Concern about care lingers after violations found at Williamstown nursing home

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WILLIAMSTOWN — A year after inspectors found evidence of patient neglect, including medication errors and calls for help being routinely ignored, a Williamstown nursing home continues to provide "much below average" care rated in the bottom 1 percent of facilities across the state.

In the past year and a half, Sweet Brook Nursing and Rehabilitation Center racked up hundreds of thousands of dollars in fines, some of which remains unpaid.

Inspections of Sweet Brook have found dozens of instances in which patients were mistreated, abused or neglected by staff from summer 2017 to as recently as March, according to federal Department of Health and Human Services inspection reports obtained by The Eagle through public records requests.

The violations noted, among other things: the resuscitation of a patient without consent, leaving residents in soiled diapers and unsanitary restraints for extended periods, and verbal and financial abuse of residents wishing to leave the facility.

The high-level employee linked to that abuse, as well as several staff members who were found not to be properly licensed, were terminated after the September 2017 survey.

The violations, documented in hundreds of pages of reports, prompted the federal office that oversees Medicare and Medicaid to temporarily freeze Sweet Brook's ability to admit new patients.

That freeze was lifted in November 2017, after the facility corrected initial deficiencies and came back into compliance with federal regulations. But inspectors discovered additional violations when they returned in March.

"I don't know what's stopping someone from suing," a resident said one recent afternoon, lying in her private room in a urine-soaked adult diaper. The Eagle agreed not to identify the resident, who has been interviewed several times about her treatment at Sweet Brook, because she is fearful that staff will retaliate against her for speaking out.

Three former employees and one current worker told The Eagle they were aware of long-standing issues about the quality of care and staffing but declined to speak on the record.

It is unclear what efforts have been made to address issues at the facility. Multiple messages left for those in leadership at Sweet Brook over several weeks, in person and by phone, have not been returned.

Based on surveys and findings from the past three years, the state has scored Sweet Brook 89 out of a possible 132. Only 1 percent of the 399 licensed nursing homes in Massachusetts have a score of 89 or lower, according to the state Department of Public Health.

On the federal level, the facility continues to be rated by Medicare as "much below average," with 1 out of 5 stars, using a system that incorporates self-reported facility staffing data and survey and complaint findings in its scoring.

Grounds for action

Sweet Brook, at 1561 Cold Spring Road, continues to operate with a license for 184 beds through the Department of Public Health. The DPH has the ability to revoke licenses for nursing homes if they violate regulations, including the facility being found in a state of "jeopardy," not correcting deficiencies by a date noted in a plan of correction, or being found in violation of the same or a similar violation twice or more within 12 months.

"While the existence of any of these at a nursing home does not immediately result in loss of licensure, it does constitute grounds for DPH to take legal action to revoke a nursing home's license," agency spokeswoman Marybeth McCabe said in an email.

The facility has been owned by Sweet Brook Equity Holding LLC since 2014, according to federal documents. Key owners are Jeffrey Goldstein, Zaleman Horowitz, and Alexander, Rochelle and Samuel Sherman.

The former director of development, who was found to be financially abusing patients, was terminated Sept. 21, 2017. The administrator of the facility was terminated Sept. 29, 2017, according to the documents.

The current administrator, Sharon LeBlanc, was hired Dec. 15, 2017. Jacklyn Seeger is the director of nursing services.

LeBlanc has not returned multiple voice messages seeking comment. On Thursday, an Eagle reporter made two visits to the facility. During the first visit, a receptionist said LeBlanc was at lunch. In a follow-up visit 90 minutes later, she was said to be in a meeting. A note left for her at the facility, with a list of questions, did not bring a reply.

A year ago, an interim administrator who held the post until LeBlanc was hired said problems related to the center's care of patients had been addressed.

"It was just an unfortunate thing that happened that doesn't represent the people who work here. It's a great facility," David Carboneau said in an interview with the Eagle. "I think it's a shame that this came out the way that it did, because they're just super here because they care about the residents. I feel things are back to normal. Things are going very well here."

In a December 2017 interview, Carboneau declined to identify the staff that had been terminated or name who was hired to replace them.

"Some of the things in the reports are not 100 percent accurate," he said at the time. "There's no way that you can refute it."

