A nursing home where all but three of the Covid-19 deaths in Orleans County have occurred is under investigation by the state attorney general, as well as the county sheriff and district attorney.
Twenty-three people have died from Covid-19 at the Villages of Orleans, according to the most recent data released by the Orleans County Health Department.
“We’ve had an inordinate number of deaths there related to Covid,” said Orleans County District Attorney Joseph Cardone. “Nearly every death we’ve had in Orleans County has been a death at the Villages. Why did it get to that point?”
In Erie County, where 226 people have died from Covid-19 in nursing homes, the District Attorney's Office is not investigating any of the deaths. The state Attorney General's Office is not aware of any district attorneys in other counties investigating Covid-19 deaths in nursing homes.
"At this time, our office has not been asked to assist in the investigation of any nursing home deaths related to Covid-19," said Kait Munro, a spokesperson for Erie County District Attorney John J. Flynn.
Cardone declined to discuss any specifics about the focus of his investigation, but said he was looking at the Covid-19 deaths as well as broader concerns regarding resident care at the Villages.
More than two dozen current and former employees, as well as many relatives of residents, have come forward to state and county officials with complaints about the nursing home, saying its management has taken steps that have hastened the spread of Covid-19, according to Assemblyman Stephen Hawley, who represents Albion.
Relatives and staff say that the administration at the Villages has:
- Placed residents who tested negative for Covid-19 in the same room as those who tested positive.
- Withheld personal protective equipment from employees, keeping masks, gowns and other equipment locked in a room that only one person had access to.
- Required staff to rewear disposable gowns, and to wear the same gown while going from room to room.
- Made staff members work even when running a fever.
- Consistently not scheduled enough staff to properly care for residents.
“Why is my 80-year-old mom expendable just because somebody made choices about locking up personal protective equipment?” said Ondrea Pate, whose mother, Connie Brakenbury, had been admitted to the Villages for short-term rehabilitation.
Her mother had tested negative for Covid-19, but was then placed in a room with a woman who was Covid-positive, Pate said. Soon after she was discharged from the Villages, she tested positive. She died two days after Mother’s Day.
Brakenbury's death certificate listed stroke as the cause of death with Covid-19 as an unrelated significant condition contributing to the death.
“They are just unnecessary deaths that keep happening,” said Pate, who started an online petition demanding that the director of nursing at the Villages be replaced.
Neither the director of nursing nor the owner of the Villages, Comprehensive Management Healthcare Systems, responded to requests for comment. The company also owns Comprehensive Rehabilitation and Nursing Center at Williamsville, along with other nursing homes outside of Western New York.
State health inspectors conducted an unannounced visit on April 29 “and found the Villages of Orleans in compliance with infection control practices and CDC-supported guidelines issued by New York State,” state Health Department spokesman Jeffrey Hammond wrote in an email.
A subsequent visit, though, uncovered problems that caused or could cause serious harm to residents, he said.
The county’s investigation extends beyond the Covid-19 outbreak to include broader issues relating to how the facility has been operated and allegations of improper care of residents, said Cardone, the district attorney.
The Villages of Orleans is rated one star out of five – "or much below average" – by the Centers for Medicare and Medicaid Services in the most recent federal data. Registered nurses there spend 12 minutes a day per patient, less than one-third the state and federal averages.
Nurse's aides at the Villages spend about the same amount of time as the state and federal averages, according to the federal data. Licensed practical nurses at the Villages of Orleans spend an average of just over an hour a day with each resident, which is slightly more than state and federal averages.
Cardone said he had considered holding a coroner's inquest, during which a coroner can call witnesses to help determine the cause of death in the case of a suspicious death. But state law precludes holding a coroner's inquest to look into deaths at a nursing home, he said.
He noted that it is not currently possible to seat a grand jury, given the pandemic, but declined to say whether he is looking at filing criminal charges related to the investigation.
