‘It was so horrific’: Family says poor nursing home care led to woman’s death

  • Daniel Simmons-Ritchie/PennLive

Rick Mantheiy says poor care at an East Pennsboro Township nursing home ultimately led to the death of his 67-year-old mother.

And the Derry Township man hopes no family has to repeat his experience.

Mantheiy, like many people, had never been eager to place his parents in a nursing home. But in 2017, his family ran out of options.

His mother, Sharon Mantheiy, had a debilitating nerve condition and had become unable to walk. His father, meanwhile, had early onset dementia.

For a time, Rick, a toymaker, and his wife, Ashley, a patient transporter, tried to care for his parents as best as they could. But between caring for them and their two young children – both of whom suffer from a rare brain condition – it became untenable.

“It was overwhelming,” Rick said. “It was almost like becoming a parent to two more kids.”

Photo provided by Mantheiy family

This photo shows Ashley Mantheiy with sons Benjamin and Drake with their grandmother Sharon.

When the couple decided to find a nursing home for his parents, however, they encountered a new problem: they had few choices.

Neither of Rick’s parents, he said, had saved much for retirement. Many of the better homes in central Pennsylvania wouldn’t accept them, Rick said, because they prefer long-term residents who can, at least initially, pay out of their own pocket.

In addition, Rick said his father had a history of aggressive behavior relating to his dementia. Many homes were reluctant to take him, he said, saying they didn’t have the skills to handle him.

The Gardens at West Shore in East Pennsboro was different: it was willing to take Rick’s mother and his father.

The family, initially, said it had reservations.

The home, formerly run by Golden Living and known as ‘Golden LivingCenter-West Shore’, had a long reputation for providing low-quality care.

The Mantheiy’s said they had heard about a much-publicized incident where state inspectors said they discovered maggots in a resident’s feeding tube. They also knew about the state Attorney General’s lawsuit against the company for a wide range of failures, including chronic understaffing.

At the same time, with few options, they tried to be open-minded.

The new owners, Priority Healthcare Group, based in New York, signaled a changing of the guard. Meanwhile, the Mantheiys said they assumed that the state was watching the new owners with eagle eyes.

“We thought there was no way they could not have improved because there’s so much oversight by the state,” Rick said.

Photo by the Mantheiy family

Sharon and Paul Mantheiy wanted to remain together.

At first, the family said they were pleasantly surprised.

Rick’s father, Paul Mantheiy, then 67, initially stayed in the facility’s physical therapy section in June. The unit was clean and homey, the family said, and staff were quick to respond when he needed help.

In August, feeling increasingly confident about the home, Rick said he moved in his mother from a different nursing home in Middletown. The couple had been separated due to their declining health, and the family had long wanted to reunite them.

Sharon, unlike Paul, was placed in the home’s long-term care section. Eventually, Paul was transferred there, too.

But in the long-term care unit, the family saw a different side of The Gardens at West Shore.

The family noticed issues that either weren’t problems in the physical therapy section or weren’t apparent in their early tours of the facility. They said they saw stained mattresses and there was food and dirt on floors.

The smell of feces and urine, they said, rarely abated.

And the entire unit, the family added, appeared to be constantly short-staffed – especially at night.

“You could hear people yelling out for help,” Ashley Mantheiy said.

In Sharon’s case, the family said, without help to get into her wheelchair, she was often forced to lay in bed. And, unable to wait for staff to help her to the bathroom, she was often forced to soil herself.

Dan Gleiter / PennLive.com

Richard Mantheiy with wife Ashley and sons Benjamin, left, and Drake, and the urn containing the ashes of Richard’s mother, Sharon, and a poster that was displayed at her funeral.

But the family’s real problems began in the fall.

On Oct. 1, according to the family, a nurse told them that Sharon had developed a bed sore on her lower back.

Bed sores, also known as pressure ulcers, are typically caused by constant pressure on the skin from laying in a bed or sitting for extended periods of time. Bed sores are often very painful and, because they can become infected easily, can be deadly.

