Daughter fights nursing home over ‘traumatizing’ care

Target 8

WYOMING, Mich. (WOOD) — Brandee Davis is a nursing home’s worst nightmare and she has no intention of letting up.

“It’s really hard to watch someone you love with all your heart suffer… beg for help, beg to leave,” Davis said in an interview at her Kentwood home.

Davis, whose mother lives at SKLD nursing home on 36th Street in Wyoming, has filed formal complaints with the state twice since May.

SKLD has a one-star rating on the federal website medicare.gov, a score that’s described as “much below average.” Of the 25 licensed nursing homes in Kent County, SKLD is one of just three with a one-star rating.

“Social services doesn’t let children live in situations like this, so why are they letting adults?” Davis wondered.


Davis is going to court in September to try to get guardianship over her mom, Michele, so she can move her.

“I shouldn’t have to keep calling and reporting,” Davis said. “My mom shouldn’t have to call me, begging me to call the home because her call light has been on for two hours and nobody’s coming to her room.”

Among Davis’ complaints to the state is that SKLD workers failed to answer her mom’s call light or change her diaper for hours; ran out of appropriately-sized briefs, thus forcing her to wear too-small briefs which ripped her skin; left her in the same clothes for five days and placed an aggressive dementia patient into her room despite her inability to protect herself.

Davis’ mom fell off a horse in Hastings in 2000 at age 40. When she emerged from a multiyear coma, she was paraplegic with limited use of one arm and a traumatic brain injury that left her dependent on 24-hour care.

“They decided to place a known violent dementia patient… in a room with an incapacitated adult who can’t do anything for herself,” Davis said.

State investigators who inspect nursing homes on behalf of the Centers for Medicare and Medicaid Services substantiated several of Davis’ complaints, including the one about her mom’s new roommate, who was moved to another room after she “went through (Davis’ mom’s) things … smacked her legs” and attacked staff, bruising a nurse, according to a state report.

“Review of documentation and interviews, revealed (Davis’ mom) was vulnerable and unable to defend herself from (the dementia patient) who wanders, has physical behaviors and a history of blocking the doorway to the residents’ room so staff could not get into the room. Which placed (Davis’ mom) at higher risk of harm,” a state inspector wrote.

>>PDF: May inspection report | July inspection report


But call light and roommate problems were far from the only issues the state cited when it visited the facility at 625 36th St. SW in response to Davis’ complaints.

Inspectors issued statements of deficiencies and ordered the home to create plans of correction after their visits in late May and mid-July. Among the deficiencies cited were out-of-reach and unplugged call lights, residents left for hours in urine-soaked briefs and dirty rooms with “dried food and liquids stuck to the residents’ room floors, dirt and dust accumulating under the residents beds, tissues and papers accumulating on the floors.” One room had dust clumps “larger than golf balls” under the bed.

One inspector wrote that an aide, while being interviewed, “looked in (a resident’s) room and found the call light cord on the floor behind the headboard unplugged and could not located where it needed to be plugged in.”

“‘That’s weird, I’m not sure where it goes,'” the inspector reported the aide said.

In another case, despite a care plan that called for frequent incontinence checks, a resident was left in the same briefs for 9 1/2 hours.

“She said, ‘They like to leave me in my diapers for a long time,’ and stated this happens frequently,” an inspector wrote.

In another incident cited by the state, a resident, not Davis’ mom, sustained “multiple severe injuries,” including two bone fractures and significant bruising when she fell out of bed after an aide tried to change her alone. The resident’s care plan had called for two aides for “bed mobility.”

“‘The aid was getting me cleaned up,'” the inspector quoted the resident as saying. “‘I was laying on my right side too close to the edge, they know I hate that, it makes me nervous. The aide was doing something on my back side, I couldn’t see what, and I felt her push me and over I went.'”

Davis said SKLD injured a helpless elderly person.

“It’s mind-blowing and traumatizing,” she said. “And when I was in there two days ago, they’re still using one person to change my mom and she can’t use her arms to stop, to protect herself. So if they roll her and she rolls to the other side, that’s going to be catastrophic.”

Davis’ biggest fear is that her mom will choke and be unable to call for help.

