Saturday, October 17, 2020

Families take their nursing home message to the State Capitol

Families who have loved ones in nursing homes across the state take their frustrations and voices to the State Capitol.

Posted By: Gary Liberatore 

Albany, N.Y. - The group called Take Back our Nursing Homes made a passionate plea at the State Capitol in Albany on Wednesday.

The group included a Utica woman, Karla Abraham Conley, who lost her mother Rosie recently during the COVID crisis and never got the chance to say goodbye due to the state's restrictions on visitation.

Some at the rally haven't seen their loved ones in months, others, like Karla, lost loved ones without seeing them before they passed away.

Those involved with the rally are not happy with the Governor's executive order stating that a nursing home or long term care facility can not allow visitors unless the facility has been COVID-free for 14 straight days, something that not many nursing home have been able to achieve since the pandemic began in march.

An attorney for the families urged them to go to the facilities and demand to see their loved ones, and if they aren't allowed, get an attorney and file a case against the state.

Abraham Conley says she's all for that, "That's something I think should happen. We have rights, we have our constitutional rights, civil rights, or human rights, the Bill of Rights, the senior rights, all kinds of rights and nobody is allowed to take those away from us and they have been, and I made the announcement today that if Cuomo doesn't sign this into executive order, walk in there go back and take your nursing home back."

Asemblywoman Marianne Buttenschon of Marcy was at the rally and supports allowing families to see their loved ones, but doesn't think having them go to the facilities is a good idea until the Executive Order is changed, "I do not recommend or support any individual taking actions that could upset the care and well being of our nursing home residents. The state has an obligation to work with nursing homes, families and residents to develop safe visitation policies and ensure residents are cared for and able to thrive. We must work on this using a regional approach, by assessing each region's COVID-19 data at any given point in time and by working with infectious disease prevention staff within each nursing home to provide the safest care for the residents."

In regards to overturning Governor's Executive Order, Buttenschon said the following on Wednesday, "The initial COVID-19 response demanded an ability for the Governor to respond quickly to the rapidly changing crisis. In May, after it was clear some of the Governor's directives were too broad and confusing, Senator Joseph Griffo and I introduced legislation (A10502/S8387) which would ensure the Legislature plays its rightful and equal role throughout emergency declarations by making the Governor's actions subject to review every 30 days. A governor should be able to do what is necessary to keep the people of their state safe in times of emergency, but this power should not be unlimited. This legislation would ensure that New Yorkers have a say in how the state deals with disasters and I will continue to advocate for it within the Assembly."

Senator Joe Griffo of Rome was also at Wednesday's rally and is also in support of overturning the Governor's Executive Order.

Griffo says he has called for the legislature to return to Albany and undertake its role and responsibility to be a co-equal branch of state government.

We contacted the Governor's office to get a response, but so far have not heard back.

Full Article & Source:

Chittenango nursing home fined $8,000 by the NYS Department of Health

by Mary Kielar

CNY Central has been reporting on The Grand Rehab and Nursing facility in Chittenango since May.

It’s where 10 residents have died, and 46 of the nearly 80 people who live there had COVID-19 during that month.

The New York State Department of Health cited The Grand after an inspection in May, which revealed the home failed to provide a safe environment for residents and to educate staff about preventing the spread of COVID-19.

On May 5th, the State Health Department did an infection control survey, which looked at procedures in place to stop the spread of COVID-19.

We now know that it uncovered that not every staff member was trained on health and safety protocols related to the virus - nearly two months into the pandemic.

The survey team also discovered some nursing home staff were not washing their hands or wearing gloves while taking care of residents.

One nursing aide even left her used disposable gown hanging on a handrail in a hallway.

The New York State Department of Health was fined $8,000 dollars for this citation.

A spokesperson tells CNY Central, "we have issued 105 citations to 77 nursing homes. To date, we have levied a total of $336,000 in fines to 24 facilities."

The health department says they visited every single nursing home and adult care facility in the state at least once since March first.

"This only represents a portion of the total number of cases for which we are actively pursuing fines. The Department will continue to hold providers who violate regulations accountable for their actions," explained a spokesperson.

Corrections submitted to the state by The Grand indicate every staff member will get the training they need, and understand the proper PPE needed while working with residents. It was approved by the Department of Health.

CNY Central has tried to contact the Vice President of the Grand Healthcare System, but has not heard back.

The Madison County Public Health Director is aware of the citation, but had no further comment when asked, according to a county spokesperson.

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Caregiver at Junction City nursing home arrested for mistreatment, theft

This is the latest controversy facing the Junction City Retirement and Assisted Living.
Posted By: Chelsea Hunt

JUNCTION CITY, Ore. – A caregiver at an embattled retirement home in Junction City has been arrested for elder abuse.

Noelle Jendraszek, 25, was taken to the Lane County Jail for 55 counts of first-degree criminal mistreatment, 44 counts of tampering with drug records, five counts of second-degree theft, and six counts of third-degree theft.

Police said the woman stole money, jewelry and drugs from residents at Junction City Retirement and Assisted Living, 500 E. 6th St.

This is the same nursing home that was evacuated last week after a power outage, drawing the attention of state regulators. Department of Human Services records show reports of abuse at the Junction City facility going back a decade.

Jendraszek has reportedly been cooperating with the investigation and has talked with investigators about her “wrongdoings,” police said. She has reportedly admitted to withholding vital and medically necessary medications from 44 vulnerable residents in her care.

The investigation began Sept. 10 when a resident’s son reported cash had been stolen from his elderly father. The man had moved into the Junction City facility in August 2018. Investigators talked to Jendraszek, who had been a med-tech there since October 2018. Within hours, the woman reportedly surrendered about 275 pieces of jewelry she said she'd stolen from residents at multiple facilities.

Jendraszek has been employed at the following facilities in the past five years, including:

  • Cedar Village Assisted Living Community – Salem
  • Capital Manor Retirement Community – Salem
  • Four Seasons Residential Care – Salem
  • Junction City Retirement and Assisted Living – Junction City
  • Gibson Creek by Bonaventure – Salem
  • Prestige Senior Living Orchard Heights – Salem
  • Redwood Heights Retirement and Assisted Living Community – Salem
  • River Grove Memory Care – Eugene

If you know someone who was a resident at any of those facilities in that time frame and believe jewelry may have been stolen, you are urged to review images of the recovered items by clicking here.

This is just some of the jewelry that police recovered in the case.

Police said Jendraszek indicated she's "at peace" with her decision to admit to the crimes. 

In a notarized affidavit, Jendraszek said: “I am very apologetic for any harm I have done and/or any sadness I have caused. It is my intent to correct my wrongs and do the right thing by taking responsibility for my actions. I hope someday that all the families and persons I have harmed can find it within themselves to forgive me because I know what I have done is wrong and I am seeking the help I need to recover and become a better person.”

