Serious violations in Connecticut’s nursing homes have increased over the last 18 months, while the state has failed to conduct routine inspections in nearly half of all facilities, a CT Mirror review has found.
Ninety-five of Connecticut’s 203 nursing homes are overdue for recertification inspections that are required in facilities every 16 months, according to state data. At the same time, immediate jeopardy orders — findings that indicate violations in a nursing home caused or were likely to cause harm or death to residents — have escalated. The state Department of Public Health issued 17 such orders in 2018, nine in 2019, 15 in 2020 and 16 in 2021. By 2022, the number jumped to 24, and the state reported 12 in the first six months of this year.
Since April 2019, 20 people have died in connection with those violations, state data show. More than a third of those have occurred since October.
An analysis of 93 immediate jeopardy findings issued by the state’s public health department since January 2018 reveals that cases appear to have become more egregious. In 2018, for example, none of the immediate jeopardy cases involved deaths, and six facilities were cited for failing to properly clean glucometers.
During the last seven months, several disturbing cases have surfaced.
A man at a Bloomfield nursing home, deemed at risk of harming himself, died after ingesting bleach from a bottle left within his reach by a nurse aide, records show.
A Waterford facility was evacuated after floors were torn up as part of a renovation project and officials failed to test for asbestos (it was later detected in the building), according to state documents. Sixty-nine residents across two units were temporarily moved out of the home.
And at least four people overdosed at a Manchester nursing home during a two-month period. One resident died.
“It makes me feel sick,” said Anna Doroghazi, associate state director of advocacy and outreach for the AARP in Connecticut. “People deserve better. Everybody deserves better care than this.”
“My first reaction is I want to cry,” Rep. Jane Garibay, a co-chair of the legislature’s Aging Committee, added. “I cannot grasp that this is happening in our communities. It’s beyond comprehension. I just know we have to react. We have to work on this.”
The health department acknowledged the inspection backlog and attributed the delays to lack of staff, a suspension on inspections during the first year of the pandemic and the length of time it takes to hire and train new surveyors. About 20% to 25% of the positions at the Facility License and Inspection Division, responsible for conducting inspections, are vacant, said Barbara Cass, the health commissioner’s senior advisor for long-term care. A year ago, the rate hovered around 40%.
Cass said the state is “aggressively” hiring and training new surveyors, but the training and certification process takes about six months.
Although 95 nursing homes are overdue for survey inspections, she said, health officials have visited roughly 80% of those facilities at least once to respond to complaints or perform other types of surveys, such as an infection control inspections.
Still, Cass said, the health department has not visited 11 nursing homes for routine inspections or complaint investigations during the last 18 months.
With the rise in immediate jeopardy violations, officials in May convened a stakeholder group to examine the issues more closely. The panel is composed of employees from the public health and social services departments and provides updates to each commissioner monthly. Other state agencies, such as the Department of Aging and Disability Services and the Office of Policy and Management, will be invited to participate, Cass said, along with residents’ families and industry leaders.
“We’re seeing increased findings in our survey and inspection activities, which has caused us to pause to look at quality and what’s happening,” she said. “We do know we’re seeing increased immediate jeopardies, increased issues with quality of care and quality of life issues.”
“The increase in the number of immediate jeopardy situations is a concern,” Cass said. “Notably, we are looking at the systems that have led to these failures and what can the two agencies do to address the current state.”
Immediate jeopardy violations have always been considered serious, but the lapses occurring in Connecticut over the last 18 months appear to be more dangerous and deadlier than in previous years.
The Connecticut Mirror requested five years’ worth of immediate jeopardy cases through a Freedom of Information Act request. The health department initially provided documents related to 32 cases but, months later, acknowledged the data was incomplete and released records for another 61 cases.
The violations are varied and troubling.
In May, an 85-year-old man at the Bloomfield Health Care Center died after drinking bleach from an unsecured bottle at a nurse’s station. Wallace Matusiewicz was left alone by a nurse aide who was supposed to be monitoring him because he had threatened suicide multiple times, according to a state inspection report.
Matusiewicz was transported to the hospital but died four days later. The state medical examiner ruled his death a suicide.
The investigation revealed that an employee had brought in a bottle of cleaning solution containing bleach and left it unattended. The state’s report said the resident had previously threatened to harm himself, including telling a nurse “if [he] was given poison, [he] would take it.” The medical examiner’s office confirmed Matusiewicz’s identity.
A resident at the Kimberly Hall North nursing home in Windsor died after eating a piece of sausage while unsupervised during a meal. A nurse aide told public health inspectors in December she wasn’t aware the resident, who had dementia and a swallowing disorder, was supposed to be monitored at mealtimes and needed to alternate food with liquids.
