The Berkshire Eagle investigated Sweet Brook Rehabilitation & Nursing Center in Williamstown, Ma.  The troubled nursing home may have its license to operate revoked following a new federal report detailing how staff failed to prevent multiple incidents of physical and sexual abuse among residents with cognitive impairments.

In February, the nursing home was added to the federal government’s list (Special Focus Facility) of the worst-performing facilities in the country. The addition to the list meant Sweet Brook was in “immediate jeopardy” of losing funding.

The federal report details multiple incidents of alleged abuse between December 2018 and February, according to the Eagle, including a Feb. 7 incident where a resident reportedly held the hand of a “severely cognitively impaired” resident over their exposed genitals, forcing the person to sexually gratify them.  That incident and several others occurred in a day room referred to as “the man cave,” the Eagle reported.

The report showed “no documentation” that the facility had staff supervise the “man cave” while residents were inside, according to the newspaper.  Neither party had the mental capacity to consent, a social worker said.

Reports of other incidents reported at the home can be found on the CMS website. One incident report details a resident being left to sit in a soiled adult undergarment for long periods of time.

According to Medicare, the nursing home has faced two fines in the past three years including a $288,267 fine on Sept. 11, 2017 and a $5,355 fine on April 11, 2017.

McKnights had an article on The Ensign Group.  National nursing home chain The Ensign Group has taken over a skilled care unit in Sonoma Valley Hospital which was originally scheduled to be closed.  The Sonoma Valley Hospital has struggled in recent years to maintain the service, which has lost about $800,000 annually but has now decided to bring The Ensign Group.  Ensign has grown rapidly in recent months and is one of the largest nursing home chains in the country. Its portfolio includes 197 SNFs and 56 standalone senior living facilities. It also owns 26 hospice agencies and 25 home health operators, which it spun off into a second company called Pennant Group earlier this month.

“Under the draft proposal, Ensign would assume operations of the skilled nursing unit on July 1. Sonoma Valley Hospital will receive funds from the operator as part of a revenue-sharing agreement. The medical center will in turn provide certain higher-acuity services to nursing unit patients. This is expected to generate incremental revenues for the hospital while at the same time, SVH will not be held liable for any losses incurred by its partner. The facility will remain under the hospital’s license and oversight.”

WHAS11 had an incredible story about two friends who really made a difference in the lives of nursing home residents.  Sandy Cambron and Shannon Blair provide baby dolls to nursing residents suffering from dementia.

It began as a gift to Sandy Cambron’s mother-in-law.  “We would buy her a TV, buy her stuffed animals and nothing would work and one day, we were out shopping and I told my husband, maybe we should get her a baby doll,” Sandy Cambron said.  It made all the difference.

“She loved it. She took that baby and slept with it, had meals with it. You could see the biggest difference with her. She would not leave that baby. It was always by her side. When she passed away, we buried the baby with her,” Cambron said.

Then, last year, when her friend, Shannon Blair, was going through a similar experience with her own mother, Sandy offered a baby doll.

“It was actually my mom’s roommate’s response. She immediately reached out and started crying. I went back to Sandy the next day and I said, I get it. I get why you wanted to give my mom a baby,” Blair said.

“300 babies later, we are boomin’. We are visiting as many places as we can,” Blair said. They hand out baby dolls, stuffed puppies and kittens. Each doll is color coordinated and wrapped in the softest of blankets.  They’re changing lives one baby doll at a time.

“It is just a baby doll, but whatever emotions it stirs up, it’s all happy. It takes them back to a joyful time. It’s happy and it’s sad at the same time,” Blair said.

Pearl’s Memory Babies runs purely on donations. Shannon and Sandy buy the baby dolls and shop all the bargains they can find to get the outfits, blankets, and even the diapers. If you’d like to donate or learn more, you can visit their Facebook page or website.

The Centers for Medicare and Medicaid Services announced that it will post a monthly list of underperforming nursing homes. CMS said that roughly once a year, it performs a health and safety survey of all nursing homes that care for Medicare and Medicaid patients. More than 500 facilities are identified with significant health and safety issues, but less than 20 percent are subject to additional oversight.  CMS maintains the list of facilities that perform poorly on the survey, but only public discloses which nursing homes are receiving the oversight. That’s despite the two groups “being indistinguishable” in terms of quality, according to the report.

