He crashed to his death down the nursing home stairs. Nobody noticed for nine hours.


Nobody at Woodcrest Nursing and Rehabilitation Center noticed Bobby Crail crashing down the stairs in his motorized wheelchair one Sunday morning in 2016.

No one even went looking for him for the next nine hours.

When Crail disappeared from a second-floor hallway, the staff at this Northern Kentucky nursing home assumed he left for the day on an unscheduled family trip without anyone signing him out. So his absence caused no concern. Also, the emergency exit stairs that he accidentally rolled into were supposed to be secured. Unfortunately, the door’s lock and alarm were broken.

Crail’s battered body was discovered in the stairwell that night. He had suffocated where he landed at the bottom of the steps from the weight of the 166-pound wheelchair on his chest. A pool of blood surrounded his head.

For its failure to protect the 45-year-old Crail from harm, Woodcrest was hit with a $73,710 fine from the state of Kentucky, which it paid, and a wrongful death lawsuit from his parents and children, which it settled for an undisclosed sum.

“We couldn’t grasp how this could happen, you know?” Crail’s father, Robert Crail Sr., said in a recent interview at his Kenton County home a few minutes away from Woodcrest. “We just hoped that maybe if we made some noise, someone would step up and start inspecting this place more seriously to make sure that people weren’t hurt there again.”

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Marcus Dorsey mdorsey@herald-leader.com

But — as so often happens with Kentucky’s troubled nursing homes — people still get hurt at Woodcrest.

Since Crail’s death, Woodcrest has racked up 44 more deficiencies in inspections, several involving what the state classifies as “immediate jeopardy” or “actual harm” to residents, and $142,714 more in fines.

The facility’s persistently inadequate staffing constitutes a “crisis,” its administrator warned inspectors in January when he quit. There have been dangerous bedsores, medication errors and residents capable of controlling their bowels who were ordered by stressed nurse’s aides to soil themselves and lie in their own feces until someone was free to assist them to the bathroom, according to a state inspection report.

For several months this year, the federal government went so far as to deny Woodcrest from receiving Medicare and Medicaid payments because of the facility’s unresolved problems.

Even after a corrective plan convinced the federal government to restore funding in May, the U.S. Centers for Medicare and Medicaid Services awarded Woodcrest just one star — “much below average” — on its five-star nursing home rating system. Woodcrest residents are more likely than those in other facilities nationally to suffer a major injury from falls, report moderate to severe pain, suffer weight loss and be put on mind-altering medication, according to CMS.

This pattern is not unusual, says a national expert.

“There is a roller coaster of compliance that we see all the time for nursing homes,” said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, which lobbies for better care for the elderly and disabled.

“They get into trouble, they fix things up just enough to get back into compliance and then they let things slip again. This cycle just goes on for years,” Edelman said. “Meanwhile, there are people living in these places.”

The Office of the Inspector General at the Kentucky Health and Family Services Cabinet, which is responsible for regulating the state’s nursing homes, repeatedly declined to be interviewed by the Herald-Leader about its work.

In a prepared statement, the office said its “responsibility is to ensure our health-care partners are providing the best care possible to residents.” It added: “This is one of the most heavily regulated industries in our country.”

Woodcrest’s for-profit corporate owner, Preferred Care Partners Management Group of Plano, Texas, sought bankruptcy protection for its 21 Kentucky facilities last fall. It was swamped by 163 negligence and wrongful death lawsuits, more than half filed in Kentucky. A Paducah jury that awarded one of its nursing home residents $28 million in damages after he was hospitalized for shock, severe dehydration and kidney failure was the last straw, the company complained at the time.

“This is yet another example of the extreme risk involved with operating a nursing facility in Kentucky, where the industry remains under attack from aggressive plaintiff’s firms that distort the facts, and where any jury in any county can, at any time, render an unlimited verdict purely at their own discretion,” the company said in a prepared statement after the Paducah decision.

Having acquired its Kentucky facilities in 2012 from another frequently sued chain, Extendicare Health Services, Preferred Care has decided to pass Woodcrest and the others, with 1,234 beds between them, to a new owner, Sapphire Care Group of Brooklyn, N.Y. A bankruptcy judge in Texas approved the deal in July.

Under the deal’s terms, Sapphire Care will not pay for the facilities and is shielded from pending litigation — from “all liens, claims, emcumbrances and interests.” Meanwhile, Sapphire Care has its own quality problems, critics in New York say. The local congressman accused it in February of “a pattern of neglect and understaffing that is absolutely unacceptable.”