At Greentree Manor Nursing & Rehabilitation Center in Waterford, crews removed carpeting and flooring as part of a renovation project in March. Two days after work began, people in the building noticed the floors were not properly sanitized, and there were uneven surfaces, gaps and scattered tile fragments in areas where residents needed to walk, according to the inspection report. The facility had not tested the floors for asbestos.
Sixty-nine residents had to be moved out of two nursing units. The building was later found to contain asbestos.
After a pipe burst at the Marlborough Health & Rehabilitation Center in February, a contractor placed plastic covering over the ceiling, leaving fire alarms inoperable. Facility administrators left it that way for 47 days, records show.
The Western Rehabilitation and Care Center in Danbury came under fire the same month after an employee allegedly sexually assaulted a resident, and the resident had her roommate call police. State officials accused the facility of failing to report or investigate the incident as required, and Western was fined more than $45,000 by the state and Centers for Medicare and Medicaid Services.
And at the Westside Care Center in Manchester, at least four people overdosed in a two-month period from November to December of 2022, according to the state’s immediate jeopardy case. One person died. But police reports and 911 call records show the situation was even more dire. From August 2022 to May 2023, there were 10 instances in which a resident overdosed and emergency personnel were called to the facility to use Narcan. One case happened after the immediate jeopardy order was issued in January.
Residents at Westside have complained that offsite visitations to friends and family are being denied, regardless of the location or time. Food deliveries are even being limited, they said, out of concern that drugs are being smuggled within takeout containers.
Bobby Willis, who has lived at Westside since 2019, has become accustomed to the sound of ambulances and police cars zipping through day and night.
Although there hasn’t been official word from Westside leaders about the drug issues, Willis said, it’s clear people with drug problems are living there.
“One way they have tried to combat it is locking the windows so there’s nobody that can come up and pass you something or drop something into your room,” he said.
Jose Pabon, 53, affectionately known as “King Pabon” to his family, died Jan. 3 of acute intoxication including fentanyl. The medical examiner’s office ruled his death an accident.
Pabon was in the middle of a short-term stay at Westside after he fell in December and needed to be hospitalized. The hospital discharged him to the nursing home for rehab.
Family members are still struggling to understand the circumstances surrounding his death. His sister, Margarita Pabon, said he wasn’t a drug user and she has no idea how he would have brought drugs into a long-term care facility.
“He was supposed to come home on January 5. It was a short-term rehab that turned into my brother’s death,” she said. “He was perfectly fine, and next thing you know he’s dead, and we can’t get any answers as to why.”
The immediate jeopardy report describes drugs hidden in the bathroom ceilings of some resident rooms and notes that drugs were coming into the facility through visitors.
State inspectors recalled at least three instances in which staff or emergency crews administered Narcan to save a person’s life.
Westside changed its visitation policy in an attempt to curb the drug transactions.
In an August 2022 memo to the security and receptionist staff, administrators said it was of tremendous importance to keep illicit substances out of the facility and that the vast majority enter through visitors or packages.
Less than a month later, supervised visits were changed, limiting them to the conference room and a room behind the receptionist area. Security must escort guests into the facility and also stay in the room while visits are happening.
“There will be no physical contact between visitor and resident, no passing of food or substances during the visit, and if a visitor requests to use the bathroom, the bathroom next to the administrator’s office will be the only bathroom used, no exceptions,” administrators wrote.
A spokesman for Westside said the nursing home is challenging the immediate jeopardy order and an appeal is pending. The facility is home to several people with substance use disorders, he said, especially involving opioids.
“As a result, this patient population tends to be younger and chronically underserved with a high levels of challenging medical and social [needs],” said David Skoczulek, vice president of business development for iCare Health Network, which owns Westside. “Many also may have past judicial involvement or a history of unstable housing, all of which can contribute to making a safe discharge more difficult to facilitate when the patient is medically stable enough to leave.
“The Westside staff must preserve and protect [residents’] rights while balancing the safety and well-being of the specific resident and all of the residents who reside with them. That means taking appropriate actions to prevent contraband, drugs, alcohol or any other risky item from being brought in either after a leave or by visitors. … We take every available precaution to prevent an outcome.”
Western Rehabilitation is also appealing its immediate jeopardy order. An attorney for the facility disputes allegations that the nursing home failed to meet regulatory requirements.
Managers at other buildings said they quickly resolved the problems outlined in the violations.
“Our staff responded swiftly and responsibly, following established policies, procedures, and protocols. The matter was promptly reported to the appropriate authorities, as required by law,” Kimberly Hall North administrator Shanique Mightly said in a statement. The facility has also appealed the findings.
