Still No Answers In Case Of NJ 'Makeshift Morgue' Nursing Home

SUSSEX COUNTY, NJ - It has been nearly a year since the Andover Subacute & Rehab Center II made headlines after stacking more than a dozen bodies in a temporary facility, referred to as a "makeshift morgue" by officials. But answers as to what happened over that long Easter weekend are still scarce as Open Public Records Act requests continue to go unfilled.

Like many members of the Garden State media, the County of Sussex continues to wait on OPRA requests. County Counsel Kevin D. Kelly first contacted New Jersey’s Department of Health on May 1, 2020 and May 12, 2020, for 19 different types of records. Kelly’s last correspondence with the state was in August, when Murphy Administration Department of Health officials requested another extension, officials said.

Among the documents Kelly asked for, were routine and complaint inspection reports for the Subacute facilities, the Department of Health’s communications with Andover Subacute’s legal counsel Christopher Porrino, communications between the state and County of Sussex and Andover Subacute’s personal protective equipment or PPE inventory.

Patch reached out to the Murphy administration who looped in the New Jersey Department of Health last week but has not received comment.

Makeshift Morgue

The State of New Jersey-licensed Andover Subacute and Rehabilitation I and II, each
recently renamed Limecrest Subacute and Rehabilitation and Woodland Behavioral and Nursing
Center, were launched into the international spotlight in April 2020 after news broke about the
discovery of 17 bodies in a makeshift morgue in the former Subacute II facility.

Murphy said that he was "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 a 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."

“The governor often says he’s being ‘crystal clear,’” said Commissioner Director Dawn Fantasia. “I’ll tell you what’s crystal clear. The New Jersey Department of Health and the Murphy Administration were clearly warned. Warned that patients would die. Warned that by demanding long-term care facilities - facilities that were in no way prepared with adequate staffing, adequatetraining, or adequate PPE - take COVID patients, that patients would die who wouldn't have otherwise, died had positive patients been screened.”

It is true, Murphy has maintained all along at numerous COVID briefings that his administration was clear in their orders. That COVID patients returning to facilities would have to be kept separately either by floor or by wing and that separation had to include staff. The Department of Health guidelines Murphy referred to noted that facilities that could not make that happen should contact the Department of Health for assistance.

“Why can’t we get a simple inspection document?” Commissioner Herbert Yardley said. “Is there something they [New Jersey’s Department of Health] don’t want us to see?”

Yardley suggested the County of Sussex file a lawsuit in Federal Court against the State of New Jersey.

Available Records

Some records, are publicly available.

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.

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 had 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.

Hearings And Investigations

“Sussex County’s pleas for help went unanswered, simply ignored, while the fear, suffering, and horror of the situation continued,” Commissioner Sylvia Petillo said. “The lack of enforcement and complacency perpetuated the problems and devastated our most precious population. Their families and the public deserve answers. It is time for a thorough investigation.”

The call for an investigation is not a new one.

Murphy has faced criticism from Senator Joseph Pennacchio, who has called for a Senate Select Committee to investigate the Executive Branch's handling of the pandemic after a report the Administration has altered the total of COVID-related nursing home deaths back in May.

"It is a disturbing and ineffective attempt to cover up the extent of an ongoing tragedy that has wreaked havoc in nursing homes," said Pennacchio after a published report that the state had altered its accounting of virus deaths in senior facilities.

Several Senate and Assembly Republicans held their first in a series of independent hearings into the nursing home response on March 5, which their Democrat colleagues and New Jersey Department of Health representatives declined to participate in.

This week Pennacchio said that Murphy withholding information is "nothing new."

“The Governor has been disingenuous to New Jersey residents,” he said. “He holds his press conference, and he does his usual routine, but he isn’t forthcoming with information the public deserves to hear. Too many questions remain unanswered."

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