Nursing home resident Sally Keller looked forward to cataract surgery on her left eye. Days earlier, the cataract in her right eye had been removed and her vision dramatically improved.
"I went down the hallway saying, 'I can see, I can see,' " the 70-year-old Keller recalled.
But after her second cataract surgery, Ellicott Center for Rehabilitation and Nursing, a nursing home on Buffalo's West Side, repeatedly put eye drops in the wrong eye, a state Health Department investigation determined.
"I said, 'The right eye is fine. It's the left eye I just had the surgery on,' " Keller said. "They said it is not written down. We only have a prescription for the right eye."
An infection ravaged Keller's left eye. Doctors said they had to surgically remove it.
Her story shows how a routine surgery can end horribly for residents in understaffed nursing homes.
Federal data shows most of the area nursing homes sold to out-of-town owners in the past 11 years are understaffed compared to nursing homes across the state – and the consequences can be tragic. The registered nursing staff at 15 of the 16 area homes sold to out-of-town investors show nurses spend less time with each resident than the state average. The registered nursing staff at Ellicott Center spends on average 30 minutes a day with each resident, according to the data. The state average is 42 minutes.
This hurts residents, according to the federal Centers for Medicare and Medicaid Services, which rates nursing homes. The federal agency notes there is "considerable evidence of a relationship between nursing home staffing levels, staffing stability, and resident outcomes."
Ellicott Center, where Sally Keller lived in October 2016 when her eye care went wrong, was bought in 2012 by a for-profit company owned by out-of-town investors. In the last three years, Ellicott Center was cited for nine deficiencies for "actual harm" to a resident or putting residents in "immediate jeopardy," the third-highest number among about 620 nursing homes in the state, according to Health Department records. It has been fined $49,053 since it was bought from the nonprofit Kaleida Health, government records show.
New York City-based Centers Health Care said it is "doing everything possible to ensure that no future occurrences like this one ever happens again." The company says it has made several changes since the incident, including having registered nurses on duty 24 hours a day and closely tracking that doctors' orders are followed.
"We have zero tolerance for any staff negligence," said a statement from Centers Health Care.
But to Keller, the mistakes that led to her losing an eye were easily preventable.
"This could have been avoided," Keller said, "if they had listened to the doctor."
What happened to Keller
Keller, a former nanny who stands 4 feet, 10 inches, says she is speaking out because she does not want to see others suffer like she did.
Here's what happened after the Oct. 10, 2016, cataract surgery on her left eye, according to Health Department investigative records:
It wasn't until Oct. 28, more than two weeks following the surgery, that the nursing staff began treating Keller's left eye. By then, her left eye was swollen, "inflamed and reddened," and Keller was in pain.
On that day, a registered nurse at the home called the Orchard Park ophthalmologist who had performed the cataract surgery and left a message that Keller's eye was possibly infected.
The call was returned 30 minutes later by a doctor serving his residency at the ophthalmologist's office. He recommended that Keller be taken immediately to the Orchard Park office's eye clinic or an emergency room.
That didn't happen.
"He was informed by the nurse that the facility had already taken care of it, that they had spoken to the facility physician who had already [prescribed] drops. The nurse expressed to the medical resident that the facility doctor and nurse did not feel that the patient needed to be examined emergently," the Health Department investigation report stated.
The News' Lou Michel and Mike McAndrew spent six months investigating Western New York nursing homes. Click here to see the results of their work.
The medical resident told the state investigator that the nursing home staff "did not seem that interested in speaking with him."
Three days later, the nursing home arranged for Keller to go to the ophthalmologist's eye clinic.
"By the time the resident was seen at the eye clinic on Monday, Oct. 31, 2016, the eye was so far gone the resident required antibiotic injections into the eye," the ophthalmologist told Health Department investigators.
Her eye did not improve. The next day she was rushed to Erie County Medical Center. Doctors told her that her left eye would have to be removed.
"I broke down and begged if there was possibly anything they could do to save the eye," Keller told The Buffalo News. "But they said they had to take it because the infection could possibly spread to the other eye. I told them do what you have to do."
During the surgery, doctors found the "the infection was so bad that bacteria had eaten a hole into the back wall of the eyeball," Keller's ophthalmologist told the Department of Health investigator.
She added that Keller "should have been seen at the eye clinic on Oct. 28, 2016, for any complications of eye surgery." The ophthalmologist said the delay resulted in severe inflammation of the inner eye "and loss of vision in the eye."
Nursing home's response
The Health Department investigation determined that Ellicott Center had allowed "significant medication errors" to occur involving Keller, as well as a second resident following cataract surgery. It cited Ellicott Center for failing to properly administer eye medications to them. State and federal officials last year fined the nursing home $21,053 for those missteps.
Ellicott Center is operated by Waterfront Operations Associates LLC, a company run by Kenneth Rozenberg and Jeffrey Sicklick, who are executives of Centers Health Care, the New York City company.
Centers Health Care, which has about 45 nursing homes in New York, New Jersey, Rhode Island, Kansas and Missouri, issued a statement expressing regret over the treatment of Keller.
“Staff from Centers Health Care and Ellicott Center are saddened by the 2016 incident involving former resident Ms. Sally Keller, but rest assured, we have been doing everything possible to ensure that no future occurrences like this one ever happens again," the statement said.
A spokesman for Centers said the company has implemented a number of changes to improve the Ellicott Center, a 160-bed facility at 200 Seventh St.
They include a new administrator, registered nurses on duty 24 hours a day and mandatory audits at the conclusion of each shift to ensure "absolute adherence" that doctors' orders have been followed in administering medications.
Still, the federal Centers for Medicare and Medicaid Services, in data released Wednesday, dropped Ellicott Center's overall rating to one star, or "much below average." That's the lowest possible rating.
Life with one eye
Keller describes the loss of her left eye as devastating.
As a young woman growing up on the East Side, she said, she was often complimented on her prominent hazel eyes.
"People would stop me and say, 'Oh, you have beautiful eyes,'" Keller said.
Keller, in her younger years, worked in local factories, married and moved to Germany when her husband served there in the U.S. military. They had one daughter before they divorced.
For many years, Keller lived with Margery and Joseph Stanton, helping them raise their children. After her health declined, she moved to an assisted living facility. She was placed at Ellicott Center in 2013 after she began to use a wheelchair.
Margery Stanton, who serves as Keller's health care representative, says it pains her to see what Keller has been through.
"Sally used to pass her time reading mystery and romance novels. Now the books she reads have to have extremely large print and she's putting strain on her one eye," said Stanton.
Removing a rubber-like, oval-shaped prosthetic eye from a case, Keller says the company that made it did an excellent job, but she rarely places it in her left eye socket.
"It feels scratchy and it bothers me," she said, explaining she would rather let her upper left eyelid droop over the hole where her eye used to be.
Ellicott Center sued
On June 20, Keller sued the nursing home, as well as Waterfront Operations Associates LLC, the limited liability company licensed by New York to operate it; Rozenberg and Sicklick; and Centers Health Care. Stanton, who has power of attorney for Keller, hired the law firm of Brown Chiari to handle the case.
Because of the errors that cost Keller her left eye, she moved from Ellicott Center to another nursing home. She resides at Absolut Center for Nursing and Rehabilitation in Orchard Park, which the federal government also rates as a one-star nursing home. It is operated by a different group of out-of-town owners.
"Now people stare at me like I'm a freak," Keller said of her missing eye. "It makes me self-conscious. I feel like, 'My God, do I look that bad?'"
Contact reporter Lou Michel at (716) 849-4508 or firstname.lastname@example.org.
Story topics: Nursing Homes