Anyone with information regarding incidents of abuse or other crimes at Junction City Retirement and Assisted Living should contact police at 541-998-1245.

Full Article & Source: 

Friday, October 16, 2020

Britney Spears Wins Right to Expand Legal Team in Conservatorship Case

By Jem Aswad

Randee-St. Nicolas/Courtesy of RCA Records

Britney Spears
won a minor victory Wednesday in her conservatorship battle against her father, Jamie Spears: The singer will be allowed to expand her legal team, after a petition request was granted.

Britney, 38, is seeking to have Jamie removed from her conservatorship, which has been in effect for 12 years. She was not present for the latest hearing, although though her mother, Lynne Spears, Jamie and her attorney, Samuel Ingham were.

Jamie had opposed Britney’s petition, citing the cost of adding more lawyers.

Jamie Spears has been Britney’s co-conservator since 2008 when she suffered a very public breakdown. He became sole conservator in 2019 after attorney Andrew Wallet resigned from his co-conservatorship. Jamie Spears is recovering from treatment of a ruptured colon, after which Spears postponed her lucrative Las Vegas residency and later checked herself into a health facility for a month-long stay.

The #FreeBritney movement has long argued that the singer is essentially being held captive by the conservatorship, and for years fans have gathered outside the court hearings and cited what they claim are secret calls for help in the singer’s social media posts.

However, in a filing in August, Spears’ attorney said the conservatorship is “voluntary,” and that the singer is “strongly opposed” to her father remaining the sole conservator.

“Britney strongly believes it is consistent not only with her personal best interests but also with good public policy generally that the decision to appoint a new conservator of her estate be made in as open and transparent a manner as possible,” Ingham wrote.

Spears is petitioning that her temporary conservator, Jodi Montgomery, take on the role permanently. Furthermore, the document states that Britney Spears opposes her father’s continued control over her estate and would like to regain oversight of her finances. As the filing reads: “Britney … strongly prefers to have a qualified corporate fiduciary appointed to serve in this role.”

The court has granted Jamie Spears to be paid around $130,000 annually by his daughter’s estate for his role as conservator, and according to court documents obtained by ET, the largest expense of Britney’s estate in 2018 was her legal and conservator fees, which, in total, equaled over $1.1 million for that year.

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Minnesota Eases Visits To Long-Term Care Facility Residents

Minnesota health officials rolled back rules Monday that prevented many families from visiting their loved ones in nursing homes and assisted-living facilities because of the coronavirus pandemic.

The new guidelines from the Minnesota Department of Health allow indoor visitations at most senior homes that have not had new infections in the preceding two weeks and when the infection rate in the surrounding county is no more than 10%. The state still recommends that long-term care facilities limit how many visitors a resident can have at once and the duration of indoor visits.

The new guidance significantly eased the restrictions that had been in place since March, when nursing homes and assisted-living complexes locked down and barred family visits in an attempt to protect vulnerable residents, the Star Tribune reported. Advocates for residents and their families have been clamoring for relief, noting that many elderly residents have suffered anxiety, depression and physical decline because of the social isolation.

“We are really looking to make sure that we do everything that we can to have the residents and families be able to connect with one another,” said Lindsey Krueger, director of the department’s Office of Health Facility Complaints.

But officials cautioned that rising community spread of the virus could still prevent many senior homes from opening their doors. Nearly 250 long-term care facilities have had at least one positive case of COVID-19 in the last two weeks, meaning they generally will remain barred to indoor visits. Two counties, Martin and Redwood, have infection rates of greater than 10%, so visitations in those counties will remain restricted under the new guidelines.

The department reported nearly 1,200 newly confirmed infections Monday after a weekend where confirmed case counts rose by nearly 3,000. Hospitalizations in the state are approaching record levels for the pandemic.

The department on Monday also reported 14 new cases among people who attended recent political rallies in Minnesota.

Kris Ehresmann, the department’s infectious disease director, said the number of confirmed cases linked with President Donald Trump’s outdoor rally in Bemidji on Sept. 18 had risen to 16, up from nine as of Friday, including four people who attended a protest. Three cases have been reported among people who attended Trump’s outdoor rally in Duluth on Sept. 30. Three people tested positive after attending a rally Sept. 24 with Vice President Mike Pence in a Minneapolis-St. Paul International airport hotel ballroom, including one who was among the Duluth rally cases. Two individual cases have been reported among people who attended Joe Biden campaign events in Duluth on Sept. 16 and Brooklyn Park on Sept. 22.

Full Article & Source:

Elderly exploitation charged former caregiver

by Michael Moser

A woman who worked as a caregiver for an elderly Cumberland County man has been arrested and charged with three felonies, including exploitation of the elderly, according to the Cumberland County Sheriff’s Office.

Samantha Nicole Hardy, 24, 191 Blaine St., Pikeville, is charged with fraudulent use of a credit/debit card, theft of property of up to $1,000 and financial exploitation of the elderly, according to Sgt. James Scott’s arrest report.

The arrest follows a weeks-long investigation that was launched Sept. 14 when Scott responded to a call on Legion Rd. on a report of a theft. The victim told investigators he noticed items missing from his home on that date that included a stolen debit card.

The credit/debit card was canceled, but investigators learned it was presented on three different locations. Fraudulent charges were made Sept. 13 at a Dollar General Store on Hwy. 127 S in the amount of $304.95, a Dollar General Store and the Food Mart, both in Pikeville.

Investigation also showed that a charge of $422.61 was made at the Walgreen’s in Crossville and $414.25 at a Family Dollar Store in Gruetli-Laager, TN.

Investigators were able to obtain surveillance video showing a woman attempting to purchase a Visa pre-paid card and other items totaling $414.25.

A home health care agency was contacted and through the use of the video footage and with help from the agency, developed a suspect in the theft.

On Sept. 30, three warrants were served on Hardy. Bond was set at $10,000 with an appearance to be set in Cumberland County General Sessions Court.

Full Article & Source:

Thursday, October 15, 2020

How Nursing Homes Can Defend COVID-19 Criminal Charges

By David Schumacher, Stanton Stock and Jeffrey Lin
Law360 (October 13, 2020, 6:00 PM EDT) --
David Schumacher
David Schumacher
Stanton Stock
Stanton Stock
Jeffrey Lin
Jeffrey Lin
On Sept. 15, Massachusetts Attorney General Maura Healey charged leaders of Soldiers' Home in Holyoke, a 247-bed long-term nursing care facility, with criminal neglect for their role in a COVID-19 outbreak.[1]

Soldiers' Home is the first criminal case brought against nursing home personnel for their COVID-19 response, but there are similar criminal investigations pending across the country. Criminal prosecution for substandard patient care is relatively rare.

