In early October the Colorado Springs Gazette newspaper published findings of its investigative report, which it said included a lack of consequences for allegedly neglectful care given in nursing homes to Colorado veterans and troubling questions about how the Department of Veterans Affairs awards contracts to nursing homes in order to meet the growing needs of aging veterans in the state.

The report included an account of an 83-year-old veteran who died from sepsis that his family contended was due to neglectful care. This occurred after the man’s wife consulted with VA personnel to get their recommendations on what nursing facility might best suit her disabled husband. Both a family doctor and a social worker had suggested the wife consider nursing home placement to keep her husband safe, because he was no longer remembering faces, often didn’t know where he was, was prone to being agitated, and had sleep problems.

Since he was eligible for full veteran health care benefits, the wife turned to the VA for advice on placement. Based on the advice she received, she had her husband moved to an 88-bed, for-profit nursing home about 15 miles from their home on the western slope in Fruita. Although this nursing facility was not run by the VA, the agency had a contract with it to provide care services to veterans. Rather than solve the wife’s concerns about her husband and bring her peace of mind, something very much different happened.

Colorado Veteran’s Health Declined Dramatically

She received a call one evening from the nursing home saying her husband had a foot sore that perhaps a doctor should check and asking the wife if that would be okay. She said that’d be fine and assumed it would be done. But a doctor never came to check, and nursing home staff offered differing reasons why. The wife was by then having other concerns about her husband’s care, including issues of hygiene, grooming, and noticeable weight loss. When she complained to the VA about such issues, she said she was told she needed to take that up directly with the facility. “I felt like they [the VA] had washed their hands of him,” she was quoted as saying.

She subsequently received another call from the nursing home, this one more urgent, saying her husband was being taken to a Grand Junction hospital because his foot had not improved. When she got to the hospital, she found her husband unresponsive and momentarily feared he might have died. She saw a large oozing wound on his ankle. She was told her husband was very ill. At this same time a nurse at the hospital reportedly called Colorado Adult Protective Services (APS) to report suspected neglect. Grand Junction police also reportedly began an investigation into a suspected crime against an at-risk person.

An APS caseworker found that although there was a standing order for weekly skin checks for the veteran patient, it was unclear if these had been done. A worker at the nursing home was quoted as saying care at the facility had decreased in recent months. The caseworker concluded that “a preponderance of evidence” pointed to caretaker neglect. The veteran was moved to a local hospice when it was determined nothing more could be done for him. He died three days later. His death certificate listed cause of death as complications of sepsis.

Five months later, the Colorado Department of Regulatory Agencies informed the nursing home there were not sufficient grounds to warrant formal disciplinary proceedings.   

The Bigger Picture of Care for Colorado Veterans

Apparently prompted by this individual veteran’s experience, the Gazette investigation went on to look into the overall issue of veterans’ care in Colorado, with a special focus on care facilities that are contracted by — but not run by — the Veterans Administration. Using data from the Centers for Medicare and Medicaid Services (CMS), the newspaper compiled a list of almost 30 such contracted facilities in Colorado, spread throughout the state. Four-fifths of the facilities were for-profit entities. The majority of these contracted facilities, all but 3, were reported to have faced one kind of sanction or another for substandard performance. Government-imposed fines ranged from a few thousand dollars to almost $200,000, with fined facilities being cited primarily for suspected resident abuse or delayed inspections.

Notably, the nursing home involved in the veteran’s story highlighted by the Gazette was issued $133,000 in federal fines between 2021 and 2022, according to CMS data. Citations included failure to bathe residents and failure to address wounds. The Gazette cites a police report it obtained as indicating Adult Protective Services was called to this nursing home 21 times in the previous year. The specific nature of these calls was not disclosed. That facility serves about a dozen veterans, according to the Gazette.

What gives rise to these circumstances? The Gazette learned that although the VA has its own nursing homes, known as community living centers, these do not provide enough beds to meet the need. Nationally there are reportedly 134 VA-run nursing homes with a total of close to 17,000 beds. In Colorado there are only two — in Grand Junction and Pueblo — with a total of 65 beds. Another option is state-run nursing homes that contract with the VA, but they also have a limited number of beds. In Colorado there are five such facilities and 165 nationally.

The Private Sector is Prominent in Caring for Colorado Veterans

To fill the gap, the VA turns to the private sector. The Gazette reported that as of last year the VA contracted with about 8,000 private or community-owned nursing homes nationwide to care for about 36,000 veterans. In Colorado there are currently 28 such VA-contracted nursing homes caring for roughly 900 veterans. Most of these are for-profit; a smaller number are nonprofit or community-run.

The Gazette further noted that a 2020 U.S. Government Accountability Office (GAO) report found that private-sector and community-owned nursing homes were the fastest growing segment among the available types of residential care for veterans between 2014 and 2018. This segment grew 26% while growth in state-owned facilities grew only 1%, and there was actually a drop in use among VA-owned nursing homes in that period. The trend is projected to continue with an anticipated 80% increase in contracts to private-sector and community-owned nursing homes over the next decade and a half.  

Advice for Persons Seeking Nursing Home Care for Colorado Veterans

What can veterans or their family/caregivers do to enhance their decision-making when it comes to selecting a VA-contracted nursing home? It may help to understand how such facilities are rated by CMS. To win a VA contract, a nursing home must apply and be scrutinized based on that CMS rating system. The rating tool uses what’s called a star system from 1 (lowest) to 5 (highest), similar to many consumer review rating tools. Three categories are combined to arrive at an overall rating. Those three categories are: 1) health inspections, 2) staffing, and 3) quality measures. The quality measures look at factors such as overall care, administering appropriate vaccines, maintaining proper weight for residents, and assessing any pain level of a resident. In addition to this rating system, the VA conducts on-site interviews with veterans, reviews medical records, and meets with facility administrators.

Using this star-rating system, the Gazette found that 13 of the 28 Colorado nursing homes with VA contracts are currently considered below average with ratings of 1 or 2 stars. Seven were ranked as 1 star, six ranked as 2, four ranked as 3, five ranked as 4, and six ranked as 5. You can see CMS rankings for any nursing home at https://www.medicare.gov/care-compare/?providerType=NursingHome.

CMS advises not to stop with just a look at rankings. “Star ratings can give you important information and help you compare nursing homes,” CMS says, “but aren’t a substitute for visiting the nursing home.” CMS says combine the ratings with other sources of information, and also suggests reviewing its Guide to Choosing a Nursing Home and the Nursing Home Checklist “to help you think of questions to ask when you visit the nursing home and determine whether a nursing home fits you or your family member’s needs.”

Another site where you can locate VA-contracted nursing homes and see their star ratings is https://www.accesstocare.va.gov/CNH/Statemap.