To avoid them, nursing homes are usually required to reposition frail, immobile residents frequently. Experts and advocates often view the development of bed sores as a sign of inadequate care or understaffing because they’re largely preventable unless a resident has particularly thin skin.

In Sharon’s case, the Mantheiy family said, they weren’t overly worried at first. They said nursing staff told them the bed sore was likely caused by Sharon’s back rubbing against her wheelchair and that it was already healing nicely.

By mid-October, however, the family started doubting those assurances.

On Oct. 18, during a wound care appointment at Hershey Medical Center, the family said they saw Sharon’s wound for the first time without its dressing.

Far from healed, medical records reviewed by PennLive show, the wound had developed into a gaping hole, roughly the size of a tennis ball, and a third of an inch deep.

The smell of dead skin, the family said, filled the room.

“You couldn’t even describe it,” Ashley Mantheiy said. “It was so horrific.”

The specialist cleaned the wound, medical records show, and gave The Gardens at West Shore a new set of recommendations to follow, including emphasizing that Sharon needed to be repositioned every one to two hours.

But, based on both the wound’s progression and statements made to them by staff, the family said they believe the home did not follow those instructions.

Ashley said she visited Sharon more than a dozen times in October and each time her mother-in-law was lying on the wound, contrary to the recommendations of the specialist.

By the end of October, according to medical records reviewed by PennLive, Sharon’s wound had grown so deep her tailbone was visible.

Meanwhile, over that month, for reasons that aren’t entirely clear, the family said, Sharon lost her ability to talk and could only mouth words. She increasingly appeared dazed and would stare into space.

Despite her changed cognitive state, the pain caused by the bedsore was apparent. Although she was prescribed painkillers, the family said, she grimaced silently every time her dressings were changed.

The family said they filed multiple complaints with the Health Department but were never contacted by inspectors. They said the department later told them it had investigated their complaints and found them unsubstantiated – a determination that the family said they still don’t understand.

In a statement, the Health Department told PennLive it can’t comment on individual complaints but that it investigates all complaints thoroughly.

Daniel Simmons-Ritchie / PennLive.com

This was condition of the floorboards in Sharon Mantheiy’s bathroom at The Gardens at West Shore in East Pennsboro Township.

While the family looked constantly for a new nursing home for Sharon, they said none would accept her because of her bed sore.

“No one is going to take you when you have a humongous hole on your back,” Ashley said.

On Nov. 1, feeling increasingly desperate, the family took Sharon to the emergency room of Hershey Medical Center. Medical records showed that she was admitted with a diagnosis of suspected nursing home neglect.

Six weeks after her admission, the hospital transferred Sharon to a new nursing home in Harrisburg. The family hoped Sharon would recover: her wound, they say, had begun to heal.

But their hopes were dashed on Christmas Day when, medical records show, Sharon was readmitted to the hospital and diagnosed with septic shock, a serious condition where the body’s immune system overreacts to an infection.

The family said that medical staff told them there was nothing further they could do and she was discharged.

A week later, in the care of Rick’s brother and his wife, Sharon died in their living room, the family said.

While her health wasn’t perfect before she entered The Gardens at West Shore, the family said they believe the home ultimately bears responsibility for her death.

“She wasn’t feeble,” Catherine Mantheiy said. “She was only 17 years older than me.”

Priority Healthcare Group, the home’s owner, told PennLive it can’t discuss Sharon Mantheiy’s care but that any allegation it caused her death is unfounded.

“The Gardens at West Shore aims to provide the highest level of care to all our residents and we take feedback from our patients and their families very seriously,” Michael Fragin, a company spokesman, said in a statement. “The incident in question has been thoroughly investigated. Our deepest sympathies go out to the family for their loss.”

In response to additional questions, Fragin added that Sharon Mantheiy was not in the care of The Gardens at West Shore when she died.

