Federal authorities had already identified Borgress Gardens Nursing Home in Kalamazoo, Michigan, as having problems. It was ranked lowest among all Michigan nursing homes by the U.S. Centers for Medicare and Medicaid Services. This summer it was placed on the federal Special Focus Facility watch list for troubled nursing homes, after a nursing home resident died and another was injured.

The 51-year-old patient, who had suffered a stroke as well as other medical problems, had a tracheostomy tube to facilitate breathing. She died when the tracheostomy tubing became tangled in a bedrail while she was being turned. The tube was pulled out and the staff was not able to get it re-inserted. The woman died from oxygen deprivation.

The woman was supposed to be attended to by two aides at a time, because of her size, but only one aide was assigned to her.

Sadly, her death was only part of a longer story of poor nursing home care. She had been hospitalized seven times in one year and doctors had repeatedly noted a lack of care for her breathing tube. She had suffered obstructions, swelling and repeated infection.

In another instance of disturbingly bad care, nurse's aides used physical force to pry apart the legs of a 101-year-old woman who suffered from a joint and muscle disease. She suffered serious injury that left her legs limp and painful, and yet one of the aides identified this troubling condition as "a miracle from God."

The dead woman's family has brought a wrongful death lawsuit against the facility after receiving $100 in compensation from the facility in payment for a civil fine levied by the state for violations of public health code.

Source: Detroit Free Press, "Borgess Gardens Nursing Home in Kalamazoo Faces Lawsuit Over Death," by Robin Erb and Kristi Tanner, December 12, 2011.