An ambulette parked outside the Golden Gate Rehabilitation & Health Center on Staten Island, June 26, 2024. Credit: Alex Krales/THE CITY

By Ashley Borja

Federal law says nursing homes are supposed to be inspected by state health authorities at least once every 15 months. But in New York City, a severe shortage of inspectors has delayed most inspections beyond the legal limit, a review by THE CITY finds.

As of June 1, 120 of the 163 federally designated nursing facilities in the five boroughs, or 73%, have not had an inspection within the required time period, and 33 have not had an inspection since 2021.

Many of those late on their inspections are among those with the lowest possible federal rating — one star out of five on a quality scale determined by inspections, quality metrics and staffing levels. Over half of the 32 one-star facilities in the city have not been inspected in more than 15 months.

A severe shortage of inspectors, known officially as health care surveyors, has hindered the state’s ability to meet the federal standard. Every inspection team must include a registered nurse, a huge challenge as demand for RNs in the pandemic era prompted many of those workers to jump to better paying jobs elsewhere, according to observers.

In 2022, nearly 60% of state Department of Health nursing home inspector positions were vacant according to a U.S. Senate investigation, up from just 4% a decade before — giving New York one of the highest vacancy rates in the nation.

In response to questions from THE CITY, the state Department of Health acknowledged a serious deficit of inspectors.

“Ensuring all nursing home residents receive proper care is a priority of the New York State Department of Health,” said spokesperson Monica Pomeroy in a statement to THE CITY. “In the wake of the lengthy COVID-19 public health emergency, the Department of Health experienced a significant increase in staff turnover due to retirements and turnover. There are workforce shortages in many areas of healthcare delivery and we recognize and prioritize the ongoing need to actively recruit and fill surveyor positions.”

‘Immediate Jeopardy’

Records show inspections have lapsed at some of the city’s most troubled care facilities.

At Golden Gate Rehabilitation & Health Care Center in Staten Island, federal regulators at the Center for Medicare & Medicaid Services (CMS) have determined its past problems are severe enough to make it a candidate for a “special focus facility,” or SFF, designation. If the federal agency eventually slaps it with an SFF label, it would then have to be inspected every six months.

However, Golden Gate hasn’t had an inspection since March 2022, records show.

The report resulting from that visit describes two separate incidents in which nurses said they’d seen nursing assistants punching patients.

One of the assistants was suspended for three days, and the other received counseling, but continued to work at the facility, according to the report, which noted that a “serious adverse outcome is likely to occur if the facility fails to immediately remove staff accused of abuse or neglect from direct resident care.”

A third patient complained to a psychologist that they had been ignored for an entire day. Staff interviewed by an inspector suspected the patient had been accidentally left off a list of the day’s rounds — yet one of the nursing assistants marked some care as having been delivered.

The inspection report found that the facility’s actions resulted in “immediate jeopardy” and substandard quality of care with the likelihood for serious harm.

Multiple calls to Golden Gate by THE CITY have not been returned.

More Visits, Better Care

When inspections happen, health care surveyors conduct unannounced investigations with staff members with expertise in nursing, nutrition and social work. When they find that regulatory requirements have not been met, inspectors can fine providers for each violation cited. In severe cases, those fines can total hundreds of thousands of dollars.

The state inspectors are also in charge of reviewing complaints by patients and family. Facilities must then develop a plan of correction for any deficit reported.

The state health department must find the plan acceptable before the facility is found to be back in compliance. The inspectors’ reports feed into care facilities’ quality ratings posted on the federal medicare.gov website, intended to help family members choose the best care for their loved ones.

Those searching the Medicare site should know that the reports posted online may be out of date. There can be delays between when an inspection takes place and when CMS posts its reports online. Some in the database appear to be delayed by months, but the typical time lapse between inspections and postings is unclear. THE CITY contacted the federal agency in charge of the report data for clarification but has yet to receive a response.

Patient advocates have been pressing for years for states to face penalties for when they fail to meet the federal standards for the frequency of inspections.

“It’s no secret that when inspectors visit a facility the quality of care improves,” said Michael J. Brevda, managing partner at Senior Justice Law Firm, which sues nursing homes, assisted living facilities and hospitals for patient neglect. “Any increase in oversight inspections would have a direct correlation with better care.”

Richard Mollot, executive director of the advocacy group Long-Term Care Community Coalition, says timely inspections are essential and that the slowdown poses potential harm to residents.

“It’s really a shame because these people are so vulnerable. If the state is not stepping in to ensure good care, then they’re at risk,” said Mollot.

‘He Still Has Scars’

New York’s nursing homes were devastated during the pandemic. Over 6,000 facility residents died in New York City alone, numbers the state Department of Health updated in May 2022 after an investigation by Attorney General Letitia James’ office highlighted the state’s failure to count people discharged from nursing homes who then died in hospitals in its tally of nursing-home COVID deaths.

Just last month, former Governor Andrew Cuomo testified to Congress about how his administration handled nursing homes then. But for all the attention to fatalities during the worst of COVID, the state’s limited capacity to monitor facilities has gotten little attention since.

Even in places targeted by lawsuits alleging extreme negative conditions for patients, inspections are lacking.

Last year, Attorney General James sued the owners, operators and landlords of four nursing home facilities across the state associated with Centers Health Care, alleging “repeated and persistent preventable neglect, suffering, and humiliation of residents.”

The state’s suit alleges that residents had to sit in their urine and feces for hours, suffered from severe dehydration and malnutrition and developed infections and sepsis from untreated bed sores and poor wound care.

Among the facilities named in the suit is Beth Abraham Center for Rehabilitation and Nursing in The Bronx, which had its last standard inspection in 2021, according to medicare.gov.

Centers Health Care spokesperson Jeff Jacomowitz told THE CITY,  “we cannot comment on pending or active litigation.”

Even at five-star facilities inspections are months overdue. The West Village Rehabilitation & Nursing Center in Manhattan hasn’t had an inspection since August 2022, when inspectors found an incident of improper administration of intravenous antibiotics but no other issues.

As THE CITY has previously reported, the West Village facility changed ownership in recent years; workers and patients alleged food and staff were cut back as the new operator, Cassena Care, moved in.

Joan Randell’s 88-year-old husband, Sheldon Fein, stayed at the facility starting last August. She says she removed him just 11 days later for repeated lapses in care.

“He still has scars from that period,” she told THE CITY.

According to a complaint she filed with the state last September, Randell said Fein’s diaper was not changed for hours and lotions he needed were not given to him.

She ran into conflicts with the staff as she attempted to remain by his side during his rehab stay, where she monitored their dispensing of medications and salves.

Ultimately management threatened to call the police to remove her if she did not leave the facility, according to her complaint, and she left.

Randell said she received an acknowledgment of her complaint from the state but has heard nothing since.

The state Department of Health also has the authority to send inspectors in response to complaints. If it does, those inspections are separate from the 15-month federal standard. Even if a complaint is filed, there is no guarantee the state will follow up.

THE CITY reached out to Cassena but has yet to hear back.

Even when the system is working as designed, it doesn’t provide enough insight, argues Mollot, who has been pressing to get the federal government to release not only the inspection reports but also the plans of correction that facility operators agree to.

The delays in inspections are making what he already considers a “weak” monitoring system less reliable, he contends.

“If you haven’t shown up in a couple of years, that’s not oversight,” he said. “It’s become like the Wild West, facilities know that they can bend the rules and that they can get away with it.”

This story was published by THE CITY on July 1, 2024.

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  abuse, nursing homes, NYC