Dr. Kate Goodrich, CMS’s chief medical officer, said this lack of surveillance is due to funding limitations and an increase in the number of long-term care facilities.  “That has made it challenging … to do all the work that is necessary to oversee these nursing homes,” said Goodrich. “But we do believe that if we had an increase in our budget, that we would be able to have more robust oversight with this increase in our workload.”

CMS selects facilities for the Special Focus Facility program, which provides additional oversight, with input from state officials. The federal agency said it asks a state which of several nursing homes most needs additional surveying, which occurs every six months.

CMS said the best way to evaluate a facility’s quality is its online comparison tool for nursing homes, which bases rankings on not only the health survey, but also on staffing levels and performance measures. It is possible for a nursing home to have a low survey score, but still rank well due to higher numbers in the other two categories.

Texas has slowly reduced the misuse of antipsychotics in nursing homes in recent years, but experts and advocacy groups say more can and should be done. Texas legislators are considering a pair of bills that would require the written consent of a patient or a family member before an antipsychotic drug is given to a nursing-home patient.

Amanda Fredriksen, associate state director at AARP Texas, explained about 12,000 nursing home residents are being given antipsychotic drugs for no legitimate reason, perhaps other than the convenience of staff in caring for patients who otherwise might be difficult. She said these medications are intended to treat schizophrenia, bipolar disease and Tourette’s syndrome, but are dangerous for those with Alzheimer’s and dementia.

“These drugs can increase the risk of falls, increase blood glucose levels, they dramatically increase the risk of stroke – all these risks are well known,” Fredriksen said. “We outlawed physical restraints many, many years ago and now we’ve moved to chemical restraints. It’s fairly barbaric. ”

Fredriksen noted there are other alternatives to antipsychotics, including music and memory therapies and safer medications.

“There are also behavior techniques that can be used to know how to anticipate some of the reactions from residents and intervene with different kinds of behavior techniques that don’t require any drugs at all,” she said.

Kristy Winburn, an employee at Five Star Senior Living assisted living facility in Hartsville, is accused of taking prescription pills from an elderly resident who was left in her care.  One employee advised officers that Winburn had taken 11 Percoset pills from an 80-year-old resident. The employee said Winburn was replacing the missing Percoset pills with vitamins and Tylenol pills and passing it off as “legitimate medication” for the 80-year-old, according to the police report.

When police interviewed Winburn about the stolen prescription pills, she admitted to taking four of the pills.

The offender admitted to taking four of the pills while on duty and was clearly intoxicated as she was almost falling asleep, her head was nodding, and was clearly under the influence,” the police report stated.

The investigation also found that Winburn forged the signature of an employee for providing Tramadol, which is a schedule IV-controlled substance

Winburn faces several charges including failing to report abuse/neglect of a vulnerable adult, petty larceny and forgery.

WSPA reported that two assisted living facility employees have been arrested following the alleged abuse of a vulnerable adult at Rolling Green Village Memory Care Assisted Living in Greenville.  According to the Sheriff’s Office news release, investigators charged Diana Rochelle Garrett and Stephanie Ann Lowden for their connection with the abuse of a vulnerable adult.

An investigation began after deputies were called to Greenville Memorial Hospital on May 22 for an 89-year-old victim who received injuries while living at the facility. An investigation revealed that the victim’s son grew suspicious of maltreatment after he noticed injuries pop up on the victim’s body.

“At some point in time the victim’s son placed a camera in his mother’s room, and upon video review, noticed Garrett and Lowden using physical force and psychological abuse on the victim after she was resisting the staff’s demands to take a shower,” according to the release.

The video was given to investigators, who charged Garrett and Lowden with abuse of a vulnerable adult.  Stephanie Ann Lowden is also a Greenville pastor and blames the elderly woman as the aggressor, not the other way around.  Lowden said the elderly woman at Rolling Green suffers from dementia and was “combative” with the staff and resisted them while the staff was attempting to get the woman into the shower.

