A bandage on the left hand of a resident at Our Lady's Residence Health Care Center drew immediate questions from a state inspector visiting the Pleasantville nursing home in June 2009.
After the bandage was removed, closer inspection revealed that the fingernails of "Resident #19" were so long that they cut his palm when he clenched his fist, a state inspection report states. One nurse thought the wound needed stitches, but another simply closed it with adhesive strips. No paperwork documented the injury. A nurse said she must have been "interrupted or distracted" that day, the report states.
How could such an injury occur, the inspector wondered in the report, if residents received daily hygienic care?
That incident was one of hundreds of violations of rules that govern quality of care, safety and sanitation found by inspectors during the past two years at the 60 nursing homes in Atlantic, Cape May, Cumberland and Ocean counties, state inspection reports reviewed by The Press of Atlantic City show. The reports are used by the U.S. Department of Health and Human Services to develop consumer ratings of one to five stars for nursing homes. The majority of area facilities - 65 percent - are rated three stars or lower, federal data show, and half are in the bottom two levels.
At the end of 2010, seven area homes were rated one star, the lowest rating. Six of the seven improved in recent ratings, but five were still in the two bottom levels.
The seven one-star nursing homes were Lincoln Specialty Care in Vineland, Eastern Pines Convalescent Center in Atlantic City, Our Lady's Residence in Pleasantville, The Shores at Wesley Manor in Ocean City, Arcadia Nursing and Rehabilitation Center in Little Egg Harbor Township, South Jersey Extended Care in Bridgeton and Absecon Manor in Absecon.
The latest ratings, released in April, brought three other area homes down to one-star status: Linwood Care Center in Linwood, Barnegat Nursing Center in Barnegat Township and Courthouse Convalescent Center in Middle Township.
The Press called each of the 10 nursing homes, and only four would discuss the ratings. Officials at Arcadia, Barnegat Nursing, Linwood Care and Absecon Manor said they act on issues when they are discovered and criticized the rating system as confusing and not reflective of nursing homes.
A Press review of more than 1,800 pages of New Jersey Department of Health and Senior Services inspection reports from 2009 through April 2011 for the 10 nursing homes showed that residents are routinely found living in dirty conditions, endure verbal and physical abuse, and are subject to neglect. Other violations include staff giving out the wrong medications, residents being strapped into wheelchairs and ignored for hours, theft, untreated infections, falls resulting from fragile residents being left unattended, and fire- and building-code violations.
"It's horrible. The quality of life is nonexistent. If you find a good one, you're incredibly lucky," said Jacqueline O'Doherty of Health Care Connect, a patient advocacy firm based in Peapack-Gladstone, Somerset County.
"If you have nobody who advocates for you, that's the person who gets skipped over and doesn't get the treatment they need. The reality is there is nobody outraged over this, and there is no system to take care of it," O'Doherty said.
Don Browne, an attorney based in Collingswood, Camden County, who advocates for patients in nursing home cases, said the state's minimum standards are too low. He said some homes hide medical problems from the families.
"Hospitals are run by medical professionals. Nursing homes are generally run by real estate investors, a lot of whom don't even know where the home is," Browne said.
The first quarterly ratings for 2011 showed improvement at six of the seven one-star homes, demonstrating that a regulatory system that requires a plan of correction and sometimes includes fines can bring results. While Lincoln Specialty Care remained a one-star home, the update raised Absecon Manor from one to three stars. The other five rose from one to two stars.
Nursing homes are threatened with fines when conditions do not improve within an allotted time. But mainly, the homes are simply told to fix the problems. Most do. But at homes that receive low ratings year after year, the next inspections typically find new issues or recurrence of past problems, inspection reports show. However, those reports show that staff who were found to have abused or neglected residents have been disciplined or fired.
"We act on issues pointed out to us," Kerry Mulvihill, administrator at Arcadia, said generally of problems found during inspections.
The home implemented a correction plan, and its rating improved to two stars. Mulvihill said "quality measures" improved at Arcadia from one star to four.
However, the "quality measures" category is self-reported, and the federal government recently decided to stop calculating it for about a year.
"We are redoing the measures completely," federal health department spokesman Jeffrey Hall said.
Tara Mullineaux, Absecon Manor administrator, spoke after the December inspection but before new ratings upgraded the home to three stars. She knew three or four deficiencies had been found, but said the state average is seven.
