7 Eyewitness News Investigates: Nursing Home Neglect

NF nursing home cited, fined; but remains open
Posted at 3:28 PM, Nov 14, 2016

Jackie Murray-White's relatives have lived in some of the most troubled nursing homes in Western New York. 

There’s Emerald South on Delaware Avenue, where a man beat 82-year-old Ruth Murray to death in August.

And Humboldt House, which drew scrutiny for a rat infestation that same month.

But Murray-White says none of those places compares to the poor conditions her mother faced at Niagara Rehabilitation & Nursing in Niagara Falls.

“Out of all the places she could have been placed, this is the worst one I've ever seen,” Murray-White said. “It's disgusting.”

Jackie Murray-White with her mother on her wedding day

Located in one of the most blighted areas of the cataract city, the Cedar Avenue facility has been called a modern day poor house – and a nursing home of last resort. 

“It’s hard not to conclude that there's some major issues at the facility,” said Niagara Falls Mayor Paul A. Dyster. “It really seemed as though the staff were being pressed to the limits of what they could try to do for the people who were there.”

One of those patients called 7 Eyewitness News, pleading for our help. Her complaint prompted us to launch a two-month-long investigation into conditions at the nursing home. 

“Out of all the places she could have been placed, this is the worst one I've ever seen,” Murray-White said. “It's disgusting.”

7 Eyewitness News dug through years of state reports and found many troubling problems. We talked to many current and former patients, employees and managers of the nursing home – many who want to see improvements at the nursing home.

“The urine stench when you walk out onto the floor was overpowering,” said Murray-White, the daughter of a recent patient. “When you walk by their room, people would call, asking for help, because none of the nurses would help them."

She said the conditions were so bad, she refused to bring her new baby there to visit – except when they had no choice but to come. 

“My sister and I would have to leave our homes because no one would come take her to the bathroom,” Miller-White said. “There was a time where she sat for two to three hours in her own pee because no one would clean her up…They would yell at her for calling.”


Sitting just blocks from City Hall – set back and hidden from the view of most downtown travelers – Niagara Rehab has quietly racked up one of the worst records in Western New York. 

The federal Centers for Medicare and Medicaid Services ranks all of the region’s 74 facilities. Only three places had lower rankings than Niagara Rehab. A manager said rankings have lowered with negative events like these:

  • In March 2008, a patient jumped out of a third-story window, falling to his death.
  • Just six months later, a nursing aide was charged with sexual assault of an 89-year-old woman.

Things were supposed to improve when Israel and Samuel Sherman of New York City bought the nursing home in 2012.

But even at the ribbon cutting, patients approached the mayor with pleas for help.

“They were saying, no one knows what's happening here,” Dyster said. “No one knows what the people living here have to go through. “Can you tell the world somehow about what it is that's going on here?”

One of the worst records in Western New York

The federal government rates the nursing home one out of 5 stars – the lowest possible rating. A January inspection by the state health department found 23 violations – nearly six times the state average for every 100 beds.

Twice in 2015, it was cited for "severe, systemic deficiencies" after regulators found the facility "failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being."

This resulted in a pattern of "immediate jeopardy and substandard quality of care to resident health and safety," reports show.  

Many patients have developed bed sores -- infections that eat through the skin. Multiple patients or their relatives have filed lawsuits against the nursing home, seeking payment for their pain and suffering.

In one case, reports show workers neglected to get the patient on antibiotics for four days, which "likely caused the resident's condition to worsen" and develop MRSA. 

Full report from Centers for Medicare and Medicaid Services

The state levied a $14,000 fine after that incident. 

We tried to speak with the owners but Samuel Sherman’s lawyer said he would decide whether it was “in our best interest” to comment for the story. We never heard from him again. 

Israel Sherman sent a letter stating he could not comment due to “privacy concerns.”

After being escorted off the property, we were able to get some answers from one of the company’s managers by phone. She said they have hired a new medical director (the last one was cited for not attending a quality assurance meeting for two years) and have made changes in other key positions.

“Anytime we hear that, we're right away [saying], ‘OK, who worked, who was in the room at that time, what did you do, what did you do,’ and if anybody did anything wrong, yes, they are disciplined, up to and including termination,” said Mary Swartz, director of strategic planning for Avante Management, which oversees multiple nursing homes in the region.

But just five months later, in January of this year, something even worse happened.

'Help! Help! I Need Help!'

State documents show that on Jan. 20, a man who was sent to Niagara Rehab for short-term care began complaining of abdominal pain at 2 a.m.

For the next two and a half hours, reports say there was "no documented evidence" that nurses monitored the man's vital signs or even so much as called a doctor.

At 6:30 a.m., the man, lying on his back, repeatedly yelled for help, saying “Help, help, help, I need help."

Inspectors said twice, nurses walked by the man's room, ignoring his pleas.

By 9:30 a.m., seven hours after he first cried out, the man was dead.

Nursing officials dispute the account of the state inspector who wrote the report. 

“One nurse in particular was very upset about that situation because...she was in the room and was acting from the moment she got on the floor before 7 o’clock in the morning,” said Swartz. “There's two sides to every story.”

