Not surprisingly, with government financial spigots open wide and few restrictions on what nursing homes should look like or how they should operate, quality issues started to come to the forefront. Among other problems, the lack of standards and the old age of many of the converted buildings made nursing homes fire hazards. When they did burn, there were often many deaths because they were filled with frail elderly residents who were unable to get themselves out of danger. One of the most tragic events was a fire in a nursing home in Warrenton, Missouri on February 17, 1957.
Although the headline says 71 died, the final death count was actually 72 residents from the Sunday morning fire. One of the articles in the St. Louis Post-Dispatch the following day reports, "Screams and cries of elderly patients trapped in the Katie Jane Memorial Home were quickly stilled by flames which engulfed the 2 1/2 story brick building within minutes...Rescuers worked frantically to assist as many as possible out of the doomed dormitory, but after the first several minutes they labored in an eerie silence broken only by the sounds of crackling flames, hissing streams of water and shouted orders of firefighters." Inspectors reported that they suspected that there was a problem with the wiring in the home which might have caused the blaze, and they had been in the process of reviewing the home's license.
A 1952 nursing home fire in Hillsboro, Missouri had claimed the life of 20 nursing home residents, and the impact of two major nursing home fires in five years stimulated the Missouri legislature into action. They met the day after the Warrenton fire and immediately introduced a bill to require sprinkler systems in all nursing homes and other institutions in the state.
A 1955 study by the Council of State Governments reported that the majority of nursing homes had low standards of service and relatively untrained personnel. Various states began to report problems. In response, the chronic disease program of the Public Health Service began to study state licensing programs, and found that few states had adequate numbers of survey staff and that the qualifications of survey personnel varied widely.
In spite of all the problems, there was still resistance to making changes. Many states said that strict enforcement of the regulations would close the majority of the homes and no one knew what they would do with the residents. Buildings had already been built and were full, and residents who were living in them had no place else to go. Putting in controls after the fact was going to cause massive disruption. In 1957 the Public Health Service began to work with the states to create the "Nursing Home Standards Guide", but it took six years to agree on what the standards should be, and the guide wasn't finished until 1963. In the meantime, hundreds, maybe thousands, of new nursing homes were built.
In 1959, a special Senate Subcommittee on "Problems of the Aged and Aging" was established. The subcommittee reported that few nursing homes were of high quality, and that most facilities were substandard, had poorly trained or untrained staff, and provided few services. But they concluded, "because of the shortage of nursing home beds, many states have not fully enforced the existing regulations, failure to do so reflecting the policy of the states to give ample time to the nursing home owners and operators to bring the facilities up to the standards."