Howard Mahan often pauses to admire the portrait of his wife, Karen, on the wall in the hallway of his Spokane, Washington, home.
A soft light hangs above the photo, brightening his bride’s already brilliant smile.
“It’s really a good picture of her, and she was gorgeous in it,” he said of the blue-eyed grandmother of six, pictured with short, blond hair.
Howard, who was married to Karen for more than 50 years, first displayed the enlarged photo at his wife’s memorial service.
The retired longtime teacher who enjoyed traveling died in 2022 after choking to death at her Spokane nursing home, Touchmark on South Hill.
“I’m very angry because I should still have a wife,” said Howard Mahan in an interview with Scripps News in early November 2023.
An inspection report obtained by Scripps News, which does not include names but matches the details provided by Mahan, says staff left a resident unsupervised while eating a sandwich, and when caregivers later discovered her slumped over with a pulse, no one called 911 for help.
“They knew the protocols. They were documented,” Mahan said. “They made some efforts to try to revive her, but they should have called 911.”
Karen’s physical condition made it difficult for her to swallow food, so she had a previously established medical care plan that was supposed to ensure that caregivers would monitor her while she was eating.
But according to the inspection report, the facility “failed to provide the level of supervision necessary,” “failed to provide all interventions necessary,” and “placed additional residents at risk for aspiration, choking, and death.”
“My goal is to let the public ... be aware of the fact that they’re not getting the five-star care that they believe they’re getting,” Mahan told Scripps News after he filed a lawsuit but before he agreed to a legal settlement with Touchmark.
In court filings, the nursing home disputed that its negligence may have led to Karen’s death. It claimed that staff saw her after she finished eating and “she was fine” about 10 minutes before another staff member found her slumped over.
A spokesperson for the nursing home told Scripps News the “safety of all residents has been Touchmark’s top priority.”
What do 5 stars mean?
Karen Mahan moved into Touchmark on South Hill in 2017 following two strokes, according to her husband, who is now in his 90s.
“She needed care. She was confined to a wheelchair. I was not a young person at that time, and I couldn’t provide all of the care that she needed,” Howard Mahan said.
He chose the facility based on positive word-of-mouth recommendations.
“Up until Karen’s death, it was a good place,” he said. “She loved it. She liked it. She liked the caregivers there. They liked her.”
Scripps News discovered the word-of-mouth reviews at the time also matched the federal government’s formal assessment of the facility.
When Karen moved in, Touchmark on South Hill had achieved the federal government’s highest overall quality assessment score, a 5 out of 5, in the Five-Star Quality Rating System established and utilized by the Centers for Medicare and Medicaid Services, also known as CMS.
The agency assigns an overall rating based on a nursing home’s health inspections, a quality-of-care assessment and a staffing evaluation.
The overall rating, according to CMS, may be used by consumers to compare nursing homes. They can find the rating online using the government’s Care Compare tool.
“Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average,” according to the government’s CMS website.
A Scripps News analysis of more than 14,000 nursing homes found hundreds of nursing homes, however, continue to maintain or display high ratings despite also being found to have had a serious incident at their facility, known as an “immediate jeopardy” incident, in the previous three years.
Immediate jeopardy incidents are those in which a facility is found by government inspectors to be noncompliant with federal health and safety standards, putting residents at risk of death or injury, as in the case of Karen Mahan.
However, not all cases of immediate jeopardy involve incidents as severe as a death, and many nursing homes take quick action to correct the problem and come into compliance to avoid losing government funding through CMS.
In Karen’s case, Touchmark on South Hill implemented corrective measures and continued to maintain an overall top federal rating of 5 stars for nearly seven months following Karen’s death.
Other problems in the facility where Karen Mahan lived — months after her death — eventually led the nursing home’s overall rating to drop to its current 3-star rating.
An August 2023 health inspection report found 13 deficiencies ranging from failing to provide and implement an infection control program to failing to ensure that residents are “free from significant medication errors.”
Hundreds of top-rated homes have past “immediate jeopardy” findings
At least 247 nursing homes had 4-star or 5-star ratings despite also being found to have had at least one immediate jeopardy incident in the previous three years, according to government data from February 2024 analyzed by Scripps News.