It is particularly alarming when such actions are initiated against front-line health care providers, who are making difficult patient care decisions, during an unprecedented global pandemic. These developments demonstrate that nursing homes must be prepared to defend their decision-making processes and infection-control practices to avoid criminal liability.      

COVID-19 Outbreaks in Skilled Nursing Facilities

Nursing homes across the country have been severely impacted by the COVID-19 pandemic. The resident population of a nursing home is particularly vulnerable, with many frail seniors who require assistance with basic activities of daily living (e.g., bathing and dressing) and 24/7 medical supervision.

Most nursing homes also promote a congregate living lifestyle, where residents have roommates, family and friends are encouraged to visit, and residents frequently come and go for appointments and other activities. The introduction of COVID-19, which is highly infectious and can spread through asymptomatic and presymptomatic individuals, can be catastrophic.

Massachusetts long-term care facilities have been hit particularly hard by the virus. There have been approximately 6,000 deaths in Massachusetts long term care facilities — constituting nearly two-thirds of the virus-related deaths in the commonwealth.

Adjusted for population, Massachusetts has the second highest rate of COVID-19 nursing home deaths in the country.[2] More than 375 facilities have reported at least one case of the virus, and approximately 25,000 residents and workers in Massachusetts long-term care facilities have been stricken by the virus.[3]

Meanwhile, federal, state and local health care government agencies were slow to provide consistent and helpful clinical guidance, because much less was known about COVID-19 relative to the diseases skilled nursing facilities ordinarily treat. Testing was not readily available. Numerous staffing obstacles created a national shortage of able-bodied nurses and nursing assistants.

Many nurses could not work because they demonstrated symptoms of COVID-19, had to care for sick or vulnerable family members at home or did not have child care when schools closed.

Nursing homes also had difficulty obtaining medical supplies, including personal protective equipment. Hospital supplies came first and skilled nursing facilities second in the new pandemic. All of these factors proved to be a catastrophic combination as deaths in nursing homes accounted for more than 40% of all U.S. COVID-19 deaths.   

Criminal Investigations

Even as nursing homes were actively responding to COVID-19 outbreaks, many state and federal criminal investigations ensued. For example, in California, the Attorney General's Bureau of Medi-Cal Fraud and Elder Abuse began investigating several nursing homes, following media reports of severe COVID-19 outbreaks.[4]

Special agents of the criminal division submitted numerous requests for evidence of infection-control policies, implementation of constantly changing clinical guidance, information about staff and resident infections, and documentation regarding transfers and discharges of COVID-19 residents. Some local county district attorneys also initiated investigations, coordinating the submission of subpoenas to all nursing homes within their respective counties.[5]

In Massachusetts, the U.S. Attorney's Office and the state Attorney General's Office have reputations for aggressively pursuing health care fraud investigations. Last year, the Massachusetts attorney general announced settlements in seven cases involving skilled nursing facilities where the office alleged substandard care or regulatory violations.[6]

Thus, in the wake of the pandemic, it was not surprising that Massachusetts state and federal regulators launched investigations into long-term care facilities .[7] In late July, several Massachusetts skilled nursing facilities reported that U.S. Department of Health and Human Services' Office of Inspector General agents made unannounced visits, leaving business cards and inviting staff to contact them with any concerns.

These states were not alone.

In Pennsylvania, a nursing home that experienced a severe COVID-19 outbreak was raided by the Federal Bureau of Investigation.[8] Investigators were executing a search warrant for evidence relating to infection-control practices.

In Connecticut, state investigators contemplated a criminal probe of a volunteer nurse who may have worked in a nursing home despite being exposed to the coronavirus.[9]

In New Jersey, the attorney general announced a statewide investigation of nursing homes and long-term care facilities, focusing on facilities that had a large number of coronavirus deaths, inadequate staffing and poor health inspections.[10]

Soldiers' Home

Soldiers' Home is the first criminal case brought against leadership of a nursing home for their role in a COVID-19 outbreak. The criminal indictment follows an independent investigation that was conducted at the request of the governor of Massachusetts.[11]

Established in 1952, the Holyoke facility is one of two long-term care centers that Massachusetts operates for veterans. In the spring of 2020, at least 76 veterans at the facility died from COVID-19, and 84 veterans and more than 80 staff members also contracted the virus.

According to the independent investigation, the most significant error on the part of Soldiers' Home's leadership team was combining two locked dementia units, which had a mix of COVID-19 statuses (i.e., positive, symptomatic and asymptomatic residents), crowding 40 veterans into a space meant to hold 25, even though some veterans from each unit had already tested positive for the virus.

The report faulted Soldiers' Home for this catastrophic decision, exposing asymptomatic veterans to those stricken by the virus, rather than isolating the veterans who were already infected. The investigation concluded that this decision was approved by the facility's superintendent and at least acquiesced to by the medical director, though both leaders would not admit to being involved in the decision-making process.

Other substantial errors included delays in isolating patients, delays in testing residents who were showing symptoms, delays in closing common spaces, rotating staff among COVID-19 positive and negative units, inconsistent use of personal protective equipment and recordkeeping and documentation failures.

According to the investigation, these errors likely contributed to the scope of the outbreak. The report also concluded that the Soldiers' Home superintendent, Bennett Walsh, was "not qualified to manage a long-term care facility"; Walsh's background was in the military, and he was reported to have obtained the position through political connections.

Theories of Criminal Liability

Walsh and David Clinton, the facility's medical director, were both charged under a Massachusetts criminal statute that punishes caretakers who cause harm to elderly individuals.[12] This law provides that a caretaker who "wantonly or recklessly permits serious bodily injury to [an] elder or person with a disability" can be imprisoned for up to ten years, fined up to $10,000 or both.

"Caretaker" is defined as a "person with responsibility for the care of an elder person" in a variety of settings.[13] "Serious bodily injury" is an injury which "results in a permanent disfigurement, protracted loss or impairment of a bodily function, limb or organ, or substantial risk of death."

Interestingly, even though the independent report concluded that the facility's director of nursing was also involved with the decision to combine the two dementia units, this individual was not charged.

This law is familiar to Massachusetts health lawyers but there are very few reported court decisions interpreting the statute. Indeed, the only reported case directly addressing the charge at issue was Commonwealth v. Cruz in the Massachusetts Appeals Court. 

In Cruz, the defendant, the caretaker for his mother, was charged with criminal neglect after his mother died from sepsis as a result of sitting in her feces and urine for several weeks. The evidence of neglect was overwhelming, and the appeals court affirmed the conviction.

