Channel 2 investigates Texas nursing home violations

Are stiffer financial penalties making difference?

HOUSTON – Texas nursing homes are among the worst in the country when it comes to caring for our vulnerable elderly and disabled loved ones. A new law meant to punish the repeat offenders took effect in 2017.

Consumer expert Amy Davis is following up to find out if stiffer financial penalties are making a difference.

"I put her there," said Rondia Crenshaw, referring to her mother, Diane Woodard. "I signed her up. I took her."

Crewnshaw admitted her mom into Willowbrook Residence and Rehabilitation Center in December 2017 after her mother fell out of her bed and hit her head. Woodard was 65 years old and battling Parkinson's disease and dementia. She had lived with her daughter until falling.

Doctors recommended a nursing home for Woodard where she could get daily physical therapy. They moved Woodard to Willowbrook Residence and Rehabilitation for what was supposed to be a three-month stay.

Just days before she was to leave the nursing home, court documents show Woodard was sexually assaulted by another resident. She was bed-bound and nonverbal, unable to call for help.

"It haunts me daily to know that I did that and she had to end in that way," Crenshaw said with a cry, explaining the guilt she feels.

Houston police said a nurse's assistant walked in on the sexual assault. She noticed Woodard's call light on and the door to her room closed.

"My mom was not able to physically press a button," Crenshaw said. "Her head just happened to be against the button. So that's why the light went on."

Attorney Charles Brown said what happened in the minutes and hours after the alleged sexual assault is also criminal.

"The first call that the facility made wasn't to the police. It wasn't to a physician. It was to their corporate office to figure out what to do," he said.

State records reveal nurses did not immediately call police or a physician. When they called the victim's daughter, there was no mention of sexual assault.

"They said, 'A man was found in her room but she wasn't touched,' is what they told me," Crenshaw recalled.

She rushed to Willowbrook to find her mom fully dressed in her wheelchair at the nurse's station.

"She was asleep. I kissed her. I looked at her and she looked fine, so I said, 'OK, she's OK,' and I left," Crenshaw told Davis.

Hours after the attack, she said the nurse who walked in on the assault sent her a message through a mutual friend detailing what she claims actually happened and the orders she said she was given by her boss to downplay the crime.

"How would you have ever known?" Davis asked Crenshaw.

"If it wasn't for the nurse feeling guilty, I wouldn't have," she answered.

It was the exact type of situation Texas lawmakers hoped to end when they passed a new law in 2017. It was supposed to crack down on nursing homes with repeat violations by imposing hefty fines.

Willowbrook Residence and Rehabilitation Center wasn't fined. State records show that a month before Woodard's assault, the Department of Health and Human Services recommended the revocation of the facility's license for unrelated violations, including failure to treat bedsores on multiple patients or alert a doctor to the wounds (view report).

But just a month after Woodard's assault and the home's failure to report it, the agency changed its mind and rescinded the revocation order. The Texas Department of Health and Human Services won't explain the about-face.

"I just think they need to be held accountable -- all nursing homes, not just Willowbrook," Crenshaw said.

Willowbrook is not alone.

We've found more than a third of Texas' 1,200 nursing homes are deemed "much below average" by the Centers for Medicaid and Medicare services; but Channel 2 Investigates has learned the state of Texas didn't revoke the license of a single nursing home last year and some were repeat offenders.

"Until we have some form of consequences for nursing homes that hurt people ... we will never have quality nursing homes for the state of Texas," Brown said.

In the Houston area last year, the nursing homes with the most severe deficiencies were Oakmont Healthcare and Rehabilitation Center of Humble, The Vosswood Nursing Center on South Voss and The Galleria Residence and Rehabilitation Center.

No one from Willowbrook Residence and Rehabilitation would talk with us on or off camera.

Matthew Lloyd, the Vosswood Nursing Center's executive director, sent this statement:

"At The Vosswood Nursing Center, residents are our highest priority. Our day-to-day operations are centered on their care, safety and well-being.

"Any deficiencies received during the last 12 months have been addressed and corrected. We consider ourselves partners with the state and respect and value the oversight provided. We continue to work in cooperation with them while focusing on providing compassionate health care services to our residents."

A representative of The Galleria Residence and Rehabilitation Center emailed this response:

"Thank you for reaching out to us for comment on your upcoming news story. Please know that we share your commitment of ensuring that all of our residents receive the highest levels of medical and personal care possible.

"Regarding Galleria; we are aware of its unfortunate recent history of being cited due to poor survey results. As a result of these surveys, and in an effort to realize our commitment of ensuring that all of our residents get the best care, we have made pervasive changes at the facility. To wit, we have overhauled our administrative, leadership, and medical staff, with a focus on increasing the level of experience and professionalism throughout our team. Additionally, we retained the most reputable consultants available to help us reach full compliance with all requirements, thus leaving our facility personnel to focus on patient care and successful outcomes. Finally, we have undertaken various educational initiatives throughout the facility, and related community, to help further boost the performance of our team. As a result of the initiatives outlined above, we have since achieved full compliance and are making great strides in working with the State to reach our common goals relating to resident care and safety.

"While we are happy with our recent work, we are not satisfied. It is our goal to constantly overachieve in the area of resident care, and we will continue to strive in an effort to realize ever higher levels of performance.

"Thanks again for your work in helping ensure that all residents of facilities such as ours receive the best care possible. Additionally, in so much as it doesn't impinge on our residents' safety, comfort, and privacy, we would be happy to host visitors to our facility to witness the great work of our team members.


"Galleria Residence and Rehabilitation Center"

While Crenshaw is still waiting for answers, her mom died waiting for justice.

"It's like they don't care about the nursing homes," she said. "I think they get away with a lot of things because look at it -- nothing really happens."

The best way to research nursing homes and their most recent inspections is on the federal nursing home compare website. Even after you choose a facility, visit your loved one often to make sure nurses and staff know who you are. It wouldn't have prevented Woodard's assault, but her daughter believes that nurse would not have come forward with the truth if she hadn't seen her there with her mom.

We reached out to the Texas Health Care Association, a group that represents 600 nursing homes in the state, to talk with us for this story. No one would sit down for an interview, but they sent this statement:

"Any violent or abusive behavior directed towards the elderly is deplorable and should not be tolerated. We must do everything we are able to prevent these types of events from occurring. Individuals found having committed these actions, whoever they may be, should be held accountable under the laws of our state.

"Across Texas, in each of our communities, are tens of thousands of caring and compassionate staff that have, for years, demonstrated their commitment to providing the level of care that is deserved and expected for our elderly. That standard must be upheld by all of who care for our seniors and the state of Texas has taken significant efforts to increase regulatory policy with the intent of further protecting the frail and elderly.

"That standard of expectation however, must also be demonstrated by our state through sound fiscal policy. The underfunding of care for the elderly in Texas has gone on long enough. The state's underfunding of Texas nursing homes by $945 million dollars sounds unimaginable; yet, it's happening right now in Texas.

"To maintain the standards of care expected by residents, families and staff in our communities across the state, a commitment from our lawmakers to ensure adequate Medicaid funding is critical to the recruitment, retention and ongoing education of the professional and committed staff necessary to sustain and exceed care delivery expectations in long term care.

"Supporting the delivery of care for the frail and elderly of our state should not be a choice, but an unwavering commitment to those who have come before us and committed themselves to building."

"Texas Health Care Association (THCA) CEO Kevin Warren"