Western Rehabilitation Care Center in Danbury. Jenna Carlesso / CT Mirror

A Danbury nursing home is facing more than $45,000 in fines after workers failed to report or investigate allegations that a nurse’s aide there had sexually assaulted a resident, records show.

In January, months after staff members at Western Rehabilitation Care Center initially learned of the assault allegations, the resident installed a video camera in their room, according to a Department of Public Health report.

The camera caught the nurse’s aide coming into the resident’s room when the resident was away. The video shows the nurse’s aide taking the resident’s underwear from the room and using their toothbrush and hairbrush, the report states. 

After seeing the video, the resident had their roommate call 9-1-1 on Jan. 30, which launched both a criminal investigation and a DPH inquiry that led to the agency issuing an immediate jeopardy order against the facility, indicating that the state found conditions that could cause serious harm or death.

Police who responded to the 9-1-1 call transferred the resident to the hospital, and administrators placed the nurse’s aide on leave that night. A week later, they fired him after becoming aware that multiple videotapes existed.

But while the police investigation continues, it is unclear whether state officials are investigating why no one from Western reported the possibility of sexual abuse by a staffer on a resident when the allegations first came to light, in October 2022.

Both a speech therapist, who suspected the abuse was occurring, and the nursing home administrator whom she alerted to the possible mistreatment are mandatory reporters and should have reported the alleged abuse to the state’s Protective Services for the Elderly, according to state law.

A spokeswoman for the state Department of Social Services confirmed the agency has not received any reports of a possible sexual assault at Western and that they have no investigation pending. 

Western Rehabilitation is appealing the fines, and its attorney is disputing allegations that the nursing home failed to meet regulatory requirements.

Western Rehabilitation Care Center in Danbury. Jenna Carlesso / CT Mirror

While Long Term Care Ombudswoman Mairead Painter wouldn’t talk specifically about the Western incident because of privacy issues, she said she is troubled by cases where nursing home managers fail to report abuse and other offenses.

“There’s a reason it’s a requirement. It’s essential that residents have accountability related to these types of concerns, whether it be abuse, neglect or exploitation,” Painter said. “The nursing home and the people who work there are mandated reporters. They’re required by law. And if they don’t do it, we need to see a higher level of accountability. That’s something my office is really going to be looking at over the next year. We want to ensure appropriate oversight is there.”

DPH investigators would not say whether their investigation of the nursing home includes referring administrators or staff for licensing action or fines for not reporting the incident.

“If we should identify, during the course of an investigation, that a practitioner deviated away from the standard of care, we will make referrals to the Practitioner Licensing and Investigation Section,” said Barbara S. Cass, Senior Advisor for Long Term Care to the Commissioner and the long-time head of the Facilities and Licensing Unit.

Cass added that DPH has issued a $7,500 fine to Western and recommended that the Centers for Medicare & Medicaid Services, the federal agency that oversees nursing homes, also fine them.

CMS officials notified Western on Friday that they were fining them $38,415, according to a five-page compliance letter sent to nursing home officials from the agency’s New England Division.

“In determining the amount of the [fine] that we are imposing, we have considered your facility’s history of noncompliance, including repeated deficiencies; its financial condition and the facility’s degree of culpability, including, but not limited to, neglect, indifference, or disregard for resident care, comfort or safety,” the CMS letter states.

The nursing home has 10 days to appeal the CMS decision and 15 days to claim financial hardship to seek a reduction of the fine. 

Western is owned by an LLC called Senior Philanthropy of Danbury, according to financial documents submitted to DSS. The documents list Chioma Thomas as the administrator of the facility.

The company has hired the law firm of Murtha Cullina to represent it in this case.

Attorney Heather Overholser Berchem has filed an appeal of the DPH immediate jeopardy finding and the fine. Cass said an informal hearing has already been held but no decision has been released.

In her two-page letter, Bercham said that Western disagrees with DPH’s issuance of the immediate jeopardy order and the fine.

“The facility is disputing any allegation that the facility failed to report or investigate in accordance with the regulation or that any of the alleged deficiencies constituted a pattern of immediate jeopardy,” Bercham wrote.

“The facility is disputing that it failed to ensure that the resident received culturally competent, trauma-informed care in accordance with the regulation or that any such alleged deficiency constituted a pattern of immediate jeopardy.” 

“In all my time here, I have rarely come across the issue of nursing facilities being criticized for their failure to report in a timely manner,” said Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities. “That’s been my experience of the sector. And so the notion that this facility didn’t report timely — which my understanding is they’re in strong dispute and disagreement with — should be given every consideration in their appeal.”

Denise Quarles, regional director of operations for Western, said facility leaders are devoting time and resources to appealing the “isolated incident.”

“We believe that when all the facts are evaluated, these findings should be reversed. The facility timely self-reported the serious allegation,” she said in a statement. “Moreover, the facility took immediate corrective action to address the matter and the plan was fully accepted by the Department of Public Health, including the immediate disciplinary action again the employee, even prior to the agency initiating a review of the matter.”

