The New Jersey nursing home where police said 17 bodies were found piled inside a small morgue was slapped with a huge penalty after an inspection revealed abusive practices and infection control failures caused or were likely to cause serious injury, harm, impairment to residents — even death.
Andover Subacute and Rehabilitation Center II faces a fine of more than $220,000 after a team from the Centers for Medical & Medicaid Services (CMS) inspected the facility, finding the non-compliance "had the potential to affect all residents" who were in "immediate jeopardy."
The center was fined more than $14,000 a day for its poor way of handling the coronavirus outbreak and patients who tested positive for COVID-19 beginning April 6 and ending April 20, among other additional fines. The CMS said that the daily penalties would continue to accrue "until substantial compliance is achieved or termination occurs." The center has 10 days to come up with a plan to address the violations.
Andover Subacute I and Andover Subacute II are separately licensed long-term care facilities with separate patient populations; both have implemented similar protocols to combat the spread of COVID-19, according to Mutty Scheinbaum, owner and operator of Andover Subacute.
"Federal regulators with CMS have been conducting a nationwide review of long-term care facilities to review their infection control protocols. The review of Andover Subacute I concluded that the facility was in compliance with applicable guidelines," Scheinbaum said in a statement Friday. "CMS noted areas of improvement for Andover Subacute II, but determined that the facility’s remediation plan was acceptable as fatalities continue to drop at the facility. We look forward to continuing our cooperative relationship with CMS and the New Jersey Department of Health as we, and nursing home patients and staff across the country, continue to battle this deadly virus.”
According to Sussex County data, Andover Subacute II has 187 residents and staff members who tested positive for COVID-19. At least 95 residents and one staff member have died from the coronavirus at the 514-bed facility.
"I am absolutely disgusted and heartbroken for the residents, staff, and families about the conditions this CMS inspection has uncovered from the facility in Andover. The loss of life and the circumstances that so many of the residents faced are a complete tragedy," said Rep. Josh Gottheimer. "We will not beat this virus and flatten the curve if the coronavirus is able to continue to spread like wildfire in our long-term care facilities."
There were a variety of highly concerning incidents singled out in the report showing the facility's apparent negligence. On April 10, a resident was found on the ground by a bed after having fallen on the wet floor, and had a small abrasion to the head. The next morning, the patient was pronounced dead.
Hand-written note's from the resident's physician showed that a physical examination may never have been done, and he questioned if a COVID-19 test was performed — even though the resident had a high fever for a number of days. That symptom had never been brought to the physician's attention, according to the note, and a "flu like illness" was suspected, "likely COVID-19."
The inspection found there were multiple patients with elevated temperatures similar to that deceased resident, with documented clinical assessment or follow-up from medical staff. Documentation at the facility showed several missing elements like missing temperature logs or a listing of resident symptoms. One resident who was sent to the hospital in mid-April and had to intubated had no documented notes regarding temperature over a span of five work shifts, and no test had been ordered for the patient.
Another resident had a temperature of nearly 105 degrees on April 6. There was no records showing the resident's temperature was ever taken the following day. On April 8, the resident was pronounced dead.
An anonymous tip in April led police to discovering more than a dozen bodies piled in a room. The bodies had been moved there after being stored in a shed.
Former employees said conditions at the facility were vile well before the COVID-19 pandemic hit.
The former workers at the Andover Subacute and Rehabilitation Center didn't want to be identified, but said that practices and regulations at the Sussex County facility were not up to regulations when they were employed there. They both left their jobs recently, in fear for their own safety after the epidemic had begun taking its toll on the center.
"There would be urine and fecal matter on the floor, in the hallway, in the bedroom, like it was just gross ... I have seen bedbugs in patient beds and, you know, we have reported this a couple of times and nothing is being done about it. Nothing. They don't care about the patients," said one former employee. "And then with the virus happening...things just got 10 times worse because there's nobody there to help these residents, because of the staff being so scared of working there."
That employee said Andover would ask staff to come in to work even if they had been symptomatic for COVID-19. Another worker said employees were not provided any of the proper PPE when working while more and residents were getting sick.
"I would wear a mask because I would bring a mask from home. They wouldn't give me a mask," they said, describing how one person, believed to be a supervisor, told them they "shouldn't have a mask on" and that the facility didn't have any to give out.
The center had a rating of "much below average" for its health and overall categories before the crisis, a Health Department report obtained by the I-Team showed. It had been issued dozens of citations over the past few years — with five coming during the most recent inspection on March 1. The Health Department report showed a lack of infection control and supplies.
Andover had also been issued two federal fines over the past three years, totaling more than $20,000.
Gottheimer said that he's working with the state health department, FEMA, the governor and the federal government to see if they can get more support because nursing homes across the state have been hit hard by coronavirus. The congressman also introduced a proposal that require nursing homes to report communicable diseases, infections and potential outbreaks to the Centers for Disease Control, and that families of residents be kept informed of infections at facilities. The measure would also mandate long-term care centers have a crisis plan in place and maintain a stockpile of personal protective equipment for residents and staff at all times.
Nursing homes have been ground zero of the national crisis but nowhere more so than in New Jersey, where they account for a disproportionate share of deaths. Fifty-one percent of the state's COVID-19 deaths to date have come from long-term care facilities, 513 of which have experienced viral outbreaks. As of Thursday night, there were over 8,801 deaths in New Jersey from COVID-19.
Murphy said Thursday he would direct the National Guard to deploy 120 members to long-term care facilities starting this weekend. New Jersey Health Commissioner Judith Persichilli said there would be around 22 members of the National Guard sent to Andover.
"We don’t take this step lightly, but the crisis in our long-term care facilities requires us to take it," the governor said.
Scheinbaum said Andover Subacute II welcomes the National Guard assistance and acknowledged the "tragic surge" of patients falling sick or dying at the height of the pandemic last month.
"We took every possible step to handle this surge internally while simultaneously making dozens of outreaches to local, state, and federal agencies for help," Scheinbaum said. "Andover has made steady progress over the past several weeks. The number of virus-related deaths at the facility has dropped precipitously and is now down by approximately 90 percent as compared to the height of the pandemic. Dozens of staff who were in quarantine have been able to return to work and the workforce is at full strength with a team of new consultants and other professionals on board to help us through this crisis."