The New Jersey nursing home where 17 bodies were found stuffed into a tiny morgue last month was hit with a hefty fine Friday after federal inspectors found that residents there were put at risk of "serious injury, harm impairment or death."
The Andover Subacute and Rehabilitation II facility in Sussex County must pay $220,235 — more than $14,000 for each day that the Centers for Medicare and Medicaid Services (CMS) found the "facility was not in substantial compliance with federal requirements," from April 6 to April 20. The home also faces other fines, and the monetary penalties will accrue "until substantial compliance is achieved or termination occurs," according to a May 7 statement by Rep. Josh Gottheimer, D-N.J.
The nursing home currently has 133 residents and 54 staff members who have tested positive for coronavirus, according to the congressman. In total, 94 residents and one staff member have died.
"These failures in proper infection control practices had the potential to affect all residents in the facility through the development and transmission of COVID-19 and other communicable disease," said the CMS inspection report cited in Gottheimer's statement. "It was determined that the provider’s noncompliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death to residents."
The report detailed specific instances of disturbing neglect and violations at the home, the statement said.
On April 10, a resident had fallen on the floor by the bed and sustained a head abrasion. The resident was pronounced dead the next day. A physician's report read: “Found dead this am ... not performed Physical-COVID-19 test was done? ... High fever for the last few days — that was not brought to my attention. Flu like illness, likely COVID-19.”
Patients' elevated temperatures and symptoms were not documented, the inspectors found.
In one case, a resident was found to have a fever of nearly 105 on April 6. Then next day, the patient's temperature was not documented, and the day after that the resident died. "No documentation of coronavirus monitoring was found regarding the respiratory symptoms which included coughing or shortness of breath assessment” for this resident," according CMS report excerpts in Gottheimer's statement.
Documentation did indicate the practice of placing patients with COVID-19 symptoms in rooms with residents who did not have symptoms, according to CMS. The inspectors also found "multiple instances of insufficient PPE usage and protection for staff in the 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," Gottheimer said.
In mid-April, an anonymous tip led to the discovery of 17 bodies crowded into a four-person morgue at Andover, which is one of New Jersey's largest nursing homes. “They were just overwhelmed by the amount of people who were expiring,” Eric C. Danielson, the town’s chief of police told The New York Times at the time.
The center has been hit with two federal fines over the past three years, totaling more than $20,000, and had a rating of "much below average" for its health and overall categories before the pandemic, according to a Health Department report obtained by NBC New York. The home has been issued dozens of citations over recent years.
Former employees who declined to be identified told NBC New York that conditions at the home were bad long before the coronavirus crisis.
"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. "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."
But Andover would ask staff to come in to work even if they had been symptomatic for the coronavirus, the former employee said.
Another worker said staffers weren't given the proper personal protective equipment. "I would wear a mask because I would bring a mask from home. They wouldn't give me a mask," the employee said, adding that one person, believed to be a supervisor, said they "shouldn't have a mask on" and that the facility didn't have any to give out.
One of the owners of the home was a top executive at a collapsed chain of troubled nursing homes previously investigated by NBC News. Federal records show that Louis Schwartz, who is listed as a 50-percent owner of the Andover, was a vice president at Skyline Healthcare, a now-defunct nursing home chain that was plagued by allegations of neglect and mismanagement and the subject of more than a dozen lawsuits.
A statement from Mutty Scheinbaum, an owner and operator of Andover Subacute, said that while CMS "noted areas of improvement for Andover Subacute II," it "determined that the facility’s remediation plan was acceptable as fatalities continue to drop at the facility."
But a letter from CMS said the Andover facility has 10 days to submit an extensive plan of correction or else it will face additional fines.
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," the statement said, adding, "PPE inventory is also being restored."
While nursing homes around the country have been hit hard by coronavirus cases, none have been more slammed than New Jersey's. More than half of the state's COVID-19 deaths have come from long-term care facilities, 513 of which have seen viral outbreaks.
This week, Gottheimer introduced the Nursing Home Pandemic Protection Act of 2020 to make it federal law for nursing homes to report communicable diseases, infections, and potential outbreaks to the Centers for Disease Control and Prevention and keep patients' families informed of infections at facilities. The law would also require homes to have crisis plans, and a stockpile of PPE.