Deficiencies in care

Inspectors descended after getting a complaint about care.

The first of the two recent cycles of inspections began in August 2017, in response to a complaint made to the state Department of Public Health, McCabe said. Auditors arrived unannounced at Sweet Brook for several inspections.

Documents show that during those visits, surveyors discovered violations:

- A patient found without a pulse was resuscitated despite having an order in place not to do so;

- Several patients were moved from private rehabilitation rooms to a locked shared dementia unit without their consent;

- Staff members were improperly administering catheters and were denied training when they requested it;

- Water was often too hot or too cold;

- Patients were not given medication as ordered by physicians;

- Several employees, including a former admissions coordinator, were working without proper licenses;

- Some staff was not trained on the facility's resident abuse policy;

- The facility failed to adequately do laundry for residents.

On Sept. 6, 2017, a surveyor witnessed a resident being restrained, without their consent, in a wheelchair using a soiled seat belt.

Devices like belts can be used on residents to assist in safety or postural support if they have medical issues that warrant them, but the resident must be physically and cognitively able to remove the devices. Surveyors found that several Sweet Brook residents, including this one, were unable to remove themselves from the restraints on their own, according to documents.

Later that same day, the surveyor found a different resident seated at the dining room table with padded mitts on both hands "which were soiled and crusted with food and liquids," according to the inspection report. The mittens were tied to the resident's wrists.

Abusive behavior

The reports said one unnamed male staff member engaged in verbal and emotional abuse. That individual, who was employed as a director of development, reportedly misrepresented himself to residents as "vice president of operations." He was terminated after the inspection report was completed, according to the documents.

This employee, and all others referred to in the inspection report, were not identified by name.

The surveyors noted that the "vice president of operations" was abusive primarily to residents who complained of care at the facility or who requested to leave.

"The VP of operations was observed by residents, staff and visitors verbally and mentally abusing, intimidating, threatening and financially exploiting residents over a period of at least two months," a surveyor wrote in a September 2017 report.

The dismissed employee engaged in financial exploitation, the report said, by telling a resident that he wouldn't be discharged from the facility. If the resident did chose to do so on their own, the employee said he would ensure that the person would lose all medical insurance and benefits for the rest of their life, documents said.

On July 10, 2017, the employee altered an admissions agreement that already had been signed by a resident to include wording that they agreed to pay out of pocket for 30 days, regardless of whether they were treated there for the full month.

Also that month, the employee threatened to take away a resident's electric wheelchair as punishment for complaining about the facility.

The man swore at residents, canceled an ambulance scheduled to pick one up and "repeatedly harassed" a resident about their requests to leave the facility, according to the reports.

That employee, and several others who had been working without the proper license — also unnamed — have since been terminated, according to the report.

The inspection findings resulted in fines, in addition to a plan to address the issues.

In response to the first batch of deficiencies, Sweet Brook was fined $433,488, which was reduced to $288,267, upon its waiving of an appeal process, and paid last year.

On Sept. 27, 2017, the Centers for Medicare and Medicaid Services announced that it would terminate Sweet Brook's Medicare provider agreement because the facility had failed to meet Medicare's basic health and safety requirements, according to the termination notice.

But a follow-up visit by surveyors Sept. 29 confirmed that Sweet Brook had "removed jeopardy" from its facility.

A plan of correction submitted by the facility at that time included, among other things, regular audits and increased staff training in a variety of disciplines.

Inspectors return

In response to the September 2017 findings, the DPH recommended to the Centers for Medicare and Medicaid Services that the facility be placed in immediate jeopardy, a sanction to freeze admissions, due to noncompliance with federal regulations.

The facility hasn't faced another sanction from the Department of Public Health or the federal office of Medicare and Medicaid Services since that sanction was lifted in November 2017.

But when surveyors returned in March 2018, they continued to find additional issues.

From March 5 to March 15, inspectors again performed interviews with staff and samples of residents.

The inspectors found that staff was not responding to residents' call bells for more than an hour at a time, sometimes turning off the bells without resolving the issue or returning to the rooms.

During the inspection, at least two residents were found to have been left for hours in soiled diapers.

On March 3, one of them told a surveyor that they had to wait 30 minutes to an hour for someone to assist them "at least 6 days a week," according to the documents.