“She can’t really eat or swallow very well, so I always get worried she’s going to choke and she’s going to push her call light and no one’s going to get there in time,” she said.


Evanston, Illinois-based Illuminate HC took over management of SKLD and 10 other Michigan nursing homes a year ago. Of SKLD’s 11 homes, four have one-star ratings (much below average), four have two-star ratings (below average), two have three-star ratings (average), and one has a four-star rating (above average). 

The company told Target 8 that it’s dedicated to improving care at all its homes.

Illuminate HC officials refused an on-camera interview, but invited Target 8 to tour the home without a camera at a later date.

“We hope that through our dialogue you will come to see that we are the ones that are trying to fix the industry, not perpetuate more of the same flaws,” an Illuminate HC spokesperson wrote in an email. “I hope that your article does not discourage the staff that we work so hard to encourage.”

The Illuminate HC spokesperson went on to say the company was pleased with the result of a recent revisit by the state.

Inspectors were checking on how the home was implementing its plans of correction, which are listed in the right-hand column of the inspection reports in response to the corresponding citations in the left-hand column. The spokesperson forwarded Target 8 an email from the nursing home’s administrator that followed the state’s revisit and announced, “We are all clear of all citations!”

“Congrats team Wyoming!!! Not only did they clear, but they cleared with flying colors and in record time. Most of all it was incredibly evident to (person) by the lack of concerns from the residents that their satisfaction and quality of care has improved significantly. Thank you ladies for your leadership and working what was by no means a paper POC (plan of correction). Your team really stepped up made meaningful changes and made a difference in the lives of these residents!”

Target 8 contacted Michigan’s Department of Licensing and Regulatory Affairs (LARA) to confirm the results of the reinspection. However, LARA’s spokesperson told Target 8 the state had not yet completed its report and, thus, could not confirm its latest determination.

“LARA is finalizing its findings and report from the August 14 onsite visit and is not able to share its findings until the report is issued,” read an email to Target 8 from Jason Moon, LARA’s Director of Communication.

“LARA has no dispute with the provider’s comments regarding their current compliance….. Both the May and July abbreviated surveys were conducted based on several complaints and allegations, as allowed by CMS (Medicaid and Medicare) procedures. Some allegations were substantiated and some allegations were not during these abbreviated surveys. This provider is federally certified to participate in the Medicare and Medicaid program so abbreviated surveys are conducted under federal regulations, which is a standard practice for almost all nursing homes in Michigan.”

While Brandee Davis wants to move her mom to another facility, Davis is not her mom’s guardian.

Brandee Davis’ 85-year-old grandma has guardianship over Michele and told Target 8 she’d give the home a “C” for the care it provides her daughter.

She also said, while there was trouble with two problem staff members in summer and fall 2018, care had improved since those employees left.

Michele’s mom told Target 8 that her daughter wants to leave SKLD, but only because she wants to move home, which Michele’s mom said is not possible.

The future of Michele’s guardianship will be examined at a hearing in Kent County Probate Court in late September. That’s when Brandee Davis will try to become guardian for her 60-year-old mom, which would allow Brandee Davis to determine where her mom should live.


Kay Scholle, the state’s long-term care ombudsman for West Michigan, said the problems at SKLD and other homes show why it’s critical that people visit loved ones in nursing facilities and check the federal website for ratings and inspection reports.

“The most important thing is how each facility responds to (statements of deficiency from the state). There’s no perfect facility. In any business, sometimes there are hiccups,” she said.

Scholle says the state inspections give homes the opportunity to correct problems and improve processes.

When asked if people should be worried about homes with one-star ratings, Scholle said, “I think what people need to be worried about is when to show up.”

“What we find often is individuals are in facilities and they don’t get a lot of visitors and that’s heartbreaking for those of us who are in there,” she continued. “You can go into the facility and assess how is my mom doing, how is my father doing, is my father groomed when I walk in, is my father being fed.”

If you find problems, advocates encourage you to report them to the home itself and the state.

Scholle also points out that if your loved one isn’t happy, they can move.

“Once you’re in a facility, if you don’t like where you’re at for some reason, you can move,” she said. “It’s not a one-and-done situation.”

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