White River Junction
Meanwhile, a contract with Dartmouth-Hitchcock to have some of its physicians oversee medical care of Brookside residents at the Christian Street facility is ending.
A May inspection by the state of Vermont identified 13 deficiencies at the 67-bed nursing home, most related to food safety and staffing levels. A New York-based group of real estate investors and nursing home operators purchased Brookside in August 2015, and inspections of the nursing home since the purchase have consistently found problems at the facility. Brookside accounts for one-third of nursing home bed capacity within 10 miles of Lebanon-based Dartmouth-Hitchcock Medical Center.
Since the May survey, conducted by the Vermont Department of Disabilities, Aging and Independent Living Division of Licensing and Protection, Dartmouth-Hitchcock has stopped providing medical oversight to Brookside and, earlier this month, there was a lapse in the facility’s contract with a provider of therapy services.
Ruth Hebert, a former resident and former president of Brookside’s resident council, said the nursing home has not accepted new admissions since she left on May 18.
But Mayer Spilman, the controller for Brookside and Green Mountain Nursing and Rehabilitation Center, a 73-bed Colchester, Vt.-based facility owned by the same group of investors, said Brookside is still accepting new residents, when it can.
“We do have a strict policy on admissions to ensure our residents and staff ratios meet the needs of the residents and admit based on that,” he said.
As of June 20, the facility’s census was down to 44 patients, Spilman said
‘Much Room for Improvement’
There are “many issues going on with Brookside,” said Sean Londergan, the state long-term care ombudsman who works out of Vermont Legal Aid in Burlington.
“Some of the things that are happening at Brookside are happening on a regular basis,” he said. The state’s previous survey results were “not the best either. It seems as though there’s much room for improvement.”
But, in a telephone interview on Wednesday, Spilman said Brookside’s leaders have addressed the bulk of the state’s concerns and made a series of improvements to the facility since taking over.
“(We) bought this business to really make it into a successful facility,” said Spilman, who said he visits Brookside weekly.
Since the facility’s current owners purchased it from White River Junction resident Thomas E. Rice, whose family opened the nursing home in the 1960s and ran it until 2015, Brookside’s overall rating by Medicare has fallen from five to two stars, primarily due to health inspections that left it with only one star in that category.
Two stars indicates a rating of “below average,” while five stars indicates a rating of “much above average,” according to the Centers for Medicare and Medicaid Services, whose nursing home ratings were last updated in May, according to the centers’ website.
Spilman said the dip in ratings was due to a state inspection conducted before the previous owners left.
“That’s the character of what we saw when we took over,” Spilman said.
State inspections conducted in May and July 2015, before Spilman’s group took over, also found deficiencies at Brookside, though not as many as the 12 that the state found last month.
The group’s work since it took over has been an “uphill battle,” he said.
Food Service Safety
Among the state’s recent findings, which are available online, along with Brookside’s plan for corrective action, is one that states: “the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.”
In late April, the facility’s staff served a resident with dementia and other chronic health conditions a meal of fish chowder that registered close to 190 degrees and burned the resident’s lower lip, inner cheek and tongue. The burn caused the patient’s skin to shred and made swallowing painful, according to the inspection report.
More than 13 hours elapsed before a licensed nursing assistant noticed swelling on the patient’s face and the resident was transferred to DHMC, the report said.
Improper food temperatures also came into play in another problem identified by regulators — the number of days the facility’s freezers were warmer than 0 degrees Fahrenheit. The dining room freezer measured above 0 degrees for 14 days in February, 26 days in March and 30 days in April, according to the report.
State officials also found that Brookside was not properly training feeding assistants.
Hebert, the former resident who left on May 18, said the food service was bad enough that she lost weight and became anemic during her nearly three-year stay. She described rancid yogurt and dirty water glasses.
The nursing home’s staff is now using new food thermometers and has pledged to more closely monitor food temperatures.
The burned resident “has healed and has no ill effects remaining,” according to the corrective action plan.
Brookside officials dispute the state’s concerns about freezer temperatures, saying that they were and are sufficiently cool to keep food frozen.
“The temperature was not in a range that would cause thawing and no evidence of thawing was found,” according to the corrective action plan.
Staff Shortage
Staffing issues have apparently contributed to the food service problems. The list of deficiencies notes that the facility had not had a food services director since March and its registered dietician, Eileen Ashe was not full-time.
“If there was a director of food services there these things wouldn’t be happening,” Londergan said.
In the interview last week, Spilman said that, since the May inspection, the owners have hired a food services director and a permanent, full-time nutritionist to serve patients at both Brookside and Green Mountain.
“Having that in place is definitely going to help improve patient outcomes,” Spilman said.
State inspectors found that Brookside’s staffing issues aren’t isolated to food service. The deficiency statement notes that the administrator of the facility splits her time between Brookside and Green Mountain. Jennifer Combs-Wilber, who signed the plan of correction, serves the dual role.
The nursing home’s new owners have had trouble finding a person with the appropriate credentials who wants to live in Vermont to serve as a full-time administrator at Brookside, Spilman said.
“In Vermont, there are no administrators available,” Spilman said. “There’s a big challenge for them with higher education.”