“The whole staff was trying to get her to stop being combative. We weren’t aggressive. We didn’t strangle her. We didn’t grab her. We didn’t throw her around. We didn’t do nothing,” Lowden said. “We were trying to get her in the shower. She was fighting. She even ripped a pole off the wall, and I came in there in the middle of it.”

Lowden said based on the woman’s needs, she should have been placed in the facility’s skilled nursing center, not the facility’s “memory care” neighborhood.

The affidavit said on May 17, Garrett did commit abuse of a vulnerable adult and that she caused the victim have an injury while “forcing the victim to take a shower. Diana was also involved in psychological abuse that cause the victim fear, agitation, and confusion.”

Investigators made administrative staff at the facility aware of the incident.


Video has surfaced of Anna Mae Blessing confessing to shooting her son dead after he threatened to put her in a nursing home. Blessing was arrested last year for shooting her son Thomas dead in Arizona. She died before going to trial.  She said in a video interview with police that she had two guns stashed inside her dressing gown. She told police that as Thomas came towards her she fired multiple rounds at her only son.

“I can’t remember the calibre, it was a good size one,” she said. “I backed up and I pulled the trigger, and it broke the mirror and I don’t know what I did. Then Tom was going to come at me again so I pulled the trigger … I’m sure the second round hit him.”

“Where did it hit him?” asked the detective.

“I have no idea, but I do know I killed him. I bent over and took his pulse, and there was no pulse. So I knew I killed him.”

“I didn’t want to go to a nursing home and he would promise me I never would have to,” she said.

“How do you feel right now about what happened?” the detective asked.

 “I wish I had stayed in Florida,” said Blessing.

“I probably ought to be put to sleep. What can I do for society? I killed my son. The person I brought into this world.”

Blessing then pointed the gun at her son’s girlfriend, Julie, before the two struggled over the weapon and it was knocked to the ground.

“Help me! Help! She’s going to shoot me! She’s going to shoot me!” Julie can be heard screaming on a 911 call.

Guettie Belizaire, an employee at Brookshire Assisted Living Facility in Melbourne, Florida, is accused of sexual battery of an elderly male patient last year, according to authorities.  Belizaire is facing a charge of lewd and lascivious molestation of an elderly person.

Belizaire denied she was in the room with the victim. However, managerial staff at the facility told police Belizaire was found naked in the bedroom of a patient.  The patient said she had sexually abused him.  The victim was taken to Holmes Regional Medical Center where a sexual assault kit was completed. DNA evidence from the sexual assault kit was returned and the results confirmed the victim’s claim of sexual battery leading to Belizaire’s arrest.

McKnight’s reported on a recent appeal of an arbitration decision in favor of the nursing home resident.  I find it funny that the nursing home industry pushes for arbitration because it is “cheaper” “faster” and “will provide closure” but still appeals the arbitrator’s decision!

Villa Huntington Drive Healthcare Center neglected Patricia Porter’s avoidable pressure injury causing her wrongful death.  Her doctor had ordered a low-air mattress to help prevent and heal a severe pressure ulcer. The order was made on July 4, 2012 but the mattress did not arrive until July 12. Caregivers failed to alleviate the pressure by turning and repositioning Porter adequately, and left her sitting in a wheelchair for six hours, further worsening her injuries. She died in November 2012 from a septic sore and urinary infections.

After listening to all the relevant evidence introduced, the arbitrator awarded the resident and her family $1 million.  California’s  arbitration awards can be reviewed by a court in limited circumstances, but the California Court of Appeal, Second District, deemed that the case did not meet those requirements. That’s because AG Arcadia did not identify any unwaivable statutory rights that the $1 million award violated, Bloomberg reported.

An appeals court ruled that an arbitrator did not exceed her authority by awarding the patient damages in excess of the $250,000 cap contained in the state’s Medical Injury Compensation Reform Act, Bloomberg Law reported.

According to court documents, the facility had argued that the arbitrator exceeded her powers by awarding non-economic damages in lump sums, rather than in proportion to each defendant’s percentage of fault. It also contended that the arbitrator failed to make any findings against parent company AG Arcadia and its facilities.

Huntington Drive Health also asserted that the arbitrator was prejudiced in the matter and did not grant the SNF added time to present testimony from treating nurses and its medical expert, according to court documents.