“As with any state survey, we take an IJ seriously,” Portia Wise Bachman, an administrator at the Bloomfield nursing home, said. “This isolated incident was thoroughly investigated. It is always our priority to maintain the well-being of our residents.”
Michael Rayel, an administrator at Marlborough Health, said managers responded promptly.
“It is always our priority to maintain the well-being of our residents, including environmental safety measures,” he said. “After a thorough investigation, we can share that the appropriate measures are and have been in place.”
Staff at Greentree are challenging their violations.
“At no time during a situation in March 2023 were any of our patients or staff in jeopardy,” said Andrea Obston, a spokeswoman for the facility. An air quality consultant found there was “no risk from asbestos fibers based on the information we obtained through continuous testing,” she added.
Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities, and Mag Morelli, president of LeadingAge Connecticut, said the increase in immediate jeopardy cases is not a reflection of overall care in the industry.
“Every day, thousands of dedicated caregivers deliver high quality, life affirming, 24-hour care to more than 19,000 nursing home residents,” they said in a joint statement. “We are fully committed to improving the care experience of all skilled nursing facility residents in Connecticut by learning from the state reports over the last year, but we believe a longer time frame of review and more detailed information is needed to better understand the trend and what factors might be the root causes.”
‘Communication is breaking down’
A confluence of issues is driving the rise in immediate jeopardy orders, experts and advocates say, including less oversight, high turnover in the nursing home workforce and gaps in training.
“The main thing that I can attribute it to is oversight and management within the facilities,” said Mairead Painter, the state’s long-term care ombudsman. “There are a lot of younger, newer administrators, directors of nursing services and management teams overall in nursing homes, where you don’t have that seasoned expertise. And what we see when we go in is, because of staffing patterns, you have supervisors working on the floor versus independently supervising. That’s less time they’re walking around seeing what’s happening, giving feedback and providing education.”
Nursing homes are seeing “constant turnover” in staff, she said, including among nurse aides, nurses and administrative positions.
“How do you develop a team when you have a different nurse aide you’re working with every day? How do you develop patterns of care or know how to care for someone? It takes a lot longer,” Painter said. “If I’ve cared for you every day for the past three years, I know how you like your coffee. I know that you like to get up and get dressed before breakfast. All of that impacts care.
“That kind of stuff isn’t happening. I think that’s why we’re seeing these incidents. Communication is breaking down. Education is breaking down.”
Facilities are experiencing a sharp increase in errors — such as feeding a resident solid food when the person is supposed to be on a soft food diet, or accidentally feeding someone a type of food they are allergic to — that can have dire consequences, Painter said.
Part of that is due to understaffing that has placed large patient loads on nurse aides. Earlier this year, the Newtown Rehabilitation & Health Care Center was cited with an immediate jeopardy order after inspectors observed nurse aides with as many as 20 residents to care for during some shifts, leading to neglect. Residents were left in their beds for hours at a time without bathroom trips or diaper changes, records show. Others missed meals.
A typical ratio to ensure residents receive good care is one worker to every eight or 10 patients, depending on people’s needs, advocates have said.
Athena Health Care Systems, which owns Newtown Rehabilitation, has said it boosted staffing after the immediate jeopardy finding. In late January, weeks after the violation, the head of the company said the facility was staffing “over what is required” on all shifts.
“This points to the issue of staffing levels,” Doroghazi, the AARP director, said. “When you have this mix of low staffing plus higher acuity — more residents with more intense health needs — it feels like a perfect storm. I’m not surprised we’re seeing the issues that we’re seeing.”
Legislators tried unsuccessfully this year to pass reform that would have required higher staffing levels in nursing homes. A bill that cleared the Public Health Committee but did not receive a vote in either chamber would have raised the mandatory minimum hours of direct care per resident each day to 4.1, up from three. But the measure required substantial funding and industry officials opposed it, saying they already were struggling to recruit and retain workers.
“We need to get bigger drums and pound harder,” said Garibay, D-Windsor, who championed the staffing bill. “We allow these things to happen in the way we treat our elderly. There just isn’t an urgency to help … but meanwhile, people are dying. I’m speechless.”
Advocates also called on the health department to speed up the hiring process for new inspectors so the state can catch up on recertification surveys.
The problem isn’t unique to Connecticut. In May, the U.S. Senate Special Committee on Aging released a 98-page report that revealed survey agencies across the country are severely understaffed and nursing homes in some cases have gone uninspected for years.
The investigation found that 32 survey agencies have vacancy rates of 20% or higher, including nine states with vacancy rates of 50% or higher — shortages linked directly to inspection delays. It also noted that a “large portion” of the inspection staff are inexperienced, reducing their effectiveness.
