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(WBIR-Maryville) Putting your loved one in a nursing home can be a difficult and costly process. While they are trusted as caretakers, when it comes to fines, five of Tennessee's facilities are ranked in the top 20 worst in the country.

For weeks, 10News combed through inspection reports and found three of the state's most fined nursing homes are in East Tennessee, and inspectors even cited the facilities at fault for incidents that led to patient hospitalization.

According to data from the U.S. Centers for Medicare and Medicaid Services, or CMS, Tennessee currently has the highest average nursing home fine in the country, at $73,000 per fine. Some facilities in the state had fines over recent years totaling $500,000.

The Office of Health Care Facilities with the Tennessee Department of Health is charged with performing state inspections and federal inspections. The inspectors are contracted through CMS to ensure operating facilities are in compliance with federal regulations.

A Blount County facility is the second top-fined facility in the state, and the 5th highest in the country;

Kindred Nursing and Rehabilitation, in Maryville, has been slapped with $543,303 in fines and 28 deficiencies, including 'level one harm,' which means at least one resident was in immediate danger.

Fort Sanders Sevier Nursing Home in Sevierville ranked fourth, with $498,355 in fines and 15 deficiencies.

The former Colonial Hills Nursing Center, also located in Maryville, was the 5th highest, with $465,195 in fines, and 46 deficiencies in 2011 alone. In 2012, the facility was forced to shut down after losing its CMS contract, and has since been battling ongoing lawsuits, including wrongful death allegations. The nursing home also ranks third in the nation for serious deficiencies, at 18.

Behind closed doors

Sybil Gamble Hall, a Maryville resident, said her mother was in a dozen different facilities before she passed away in January of 2013.

"It's hard to see anyone that deteriorates so much. When they've been feisty and vivacious, it's even harder," said Hall. "After Mother had her stroke, Mother changed completely, like so many people do."

Hall said she often slept in nursing homes for weeks at a time, getting a look at what's really happening behind closed doors.

"You'd be amazed at the things you see in nursing homes," said Hall. "I have dealt with 12 different nursing homes. In Chattanooga, Maryland, Florida, here, and Knoxville. And in all of them I would see people just not getting the care they need."

Hall's mother stayed at two local and highly fined facilities; Colonial Hills and Kindred. She said patients were dehydrated, ungroomed, and fed poor quality food that even led to hospitalization.

According to state inspection reports from 2011, Colonial Hills added 25 pounds of salt to 12 pounds of beets, putting seven patients in immediate jeopardy and sending two to the hospital. The salt was added in the place of thickener, elevating the residents' sodium and chloride levels.

Another report shows the facility didn't ensure a safety device was in place for a resident with a history of falls who was hospitalized for a fractured rib and laceration to the head that needed staples.

10News found two Certified Nursing Assistants, or CNA's, were fired after taking a picture of a resident in bed after underwear fell on their head. Reports also show multiple incidents of staff members failing to notify physicians and family members of medical condition changes for some residents, along with issues of misappropriation of medication.

"There was just so many things that would happened and then they would try to cover it up," said Hall.

10News found the facility's parent company, Life Care Centers of America, is still facing ongoing lawsuits, including allegations of wrongful death and medical negligence.

In an emailed statement, the company did not address the lawsuits, but instead provided details on a new, nearly 90,000 square foot facility that is under construction about 15 minutes from the site of the former Colonial Hills Nursing Center, which will feature 120 beds and amenities like spa bathing rooms, a library, putting green, and ice cream shoppe.

"I'm concerned about that, I'm concerned about that," said Hall. "It's just really scary to think they're going to have another one coming to the area.

"It was terrible, they shouldn't be opening a new one," said Shelly Barton, a former patient at Colonial Hills Nursing Center.

Barton spent several months at the facility after suffering a broken leg and arm.

"The staff wasn't nice, I didn't get a bath for two weeks, not even a wash off," said Barton. "It needed to be shutdown. I wouldn't advise anyone to go there."

Barton also spent time at Kindred's Fairpark location. While it had the 8th highest total fines, $311,220, she said it was the best facility in Blount County.

"They were so caring for you, and I felt safe," said Barton. "If I had to go back to a nursing home, that would be the one I choose."

Kindred's Maryville location, which is East Tennessee's highest fined facility, inspection reports showed level one harm ratings. A recent report showed it was the facility's fault a patient suffered severe dehydration and was transferred to a hospital's Trauma Intensive Care Unit.

"Dehydration is a problem I saw everywhere, just everywhere," said Hall.