The State Department of Health takes the health and safety of residents very seriously. State DOH conducted an onsite recertification inspection at Niagara Rehabilitation & Nursing Center in January, 2016 and cited 23 deficiencies, including one at harm level due to DOH’s findings that the nursing home failed to conduct a timely comprehensive assessment of a residence’s change in condition by an RN, to timely notify the resident’s physician and to monitor the resident’s condition. The resident passed away. As a result, state DOH imposed a $10,000 fine against Niagara Rehabilitation & Nursing Center. The nursing home was also required to submitted a Plan of Correction on February 14, 2016 to DOH for review and approval.
Statement from NYS Department of Health

After that death, the state fined the facility $10,000.

To be sure, nursing home officials at the facility are fighting an uphill battle. 7 Eyewitness News has talked with employees who appear to be making an honest effort to improve the situation. Many of them are taking extraordinary measures to care for those who much of society has left behind.   

There are broader issues at play here, Dyster said, such as funding for and affordability of health care in America and the condition of the country’s social safety net. 

State Department of Health officials say they have approved a plan of correction for the facility and the number of violations in recent months was down to eight.

Swartz says she has hired a new nursing director and administrator to make sure mistakes like this never happen again. 

“We don't want this to be like this,” Swartz said. “We have to investigate it, we have to report it, and people lose their jobs.”  

Members of the ownership group also own the Absolut nursing homes in East Aurora, Dunkirk, Eden, Gasport, Orchard Park, Houghton, Salamanca, Allegany and Westfield.

Nursing homes are ranked on a five-star scale, with five stars being the best rating and one star the worst. 

All but one of those homes received 1- or 2-star ratings from the federal government, and the highest rated facility – Absolut in Gasport – received 3 out of 5 stars.

Humboldt House, which was cited for the rat problem earlier this year, is also owned by the family.

Drug Use Has Plagued Facility

Drugs – legal and illegal – also appear to be an issue.

One source has told 7 Eyewitness News that 100 of the 140 patients currently at the nursing home are on psychotropic drugs.

“This is a scary place,” Gromosiak said. “They don’t know what the hell they’re doing, and those that are doing anything are haphazard about it.”

A former employee also told us that staff members have been known to go to the nearby Tops parking lot to do drugs. Others pile into a pickup truck, leave the facility and smoke marijuana, the source said.

The facility was cited by the federal government for improperly securing prescription drugs like hydrocodone, oxycodone and fentanyl, and a staff member confirmed that at least one employee has been suspended for using drugs or taking them from the facility.

Dyster said: “One of the complaints I heard was that there was substance abuse, perhaps by some staff members but certainly by people who were residents there, so you had people who are leaving the facility, becoming intoxicated or high on drugs, returning to the facility, and then you’ve got them across the hall from someone who is sitting there quietly trying to read a book or watch a television show.”

Paul Gromosiak just recently escaped this environment.

Paul Gromosiak

“This is a scary place,” Gromosiak said. “They don’t know what the hell they’re doing, and those that are doing anything are haphazard about it.” 

Gromosiak said his treatment started improving after 7 Eyewitness News made visits to his room and started asking questions of the administration.

After management cut off our visits, we spoke with Gromosiak by phone. He described the nursing home in biblical terms.

“Hell,” he said. “Yes h-e-l-l…or, maybe purgatory, one or the other…but more like Hell.”

“This is not a prison,” he added. “We’re not in prison being punished for something. We’re here to get well – at least some of us are.”

Others – one in four patients who come through the doors for a long-term stay -- actually see their conditions worsen inside the rehab center, reports show. Gromosiak said he felt like this before discovering that nurses had made a mistake with his medication. 

“I don’t know when I’m gonna get the hell out of here. And I hope nobody else dies.”

Like Murray-White's mother, Gromosiak finally received his transfer to another facility recently. 

He is reported to be doing much better.

Charlie Specht

This story is a result of a two-month long investigation that started with a tip from a 7 Eyewitness News viewer. If you have any tips about nursing homes, or other places you would like investigated, please contact reporter Charlie Specht at charlie.specht@wkbw.com

WKBW photojournalist Jeff Wick edited this piece for television. WKBW Digital Site Director Catlin Bogard assisted with this web story.


Since this story aired...

Since this story first aired last night, 7 Eyewitness News received more than a dozen complaints from former residents who had horror stories of their own to tell.

“Everyone in the community knows of its reputation and prays we don’t end up in there one day,” said one Niagara Falls resident.

Another said she had to quit her job in Tampa and move back to Western New York to care for her father, a former patient there, “to make sure he didn’t die” in the nursing home.

The daughter of another former patient said her father, when he asked to go to the bathroom, was told that he had to wait – sometimes for hours – and sometimes had an accident, at which point she said staff members yelled at him for having the accident.

“He begged me to take him home,” she said. “It was heartbreaking.”

Still, amidst all the pain and suffering, some positive signs have emerged:

  • The number of violations in recent months went down from 23 to just 8 and in some categories, the nursing home’s star rating has improved from 1 to 3 stars.
  • According to a staff member, a “new regime” has been put into place in recent months with seven new department heads and managers. They say they are committed to turning things around.
  • The staff member provided documents showing that as recently as October 17, the State Health Department investigated a complaint and determined that “there were no violations of state or federal regulations.”