Legislators say the inspection backlog in Connecticut must be addressed swiftly.
“If they don’t have the staff, they should be authorizing overtime to get them done,” said Sen. Cathy Osten, co-chair of the Appropriations Committee and an influential member of the state’s Nursing Home and Assisted Living Oversight Working Group. “I’m shocked at some of these reports of what’s happening in facilities and it is inexcusable to me. It’s the state’s job to make sure a safe environment is being provided to our most vulnerable residents, no matter the cost.”
“There has to be a lot more oversight,” Sen. Jan Hochadel, D-Meriden, co-chair of the Aging Committee, added. “I think for too long we have relied on a nursing home like we would a hospital. You go there, you think you’re going to be well taken care of. We’re finding out now you can’t just trust, you really have to do your homework. We have to be diligent in making sure people are safe.”
‘We need to do everything we can as quickly as possible’
Along with a quicker hiring process, advocates are urging the health department to broaden the pool of candidates for inspection jobs.
Health officials typically hire nurses to survey long-term care facilities, but social workers, physical therapists, dietitians, occupational therapists and others should also be considered, they said.
“When you’re talking about seeing people in a holistic way, the complaints we get aren’t just about nursing,” Painter said. “They’re about quality of life. They’re about dignity. They’re about residents’ rights, physical therapy, food. If the team’s diversified, we’ll start to see survey outcomes that are diversified.”
A wider candidate pool also means positions could be filled more quickly, she said.
Cass, the long-term care advisor, said the health department has begun looking beyond nurses.
“Because of the nursing market being what it is … we are now looking at reclassifying positions, and we see real value in an interdisciplinary team,” she said.
Advocates have suggested several strategies to put pressure on nursing homes.
One is to mandate that facilities halt new admissions if they are not meeting the state’s minimum staffing threshold of three direct care hours per resident each day.
Another is requiring nursing home owners to pay fines to state or federal agencies with money only from administrative fees that their companies collect.
Lawmakers could also designate a certain portion of taxpayer money to go directly toward resident care, they said. New York, New Jersey and Massachusetts have adopted policies setting requirements for how much nursing homes must spend on care and limiting what they can spend on other expenses, such as administrative costs and salaries.
“Connecticut taxpayers pay a lot of money with the expectation that people are going to receive a high level of care,” Doroghazi said. “If they’re not, we need to do everything we can as quickly as possible to improve that care.”
Some recommended more resources for the long-term care ombudsman’s office, which advocates on behalf of residents. Only one additional position was approved for the office in the biennial budget adopted this year, even though Painter had asked for 12.
And in order to attract and retain nursing home staff, higher wages and better benefits must be weighed, said Sen. Martha Marx, a New London Democrat who works as a home care nurse.
“Any business plan whose profits are based on the lowest-paid workers needs a new business plan,” she said.
Sam Brooks, director of public policy for National Consumer Voice, an advocacy organization, encouraged state and federal officials to reexamine their relationship with nursing home operators.
“For too long, it’s been this idea of collaboration. That’s not the job of state survey agencies,” he said. “We believe that strong enforcement, strong corrective action incentivizes change. Many of these operators are in it for the money. And until you reduce the amount of money they can suck away without repercussions, you’re not going to really change the behavior. Five thousand dollar fines, that doesn’t do anything to them.
“If you look at the amount of fines and you look routinely at the type of severe, endemic problems that are hurting nursing home residents, it’s pathetic. … There’s no real incentive to change,” Brooks said. “What we’re hearing is there’s just this huge decline in quality of care across the country. … And the fact is, it’s made worse by poor enforcement.”
Osten recently confronted state officials about the inspection backlog and state of care in nursing facilities. She asked that the Nursing Home Financial Advisory Committee, a group of stakeholders that meets quarterly, call a special August meeting to address the issues facing the industry.
Hochadel and her legislative colleagues have formed a working group this summer to explore elder care reforms for the next regular session.
“It terrifies me,” she said of the care climate. “We really want to hit the ground running next year. We’re gathering a list of the bills that didn’t get out of committee, some of the things that didn’t make it to the floor [this year] and looking to involve our community partners to have something strong ready to go in February.”
Advocates urged the state to view the lapses as a chance to improve care.
“Imagine if  day care centers in the first half of this year had been found to be putting children at risk of serious injury or death. Imagine what kind of reforms would be happening,” Doroghazi said. “We need to see this as an opportunity to rethink how we provide care to older adults and people with disabilities.”
CT Mirror staff writers Andrew Brown and Katy Golvala contributed to this story.