19 reports of elder care abuse this year

Under state statutes, a mandatory reporter who suspects elder care abuse must report it to the Protective Services for the Elderly within five days by filling out a form, known as a W-410, detailing where, when and by whom the abuse occurred.

“DSS has not identified a record of any W-410 report from this facility during this time period,” Maura Fitzgerald, a spokeswoman for DSS, said. “If a W-410 had been submitted, DSS would have turned it over to DPH as the investigating authority for incidents involving skilled nursing facilities.”

Over the past five years, there have been 263 forms submitted by mandatory reporters of possible abuse or neglect in a long-term care facility, Fitzgerald said. The state has more than 200 nursing homes.

Last year, there were 50 forms submitted to DSS. There have been 19 so far this year, DSS data show.

Fitzgerald said the current reporting system doesn’t allow the department to determine how many filings are duplicates, nor can it tell them how many have been referred to DPH for further investigation.

The penalties for not reporting increase if it happens more than once. Mandatory reporters who fail to report an incident are required to retake elder abuse training upon their first offense, Fitzgerald said.

Any mandatory reporter who subsequently fails to make such a report within the prescribed time period can be fined not more than $500 and be required to retake the mandatory training. The statute does include a misdemeanor criminal charge, but there are no records of anyone ever being arrested. 

Painter has concerns that not all abuse cases are reported. Some people may be reluctant to speak up for fear of being found not credible or if the abuser is a staff member.

Painter’s office conducts training sessions with certified nurse’s aides and other employees, and part of the focus is on handling abuse and neglect cases. She said many times staff have a difficult time believing that the abuse has occurred.

“When things like this happen, I’ve been trying to educate staff — you take everything seriously. Residents don’t just bring this stuff up out of the blue,” Painter said. “You need to report it, it needs to be appropriately investigated, and they need to be supported appropriately. Because nine times out of 10, something is happening, whether we want to believe it or not.”

A special friendship

The state’s 31-page report in the Western case shows that several staff members suspected something was wrong. The resident told DPH investigators that the sexual abuse and harassment had been going on for nearly two years.

The resident told them the male nurse’s aide routinely rubbed up against them, that he tried to put his hand down the front of their pants several times, and once inappropriately touched them with a washcloth while they were taking a shower.

The resident told investigators that they notified their roommate, who encouraged the resident to tell staff. But the resident was reluctant to do so for fear of retribution or that nobody would believe them.

When DPH investigators interviewed the nurse’s aide seen on the video sniffing and removing underwear from the resident’s room, he admitted it, according to the incident report. He told DPH investigators “he developed special feelings for resident #1 early on and felt they had a special friendship.”

He admitted the incident in the shower and rifling through the resident’s personal items but “had no explanation for doing so.”

Exposed to months of abuse

As part of their investigation, DPH officials interviewed several staff members, including a speech therapist who told investigators she herself had reported an incident to administrators, claiming that, in late October 2022, the same nurse’s aide had grabbed her breast. She said it was not the first inappropriate sexual encounter with the nurse’s aide.

The speech therapist told DPH investigators that she learned from other staff that the same nurse’s aide may have made sexual advances toward the resident. 

The therapist told Western’s administrator in October that she should investigate whether the nurse’s aide had “inappropriate encounters” with the resident. The therapist told investigators the administrator said “they would not be involving residents in a staff-to-staff allegation that was rumored to have happened.”

When DPH investigators interviewed the administrator on Feb. 21, she admitted that the therapist had mentioned she should talk with the resident but “gave no other details.” The administrator told investigators that she didn’t follow up or ask the resident about possible sexual abuse because “the resident was alert and oriented and could express any concerns herself.”

In its immediate jeopardy finding, DPH investigators concluded that because the facility failed to act when the speech therapist reported possible abuse, nursing home officials exposed the resident to months of more abuse.

“The facility failed to conduct a comprehensive investigation of potential misconduct when a speech therapist expressed concerns on 10/28/22 and as a result resident #1 continued to be abused by a nurse aide until 1/30/23 when the police arrived to investigate concerns of abuse, which resulted in immediate jeopardy,” the DPH incident report states.

Immediate jeopardy

DPH issued the immediate jeopardy order on Feb. 23 and lifted it hours later after Western presented a plan of correction that included interviewing all 81 residents of the nursing home to see if there had been other unreported instances of sexual abuse.

Administrators also promised to provide training for all staff on reporting possible incidents of abuse and neglect, to develop a plan for how to investigate any allegations, and to hold a meeting with the residents’ council to explain what was happening.   

CMS 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.

While the nurse’s aide involved in the incident was fired after police came to the facility, the resident is still there, according to the DPH incident report. The resident is receiving psychiatric treatment as well as medical treatment, as they suffer from increased anxiety and insomnia.

Danbury police said no charges have been filed yet but that the incident is still under investigation.

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.

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.