This, too, is a common pattern. Substandard nursing homes often are tossed from owner to owner like a hot potato, milked of their profits for a few years and then flipped once the fines and lawsuits become too expensive, Edelman said.

As of August, 13 of Preferred Care’s 21 Kentucky nursing homes were rated “below average” or “much below average” by CMS, with more than $1.8 million in fines between them over the last three years. A report on the Kentucky facilities by an ombudsman in the bankruptcy proceedings found continued staff shortages and “significant cleanliness issues.” At the Preferred Care nursing home in Franklin, “fecal residue was seen on several surfaces and flies were observed,” the ombudsman wrote.

“A lot of these people just shouldn’t be running nursing homes,” Edelman said. “You can only have those massive jury verdicts the industry complains so much about when your residents have egregious outcomes. Maybe you wouldn’t end up in court so often if you didn’t let your residents go headfirst down the stairs in a wheelchair.”

Repeated calls to Woodcrest and Preferred Care seeking comment for this story were not returned.

Founded in 1992, Preferred Care is privately held and does not disclose its internal finances. However, its 21 Kentucky nursing homes generated $135 million in revenue and $17.5 million in net income in 2012, the year they were transferred from Extendicare.

Preferred Care’s political action committee and its owner, Thomas D. Scott, have given at least $22,600 in donations to Kentucky state politicians in the last five years, including $10,000 Scott paid to the Republican Party of Kentucky six months after Republican Gov. Matt Bevin was elected.

The lobbying group that represents Kentucky nursing homes at the state Capitol says Preferred Care is a high-quality company.

“I don’t know anything about that one incident (with Bobby Crail) or Woodcrest. I can tell you that Preferred Care has a lot of compassionate people who work there, one of whom serves on my board,” said Betsy Johnson, executive director of the Kentucky Association of Health Care Facilities.

“I know these people. They are committed to providing quality care,” Johnson said. “And again, unfortunately, things happen. Because as you know, when you live in a nursing facility, you are a person who can move about the building as you want as long as there are safeguards put in place. We are a long way from restraining people, the dark ages of long-term care.”

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Marcus Dorsey mdorsey@herald-leader.com

‘Help me! Help me!’

Bobby Crail had muscular dystrophy, a progressive disease that erodes muscle mass and causes physical weakness.

He shared an apartment with a roommate for a while and fathered two children, both now grown and still in Northern Kentucky. But as his condition worsened, Crail needed help with eating, bathing and other daily activities. He entered the 127-bed Woodcrest nine years ago, shortly before it was acquired by Preferred Care.

His parents bought a house in Erlanger, a few blocks from Woodcrest’s hilltop location, so they easily could visit him.

“When he first moved there, the place looked pretty nice, at least if you’re just walking in the door,” Robert Crail Sr. said. “It wasn’t a dump or anything. It was clean, it was a modern building. It wasn’t until the last couple of years that we started having issues.”

The quality dropped at Woodcrest after the attentive administrator who had been running the place departed, the Crails said. Floors grew sticky with spilled food and liquids; residents were not bathed regularly. There weren’t enough nurses and nurse’s aides on duty to provide care, Robert Crail Sr. said.

“They were always short-staffed,” he said. “You would hear people up and down the halls saying, ‘Help me! Help me, I’m hungry! Help me, I’m thirsty! Help me, I’m cold!’ And nobody would come. There was nobody there. My son’s oxygen tank would run out and we had to go looking for someone, and when we finally found an aide, it would take them a month of Sundays to come and refill it.”

“They really needed to hire more staff,” recalled Dororthy Crail, Bobby’s mother. “There would be hallways where we were lucky to have one nurse or one aide for the entire hallway. For all of those people in all those rooms!”

Frank Nathan, who was Woodcrest’s administrator during Bobby Crail’s final months, defended his leadership in a recent interview. But he acknowledged that Woodcrest did not have enough direct-care staff.

Nurses were lured away by more lucrative offers from the hospitals in nearby Cincinnati, while lower-paid nurse’s aides burned out on the difficult work and often quit with little to no notice, Nathan said. Preferred Care “locked in wages,” which meant he was not free to offer additional money that could have encouraged employees to stay, he said.

“The quality of care itself I never felt was bad,” said Nathan, who presently runs a nursing home for a different chain in Fort Myers, Fla. “Now, there’s always a problem. People turn on their call lights and expect quick service and they don’t necessarily get it. Did we have issues? Of course we had issues.”