“The patient that is the subject of your inquiry was not admitted to the hospital from the Gardens at West Shore but was discharged on November 4, 2017,” Fragin wrote in a statement. “Two months prior to her passing.”

The Mantheiy family, however, remain unconvinced.

Their story, they hope, will not only spur families to avoid homes run by the company but to push Pennsylvania lawmakers for better oversight of nursing homes.

“How many people have to die?” said Ashley Mantheiy. “This has been an ongoing problem and now my mother-in-law is a statistic of this problem.”

Is your nursing home understaffed? How much profit did it make?

PennLive has compiled a one-of-a-kind database of nursing home financial and staffing information based on a complex analysis of Medicaid data.

Most of this information is tucked away in what are called “Medicaid cost reports,” complex documents that are filed annually by nursing homes but aren’t easy for the public to access or understand.

By clicking “Details” you can see profits reported by Pennsylvania nursing homes between 2013 to 2017. You can also see their staffing levels and how much they paid their nurses.

Please note, however, that figures on profits may be deceptive: Some experts and elderly care advocates believe that nursing homes disguise profits in “related party transactions.” Those are contracts that nursing homes make with other business entities that they own. A nursing home that appears to be losing money, they argue, may instead be funneling money to itself through related party transactions.

You can see how much a home spent on related party transactions by also clicking “Details.”

To better understand how you can investigate your own nursing home’s finances take a look at our explainer.

Click here to load this Caspio Cloud Database

NOTE: City, address, and nursing home chain information is missing for some nursing homes. If you’re looking for a specific nursing home, we recommend searching based on keywords in its name. In addition, information for some homes in 2017 may be missing because cost reports had not been filed at the date this database was published.

About this investigation


In 2016, PennLive published ‘Frailing the Frail’, a six-part investigative series that explored major problems in Pennsylvania’s nursing home industry, including the death of 46 residents.

That investigation was prompted in part by a 2015 lawsuit filed by Pennsylvania’s Attorney General against Golden Living and other nursing home chains in Pennsylvania. Three years after that lawsuit and two years after the publication of ‘Failing the Frail’, PennLive wanted to use Golden Living’s nursing homes as a lens to re-examine the state of Pennsylvania’s nursing home industry.

PennLive reporter Daniel Simmons-Ritchie discovered that Golden Living sold the licenses of all 36 of its homes to new operators. And, over eight months, based on interviews with more than a dozen families and residents, and an extensive analysis of state and federal records, PennLive found most of those homes had the same or more citations and lower staffing under new operators than under Golden Living. Two of the operators defended they are dedicated to providing quality care.

The timeliness of PennLive’s reporting was only heightened in April when one of the companies operating Golden Living’s former homes, Skyline Healthcare, went into receivership in Pennsylvania and other states, forcing state agencies to take emergency control of those homes to protect residents. That situation raised new questions about how closely Pennsylvania scrutinizes the financial stability of new nursing home operators.

Beyond that, as Simmons-Ritchie’s reporting progressed, he discovered that Golden Living may still be influencing care inside those homes: The company continues to own the real estate to all 36 of its home and it remains unknown how much control Golden Living may exert over the companies now managing those facilities.

PennLive ultimately concluded that three years after the Attorney General’s lawsuit, Pennsylvania appears to still be failing its frailest citizens.

REPORTING: Daniel Simmons-Ritchie is an investigative reporter with PennLive and the Patriot-News. He has earned state and national awards for work on a variety of subjects, including health care, criminal justice, and the environment.


PROJECT EDITORS: Ron Southwick and Burke Noel

DESIGN & PRODUCTION: Megan Lavey-Heaton

DATA & INTERACTIVES: Nick Malawskey and Daniel Simmons-Ritchie

PHOTOGRAPHY & VIDEOGRAPHY: Dan Gleiter, Mark Pynes, Sean Simmers, and Daniel Simmons-Ritchie

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