Patty Bausch, a resident at Newtown Rehabilitation & Health Care Center, attached a notice above her bed, asking to move her out of bed to her wheelchair by 11:15 a.m. She said otherwise, staff who are busy with caring for an overwhelming number of residents might forget and wake her up at a much later time. Yehyun Kim / CT Mirror

The state Department of Public Health issued an “immediate jeopardy” order to a Newtown nursing home owned by Athena Health Care Systems, indicating that the state found conditions at the facility that could cause serious harm or death.

Department spokesman Christopher Boyle confirmed that the immediate jeopardy order was issued for the Newtown Rehabilitation and Health Care Center and said the state has 10 days to submit written findings on what it found during recent inspections there. State health officials did not release details of what prompted the order.

Athena, meanwhile, has agreed to stop taking admissions at the Newtown facility.

After the order was issued Friday, Athena moved quickly to correct the problems and by Sunday, the order was lifted, Boyle said. The health department has asked Athena to continue halting admissions until further notice, however. The Centers for Medicare and Medicaid Services were notified of the immediate jeopardy finding on Tuesday.

“Removal of the immediate jeopardy does not literally remove the finding of IJ from the facility’s record,” Boyle said in a statement. “DPH is currently completing the documentation related to the IJ and understands that the facility is working on its formal Plan of Correction.”

The Centers for Medicare and Medicaid Services defines immediate jeopardy as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident.”

Once the state issues a finding of immediate jeopardy, a facility has 23 days to correct the problems or it could be terminated from participating in Medicare and Medicaid funding programs.

“Newtown Rehabilitation & Health Care Center has been working cooperatively with the Department of Public Health and has put in place an immediate plan of correction to resolve the identified concerns,” said Lawrence Santilli, Athena’s owner.

“Our residents’ care, health and wellbeing are of the utmost importance to us, and we are continually working through industry challenges, including staffing, to maintain the appropriate ratios for patient care,” he added.

There are about 130 residents at the Newtown facility. 

During the last quarter, the health department issued four immediate jeopardy findings in Connecticut. In general, there has been an increase in those orders, at least partially due to staffing issues in nursing homes, Barbara Cass, chief of DPH’s health care quality and safety branch, said at a public meeting recently.

“We are seeing inconsistencies in the industry; some nursing homes have recovered from the pandemic and are moving in a good direction, and others are still challenged with all of the aftermath or the byproduct of the pandemic,” she said.

Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities, said that in most cases, when immediate jeopardy is found, the provider moves swiftly to fix the problems, and it rarely leads to a building closure.

“An IJ order is serious, and most facilities very quickly go into immediate compliance with what the state has found,” he said. “That is my understanding of what is happening here; they [Athena] are moving very quickly to address DPH’s concerns.”

Athena operates 21 nursing homes in Connecticut from Middletown to Sharon and serves more than 2,500 residents. One other facility — Middlesex Health Care — is currently under a consent order signed last summer. 

The consent order required Athena to hire an independent nurse consultant who reports weekly to DPH on patient care, staffing levels and food delivery. Athena also voluntarily agreed not to take any new admissions at that facility.

Mairead Painter, the state’s long-term care ombudsman, said the Newtown facility was among the five Athena homes that received the most complaints between October 2021 and September 2022. The others were Middlesex Health Care Center in Middletown, Valerie Manor in Torrington, Abbott Terrace Health Center in Waterbury and Bayview Health Care in Waterford. 

“The regional Long-Term Care Ombudsman has been responding to calls and complaints from residents and family members at this skilled nursing facility,” Painter said Wednesday, referring to Newtown. “When given appropriate consent, [we] have communicated with the facility management team as well as DPH regarding the complaints. I appreciate DPH responding to and addressing these concerns.

“We need to see accountability related to appropriate staffing levels in all skilled nursing facilities, as this directly impacts the quality of care and services received by residents.”

Residents at Newtown Rehabilitation and their families have complained of filthy conditions, cold or missed meals and a lack of staff that has left some residents stranded in bed with soiled linens and clothes.

Hermann Montano, 69, was admitted to the facility last fall. When his daughter, Paola Lopez, began visiting him, she noticed that he appeared unkempt.

“We have found my father numerous times with his nails dirty, his face dirty, his eyes closed from being dirty,” Lopez told the CT Mirror this week. “His hair was not being combed. He was not shaved.”

The family visited Montano on Christmas Day.

“When we got there, my father was sitting in a puddle of urine,” Lopez said. “His socks were soaked in urine.”

Montano has Alzheimer’s and dementia, and he is unable to advocate for himself or express what he needs, she said.

Lopez complained about the conditions to DPH and to the Long-Term Care Ombudsman’s office.

“My father has been a very proud man, very well dressed, always smelling good, very well kept,” Lopez said. “For him to be in this condition … it’s actually inhumane. You wouldn’t even keep an animal in that condition. And for someone nonverbal, where you can’t speak up for yourself, it’s even worse.”

The CT Mirror reported Sunday that Athena is facing numerous lawsuits alleging it owes money to temporary employment agencies that provided workers to short-staffed facilities. The company is also accused of failing to pay nearly $6 million in employee health benefits and has faced consent orders at long-term care facilities in three different states.

A wrongful death lawsuit was also filed against Athena in Massachusetts by the family of a man who died in its Oxford, Mass., facility after his roommate hit him multiple times in the head with a walker.

In a statement to the CT Mirror, Santilli said that “unprecedented challenges and expenses and the resulting severe staffing shortages have resulted in significantly higher expenses and have put a strain on resources.”

“To meet the discharge needs of the state’s hospital system and existing residents, Athena was forced to resort to using temporary nursing staffing agencies at the highest levels and the highest costs ever experienced by the company, and at times undermining the quality and consistency of care that has always been our goal,” he said. 

Though many immediate jeopardy orders are resolved quickly, there have been cases where the health department has had to close facilities.

Last year, DPH issued a finding of immediate jeopardy at a Wallingford nursing home after the deaths of two residents. The state decided to close the home after it found seven violations that constituted immediate jeopardy and determined the owners had not moved quickly enough to fix the problems. The state transferred the facility’s 94 residents to other homes.

DPH also ordered the evacuation of all residents from Three Rivers Healthcare in Norwich in 2020 after a nurse violated COVID protocols and showed up for work without getting tested and without wearing a mask following a beach vacation.

A COVID outbreak occurred, with 21 people getting infected and four dying. DPH placed the home in immediate jeopardy and brought in a private manager, who after only a few weeks recommended that DPH close the facility.

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Dave AltimariInvestigative Reporter

Dave does in-depth investigative reporting for CT Mirror. His work focuses on government accountability including financial oversight, abuse of power, corruption, safety monitoring, and compliance with law. Before joining CT Mirror Altimari spent 23 years at the Hartford Courant breaking some of the state’s biggest, most impactful investigative stories.

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Jenna CarlessoHealth Reporter

Jenna is CT Mirror’s Health Reporter, focusing on health access, affordability, quality, equity and disparities, social determinants of health, health system planning, infrastructure, processes, information systems, and other health policy. Before joining CT Mirror Jenna was a reporter at The Hartford Courant for 10 years, where she consistently won statewide and regional awards. Jenna has a Master of Science degree in Interactive Media from Quinnipiac University and a Bachelor or Arts degree in Journalism from Grand Valley State University.