Marcus Dorsey mdorsey@herald-leader.com

A fatal assumption

On March 20, 2016, according to subsequent reports from Elsmere police and inspectors with the Cabinet for Health and Family Services, Crail ate a bowl of breakfast cereal and rolled to the large window at the end of the west wing hallway on Woodcrest’s second floor. From that window — a favorite spot, his family said — he could see trees, birds and passing traffic.

Nurse’s aide Jessica Stines noticed him there at 11:25 a.m. as she entered another resident’s room. She emerged a few minutes later. Crail was gone.

His disappearance went unremarked until Stines brought a lunch tray to his room, according to investigative reports. Crail’s television squawked at an empty bed. The bag holding the medicines he needed throughout the day sat in its usual spot.

Now curious, Stines asked her supervisor, nurse Barbara Beckley, if she knew where Bobby Crail was.

Beckley assured her Crail was “out with family” on a visit, although nobody saw him leave the facility and no one signed him out as rules required, Stines later told officials investigating the case. (Beckley repeatedly refused to speak with police or state inspectors. She would lose her Kentucky nursing license within days.)

At the 3 p.m. shift change and again at dinner, staff noted that Crail still was gone. But the night-shift nurse’s aide, Monica Daniels, said Beckley and Stines both told her that Crail was out with his family, according to reports. He’ll be back later, they said. So Daniels didn’t fret.

She started fretting around bedtime at 8:15 p.m. when she discovered Crail’s cell phone lying on his bed. Crail never went far without that phone. It was his lifeline to family and friends.

Daniels quickly walked back to Beckley to ask: Are we sure Bobby Crail is with his family? Have we spoken to his family today?

One phone call later, a frantic Robert and Dorothy Crail were racing to Woodcrest to search the premises for their son, soon to be joined by the Elsmere police and fire departments.

It was too late. By then, Crail was dead.

John Cheves jcheves@herald-leader.com

While nobody was looking for him hours earlier, he was dying in the stairwell where — as security video footage would show — his wheelchair rolled through an emergency exit door. The door had a safety lock that was supposed to prevent it from opening, but it was broken that day, as was an alarm that was supposed to blare if someone entered.

His parents aren’t sure what happened that morning, but they can make an educated guess.

Crail’s hands were curled by his muscular dystrophy, so he steered his wheelchair using the two working fingers on his right hand to operate a joystick. Not surprisingly, his control was imperfect. He sometimes shot forward and bumped into things. It’s likely he accidentally rolled through the unsecured door, perhaps while trying to turn his chair around in the hallway, his parents said.

“You would think a 200-pound wheelchair going down a concrete stairway surrounded by drywall would have made a racket. But nobody heard a thing,” Robert Crail Sr. said.

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Marcus Dorsey mdorsey@herald-leader.com

‘Short-staffed all the time’

Woodcrest has continued to be one of Kentucky’s worst-rated nursing homes since Crail’s death.

In a sharply critical 47-page report issued in February, state inspectors cited a series of problems that “presented an imminent danger and created substantial risk that death or serious mental or physical harm to the residents could occur.”

Nurse’s aides told inspectors that Woodcrest “was short-staffed all the time.” At least six residents suffered bedsores — skin ulcers —from not being periodically repositioned as they are supposed to be. Insulin was given several hours late without any adjustments to account for the resulting change in blood-sugar levels, negatively affecting at least 16 residents, inspectors wrote.

Meal trays sat for a half-hour or more, the food growing cold and congealed, before being dropped in front of residents. By then, meals tended to be “unpalatable,” inspectors wrote — a problem for elderly or sick people already battling weight loss.

The activities director was a receptionist who was promoted when the last activities director quit, unaware that the job came with regulatory requirements, such as coming up with creative programs and keeping progress notes, inspectors wrote. A review of her logs showed that some residents had little activity beyond lying in bed to watch television.

“Observations on 1/30/18 and 1/31/18 revealed (one resident) had been placed in a wheelchair at the bedside facing the wall, with no interaction from staff or the activities department,” the inspectors wrote. “Resident stated he/she was lucky to get one to two baths a month because the facility was always short-staffed.”

The facility’s latest administrator, who quit in January after less than a year, told inspectors he was continually frustrated that corporate owner Preferred Care did not provide him with enough employees. When he left, Woodcrest had nine vacancies for nurses and 17 vacancies for nurse’s aides. Aggravating matters, it was common for employees simply to not show up for their shifts, he said.

