A four-month Bridge Michigan investigation documented at least 5,915 cases of abuse, neglect, exploitation, and care violations at the state’s 420 nursing homes and identified nearly three dozen residents who died from suspected neglect or abuse over the past four years, according to a report distributed Monday by the Associated Press.
Investigators reviewed more than 45,000 pages of state and federal inspection records, submitted dozens of public records requests, examined more than 30 death certificates, and spoke with nearly 100 family members, current and former staff, administrators, consumer advocates, researchers, and policymakers.
The investigation found Michigan law sets the minimum daily care standard at 2 hours and 15 minutes per resident — a level unchanged for 45 years and less than half of the 4.1 hours the U.S. Centers for Disease Control and Prevention recommended in 2001 — while major legislative reforms have not advanced in more than a decade.
Deaths and individual cases
Lorena Brown, 68, died on Sept. 12, 2022 at the SKLD Muskegon nursing home after choking on vomit. Her roommate called for a nurse, who responded, “Mind your own business,” according to state inspection reports based on interviews with Brown’s roommates and staff. The roommate used a washcloth to clear Brown’s airway and called again for help. No nurse came. Brown died, the inspection report and other public documents show.
The facility’s administrator did not call police or report the death as a “sudden and unexpected” fatality to the state, inspection records show. The nurse continued working at the facility and was terminated only after state inspectors received a complaint and opened an inquiry.
Morris Wilson, 69, died in 2023 at the Detroit Nursing Center — also known as Imperial, a Villa Center — after a series of falls, medical errors, and sepsis, according to a lawsuit filed in Wayne County Circuit Court. After one fall, staff waited four days before sending Wilson to a hospital, where X-rays revealed a fractured hip, the lawsuit states. When Wilson died, a pressure sore was large enough that a latex glove was found inside it, covered by bandage and gauze, according to medical records cited in the lawsuit.
“My dad’s body was not somebody’s trash can,” said Shanica League, Wilson’s daughter, of Garden City.
Villa Healthcare Management and related parties agreed in July to pay $4.5 million to settle a federal complaint alleging that six of its Michigan facilities kept costs in check by hiring too few staff; the parties admitted no responsibility. Federal authorities alleged the homes billed Medicaid for care that was never provided.
Cindy Ruschke died in 2022 at Optalis Health and Rehabilitation St. Francis in Saginaw, 41 hours after entering the facility for what her family expected to be a brief stay, according to state inspection reports. A nurse who found Ruschke struggling to breathe at 4 a.m. mistook her for a hospice patient in a nearby room and turned up her oxygen tank before leaving to tend to another patient, the reports state. Ruschke was dead by the time the nurse returned. A staff member sent to prepare Ruschke’s body for the family entered the hospice patient’s room by mistake.
“I’m not dead yet,” the hospice patient said, according to state reports.
The facility was fined $39,231 and cited for failing to report the nurse to the Michigan Bureau of Professional Licensing. Cindy Ruschke’s son, Anthony Ruschke of Coopersville, said Bridge Michigan’s inquiry was the first he had heard of the circumstances surrounding his mother’s death or of any state investigation.
“There’s nothing about this that makes sense,” he said.
Staffing, training, and unspent funds
Bridge Michigan’s review found Michigan’s minimum care standard has remained at 2 hours and 15 minutes of daily care per resident for 45 years, despite a 2001 CDC recommendation of 4.1 hours per day. The state’s training requirement for nurse aides stands at approximately 100 hours — the investigation noted Michigan requires 400 hours of training for manicurists and 1,800 hours for barbers.
Michigan holds a $35 million fund, collected from nursing home penalties, intended to improve care. Administrators told Bridge the fund is effectively inaccessible because of bureaucratic rules governing its use.
More than three-fourths of Michigan’s nursing home beds are in for-profit facilities. Those facilities had 43% more citations per bed than nonprofit and government-run facilities on average, according to the investigation. Only 39 government-run nursing homes operate in Michigan, the fewest citations and highest staffing levels among facility types the investigation found.
Michigan nursing homes were cited 290 times in a five-year period for medication errors and 549 times for failing to provide essential care for pressure wounds, the investigation found. In all, homes have been fined $21.5 million over the past three years and denied 6,451 days of Medicaid reimbursements.
Legislative gridlock
Only one bill now before the Michigan Legislature addresses nursing home care. It would allow cameras in nursing homes upon request. Its sponsor, state Sen. Jim Runestad, R-White Lake, said it is “dead on arrival.”
An earlier version passed the Legislature by a wide margin but was not signed by Gov. Gretchen Whitmer. A second version died in committee. Whitmer did not respond to multiple inquiries from Bridge Michigan about her decision.
“We need to find a champion,” said Paula Cunningham, state director of AARP Michigan.
The last major regulatory change came in 2015, when lawmakers reduced mandatory annual nursing home inspections from once a year to once every three years.
“There’s also just a lot of people who are OK with pretending like we’re never going to get old, and we’re never going to need care for months and years,” said state Rep. Carrie Rheingans, D-Ann Arbor.
Lobbying and political money
Two major donors tied to the industry give to both political parties. The Health Care Association of Michigan, which represents nursing home operators, has donated $1.7 million to candidates, committees, and parties since 2003 and spent $1.2 million on lobbying over the same period, Bridge Michigan found. Favoring Democrats is the Healthcare PAC of the Service Employees International Union, which represents more than 30,000 nurse aides and has given $708,000 to candidates, PACs, committees, and parties since 2008.
“They have an incredible power base, an incredible lobby base,” Runestad said of the industry.
Transparency and comparisons with other states
State inspection reports identify neither residents nor staff by name, making it difficult for the public, families, or other employers to track individuals cited for wrongdoing, the investigation found.
“Families deserve transparency,” said Alison Hirschel, director of the Michigan Elder Justice Initiative. “Right now, they don’t have it.”
Several other states have enacted recent reforms. New Jersey, Pennsylvania, Virginia, and others have passed laws raising minimum staffing requirements. California and New Jersey have taken steps to prevent low-quality facilities from expanding. Minnesota established a workforce standards board for care workers. Connecticut is pursuing requirements that nursing homes direct at least 80% of revenue to direct care.
Industry response
Melissa Samuel, president and CEO of the Health Care Association of Michigan, said the oversight system works to identify and address problems, while acknowledging care failures occur.
“We’re not building widgets … and yes, mistakes are going to happen. And they happen in all the different settings,” Samuel said.
Richard Mollot, executive director of the Long Term Care Community Coalition, said Michigan does not rank as particularly good or bad nationally in nursing home care, safety, or staffing — and that a middling ranking offers residents little comfort. “You don’t want an average nursing home. That’s a terrible place to be,” Mollot said.
Reporting by Robin Erb, Bridge Michigan, distributed through a partnership with the Associated Press.