"The five-star rating system is confusing to us, the people who work in the business. You can pretty much walk into a nursing home and find any issue. It's an industry that never shuts down. We try, but we're not perfect," Mullineaux said.
State reports provide details of problems found during inspections.
Some residents live in fear of reprisal if they complain about conditions. A 2009 report on Eastern Pines on Vermont Avenue in Atlantic City showed that residents complained to the inspector about abrupt treatment and theft. After talking, they worried about retribution.
"Don't tell them what I said because they could get angry," one resident said.
Another pleaded for anonymity: "You need to promise me you won't tell anyone you talked to me about my problems."
One woman said she was lucky to have a daughter who looked out for her. But she began crying as she discussed people who had no loved ones around.
"Oh well, what would they - the staff I mean - do anyway?" she said.
A recurring theme was a failure to investigate or report incidents of abuse. Inspectors found that 23 of 46 residents interviewed at Eastern Pines reported some form of verbal or other abuse, but few thought speaking out would do any good. Under state law, residents have the right to voice grievances without reprisal.
Another recurring problem was failure to properly administer medication.
The medication error rate is not supposed to exceed 5 percent. A November inspection found an 18 percent error rate at South Jersey Extended Care. Our Lady's Residence had a 14 percent error rate. Lincoln Specialty Care was at 9 percent, and Arcadia was at 8 percent.
In one case at South Jersey Extended Care, a resident was supposed to get morphine every three hours for rectal pain, but went days without it because there was none.
"The resident appeared to be in distress, moaning and wincing while moving around in bed," a 2010 inspection report states.
The inspection led to the home hiring a new pharmacy consultant and policy changes regarding orders for narcotic pain medication.
Year-to-date inspections included visits to Lincoln Specialty Care, Eastern Pines and The Shores at Wesley Manor, where new problems were found. At Lincoln Specialty Care, several residents alleged thefts, and the home was accused of improperly restraining a resident. The home did not fully investigate possible violence against two residents, the report states.
Medication error rate problems were reported at Eastern Pines, as well as issues with fire exits, electrical wiring and the sprinkler system.
The 60-bed Shores at Wesley Manor also has registered new problems in 2011 concerning medication dosages and lack of physician visits. Inspectors also found code violations with the building, a report states.
The Linwood Care Center in Linwood was cited in an Oct. 25 inspection for deficiencies involving patient dignity, sanitation and fire safety.
Several residents of Linwood Care Center said it takes so long for staff to help them get to the bathroom that they soiled themselves, the inspection report states.
One resident was quoted as saying: "I really felt if they had come a little sooner, I wouldn't have wet the bed and myself. I was so upset and so embarrassed, I could have cried." One resident who was found with a medically unnecessary catheter did not want it removed because it takes so long to get help to get to the bathroom that the catheter prevents accidents.
Administrator Carol Shrouder Erhart of Linwood Care Center said she did not consider the ratings "a true indication of where we are." She said a revamping of the rating system is expected to compare "like" nursing homes.
She said Linwood Care Center takes high-risk patients, such as those on ventilators and those with infections. The home has more training for nurses and other employees to be rated for this higher level of care, she said.
"You can't compare the same exact way. We don't like the old system and are looking forward to the new system. It will compare like nursing homes," Shrouder said.
As for the inspection report specifics, she said: "I can't say it's normal stuff when we are committed to taking care of our patients. "There are always things we'll be able to improve on. There's no nursing home that's perfect."
On Thursday, the nursing home issued a press release saying it had won a Bronze Commitment to Quality Award from the American Health Care Association and National Center for Assisted Living.
A Nov. 5 inspection of the Barnegat Rehabilitation and Nursing Center was prompted by a complaint about verbal abuse of a resident.
A nurse and an aide allegedly told a resident who wanted help getting out of bed frequently overnight that she could not get up before 4 a.m. The inspection report states the staffers threatened to take away her wheelchair, withheld snacks and threatened to keep her in bed longer if she complained. The report states the resident shook in fear in the presence of the nurse and aide.
After other staff complained about the resident's treatment, the nurse, the aide and another staffer were suspended, the reports state. A $2,100 penalty was recommended to the federal health department.
Larry Sullivan, Barnegat Nursing Center administrator, declined comment on specific incidents due to resident rights and confidentiality.