Inspection reports also showed Kindred failed to notify doctors and family members of injury and health decline of patients, prevent misappropriation of narcotics for residents, and train nursing staff for negative pressure wound therapy.

"Staff can make or break a facility," said Hall.

"I think all nursing homes and hospitals are understaffed," said Barton.

As for reports at Fort Sanders Sevier Nursing Home, inspections showed similar issues, along with failing to serve meals on time, provide two baths a week, and clean blood glucose meters. 10 residents were also put in immediate jeopardy when the facility failed to follow procedures for bed side rails.

The facility provided the following statement:

"Fort Sanders Sevier Nursing Home viewed the findings in the 2013 state report seriously, and took immediate steps to address the issues identified in the report. The nursing home has served the community for more than 30 years, and believes every patient deserves quality, caring service. The state made an unannounced follow-up visit this week for the 2014 annual survey, and while it has up to 10 days until the results are required to be posted, the 2014 exit interview indicated a highly favorable survey, showing marked improvement with no substantial deficiency findings and no immediate jeopardies."

Annual Inspection vs. Complaint Investigations

Under federal and state guidelines, annual surveys are done for every facility, and investigations are launched when a complaint is filed.

"We wear two hats," said Vincent Davis, Office of Health Care Facilities Director. "We license facilities on the state side, and we certify that facilities are operating in accordance with CMS guidelines."

Davis said annual surveys are done anywhere from every nine to 15 months.

"All of our inspections are unannounced. That means we don't give any of our facilities a heads up that we are coming," said Davis. "However, because it is annual than if a facility had an annual inspection on May 21st, 2013, then somewhere around May 21st, 2104, the facility is going to expect to see the state in their facility."

Hall said the inspections should be random, since she noticed all nursing homes seemed to be prepared for the surveys.

"You can always tell when the state inspectors are coming. Oh, they start cleaning up and they get their act together," said Hall.

State inspectors also visit facilities when complaints are filed.

"Complaints are triage as they come into our complaint intake hotline," said Davis. "There are four different levels of severity that we receive, so for example, priority one complaints are those we deem immediate jeopardy.

Davis said the state has two days to investigate Priority 1 complaints, and 10 days for Priority 2, which could be someone who was injured on a fall or patient having an issue with getting medication.

Investigations for Priority 3 complaints, like cold food or a resident not receiving a blanket, can take up to 45 days. Missing documents, like an elevators inspection report, would be deemed Priority 4, which are handled the next time the inspector visits the facility for the annual survey, or to investigate a higher level complaint.

"We will do our record review, our observation, our interviews, and often we will find additional observations and concerns," said Davis. "When a facility is in an immediate jeopardy situation, again, they've got 23 days to respond as to how they have corrected the immediacy of that deficient practice."

As for fines, Davis said they are based on two factors; the priority the complaint is triaged, and the scope of how many residents were impacted by the deficiency.

Since the state conducts federal and state inspections, the reports also determine fine issued. Davis said state deficiencies are fined lower, a $50 to $1,005 one-time penalty, while federal fines can be significantly heavier, at $1,005 to $10,000 a day, until the problem is corrected.

"Things have to be in pretty bad shape, and can't be turned around in a specific period of time, to have a facility terminated," said Davis.

"And that's the last thing we want to do because we understand that impacts the lives of not only residents, but their family and staff members who are displaced."

Choosing a nursing home

While inspection results are available on Medicare's website, other tools can help families and caretakers find a facility that meets their needs.

"Just the word 'nursing home' is not something you're going to say with a smile. It's one of those things people say they don't want to have to deal with that now," said Edward Harper, Senior Services Coordinator at Blount Memorial Hospital. "Coming into it at the last minute, you're actually not making a choice, you're taking what's available."

Harper said if families have the opportunity, they should check out facilities in their community, and often. He said it's important to look at the patient to staff ratio, and whether or not the staff is happy.

"Researchers have looked at the ratio of staff to patient care. The higher the ratio of staff to patient care, seems to be the higher the star rating."

Medicare.gov lists overall, health inspection, staffing, and quality star ratings for all active providers. There's also a 54-page guide on choosing a facility.

"This is a real boom, that you don't have to reinvent the wheel. So those pages, 17 through 34, are going to put you into a checklist," said Harper. "The entire pamphlet is written very succinctly and gives you a very quick education on how to use Medicaid and medicare services. It also tells you how they rate the nursing homes."

Harper also gave tips like checking the number of patients per room, whether the staff is overworked, and stressed the importance of visiting the facility several times before making a selection.

To compare nursing homes, click here.

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