Here, no one can dispute that the Soldiers' Home circumstances were tragic. However, to sustain a criminal conviction, the government will have to prove that the defendants committed "wanton or reckless conduct," which, in this context, means "intentional conduct, by way either of commission or of omission where there is a duty to act, which conduct involves a high degree of likelihood that substantial harm will result to another."[14]

While the defendant need not intend that his or her conduct will result in substantial bodily injury, the government must prove more than a mistake of judgment or even gross negligence.[15] The standard is objective: What would a reasonable person do under the circumstances?

A jury will have to determine if the conduct of these skilled nursing facility executives — in particular, bringing asymptomatic veterans in close contact with infected veterans — rises to the level of wanton or reckless conduct under the law.

Other states have similar criminal statutes, targeting wanton or reckless care of elderly persons.

For example, in relevant part, California's Penal Code Section 368 provides that a caretaker who "willfully causes or permits the person or health of the elder or dependent adult to be injured, or willfully causes or permits the elder or dependent adult to be placed in a situation in which his or her person or health is endangered," is punishable by imprisonment for up to seven years, a fine up to $10,000 or both, depending on the facts and circumstances of each case.

Thus, it is possible that the Soldiers' Home indictments are a model of cases to come.

Defending a Response to an Outbreak

The unavoidability of COVID-19 outbreaks is an issue yet to be determined. Indeed, studies conducted months after the COVID-19 pandemic began have found that there was no correlation between having a COVID-19 case and a facility's star rating on the five-star quality rating system, prior history of infection violations, and "whether it was for-profit, part of a chain, or having a high Medicaid census."[16]

Without systematic testing, which was not available at the early stages of this pandemic, "COVID-19's ability to hide in plain sight [could] continue to crush expectations of halting its spread."[17] Regardless of whether an outbreak could have been avoided, nursing homes can take precautions now toward demonstrating they acted reasonably under the circumstances.  

Document pre-COVID-19 infection-control efforts.

Maintaining documentation that demonstrates pre-COVID-19 infection-control practices/programs can help demonstrate a nursing home acted reasonably. Federal regulations set the baseline for the infection-control procedures, including specific types of documents nursing homes should maintain (e.g., policies and procedures).[18]

Demonstrating adherence to these regulations can provide evidence that a nursing home acted reasonably. Skilled nursing facilities should also determine if their state maintains infection-control requirements.

Document efforts to reasonably monitor and implement updated COVID-19 guidance.

Documentation of efforts to monitor and implement COVID-19 guidance can provide additional evidence that a nursing home acted reasonably. Skilled nursing facilities should monitor when the guidance was provided, any staff training and implementation of any guidelines. Investigators may look at emails as to when a new policy was implemented and in-service records as to when staff were trained.

Understandably, keeping up to date with all COVID-19 guidance is a challenge. Guidance has poured down from multiple levels — the Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, state public health departments, county public health departments, city public health departments, and even specific survey teams.

In tracking such guidance, note any inconsistencies between guidance, infeasibility in following the guidance, or simply dangerous guidance. For example, the U.S. Department of Justice has requested COVID-19 data from New York, New Jersey, Pennsylvania and Michigan regarding a potential investigation into whether those states endangered residents by requiring nursing homes to admit COVID-19 patients.[19]

Document efforts to maintain adequate staffing and medical supplies.

Staffing and supply shortages may have been unavoidable for many nursing homes, but it helps to demonstrate efforts to address these issues. Below are some steps nursing homes can take to document their efforts.

  • Maintain invoices of medical supply orders, which were not able to be filled.

  • Document inventory accurately and proper storage procedure (e.g., secured/locked office).

  • Document efforts to contract with third parties for staffing support, seek nursing assistance from local hospitals or utilize support from other company facilities.

  • Document efforts to incentivize staff to work extra hours, e.g., pay differentials, hotel accommodations, etc.

Consult with counsel about any communications with a criminal investigator.

Concurrent civil and criminal investigations may also raise Fifth Amendment concerns. As mentioned above, Office of Inspector General investigators have made unannounced visits to numerous skilled nursing facilities. If a criminal investigation is ongoing, the facility should consult with experienced counsel before any employee interacts with a criminal investigator to minimize the potential of self-incrimination.

Analyze state-specific legal defenses.

This article predominately focuses on the investigative phase, but providers should be aware of what legal defenses are available in their state. Some states have enacted immunity legislation.

For example, Massachusetts passed a law in April providing certain liability protections for acts or omissions by health care professionals and facilities, but there is no immunity if the act or omission constitutes "gross negligence, recklessness or conduct with an intent to harm or to discriminate based on race, ethnicity, national origin, religion, disability, sexual orientation or gender identity."[20]

Other defenses to consider include breaks in the chain of causation, impossibility (e.g., if it was impossible to obtain adequate medical supplies or sufficient staff) and reasonable reliance on government-issued guidance.


The COVID-19 pandemic has had a devastating impact on the entire country, but nursing homes have become ground zero. The introduction of COVID-19 into a congregate living environment, which is occupied by an elderly and frail population, has led to catastrophic outbreaks in many instances.

While the unavoidability of these outbreaks is an issue yet to be determined, allegations of substandard care are usually litigated through regulatory enforcement actions or civil matters premised on ordinary negligence.

The use of criminal statutes to prosecute allegations of substandard care is relatively rare and aggressive. This is particularly true in the middle of an unprecedented, global pandemic. Nonetheless, criminal investigations are pending, and indictments have already been filed. Thus, nursing homes should be prepared to defend their decision-making processes and infection-control practices in these uncertain times.

David S. Schumacher and Stanton J. Stock are partners, and Jeffrey Lin is an associate, at Hooper Lundy & Bookman PC

The opinions expressed are those of the author(s) and do not necessarily reflect the views of the firm, its clients, or Portfolio Media Inc., or any of its or their respective affiliates. This article is for general information purposes and is not intended to be and should not be taken as legal advice.

[1] See AG Healey Announces Criminal Charges Against Superintendent and Former Medical Director of Holyoke Soldiers' Home for Their Roles in Deadly COVID-19 Outbreak, (Sept. 25, 2020),

[2] See Lizbeth Kowalczyk and Robert Weisman, Last Words Part 2: A home to die in, The Boston Globe (last accessed Oct. 2, 2020).

[3] See Lisa Kashinsky, Massachusetts nursing homes still face PPE issues as coronavirus creeps back, Boston Herald (Aug. 9, 2020, 11:16 AM),

[4] In California, the BMFEA has the authority to conduct an investigation at the business location of any Medi-Cal provider. Cal. Gov't Code § 12528.1(a); see also Cal. Code Regs. tit. 22, § 51476(g) ("A provider shall make available, during regular business hours, all pertinent financial books and all records concerning the provision of health care services to a Medi-Cal beneficiary" to a BMFEA employee when acting with the scope of his or her employment.).

