INDIANA, Pa. -- The tell-tale sign that this is Mary Deffner's home might be the Christmas cookie flour sprinkled across her purple sweater. It might also be the grandmotherly look she gives the children dancing in front of her, or the caged finches chirping behind her.
The 73-year-old Beacon Ridge nursing home resident doesn't view her future at the home as a death sentence. She may be living out her later years with 120 or so other old souls needing daily assistance, but she's also among live plants, colorful murals, wandering animals, friendly staff and regular visitors from the day care center next door.
"It seems trite to say it, but it's like a family here. I'm very comfortable," says Ms. Deffner, a former nurse from Shaler, who uses a wheelchair and who posed as horror movie villain Freddy Krueger to entertain the children at a Halloween party this year.
The facility, which embraces the modern "Eden Alternative" vision of nursing home care, shows how the industry is trying to shed its longtime, negative image. Occasional horror stories of blatant neglect and more frequent tales of frustrating mediocrity, by way of unanswered call lights and undiagnosed maladies, have created a sense of dread across the country for many families faced with a first-time nursing home admission.
A set of positive signs in Pennsylvania indicates the need for such fears may be diminished.
The number of penalties issued by the state Department of Health for substandard nursing home care has dropped dramatically from earlier this decade. Consumer complaints to the department and to most ombudsmen who work separately through county Area Agencies on Aging have also declined.
The number of Pennsylvania nursing homes with deficiencies involving actual harm to residents in both 2005 and 2006 was just half that found in 2000, which was even better than the significant reductions showing up nationally, according to the Government Accountability Office, the watchdog arm of Congress.
Meanwhile, state and national projects intended to reduce common nursing home problems, such as patients' pressure sores, persistent pain and use of restraints, have brought improvements. And, like Beacon Ridge, more and more facilities have adopted a philosophy of "culture change." It comes in many forms, but shares two themes: more control by patients over their lives and better conditions for the direct-care staff who work closest with them.
Administrator Kelly Pidgeon said Beacon Ridge was like any traditional nursing home until it embarked on the Eden Alternative form of culture change in 2001. Eden is a philosophy and program taught nationally by a nonprofit group that believes nursing home residents in traditional settings have been plagued by loneliness, helplessness and boredom. Ten other Pennsylvania facilities, besides Beacon Ridge, use it.
Crucial to the culture change were staff meetings and training sessions over the past six years in which Ms. Pidgeon asked employees what they would dislike about the place if they were a resident.
Gradually, Beacon Ridge was transformed from an institution where none of them ever wanted to reside to one where they agreed they could be happy, whether as employees or residents. Aromas from baking cookies or fresh-popped popcorn are common. Patients and staff share in caring for ubiquitous plants and a dog, cats, birds and guinea pigs. There are many more activities than bingo and movies, and much encouragement of patients to leave their rooms.
"The main principle is that living is more than just 'not dying,' " Ms. Pidgeon said. "Before, it was too sterile, too regimented. Yes, it was sanitary, but it was like a big clinically sterile hospital, and that's not the case now. ... It's like grandma's house. This is what we want."
Few facilities have so radically shed the institutional look or philosophy, but more are moving in a similar direction. The annual conference of the Pennsylvania Culture Change Coalition, which seeks to have nursing homes develop better conditions for patients and staff, filled to capacity with more than 400 administrators, nurses and other workers at a Lancaster hotel in November. It was three times the number at an initial meeting in 2004.
State regulators and industry leaders cite a number of reasons they see improvements in conditions at nursing homes. Among them are: more competition from the assisted-living industry, which has emphasized home-like features; more consumer access to state and federal evaluations of nursing homes; and increased scrutiny from baby boomers who want better conditions for their parents, while also eyeing their own future care.
Also, a number of nursing home officials in Pennsylvania say local operators were affected by the prosecution of the Ronald Reagan Atrium I Nursing and Rehabilitation Center in Robinson and its administrator, Martha F. Bell, for financial fraud and attempted cover-up of the circumstances of a patient's 2001 courtyard death. It was the first local prosecution of its kind involving a nursing home, and local and federal prosecutors have found no need to bring similar charges since.
"I think nursing homes are focusing on systematically evaluating everything they do to make sure that they make improvements," said Dr. Stuart Shapiro, president of the Pennsylvania Health Care Association, a leading industry group. Homes that want to do well are taking steps such as using more surveys of families and assigning staff members to care for the same patients day after day to know them better, he said.
It's not surprising to hear nursing home representatives or state regulators tout improvements, but similar sentiments are also voiced by many Pennsylvania advocates for the elderly.
Most of the county ombudsmen interviewed around the state say they are receiving fewer serious complaints from nursing home patients or families than in the past, and a Pennsylvania AARP official made the same observation. The Rendell administration's increased funding of home-based care in recent years, in an effort to reduce nursing home use, could be one more factor leading to overdue quality improvements, said Mary Anne Kelly, executive director of the Southwestern Pennsylvania Partnership for Aging, an advocacy group that also includes industry representatives.
