Abuse and Neglect
Shepherd Hills has a long history of abuse and neglect allegations. But a few incidents stand out more than others. One particularly horrific incident involved a 93-year-old resident who died at the facility in 2015. Rebecca Zeni was a model known for her beauty and charm. In 2010, her daughter made the decision to move her into Shepherd Hills Nursing Home because she had dementia.
In 2015, she suffered what one forensic pathologist calls “one of the most horrendous things” he has ever seen during his career. Zeni died due to a scabies infestation that led to septicemia. Essentially, Zeni was eaten alive over the course of months or possibly years. It is estimated that there were hundreds of millions of parasitic mites living in Zeni’s body. The cause of death on the autopsy report lists “septicemia due to crusted scabies.” Scabies are parasitic mites that burrow into the skin. They then lay eggs and multiply, feeding off of the body in order the thrive.
Records show that state health inspectors were notified multiple times about a scabies outbreak, but an inspection was never done. Reports were filed in 2013 and 2015. Records show that at least 35 residents and staff members were exposed to scabies in 2015. The state health department did not inspect the facility, but rather sent an email with a manual for how to treat scabies. Zeni passed away just eleven days later.
Family Speaks Out, Files Lawsuit
An attorney representing Zeni’s family says that the facility knew there was a problem but did not protect residents. In one alleged conversation, a healthcare provider at the nursing home warned the family not to touch Zeni’s hand because it might fall off. Photographs show her hand blackened, with skin peeling off. Other photos show Zeni’s body seemingly flaking away.
Pathologists fear that Zeni’s death was likely painful. The pathologist who conducted the autopsy stated, “I would seriously consider calling this a homicide by neglect.” Pruitt Health has denied the allegations. In a lawsuit filed by her family, Pruitt Health responded denying that they are a “medical or healthcare provider and it, therefore, owed no legal duty to Plaintiff or Ms. Rebecca Zeni for which it could be held liable in this litigation.”
Nursing Home Receives Reimbursements Despite Abuse and Neglect
Despite allegations that the facility is providing substandard care, it continues to be funded by taxpayer dollars. In 2018 and 2019, Shepherd Hills received $8.1 million in Medicaid reimbursements. Shepherd Hills is owned by Pruitt Health, which operates 56 facilities in Georgia. Pruitt Health received at least $453 million dollars in 2018 and 2019 in reimbursements. All the while, Shepherd Hills was receiving citations every year.
State inspection reports show a slew of violations and citations. From 2014 to 2016, around three dozen violations were identified in inspection reports, including issues like medication errors, failing to maintain equipment and residents being put in immediate jeopardy. Each year, DCH threatened to withhold funding if the facility did not fix the problems.
After promising to fix the problems, Shepherd Hills continued to operate and continued to receive complaints and citations. All the while, they also continued to receive taxpayer funds. Despite receiving so much in funding, the facility maintains a one star rating, or “much below average.” It has the lowest rating that CMS allows.
Not only is Shepherd Hills’ funding being called into question, but so is the funding of other facilities owned by Pruitt Health. Almost half of Pruitt Health’s facilities in Georgia (46 percent) have a rating of “below average” or “much below average.” Facilities with one and two starts received $221 million in Medicaid reimbursements in 2016 and 2017.
Lawmakers and advocates for nursing home residents are calling for more oversight and accountability in nursing homes. Rather than accepting that a facility is going to make improvements, officials should follow up and be thorough in investigating claims of abuse and neglect.