17 November 2020, Bavaria, Krailling: A resident of the Maria Eich nursing home walks across a corridor with his walker. Photo by: Sven Hoppe/picture-alliance/dpa/AP Images

In her 30 years as a certified nursing assistant, nothing prepared Melinda Wells for the unsanitary and dangerous conditions she said she witnessed at Yazoo City Rehabilitation and Healthcare Center. 

When she arrived for her first day at the Yazoo City nursing home on Feb. 13, 2021, Wells said she saw resident bedrooms and bathrooms that had not been cleaned in weeks. Floors littered with trash, dirt and dead bugs. Feces-stained bed sheets that sat in a utility sink for days. 

“That’s the worst (nursing home) I’ve ever been to in my life,” Wells said. “You don’t understand how bad it was. It was awful.”

Nursing home management did not respond to multiple interview requests. 

Horrified by what she saw and upset with facility leadership she viewed as uncaring, Wells reported her findings to the Occupational Safety and Health Agency (OSHA) on Feb. 17. The agency then notified the nursing home of the allegations and gave the facility a week to investigate and provide documentation that the issues had been corrected. 

Two days later, YCRHC responded to each allegation calling them meritless, and provided photos to back up their claims. OSHA closed the case, which left Wells feeling angry and disillusioned with the systems meant to protect nursing home residents and employees.

“I did what I was supposed to do, but it didn’t seem like anyone cared,” Wells said.

A few days later, a YCRHC resident would lose his life. 

On Feb. 21, 2021, just after 3 p.m., a resident lit a cigarette while in bed. Because he was wearing supplemental oxygen, the man immediately caught fire, suffering third degree burns to his right shoulder, chest and upper back, along with inhalation burns. The man later died in the hospital while being treated for these injuries, according to an MSDH report.

An entire wing of the nursing home, 23 residents total, had to be evacuated and relocated due to the fire. Many lost their personal belongings to water damage from the facility’s sprinkler system, the report said.

Health inspectors determined that the nursing home had endangered residents and violated federal regulations, and the facility was given an Immediate Jeopardy citation on March 8, one of the most serious citations health inspectors can give. 

YCRHC submitted a removal plan the following day that was accepted, and the Immediate Jeopardy citation was removed on March 10. If left unresolved, these citations prevent nursing homes from participating in Medicaid. The home was fined $186,111 a few weeks later for its failure to follow federal guidelines for smoking safety.

After an Immediate Jeopardy citation is removed, however, it largely falls on the facilities themselves to implement the systemic changes necessary to ensure regulatory compliance. Often, the same problems reappear after the heat is off. YCRHC was cited by state health inspectors in September 2017 for not properly supervising outside smoking or preventing residents from smoking inside bathrooms.

Following the February 2021 fire, YCRHC revised its smoking policy, removing wording that allowed residents to retain their lighters if they’re “deemed safe.” Room checks of all residents were also conducted, and multiple lighters were confiscated. These changes, among other safeguards, were meant to prevent a similar incident from happening in the future. But they didn’t.  

On July 26, around 1:30 a.m., a resident set his bed linens on fire with a cigarette lighter and then threw it into the hallway, according to MSDH report. The incident set off the fire alarm, but a nurse was able to quickly put out the flame and no one was hurt.

Though state and federal regulations required the nursing home to report and investigate the fire, they did not. As a result, the Mississippi State Department of Health didn’t investigate the incident until Aug. 10, after receiving an anonymous complaint. 

Documents show an MSDH investigator interviewed the resident, who said that he believed being overmedicated caused him to set the fire and he “was having one of those bad days.”

“I really don’t know what happened,” the man said. 

In another interview with the investigator, a Yazoo City nursing home administrator said that the man left the facility three times per week for dialysis treatment, and that she felt it would be a violation of his rights to go through his belongings each time he returned to the facility. She also said that she was aware that several other residents likely had lighters in their possession because they were not consistently monitoring the belongings of residents who smoke or monitoring the packages mailed to them. When asked if they had confiscated all the lighters residents had after the fire, she said she hoped they had. 

In its investigation report, MSDH wrote that the nursing home failed to thoroughly assess the resident’s mental and behavioral health before and after the fire. 

This lack of individualized care for nursing home residents isn’t unique to Yazoo City, Wells said. Many facilities were short-staffed before the COVID-19 pandemic, and the problem has only gotten worse over the past two years.

Often, a certified nursing assistant (CNA) is assigned 15-20 patients for one eight-hour shift, a workload Wells says is impossible for anyone to manage. Additionally, the practice of rushing new hires through training and orientation processes is resulting in worse outcomes for everyone involved, she said.

“They’re certifying these CNAs in three weeks, putting them on the floor and they don’t know what they’re doing,” Wells said. “They’re causing all kinds of injuries and problems in nursing homes with these residents. They’re not getting the treatment they deserve.”

While many of the issues that the Yazoo City nursing home has encountered are present in other nursing homes, it is still somewhat of an outlier in Mississippi. YCRHC has received 16 health citations over the past three years, nearly double the national average and nearly quadruple the average for Mississippi facilities.

It has an overall one-star rating from the U.S. Centers for Medicare & Medicaid Services ratings program. Their low rating stems from deficiencies found during on-site examinations by state health inspectors, the amount of time nurses spend with individual residents and the overall quality of care those residents receive. 

Wells, now working at a nursing home in Michigan, said she decided to share her experience publicly out of concern for nursing home residents and their families. Wells wonders: If something as big as a facility fire at YCRHC can go unreported for so long, and no real consequences come from this lack of care, what else is being swept under the rug at other nursing homes? 

“People need to check on their family members in these nursing homes, because who knows what they’re going through. They’re not being protected,” Wells said. “Something’s gotta change, but I got to get it out there before it can get changed.”

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Will Stribling covered healthcare and breaking news for Mississippi Today.