"Staff come in sometimes, shut the call bell off and say I can't help you now," a resident told the surveyor, according to the documents. "Staff say that you are not the only resident, and you will have to wait. A housekeeper and certified nursing assistant (CNA) told me a bunch of staff were sitting at the nurses' desk and ignoring the call bells."

The resident also told the surveyor that they don't like to sit in their own urine and feces and "that it was embarrassing," the documents say.

Two days later, another resident reported a similar instance of neglect.

The individual said they rang the call bell and a CNA came into their room and turned it off and left without helping. Despite requiring assistance to get to the bathroom, after waiting 90 minutes the resident went on their own because their adult diaper was "soaking wet."

"I have had to wait 1/2 hour to 1 hour a few times to have the call bell answered," the resident told a surveyor.

With another resident, a nurse was seen lifting the individual's shirt in a public area of the facility, exposing their abdomen, while injecting them with insulin, according to a report.

When the inspector asked whether the resident minded having the medical procedure done in a public area, that resident responded: "You should have seen what they did yesterday. One of the nurses emptied my catheter bag in the day room," the resident said in a remark included in the federal report. "They emptied 2 buckets of piss in the day room! They aren't supposed to do that."

Other violations included a resident being administered anti-psychotic medicine without a court order, infrequent foot care, nurses using soiled gloves during medical procedures, theft from a patient and having an inadequate emergency preparedness plan.

Sweet Brook was again fined based on these surveys: $63,180, which has not yet been paid, and a separate fine of $8,237, which was lowered to $5,354 and paid in July, according to a spokesman from the office of Medicare and Medicaid.

The most recent inspection of Sweet Brook was in October, when surveyors responded to a single complaint that a patient's rights were violated when staff revoked his smoking privileges for a week as punishment for not following the facility's policy. The issue was resolved without a fine, according to documents. No other violations were noted during this visit.

The town of Williamstown, too, is occasionally notified of concerns about conditions at Sweet Brook. The town's authority is limited, according to Town Manager Jason Hoch.

"The town's routine oversight is limited to kitchen safety and annual building code occupancy requirements, similar to other residential facilities like dormitories," he said recently in an email. The Department of Public Health is responsible for overseeing operational and patient care issues at the facility, he said.

Last year, the town inspected the kitchen and building code conditions. Any building violations noted had been resolved by the time of re-inspection, Hoch said.

Concerns continue

Amid leadership changes, the resident interviewed by The Eagle alleges that the center continues to neglect patients.

During one December afternoon visit, the scent of urine filled her dimly lit room. Sounds of televisions in adjacent rooms came through her open door.

During several interviews over the past month, the woman, in her 70s, detailed instances she found to be concerning.

The alleged neglect started almost immediately after her arrival at the facility, where the woman, who can't walk on her own, planned to receive regular physical therapy to prepare for a surgery.

Instead of being placed in a private room, as she expected, staff put her in a locked dementia unit, she said.

In the middle of the night, confused patients with dementia tried to climb into her bed, she claimed. Being immobile, she felt like she was defenseless.

After a few days, someone in leadership moved her to a private room but didn't acknowledge the mistake. She was offered cookies, but she is diabetic, so she refused them, she recalled.

Now in a private room, she feels that nurses and staff have continued to neglect her.

On some days, she waits over an hour for a staff member to respond to her call bell, she said.

She relies on staff to get her to the bathroom within about 25 minutes of her ringing the bell. Because they rarely get to her in time, she has been made to use adult diapers, which, she claims, wouldn't be necessary if staff came when she rang the bell.

While staff offers to change the diapers after she is forced to wet herself, she only receives a full assisted shower once a week, she said.

While the resident had good things to say about a few nurses who are reliable, she said staffing is unpredictable and turnover is high.

Unhappy with her treatment at the facility, the woman said she has been trying to transfer to a nursing home in her home state before she undergoes surgery so she would be able to recover there, but administration has dragged out the process for months, she claims.

"It's just a constant delay of one kind or another," she said. "I will not return to Sweet Brook under any circumstances. There's just no care here."

Haven Orecchio-Egresitz can be reached at horecchio@berkshireeagle.com, @HavenEagle on Twitter and 413-770-6977.


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