[5] California district attorneys have the authority to investigate violations of California's false advertising laws. See Cal. Bus. & Prof. Code § 17535. California Business & Professions Code section 17500 is a statute that prohibits false or deceptive advertising to consumers regarding the nature of a product or service. A conviction is a misdemeanor that carries a maximum sentence of up to 6 months in jail and/or a fine of up to $2,500.00. Id. at § 17500. In addition, California district attorneys have the authority to investigate alleged violations of certain chapters of the California Business & Professions Code including but not limited to Chapter 4 (commencing with Section 17000) and Chapter 5 (commencing with Section 17200). Id. at § 16759.

[6] See AG Healey Announces Seven Settlements Following Major Investigation into Nursing Home Facilities, (Mar. 13, 2019),

[7] See, e.g., Mass. AG Investigating Coronavirus Response at Littleton Nursing Home, NBC 10 Boston (May 27, 2020, 12:11 PM),

[8] See Tim Stelloh, FBI raids Pennsylvania nursing home where hundreds caught coronavirus, dozens died, NBC News (Sept. 3, 2020),

[9] See Dave Altimari, Nurse accused of reporting for work at Norwich nursing home despite possible coronavirus infection could face criminal probe, Hartford Courant (Sept. 2, 2020),

[10] See Nursing Home Misconduct Reporting Form, New Jersey COVID-19 Information Hub, (last accessed Oct. 2, 2020).

[11] Mark Pearlstein, et al., The COVID-19 Outbreak at the Soldiers' Home in Holyoke; An Independent Investigation Conducted for the Governor of Massachusetts, (June 23, 2020) ("Report"),

[12] Mass. Gen. Laws. c. 265 § 13K(e).

[13] Id., § 13K(a).

[14] Cruz at 209.

[15] Commonwealth v. Michaud, 389 Mass. 491, 499 (1983).

[16] Amy Mendoza, Facility Location Determines COVID Outbreaks, Researchers Say, Provider Magazine (May 12, 2020),,-Researchers-Say.aspx; see also H. Abrams, M.D. et al, , Characteristics of U.S. Nursing Homes with COVID-19 Cases, Journal of the American Geriatrics Society (June 2, 2020), ("COVID‐19 cases in nursing homes are related to facility location and size and not traditional quality metrics such as star rating and prior infection control citations."); The Five-Star Nursing Rating comes from the Centers for Medicare & Medicaid Services' ("CMS") Five-Star Quality Rating System, designed to help consumers compare nursing homes more easily. Five Star-Quality Rating System, (Oct. 7, 2019)  For example, a nursing home with 5 stars is "considered to have much above average quality." Id.

[17] James M. Berklan, The only hope we have is for testing, top nursing home analyst says, McKnight's Long-Term Care News (May 11, 2020),

[18] See 42 C.F.R. § 483.80.

[19] Department of Justice Requesting Data From Governors of States that Issued COVID-19 Orders that May Have Resulted in Deaths of Elderly Nursing Home Residents, Department of Justice (Aug. 26, 2020),

[20] S.B. 2640, 191st Gen. Ct. of the Commonwealth of Mass. (Mass. 2020).
Full Article & Source:

3 southern Indiana residents charged with neglect, abuse of woman

LOUISVILLE, Ky. (WDRB) -- Following a seven month investigation, three people in southern Indiana accused of abusing a 22-year-old woman in their care are facing felony charges.

Indiana State Police began investigating John Staples and Rose-Kathryn Staples in February after they received a report that they physically harmed and confined in their home a woman who was under their guardianship, according to a news release.

Police say the abuse occurred while the woman was in their custody in 2019 and early 2020 in Butlerville. Trudy Henry, a caretaker of the woman, is also accused of placing her in a straitjacket.

All three are facing felony neglect of a dependent and criminal confinement charges and were booked into the Jennings County Jail. 
Full Article & Source:

‘Shutdown is literally killing people’: families of isolated nursing home residents demand compromise

by Jessica Glenza

Relatives visit a loved one in a nursing facility in
Lindsay, California. Photograph: Jeremy Hogan/Barcroft Media via Getty Images

Eldercare advocates argue that facilities have allowed asymptomatic staff members with Covid-19 in, but kept loved ones out 

Martha Louise Duncan was as bright as the blue Texas sky of the Rio Grande Valley where she was born, and when she was young, she styled her hair to just about touch it. She was clever, fashionable, and determined to climb the corporate ladder.

She worked her way up to become the vice-president of one of America’s largest advertising firms, and bought a dark red Porsche and mauve Pendleton suits along the way.

“My mom was a brilliant, brilliant woman,” said Duncan’s daughter, Mary Nichols. Duncan would marry five times and have four children before she began to suffer from Alzheimer’s disease.

What made Duncan the “runway-ready” woman of Nichols’ memories has now slipped away, much of it during the 202 days when nursing homes in Texas were entirely shut to visitors due to the coronavirus pandemic.

Just as the virus has exposed chasms in American society around race and inequality, it has also sharpened the plight of many families with vulnerable members in care homes: denying them vital social contact when time is a rapidly vanishing possession.

“There’s no eye contact, she can’t speak, she can’t move her own arms or legs, she can barely, and I mean just barely, turn her own head. She can barely swallow her own saliva at this point,” said Nichols. “She doesn’t look like she’s going to die any day now. Her organs are still functioning, but she’s definitely – there’s no cognition left at all.”

A grassroots movement of families is demanding compromise on nursing home lockdowns, arguing that social isolation for nursing home residents is nearly as deadly as the virus that sent their facilities into lockdown. The calls come amid uneasiness from eldercare advocates and as rapid Covid-19 tests are only beginning to reach nursing homes.

“Many of these facilities’ families haven’t been in there in months, and they can see their family members dwindling away, and they’re losing days they can never get back,” said Dave Bruns, a spokesperson for the American Association of Retired Persons (AARP) of Florida. Nevertheless, they face a “lose-lose” proposition.

“Just the isolation caused by the shutdown order is literally killing people,” he said. “If you don’t reopen them, that’s definitely going to kill some people, and if you do open them it’s definitely going to kill some people.”

Jack Campise talks with his mother Beverly Kearns through a window at a nursing home in Windsor, Connecticut. Photograph: Chris Ehrmann/AP

Window visits and FaceTime, caregivers argue, are insufficient and can be actively distressing to some patients. Further, they argue lockdowns have allowed asymptomatic staff members with Covid-19 into nursing homes, but allowed “no room for error” for family members.