When Brookside officials attempted to relocate administrators from other states, Spilman said, they experienced culture shock moving from a city to rural Vermont.
For now, an on-site assistant helps Combs-Wilber manage Brookside, Spilman said. The nursing home’s owners continue to seek a full-time administrator and have offered current staff with associate degrees the opportunity to continue their education so they might become qualified for the administrator role.
State inspectors found that Brookside has also been short on licensed nursing assistants. The facility failed to provide standard LNA care for more than the required two hours per day per resident on six days during the months of April and May, according to the state’s deficiency statement.
In an interview with state officials on May 17, Brookside’s director of nursing, who is not named in the report, said that “the facility has been short staffed and (the director of nursing) has brought this concern to (the) administration every day at morning meeting.”
But Spilman said the facility was adequately staffed by LNAs. A mistake in the way certain forms were filled out created the appearance that it wasn’t, he said.
In addition, he said, Brookside’s new owners have increased the rate of pay for many members of the staff.
“(We’ve) worked very hard since we took over the place (to) make a change in how staffing is done there,” Spilman said.
In terms of monetary penalties, Brookside owes the Center for Medicare and Medicaid Services nearly $4,000 resulting from a deficiency the state inspectors found earlier this year, according to a bill obtained from CMS’ Boston-based Northeast Division of Survey & Certification. In that instance, an employee verbally abused a patient with mobility issues, calling the patient “an (expletive)” and a jerk and telling him “that I hate him,” according to the state’s March 8 inspection.
For 24 hours following the verbal abuse, other staff members noted that the patient, who suffers from a brain injury, was unwilling to make eye contact and did not smile or laugh.
No information about fines potentially stemming from the May inspection was available last week because the case was still under review, Beverly Hughes Kercz, a CMS health insurance specialist based in Boston, wrote in an email.
D-H Relationship Ends
Other recent changes at Brookside include the splintering of the relationship between Dartmouth-Hitchcock and Brookside.
On May 24, D-H’s Dr. Daniel Stadler stopped providing medical direction for the facility, according to the hospital system’s spokesman Rick Adams.
“We didn’t see the level of engagement that we’d expect,” Adams said.
He later clarified, “By engagement, we mean a collaborative approach to work together on issues with the administration, to ensure the provision of high-quality care.”
D-H physicians will still refer patients to Brookside when beds are available and patients request them, Adams said. They provide patients and families with information about Brookside’s Medicare star rating, the state’s investigation and other area nursing homes such as Hanover Terrace, which has one star, and Genesis Lebanon, which has five stars.
“Patients have the right to choose,” Adams said.
A medical director is required for facilities that bill Medicare and Medicaid, as Brookside does. As part of its contract with Brookside, D-H provided that service through Stadler, Adams said.
Among other things, Stadler was responsible for ensuring that all patients had an attending physician, addressing any outbreaks in the facility, overseeing clinical policy development, participating in routine quality reviews and exercising final say on whether a patient ought to be cared for in the facility.
Spilman said Brookside has “moved in a different direction,” hiring Brooklyn-based Dr. Simon Fensterszaub as its new medical director along with new nurse practitioners. Fensterszaub visits Brookside weekly, or as needed, Spilman said.
Brookside officials wanted a medical director to help the nursing staff provide a higher level of care, Spilman said. But D-H physicians were interested in being involved in the facility’s operations at a big-picture level, Spilman said.
He described the split as a “somewhat mutual” decision to go in different directions and said residents seem happy with the change.
In addition to ceasing to provide medical direction at Brookside, Stadler and other D-H physicians will stop seeing patients at Brookside July 15, Adams said.
Therapy Provider Changes
Another recent change at Brookside is that RehabCare stopped providing physical, occupational and speech therapy services at the beginning of this month, Spilman said. He said the firm pulled out once it discovered Brookside officials were seeking to contract with another firm.
An email to the Kentucky-based RehabCare was not returned by deadline.
A staffing agency provided therapy services until a new firm, Reliant Therapy, began providing care last week, Spilman said.
He said there was not a lapse in therapy care, but Londergan, the Vermont long-term care ombudsman, said a lapse in services affected two patients at Brookside.
In addition, 11 patients at Green Mountain Nursing and Rehabilitation were similarly affected when a contract for therapy services there ended on June 2, before another contract was in place, Londergan said.
Londergan said he was troubled by the timing of this change in services. He said he would expect a nursing home provider that had just received a statement of deficiencies to “be extra cautious” and aim to avoid additional scrutiny.
He questioned the owners’ intent, particularly in light of the fact that a state inspection last August also found staffing issues, including a reduction to two, from three, licensed nursing assistants who worked in a unit that usually had 19 to 21 residents. Some overlapping shifts that had helped staff address incontinence and bed sores were eliminated as well.
But Spilman said Brookside’s new owners are working to improve the facility. They have invested in electrical upgrades, digitized medical records and purchased computers, he said.
“Our overall goal is to really make this a premier facility in the region,” Spilman said.
State officials will return to Brookside within six months to determine whether the facility has made the necessary changes to comply with federal regulations and ensure that it can still bill Medicare, said Suzanne Leavitt, the state survey agency director of the Division of Licensing and Protection.
Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.
