NJ 'Makeshift Morgue' Nursing Home Hit With Another Lawsuit

NEWTON, NJ - Another class action lawsuit has been filed against a Sussex County long-term care facility already fined $220,000 after an investigation into its COVID-19 response.

Brian Roberts filed the lawsuit Tuesday in Sussex County Superior Court which alleges his uncle, Albert Roberts, became infected with COVID-19 at Andover Subacute & Rehab Center Two and died on April 1.

The suit joins one filed in May, one month after 17 bodies were removed from what officials referred to as a "Makeshift Morgue." The facility had upwards of 75 deaths and 250 total cases among patients and staff before the state switched over to the "confirmed deaths" reporting metric. A further breakdown with new numbers was unavailable as updated spreadsheets only show new infections and new deaths.

The facility was fined $220, 235 for putting their patients in jeopardy and providing substandard care according to a federal report.

The Centers for Medicare & Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS), issued its inspection report for the Andover Subacute and Rehabilitation II and found that the facility was not in substantial compliance with federal requirements.

CMS has imposed a Civil Money Penalty accruing a total of $220,235 for the 15 days of Immediate Jeopardy and Substandard Quality of Care, beginning April 6 and ending on April 20. This translates to more than $14,000 per day, in addition to other fines. CMS has stated that the monetary penalties to the Andover facility will continue to accrue until "substantial compliance is achieved or termination occurs."

CMS defines a situation in which a long-term care facility is non-compliant when the facility has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.

"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," said Rep. Josh Gottheimer at the time. "The loss of life and the circumstances that so many of the residents faced are a complete tragedy."

Makeshift Morgue

The facility first drew attention last month after authorities responded to an anonymous tip that bodies were piled up at a "makeshift morgue," according to officials.

Gov. Phil Murphy said that he is "outraged" by the reports, saying the idea that the deceased were treated this way "is completely unacceptable."

Andover Police Chief Eric C. Danielson said in a statement that the facility was overwhelmed.

"There were originally 17 bodies within the facility, of which two had been transported by a local funeral home, 13 transported via assistance from local EMS agencies to a refrigeration trailer located at Newton Medical Center and two deceased bodies remained at the facility for transport the following day (Tuesday)," he said.

Co-owner of the facilities, Chaim Scheinbaum, of Lakewood, sent a letter to authorities that Danielson shared. In it, Scheinbaum said that the backup and after hours holiday weekend issues plus more than average deaths contributed to the presence of more than normal in the facility holding room.

"According to the medical director, desired or normal capacity of the holding room is four with a maximum of 12," Scheinbaum said, noting that the medical director was "aware of the situation and in control at all times."

Within the new inspection report, CMS noted, "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 diseases. It was determined that the provider's non-compliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm impairment or death to residents."

When first contacted about issues at the Andover facility in mid-April, Gottheimer continued to request coordination, action, and resources from the State of New Jersey, FEMA, and the federal government to address COVID-19 outbreaks in long-term care facilities in North Jersey. Since learning of the crisis at the facility, Gottheimer has been in regular touch with New Jersey Department of Health (NJDOH) Commissioner Judith Persichilli and with the Governor's office. Gottheimer also asked the State and CMS to investigate the facility.

Gottheimer has also asked the Federal Emergency Management Agency (FEMA) to deploy National Guard and Reserves to assist North Jersey long-term care facilities in need, and he requested that the U.S. Department of Health and Human Services (HHS) deploy U.S. Public Health Service front-line health care workers.

Andover Subacute II was cited for variety of concerns including:

• A resident was found on the floor by the bed, had fallen on the wet floor and obtained a small abrasion on the head. The resident was pronounced dead the morning the next day. The following is an excerpt from handwritten notes from the resident's physician: "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."
• Multiple patients with elevated temperatures and no documented clinical assessment or follow-up from medical staff;
• Documented incidences of a patient under investigation (PUI) for COVID-19 being placed in a room with a resident who was asymptomatic. In one case, the PUI's test came back positive and only then was the resident moved to a different room;
• Review of facility documentation found several missing elements including missing temperature logs for residents and a lack of documentation of resident symptoms;
• A resident was documented to have a temperature of 104.9 on April 6. The following day, the resident's temperature was not documented at all. The resident was found unresponsive and pronounced dead on April 8. "No documentation of coronavirus monitoring was found regarding the respiratory symptoms which included coughing or shortness of breath assessment" for this resident;
• On April 16, a resident was admitted to the hospital with respiratory failure and possible COVID-19. There were no documented notes in the resident's temperature log regarding their condition for the previous five shifts and no test had been ordered for the resident. The resident was subsequently intubated at the hospital;
• Multiple instances of insufficient PPE usage and protection for staff in the facility.

History Of Issues

This is not the first time this particular facility has come under scrutiny, according to inspection reports.

Over the past three years the overall rating for Andover Subacute and Rehab II is one star, placing it "much below average." The health inspection during that time brought up five citations and also saw the facility one star. The health inspection star rating is based on each active provider's current health inspection survey and the two prior surveys, as well as findings from the most recent three years of complaints information and inspection revisits, records note.
The records also indicated that many of the health violations were the result of complaints to the survey agency.

Records show the facility was also found deficient in:

• telling residents, the resident's doctor, and a family member's of situations, such as injury or decline, that affect the resident.
• honoring the resident's right to a safe, clean, comfortable and homelike environment
• ensuring services provided by the nursing facility meet professional standards of quality
• ensuring that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

'Screaming For Water'

Those violations did not come as a surprise to Nina Solomon, who told Patch she has a dear friend in the facility.

"Patients on her floor scream for two hours just to get water," she said. "There will be more deaths because no one cares about these people. They are dying without dignity."
Solomon said more people, like her friend, could be next.

The facility also had a series of fire safety deficiencies in the records, such as not having elevators that firefighters can control in the event of a fire, not keeping aisles, corridors, and exits free of obstruction in case of emergency, improper usage of power strips and extension cords and not having an Emergency Preparedness Program, records show.

The Andover Subacute and Rehab II was also fined by the Federal government for these deficiencies. $13,905 in January 2019 and $7,673 in November 2017.

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