“I know there are groups out there who do feel it’s too soon. We still need to be social distancing,” said Mary Daniels, founder of Caregivers for Compromise. She has organized the groups primarily on Facebook, after she was barred from seeing her husband.

US health authorities severely restricted visitation to long-term care homes in March, after 46 people associated with the Life Care Center in Kirkland, Washington, died. Those who helped feed, bathe and dress their loved ones were suddenly and summarily locked out, including Nichols and Daniel.

Since the early days of the pandemic, experts have said the key to reopening nursing homes is rapid Covid-19 testing. But seven months later, nursing homes are only beginning to get the kinds of less-accurate-but-rapid tests experts believe are needed.

According to the publication LeadingAge, federal authorities say about 7,600 nursing homes have received rapid tests to date, focused on facilities in counties with high infection rates. That is about half the nursing homes in the United States.

The new tests have also posed a new problem: once facilities run out of testing supplies provided by the government, they must pay $32 per test for more supplies, the New York Times reported.

Now, seven months after facilities were sent into lockdown, families have watched loved ones wither, lose weight, and withdraw. Many were helpless as loved ones died alone from Covid-19. And the United States is diagnosing more than 50,000 new Covid-19 cases per day. Concerns about isolation are “pervasive” across the industry, experts told the Journal of the American Medical Association.

Mary Daniels got a job as a dishwasher just so she could visit her husband Steve who lives in a nursing home in Jacksonville, Florida. Photograph: AP

Caregivers for Compromise has been especially influential in Florida, after Daniels went to drastic lengths to see her husband. Daniels, after watching her husband cry in confusion through a window, got a job as a dishwasher to see him. She was permitted to see him in his room on her days working.

“My response to that, again, is why is it OK as a dishwasher, but it’s not OK as a wife?” she said. “I would buy that at two months, and three months and four months, but these patients need stimulus and touch,” she said.

Nichols has a starker way of putting it: “We have been saving them to death.”

Daniels was able to gain significant traction with Florida’s “mini-Trump” Republican governor Ron DeSantis, after her story went viral. She served on a task force, and successfully lobbied for an “essential caregiver” designation and hugs.

But other advocates noted Florida loosened restrictions, but did not enhance testing protocols, even as rapid tests were just becoming available.

“They specifically did not require testing, and it came at a time when the facilities, many of the facilities, were just getting the rapid point-of-care testing that would be perfect for this,” said Jeff Johnson, state director of AARP Florida. “If we didn’t need to wait for the testing, why did we need to wait to let people back in?”

Many facilities, petrified of legal liability and reeling from the cost of caring for patients with Covid-19, still bar visitors. Others severely limit time with family, many require all visits be conducted outdoors.

Sue Grover has to be monitored while she visits with her mother, Betty, in full personal protective equipment on a hot Florida patio. But the aides who accompany her mother wear no PPE at all, Grover said.

She asked: “If [the staff] can be there right up next to my mom … without anything, why can’t I go in and be in her room with a face mask? With whatever?”

The issue of how to reopen nursing homes is still one of “dignity”, said Patricia Davidson, a professor of nursing at Johns Hopkins University.

“The big challenge in the US is dealing with a pandemic in an individually focused, non-coordinated way,” said Davidson. “You can be a fabulous healthcare facility and have every system and process including testing, but people are going out into a world where bars are open and people are out in the street,” she said.

“This is something that I really believe we’re going to be debating for decades to come: what was really the right thing to do?”

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Wednesday, October 14, 2020

‘We can’t help her:’ Families of residents forced to leave Norwich nursing home in wake of coronavirus outbreak frustrated, worried

By Dave Altimari
Karen Kingston stands on her front porch for a portrait at her home Friday, Sept. 18, 2020, in Old Lyme. Kingston's 98-year-old mother lives at Three Rivers Healthcare nursing home in Norwich, which the state Department of Public Health moved to close this past Wednesday, Sept. 16, 2020, after several residents have died from COVID-19 and over two dozen others became infected with the virus. Kingston, whose mother tested negative for the virus, said all the residents have to be moved out in two weeks. (Kassi Jackson/The Hartford Courant)

The moment she learned about the first COVID-19 case in the Norwich nursing home where her mother lives, Karen Montanaro Kingston had been frantically trying to get the 98-year-old out of there.

But word of the outbreak at the Three Rivers Healthcare Center got out. Other homes shied away, she said, saying her mother was a “high risk” patient — even as Three Rivers staff assured her that her mother, Irene Montanaro, didn’t have the coronavirus.

Karen Kingston's mother, Irene Montanaro is 98 years old and lives at Three Rivers Healthcare in Norwich, Conn. She has tested negative for COVID-19. (Provided by Karen Kingston)

Kingston watched as the situation at Three Rivers worsened, an outbreak that would infect more than two dozen patients and staff and claim at least four lives. Montanaro’s former roommate at the facility died on Sept. 10 as the number of cases kept climbing.

“We would get these robocalls every Tuesday or Thursday and one time it said there were 10 new cases and that’s when I knew it was out of control and we needed to get her out of there,” Kingston said.

Now, with the state taking the dramatic step of ordering all patients out of the nursing home, Kingston and the family members of the other residents at Three Rivers are dealing with another disruption. The evacuation is the latest blow to families who had little contact with their loved ones because of the coronavirus lockdown and dealt with ongoing reports about the outbreak spreading and residents' dying. Now, their loved ones are being abruptly uprooted.

“We are kind of in limbo right now and don’t know what’s going to happen,” Kingston said. “Who is going to move my 98-year-old mother? We can’t go in there and help her pack. We can’t help her settle into a new place. She is going to have to go through this alone at 98-years-old.”

One tragedy after another

The decision to relocate all 53 residents was made quickly by state officials as they came to realize the depth of problems inside the Norwich facility.

Two inspections at the facility identified a range of infection control issues — many preventable errors in areas that received widespread attention as COVID-19 tore through nursing homes across the state, killing upwards of 2,500.

The problems cited by the health department included staff shortages, failure to properly cohort COVID positive and negative residents, having staff work with both COVID positive and negative residents on the same shift and lack of proper PPE. Among the issues that has generated widespread attention is the decision to work by a nurse who had vacationed with family members concerned they might be infected.

Now, in wake of the decision to move the residents out, state officials are scrambling to contact all of the families of residents to assure them their loved ones are OK and to get a sense of where they might want to go next. Some families haven’t been contacted, while other residents don’t have families to contact and are under the care of a conservator.

“We have not heard anything from anyone as to what is happening in there. We are completely in the dark,” Katelynn Gosselin said.