Scripps News found other examples of cases like this.
In Pennsylvania, an elderly woman froze to death outside her nursing home in 2021 after staff failed to notice she was missing. Despite a finding of immediate jeopardy, the facility continued to maintain a 5-star rating for more than a year following the incident before dipping to 4 stars for three months and then returning to 5.
In Minnesota, a facility maintained a 5-star rating for more than a year after a resident slipped out of the facility in 2021, purchased a knife and killed himself. The facility then sank to a 4-star rating for several months before returning to 5.
A 5-star home could be 1-star in another state
Scripps News discovered the method by which the federal government assigns ratings to nursing homes is not uniform across state lines.
Even with the same health inspection findings, a nursing home that has a 5-star rating in one state could be rated much lower in a different part of the country. That’s because a nursing home’s health inspection rating — the baseline for its overall rating — is assigned based on how its inspection findings compare to other nursing homes in the same state.
According to a Scripps News data analysis, there were 397 nursing homes with 4- and 5-star ratings that could have had just 1 star if they were rated against a different state’s homes.
U.S. senator says several things are wrong with system
“Until we get this star system straightened out, you better not use that as the sole judge of where you ought to put somebody,” said Sen. Chuck Grassley, R-Iowa. “There are several things wrong with the system.”
For years, Grassley has been pushing for reforms that would improve the country’s nursing home system. He told Scripps News he would like to see more consistency in the way quality of care is measured.
“You could be a 5-star and still have very poor quality of delivery of services to older people,” he said. “If a nursing home is a 5-star, it ought to be the best you can go to, and it doesn’t matter whether it’s in Iowa or Arizona, it ought to be the same quality,” he said.
In 2016, the Government Accountability Office (GAO), which serves Congressional leaders like Sen. Grassley, audited CMS’s system and recommended that CMS “add information to the Five-Star System that allows consumers to compare nursing homes nationally.”
But CMS did not implement the recommendation.
“It’s important to note that CMS reminded the GAO that the Five-Star Rating already does compare nursing homes nationally,” said Julie Brookhart, a spokesperson for CMS.
There are multiple factors that make up an overall federal star rating, including an evaluation of a facility’s quality, staffing and health inspections. Two of those measures — staffing and quality — are determined using national thresholds, said Brookhart.
However, the health inspection scores that contribute to an overall federal star rating are based on comparisons to other facilities in the same state, she said.
“This is due to variations between states,” she said, "however ... when someone is looking for a nursing home, they are typically looking for one in a particular state (vs. choosing a nursing home from a few or many states). So, using the in-state comparison provides more relevant information about the local conditions for consumers.”
Why the system may not be enough to make a decision
“It’s very hard to make a perfect system,” said Lee Fleisher, the former chief medical officer and director of the Center for Clinical Standards at CMS, who oversaw the star-rating system before he left the agency in 2023.
He advises consumers to look beyond the star rating when assessing whether a nursing home is right for their loved one.
“Something can happen anywhere, especially these days,” he said. “I think it’s important to look if there are recent complaints ... There could be a change in the staff. There could be a change in the leadership. So that, I think, is an important thing for people to think about,” he added, explaining that even great facilities may experience a bad event.
Brookhart echoed the sentiment.
Star ratings may not reflect every individual incident that occurs, she said. “They are a summary of many different data elements to reflect a general level of quality on a scale of 1 to 5.”
Only 1% of nursing homes with high ratings had an immediate jeopardy inspection finding on their most recent inspection cycle, she said. “It is likely that these ... facilities had an isolated issue leading to the [immediate jeopardy] but did not have many other citations that could indicate systemic issues.”
The agency said people who use the star-rating system to compare nursing homes should consider a “range of information” before deciding.
“We recommend individuals contact the nursing home they are considering and talk to the administrator, director of nursing or medical director, and inquire about the type of care they provide and ask questions that are important to them,” Brookhart said.
While Howard Mahan did not rely on the federal star-rating system to select the nursing home for his wife, he said he hopes others will learn from his experiences and do their own research before choosing a place for their loved one.
“I want the word out there,” he said.