"Nobody's been arrested at this point," Cardone said. "There are no grand jury indictments."
Hawley has been pushing state officials to investigate the Villages. More than two dozen employees have contacted him with concerns, he said.
“It’s horrific because we’re talking about frail and elderly people losing their lives,” Hawley said.
Aides: PPE was limited
Some current and former employees say that since the outbreak began, they have gone without the necessary personal protective equipment.
The nursing home has a supply of PPE, they say, but it has been kept in a locked room to which only the director of nursing has a key. Some gowns and masks would be made available in the morning, but when the supply ran out, no more would be distributed, they said.
One employee said that the director of nursing said in March that she was not giving employees full access to the equipment.
“She said sometimes people take more than what they need. And she was saving it for when the virus got worse,” said a nurse’s aide who works at the Villages and asked to not be identified. “Face masks, hand wipes, gallons of hand sanitizer and bleach – and she just had it locked up.”
For several weeks, employees were told to reuse and share disposable gowns, she and another aide told The Buffalo News.
“To use a gown in a bunch of different rooms – that’s cross-contamination,” said Hope Albone, a nurse’s aide who recently quit. “You’re wearing a dirty gown into a Covid patient’s room. Then you wear it into another patient’s room.”
It was mid-April before staff were given any N95 masks, according to the former aide.
“I had the same N95 for two weeks. When the strap broke, I was told to staple it back on,” Albone said.
Aide quit over staffing levels
The nursing home has consistently not scheduled enough employees to provide adequate care, some current and former employees say.
Albone recalled one overnight shift when she was the only aide scheduled. Typically, she said, four to seven aides would work that shift in the 120-bed nursing home.
“I didn’t know where to start,” Albone said.
Because staffing was so thin, when more than one aide worked, the aide working with Covid-positive residents often had to assist the aide working with residents who had not tested positive, she and the other aide said.
Employees have been required to take their temperatures at the start of every shift. One evening, Albone’s temperature was 101.8 at the start of her shift. She was one of only two aides scheduled.
“My supervisor told me to suck it up. My co-worker was an older lady, so I didn’t want to leave her by herself with all those residents,” she said.
Albone stayed and worked. That was the night she decided to quit.
Sheriff’s deputies assist probe
Orleans County Sheriff Chris Bourke's office has been reaching out to staff and to relatives of residents, asking them to provide statements about the Covid-19 deaths at the Villages and the way the nursing home has responded to the pandemic.
Representatives from the state Attorney General's Office also have been reaching out to employees and residents' family members. More than one has said that someone from the Attorney General's Office has been in touch with them nearly every day by phone or text for at least a couple of weeks.
The daughter of one former resident said she told the sheriff she had concerns regarding the care the Villages had provided to her father. The sheriff offered to provide deputies to accompany the woman to the nursing home to ensure that the administration there would let her move her father out of the nursing home, she said.
“He said if you want to pull him out today, I will give you the support, the manpower, and you can take him out,” said the daughter, who asked that her name not be used.
Four or five deputies accompanied her to the Villages, and she signed papers acknowledging that he was being discharged against medical advice. An ambulance took her father to a hospital in Batavia, where the family has been paying out of pocket for his care.
“He’s doing great,” his daughter said. “He’s one of the very, very lucky ones.”
When state health inspectors visited the Villages at the end of April, they found the nursing home to be in compliance with state guidelines for infection control.
But inspectors soon returned for another unannounced visit.
On May 9, inspectors who visited the Villages cited immediate jeopardy – a designation given “when the provider’s noncompliance has caused, or is likely to cause, serious injury or harm and there is an immediate need for it to be corrected to avoid further or future serious harm,” Hammond, the state Health Department spokesman, wrote in an email.
The nursing home took steps to correct problems, and the immediate jeopardy has been lifted, Hammond wrote.
Because the state's investigation of the Villages is ongoing, he said, he could not comment further.
The state is continuing to closely monitor the facility, he said.