"There have been nursing homes that maybe for the first time got scared and said, 'I have to become a provider of choice. I have to be the best home so people will still come to me,' " Ms. Kelly said.
After a historic climb year by year, the number of nursing home patients in Pennsylvania actually declined slightly in the past two fiscal years, with 80,266 individuals occupying beds in 2006-07. The number of nursing homes in the state, 729, has also declined in recent years.
The slide in both statistics, a trend encouraged by the state government to save Medicaid dollars, comes at a time when many facilities are either saying or doing something about quality. While attracting and retaining quality staff is still difficult, national studies have shown the number of staff on average is up slightly in recent years, and turnover rates in Pennsylvania are less than the national average.
Forty percent of the 16,000 homes nationally, and 48 percent in Pennsylvania, have signed up for a two-year national Advancing Excellence campaign in which they identify at least three of eight measurable goals to improve upon.
In addition, under a project funded by the federal Centers for Medicare and Medicaid Services, 110 Pennsylvania facilities are voluntarily receiving training from a consultant, Quality Insights of Pennsylvania, to reduce pain, pressure sores and use of restraints among patients.
Dr. David Wenner, medical director for Quality Insights, said statistics show tangible improvement by one-half to two-thirds of the participating homes. Even nonparticipating facilities in the state, he noted, are scoring better in the same categories than they did previously.
"We feel the quality has improved for the 110 participant homes," said Dr. Wenner. "I also think that as we get more publicly reported data, as more people are interested in that and more questions are asked by consumers, I think it raises the bar."
The pronouncements of quality improvements aren't always echoed on a national level. Advocates caution that the inspection process varies widely from state to state, making generalizations about the survey results unreliable. A minority of facilities have actively embraced the culture-change concept, they note, and the scoring of how well facilities do in measurements such as pain relief and pressure sores can be tainted by self-reporting of problems.
Concerns have also arisen over the increasingly common acquisition of nursing home chains by financial companies with more experience in profit-seeking than patient care. The latest example is equity firm Carlyle Group, purchasing Manor Care Inc., which operates 46 nursing homes in Pennsylvania.
Overall, incidents of neglect and abuse and understaffing persist, as data show nearly one of five homes, or 20 percent, nationally were cited for a serious deficiency in 2006 (compared to Pennsylvania's 13.6 percent rate), according to a GAO report. The national rate of deficiencies labeled serious has hovered between 16 percent and 20 percent the past five years, but in 2000 was 28 percent nationally and 30 percent in Pennsylvania.
"Many people still feel the state survey agencies don't react quickly enough or appropriately enough," observed Janet Wells, director of public policy for the National Citizens' Coalition for Nursing Home Reform. "You have [homes trying to improve] on the one side, and on the other side people angry about poor care, who see owners of poor facilities as not caring, who have difficulty getting anyone to pay attention to anyone being harmed."
Dr. Nicholas Castle, a University of Pittsburgh associate professor of health policy and management who has been involved inseveral nursing home studies, said that while state surveys alone aren't reliable, "most of the indicators seem to be going in the right direction." He attributes much of that to the rise of assisted-living alternatives in the past decade.
"The fact is nobody wants to go to a nursing home," Dr. Castle said. "It's a choice people don't want to make, but these days it's not as horrendous a choice. ... I've seen improvements from five years ago, and especially from 10 years ago."
Ms. Pidgeon at Beacon Ridge said the change in attitude among patients and families should be motivation enough for homes that want to survive. People have different expectations from a decade ago and are less willing to accept mediocrity.
When Ed Speidel visits his 80-year-old wife at Beacon Ridge, he sees a group of people who care for her -- and him -- like family. When he misses a day or two of visits, the staff calls to check on him. On the couple's 55th wedding anniversary, the staff threw a surprise party -- never mind that his wife, who has dementia, didn't know what it was about.
Nursing aide Theresa Kline, said Beacon Ridge has gone from a "gloomy" environment to one she looks forward to being part of. The staff turnover has dipped from 60 percent annually to 15 percent, and one of Dr. Castle's studies shows that facilities with lower turnover fare better in measurements of patient problems.
Ms. Pidgeon said the overall objective is establishing "relationships" that matter among the staff, residents and family members. It has not come overnight, she noted. But she felt reassured on the day a child was screaming in the nursing home while joining her mother in visiting her grandmother.
"She was throwing a tantrum because she didn't want to leave," Ms. Pidgeon recalled. "I said, 'This is stressful, but it validates everything we've been working for.' "
Next Sunday : A longtime nursing home patient makes the transition to her own apartment. Gary Rotstein can be reached at firstname.lastname@example.org or 412-263-1255. First Published December 30, 2007 5:00 AM