MUSKEGON, MI — Nearly three dozen nursing home residents have died from suspected neglect or abuse in Michigan over the past four years, according to an investigation that examined more than 3,100 state and federal inspection records.
The investigation, conducted by Bridge Michigan, documented at least 5,915 cases of abuse, neglect, exploitation, or quality of life and care violations among 15,471 total citations issued to the state's 420 nursing homes. Facilities have been fined $21.5 million over the past three years and denied a total of 6,451 days of Medicaid reimbursements, according to the findings.
Among the deaths examined was that of Lorena Brown, a 68-year-old former foster parent and cosmetologist who died at SKLD Muskegon nursing home on September 12, 2022. According to inspection reports based on interviews with Brown's roommates and staff, she gasped for air and turned blue while her roommate desperately called for help from a nurse. The roommate reported receiving the response: "Mind your own business." Despite attempts by the roommate to clear vomit from Brown's mouth using a washcloth, no assistance arrived and Brown died, according to inspection reports and public documents.
The facility administrator did not contact police or report the sudden death nor the allegation of neglect to state authorities, according to reports. The nurse involved continued working at the facility and was terminated only after state inspectors received a complaint and began investigating.
The investigation revealed significant disparities in citation rates between facility types. For-profit nursing homes, which operate more than three-fourths of all nursing home beds in the state, averaged 43 percent more citations per bed than nonprofit and government-run facilities. Government-operated homes recorded the fewest citations and maintained the highest staffing levels, though only 39 such facilities exist in Michigan.
Systemic Challenges in Michigan Nursing Home Care
Michigan's regulatory framework for nursing home care falls short of standards recommended by advocates and implemented in other states. The state mandates only two hours and 15 minutes of direct care per resident each day, significantly below the more than four hours daily that advocates recommend as necessary for adequate care.
Staffing levels across Michigan nursing homes vary dramatically, ranging from the state minimum to approximately seven hours of care per day at a small number of facilities, according to the investigation.
Training requirements for nurse aides in Michigan rank among the lowest in the nation at approximately 100 hours. By comparison, state law requires 400 hours of training for manicurists and 1,800 hours for barbers, according to regulatory standards.
The investigation documented conditions at various facilities including mold and gnats, odors of human waste, filth, rodents, flies, and isolation that left residents staring at walls in inactivity, according to inspection reports.
Michigan maintains a fund worth $35 million collected from penalties for violations that is designed to improve care quality. However, administrators told investigators that bureaucratic rules make the money nearly impossible to access.
"We need to find a champion," said Paula Cunningham, state director of AARP Michigan, as reported by Bridge Michigan.
Transparency and Accountability Gaps
Public transparency remains limited when staff members are cited for wrongdoing. State reports do not identify residents or staff involved in incidents, making it difficult or impossible for the public to determine whether cited employees remain in the workforce. Nursing home administrators told investigators they may not know about a nurse's previous violations when making hiring decisions. Family members frequently remain unaware that their relative's death or injury is under investigation, according to the findings.
Only one bill currently pending in the Michigan Legislature addresses nursing home care, according to the investigation. It would permit cameras in nursing home rooms.
Melissa Samuel, president and CEO of the Health Care Association of Michigan, an industry group, acknowledged that abuse and neglect are indefensible but stated the system functions to identify and punish wrongdoers, as reported by Bridge Michigan.
"We're not building widgets … and yes, mistakes are going to happen. And they happen in all the different settings," Samuel stated, according to the report. She expressed frustration that media coverage focuses on poor care incidents rather than positive aspects of nursing home operations.
Other states have enacted legislation in recent years to strengthen protections for nursing home residents, but similar efforts to improve care for Michigan's approximately 34,000 nursing home residents have not advanced.
Federal regulations require nursing homes to maintain adequate staffing levels to meet residents' needs and to ensure prompt response to emergencies. Facilities must also report allegations of abuse, neglect, or exploitation to administrators and appropriate authorities within specific timeframes.
Resources for Families
Families concerned about care quality at Michigan nursing homes can contact the National Long-Term Care Ombudsman Resource Center at 1-800-677-1116. The ombudsman program provides free advocacy services for residents and can investigate complaints confidentially.
Additional resources include the Michigan Department of Licensing and Regulatory Affairs, which oversees nursing home inspections and licensing. Families can request inspection reports and complaint investigation findings for any licensed facility in the state.
Anyone who suspects abuse, neglect, or exploitation should report concerns immediately to Adult Protective Services and local law enforcement. Federal law protects individuals who report suspected violations from retaliation.
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