“Quality of care was compromised during the staffing crisis, and (the administrator said) he and corporate were responsible,” the inspectors wrote.

Marcus Dorsey mdorsey@herald-leader.com

‘Profit by cutting corners’

While Woodcrest was getting more negative reviews in Kenton County, down at corporate headquarters, Preferred Care was giving up on Kentucky.

The Texas-based chain of 107 facilities filed for what it called “strategic” bankruptcy protection for its Kentucky and New Mexico operations last November after losing a $28 million jury verdict in McCracken Circuit Court to Cecil Gary.

Gary, a 60-year-old stroke victim, suffered dehydration in a Preferred Care nursing home that was so severe, he had to be hospitalized and given 27 liters of fluid, according to his lawsuit. On his return to the nursing home, Gary fell and shattered his hip. The Paducah jury’s decision included $25 million in punitive damages against Preferred Care.

Jurors were upset by the evidence they saw and wanted to send a message, said Ross Mann, Gary’s attorney.

“It was a pattern of really substandard care. It was truly awful,” Mann said. “He was so terribly dehydrated, and then he was dropped off his bed.”

But it wasn’t just Cecil Gary. Among the mountain of costly litigation that Preferred Care faced were 97 lawsuits in Kentucky and 27 in New Mexico.

One of those suits was filed by New Mexico Attorney General Hector Balderas. He alleged “deplorable conditions” in the company’s 13 nursing homes in his state. Also, Balderas said, he had studied the company’s payroll data and concluded it was physically impossible for so few employees to provide even the most basic care for residents. Apart from being cruel, that amounted to taxpayer fraud, because Medicaid and Medicare foot most of the bill for those $80,000-a-year beds, he said.

If all went as planned, however, bankruptcy would let Preferred Care shed its Kentucky and New Mexico operations and their financial liabilities. That freedom to walk away from lawsuits is essential for the company’s survival, its attorneys argued.

“The cost and expense of defending the pending litigation has drained the debtors of precious resources better used for quality patient care,” lawyers for Preferred Care wrote in a bankruptcy filing. “New Mexico does not have tort reform, and Kentucky has only recently enacted a limited tort reform statute. (And) the debtors operating the Kentucky facilities have no professional liability insurance to cover tort claims.”

Sapphire Care, the New York chain acquiring Preferred Care’s Kentucky facilities, has caused its own controversies by using job cuts to boost profits. New York state health inspectors, residents’ families and employees picketing the nursing homes say that Sapphire Care slashes staffing to dangerously low levels at the places it takes over.

At the Sapphire Care nursing home in Goshen, N.Y., for example, a single nurse was responsible for giving medication to 40 residents on top of his other duties, a workload that meant people didn’t get their medicine until several hours after the scheduled time, according to state inspectors. Inspectors also noted an unacceptably high medication error rate.

“My family and I truly believe that Sapphire has my mother’s blood on their hands,” said Joseph Guyt, whose mother died in the Goshen facility after Sapphire Care acquired it in 2017. The cause of death for 84-year-old Lillian was kidney failure, brought on by a urinary tract infection and sepsis that developed from her being left in her own waste, Guyt said.

“When Sapphire came in, they immediately cut the nursing staff nearly in half,” Guyt said. “So Mom wasn’t being cared for properly anymore. She was just left there to lie in it. We were trying to get her out of there, to find her a bed somewhere else, but we weren’t fast enough.”

In an application to the federal government in 2016, Sapphire Care described itself as bringing nursing homes “from states of dire financial status to full profitability.” And job cuts could be coming in Kentucky: Sapphire Care’s transfer agreement for the Preferred Care facilities only requires it to keep 70 percent of existing employees on payroll.

Sapphire Care owner Richard Platschek did not respond to calls seeking comment for this story. Officials at the Goshen nursing home referred questions to Platschek.

Bobby Crail’s parents said they don’t hope for improvements at Woodcrest anymore. They just try to avoid driving past the place, although that usually means going out of their way because it’s on a main route in their town. Too many bad memories resurface whenever they see the entrance sign, Dorothy Crail said.

“My son is dead. He’s dead! And they want to complain because they’re getting hit with some lawsuits? Whose fault is that?” she asked. “My son shouldn’t have died the way he did — the awful, terrible way he did — just so some company in Texas could make a little extra profit by cutting corners.”