"I do believe our residents are happy here. We strive to give quality care," he said. "We have some of the best employees in the industry, and I think we do a very good job taking care of our residents.
Like other administrators, Sullivan said the rating system is not good.
"It's not a good barometer of how facilities actually operate," he said.
At the Courthouse Convalescent Center, the state ombudsman for the elderly investigated an allegation of abuse of a resident by the resident's family. The report states the nursing home failed to investigate the claims of abuse and to supervise family visits of the resident.
Family members repeatedly called the resident, who had dementia, "stupid," "crazy" and in need of shock therapy.
The home filed a plan of correction after it was cited for failing to act. But a March 7 document states the resident no longer lives at the facility.
One man's battle
The experience of the Holt family illustrates the emotional strain of worrying whether a loved one is receiving good care. Frank Holt claimed he had difficulty convincing staff his 74-year-old wife, Theresa, needed to get to a hospital.
AtlantiCare Regional Medical Center's Mainland Campus is near The Health Center at Galloway, a longterm care facility where his wife lived in Galloway Township. Holt said 45 minutes elapsed before Theresa was taken to AtlantiCare following her third stroke, which made her an invalid.
"She should have been taken to the hospital quicker after the October stroke. I had to tell the nurse in charge that she had to get to the hospital," Holt said.
Holt, 66, of Egg Harbor Township, claimed in complaints to the state ombudsman for the institutionalized elderly that his wife was not treated well. He has sent photographs of her to news outlets, the state health department and home administrator.
Holt's cellphone photos show Theresa wearing diapers and no pants, and hugging herself as if cold. Others are close-ups of a mouth infection Holt says is a fungus caused by improper oral hygiene when she was fed through a tube. Others show carpet stains and litter strewn about the room.
Holt, who lives on Social Security, said his wife's clothes are frequently stolen or at least disappear.
"They go down the (laundry) chute and don't come back," Holt said.
Holt brought a Press reporter and photographer to Theresa's room in January, but officials ordered them off the premises. Afterward, Holt was not allowed back to his wife's room. She was brought to the lobby when he visited.
And The Health Center of Galloway is not one of the worst, the reports state. The center got three stars in 2010. The recent update dropped it to two stars.
"Inspectors come in once a year. There's nothing to hide. We do a good job. It's a good building," Administrator Diane Delaney said.
Delaney referred questions about Theresa Holt's treatment to corporate officials, saying the issues were being addressed. Arthur Stern of Seniors Management North, however, said privacy laws prevented him from commenting.
The state ombudsman's office representative who handled the Holt case did not return calls, although Holt said the office did not find that his wife was mistreated.
Nursing home ratings
Nursing homes, to some extent, compete against each other in the ratings. Brian Holloway Jr., whose family owns the five-star Seacrest Village in Little Egg Harbor Township in Ocean County, said it was four-star but moved up when another home dropped down, even though nothing changed at the 171-bed facility.
Besides the overall rating, the star system is used in four categories that rate nursing staff and registered nurses specifically, 180 health items and quality of life for the residents. Consumers can look up ratings online in the federal Nursing Home Compare database.
Holloway said state inspectors do a thorough review of staff, the facility and the administration, and even interview residents and family members.
"They really do an extensive look under the hood, so to speak," Holloway said.
State, federal regulation
There are 367 nursing homes in New Jersey charging an average of $250 per patient per day, said Paul Langevin of the Health Care Association of New Jersey, a trade group of 185 homes. He argues it's a pretty good deal.
"Compared to a day in a hospital, we are a bargain," he said.
It may be cheaper, but nursing home litigant Browne said it is not as good.
"It's not a hospital. It's more like a hotel where you get a little medical care," Browne said.
Most homes are for-profit businesses run by companies that have multiple facilities. Costs of more than $90,000 per patient per year are often paid through Medicare and Medicaid, so tax dollars pay much of the bill.
Hall encourages the public not to rely solely on the department's rating when choosing a nursing home. The department urges people to talk to physicians, to visit nursing homes and to talk to staff.
Laurie Brewer, state ombudsman chief of staff, said her office investigates 6,000 nursing complaints a year received through a toll-free hot line. The office represents residents' interests but has no regulatory power. After investigating, it will call regulators or sometimes the police.
"Abuse and exploitation are issues, and with an aging population, it will continue to grow. It's important to have an organization like ours," Brewer said.
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