Katelynn Gosselin (left) is pictured with her grandmother Maryjane Jackson who is a resident of Three Rivers Healthcare in Norwich, Conn.
Katelynn Gosselin (left) is pictured with her grandmother Maryjane Jackson who is a resident of Three Rivers Healthcare in Norwich, Conn. (Provided by Katelynn Gosselin)

Gosselins’ 82-year-old grandmother, Maryjane Jackson, has been at Three Rivers since February. Jackson fell at home and was injured. She went to Three Rivers for rehabilitation, but needs 24-hour supervision now.

“I would like to get her out of there and home but that’s not possible,” Gosselin said. “I would hope they will move her somewhere close.”

Some families were told Friday by DPH officials that they plan to have everyone out of Three Rivers within two weeks. They will be moving four or five residents a day, starting with the COVID positive cases. Many of those, officials have said, are going to the Riverside Health and Rehabilitation Center in East Hartford.

Long-term Care Ombudswoman Mairead Painter said her office has been swamped with calls from family members since the announcement. She said the fast moving situation has left everyone with questions and family members worried about their loved ones.

“For some of them this has been their home for years and now they have to move somewhere new,” Painter said. “It’s been one tragedy after another for these families.”

“Mom was OK there”

When the first COVID case was announced in mid-August, Gosselin started a petition seeking to have any residents who were positive transferred out of Three Rivers before the virus spread. About 200 people signed it.

“We thought she was in a safe facility where they would take good care of her — and that didn’t happen,” Gosselin said.

Gosselin said she has no problem with the state moving patients out of Three Rivers.

“I have to say I see it as a good thing that they’re closing it because I don’t think the staff did a very good job of protecting people,” Gosselin said. “The fact a nurse was able to go to work while she was sick and not wear a mask and no one said anything to her is more than enough to close it down.”

Gosselin is referring to the actions of a supervising nurse who worked a double shift on July 24 after going on vacation in Rhode Island. She told several of her fellow employees that she wasn’t feeling well and that at least two members of her family had gotten COVID-19 tests, according to DPH investigators.

Three days later the nurse tested positive as well. Several employees told the DPH that the woman didn’t wear a mask as she worked the double shift.

DPH hasn’t identified the supervising nurse, but the Courant has learned her name is Mary Ciezynski, who was working as a part-time employee at Three Rivers. Among those infected was her mother, a patient at the facility who has since died, though not of COVID.

All told, 21 residents have tested positive as well as six staff and at least four residents have died. The outbreak spread beyond the walls of Three Rivers to nearby Backus Hospital where at least nine employees were infected by a Three Rivers resident who spent several days in the hospital in mid-August.

Norwich, CT - 9/16/20 - The Connecticut Department of Public Health announced Wednesday that Three Rivers Healthcare will be closing after several COVID-19 patient deaths and at least a number of other infections. Photo by Brad Horrigan |
Norwich, CT - 9/16/20 - The Connecticut Department of Public Health announced Wednesday that Three Rivers Healthcare will be closing after several COVID-19 patient deaths and at least a number of other infections. Photo by Brad Horrigan | (Brad Horrigan/The Hartford Courant)

The rapid outbreak was an abrupt turnaround. Up until the late July incident, Three Rivers had been relatively COVID-free with only a handful of cases and no deaths.

“My mom was OK there. It’s an old building but she liked the people taking care of her,” Kingston said.

While she didn’t like that she couldn’t visit her mother all of the time, Kingston was aware of how the virus was impacting other long-term care facilities across the state and knew the sacrifice was necessary.

Since Eastern Connecticut in general had very low case volumes she thought her mother was safe.

“They had done so well for so long but once they got one case it went down fast,” Kingston said.

Infection spread rapidly

The two DPH reports on Three Rivers revealed a litany of problems.

The facility, investigators found, was short-staffed. Eighteen of the 21 shifts that DPH reviewed between August 28-September 3 showed that one nurse worked alone in the A Wing, where patients with suspected COVID-19 were under observation.

Three Rivers also failed to properly test all of its employees as mandated by Gov. Lamont’s executive orders, the state found. A review of testing records showed that of the nursing homes' 55 employees, 16, or 29 percent, had missed weekly testing for COVID 19.

At least three patients were sent to the emergency room at William Backus Hospital without written documentation that the residents had COVID-19. DPH also cited Three Rivers for failing to cohort patients once the virus was detected and for having nurses working with both COVID positive and negative patients on the same shift.

Given the range of problems, the state late last week quietly appointed attorney Katharine Sacks as temporary manager of the facility, taking over all clinical decision-making from the owner, JACC Healthcare Inc.

But Sacks said it took her about 30 hours in the facility to realize that residents needed to be removed and that there was no way she could bring back into compliance by the state’s deadline of Sept. 30.

“I realized the building blocks of compliance weren’t here,” Sacks said, last week. She added she has been appointed a temporary manager of a long-term care facility about 30 times and had “never been in a facility she didn’t think could be brought up to compliance.”

Sacks said there was a severe staff shortage, lack of training for staff and no competent oversight of staff that was there.

In a statement, the nursing home owners, JACC Health Center of Norwich, said that it supported Gifford’s order to move all patients out of the facility. While Gifford’s executive order doesn’t actually close Three Rivers, it is unclear how it would operate without any residents.

“Since the initial COVID outbreak, we have been cooperating with the State Department of Public Health to bring our facility into full compliance with state and federal regulations, including the engagement of a Temporary Manager to oversee the facility,” the statement said. Following an initial assessment, the temporary manager concluded that bringing the facility back into substantial compliance within the timeframe mandated by regulatory bodies was not feasible due to a number of concerns, including the absence of critical staff."

Painter said given the depth of the issue at Three Rivers, she understands why DPH made such an unprecedented decision.

“It all comes down to poor management by a private, for-profit company,” Painter said. “This is opening people’s eyes about what no one sees inside a nursing home.”

The state’s plan is to first move the 17 residents identified as COVID positive and the seven residents under observation to the Riverside Health and Rehabilitation Center in East Hartford which still maintains a COVID-only wing. Riverside has had its own problems with COVID with more deaths than any facility in the state.

The 29 residents who have tested negative, including Irene Montanaro and Maryjane Jackson, will be placed in nursing homes within 15 miles of Norwich, if possible. While state officials have said there is capacity in nearby nursing homes to place Three Rivers residents, Painter believes it will not be easy or quick.

Just because a facility may have beds available doesn’t mean it’s the right fit for someone from Three Rivers. Painter said some people need 24-hour care, certain medications or a facility may not have the staff to handle more residents.

“Many families have been trying to get their loved ones out of there for weeks and can’t because other facilities don’t want people from a ‘high risk’ facility,” Painter said. “The state is going to have to make sure all the residents are tested and assure other facilities they aren’t exposing their residents to COVID.”

Kingston said she is hoping to get her mother moved closer to her Old Lyme home.

“I want to call somewhere and reserve a room but what if they can’t move her right away and we lose our spot?” Kingston said. “A 98-year-old woman shouldn’t have to go through this.”

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‘Sadistic’ Nurse Who ‘Enjoyed Inflicting Pain’ On Elderly Patients Killed 3 With Antipsychotic Drug

By Aly Vander Hayden

In the spring of 1990, 82-year-old Alphonse Silva underwent treatment for throat cancer, and he was subsequently admitted to the Rosedale Manor Nursing Home in St. Petersburg, Florida as part of his recovery process. 

“[W]e hoped that Rosedale Manor would enable him to eventually recover and come home,” his son, Art Silva, told “License to Kill,” airing Saturdays at 6/5c on Oxygen

Not long after Alphonse settled in, however, he passed away, and his family believed he had succumbed to the cancer. It was not until 10 weeks later that an investigation was opened into a Rosedale Manor nurse, proving Alphonse’s death was anything but natural. 

On July 31, 1990, Helen Gasky-Brummer, who specialized in elder abuse at the Florida Department of Child and Family Services, received a call from the abuse hotline about a suspicious nursing home death. Muriel Watts, a 79-year-old comatose patient at Rosedale Manor, had passed away, but multiple nurse’s aides on duty at the time reported that they did not believe Watts had died from natural causes. 

When Gasky-Brummer arrived at Rosedale Manor, she spoke with the licensed practical nurse in charge, who was convinced that some type of mishap had led to Watts’ death, piquing Gasky-Brummer's suspicion that foul play could have been involved. 

“Nurses see death every day. Why is she concerned about this one patient?” Gasky-Brummer told producers. 

The night of Watts’ death, the LPN in charge of the wing was Brian Rosenfeld, and witnesses reported an alarming interaction between him and the comatose patient. 

“Muriel Watts had a fever. Brian Rosenfeld put some Tylenol down the tube, but then two aides had observed him pouring some brown liquid, a huge amount, down her feeding tube,” former Tampa Bay Times reporter Stephen Nohlgren told "License to Kill.” 

When an aide asked Rosenfeld why he was administering the mystery liquid, he instructed her not to question his methods, and she later heard Rosenfeld say that Watts “would be gone soon.” 

Within hours, Watts was dead, and Rosenfeld insisted on cleaning her body before the undertaker arrived, a task that was normally carried out by nurse’s aides. Even stranger, he washed Watts’ entire body with mouth wash and refused to let anyone else help or touch her remains. 

In order to have Watts’ body examined for evidence and halt her scheduled cremation, Gasky-Brummer contacted local authorities to report her suspicions, and the Pinellas County Sheriff’s Office took on the case. 

After speaking with Gasky-Brummer and reading her investigative report, Pinellas County Sheriff’s Office Deputy Chuck Vaughn placed a hold on Watts’ remains, and an autopsy was performed by the medical examiner’s office.  

Vaughn then made his way to Rosedale Manor, where he learned that Rosenfeld had been fired not just for the Watts incident, but also for recurring behavioral issues. 

“The nursing assistants complained that if they had done something that irritated Rosenfeld, he would over-administer laxatives to patients as a means of getting back at the nursing assistants,” Vaughn told producers. 

Nursing aides also described Rosenfeld as “sadistic” and said he had come “to enjoy inflicting pain on other people,” Nohlgren said. 

Digging further into his background, investigators learned Rosenfeld had worked in more than 16 nursing homes over a 10-year span, and former colleagues relayed incidents in which Rosenfeld would physically abuse his patients. Some recalled that he bent patients’ fingers back until they screamed in pain, and other co-workers detailed times when Rosenfeld threw water on a patient and shoved a banana down another’s throat. 

Any time nursing assistants challenged Rosenfeld and his behavior, he would simply pull rank. 

No formal complaints were ever filed against Rosenfeld, however, and there was no physical evidence or proof to validate the witnesses’ claims. So, he went on to work in multiple nursing homes without consequence. 

“It was hard to tell whether he was fired or whether he left on his own, but it could be what would lead to him jumping from nursing home to nursing home,” Gasky-Brummer told producers. 

Brian Rosenfeld Ltk 210 2

While Watts’ autopsy revealed no external signs of injury and no definitive cause of death, investigators sent blood and gastric content samples to the lab for further analysis. Vaughn then met with Rosenfeld at his apartment to discuss the various complaints against him, which he claimed were nothing more than malicious accusations. 

After the toxicology report came back, it revealed that Watts’ blood had toxic levels of acetaminophen and five times the normal dose of a drug called Melleril, which is an antipsychotic medication normally prescribed to patients with schizophrenia or mood disorders. 

As Watts was comatose, there was no reason for her to have Melleril in her system, according to “License to Kill.” 

Authorities brought Rosenfeld in for an interview on Aug. 23, 1990, and he told investigators that due to him being stressed and overworked, he may have accidentally administered the wrong medication to his patients. When questioned about Watts, Rosenfeld admitted he possibly could have given her the Melleril in error. 

“He said, ‘I have occasionally mixed up medications for patients,’ and he even went so far as to say it was about 50 percent of the time,” Larry Bedore, chief investigator for the medical examiner’s office, told producers. 

Rosenfeld was then arrested for Watts’ murder and held without bail, and law enforcement began to expand its investigation, learning that a total of 201 patients had died during Rosenfeld’s shifts, according to “License to Kill.” 

“That gave us a list of potential bodies that needed to be investigated for evidence of malfeasance on Brian Rosenfeld’s part,” Assistant Medical Examiner Jackie Martino told producers. 

Investigators narrowed down the investigation to three cases — including Alphonse and Hazel DeRemer, an 81-year-old Alzheimer’s patient who died three years earlier — in which the bodies could be exhumed and autopsied for evidence.  

As they awaited the autopsy results, David Greenway, a former cellmate of Rosenfeld’s, contacted authorities and told them that Rosenfield had admitted to injecting a female comatose patient with Melleril because he felt sorry for her.  

He claimed Rosenfeld said he had done this on numerous occasions and had claimed approximately 23 victims across various nursing homes.  

It was ultimately revealed that Alphonse and DeRemer had lethal amounts of Melleril in their systems, and Rosenfeld’s charges were upgraded to three counts of first-degree murder.  

The case never went to trial, however, as Rosenfeld agreed to plead guilty in order to avoid the death penalty. He was given three life sentences without the possibility of parole.  

To learn more about the case, watch “License to Kill” on

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