A report from the Missouri Department of Health and Senior Services concludes that the owners of a north St. Louis nursing home didn’t develop emergency protocols and procedures before moving residents out in December.
Northview Village workers moved 174 residents to different nursing facilities hours before the location on North Kingshighway abruptly closed. The report finds that the nursing home did not inform residents’ family members or guardians before moving them and that many residents did not have access to medications or possessions.
The report cites various problems, among them that workers moved residents from their rooms while alarms went off and that some people were trapped in an overcrowded elevator while phone lines were down.
“The facility failed to take measures to ensure security of the residents and staff during the evacuation and failed to secure resident belongings from theft. The failures jeopardized the health and safety for all residents and staff,” the authors of the DHSS report wrote.
The state’s health department released the report on behalf of the U.S. Department of Health and Human Services, since most facilities receive Medicare and Medicaid funding and are therefore required to follow federal requirements, a DHSS spokesperson said.
The owners moved residents from the building after running out of money to pay workers, according to the report. The closing sparked ire among residents, families and city officials who criticized the nursing home owners for not properly notifying residents and employees, almost one week before Christmas.
Medicare records show Mark and Lorraine Suissa, from Chicago, both own a 26% stake in Northview Village. Mark Suissa could not be reached for comment. Other people who own a stake in the company, including a member of the Illinois-based Rothner family, also could not be reached.
“I think it brings into clear focus how terribly run this was and how unnecessary that the way that this facility closed was,” said Marjorie Moore, executive director of VOYCE, a nonprofit advocating for nursing home residents and families. “Some of the stories about residents being moved out, residents not wanting to leave, some residents not being told that they were leaving until well after midnight is just something that I don't think we've ever seen before.”
Part of the report cites an interview with an administrator who said one of the owners didn’t have enough money to pay staff. The CFO told the administrator to transfer as many residents as possible to other facilities. Workers began an emergency evacuation of residents, and vans and buses from other homes arrived.
The report describes more chaos as the night went on. It notes that the facility moved some residents against their will.
Around 7 that night, “there was a lot of activity on the floor, with representatives from other facilities reading medical records, bagging medications from the medication carts, obtaining medical records and resident belongings,” the report’s authors wrote.
The investigation describes workers from other facilities moving people but medical records being lost in the shuffle.
According to the report, one witness said that as representatives from other nursing homes came, “they had notepads and the nurses were supposed to keep track of who was going where, but it was overwhelming. The facilities were pulling charts and not signing in. They were going floor to floor and it wasn't organized.”
Some residents were disoriented and crying, the report found. Others did not want to leave the facility. Emergency personnel sedated at least one person who refused to leave. According to another interview, one staff member threw up because of the chaos.
At least two residents, one with diagnosed schizophrenia and cognitive impairment and another who exhibited “grandiose delusions,” were free to walk off the property.
“Things could have been said earlier on that could have prevented a lot of this chaos.” Moore said. “I think that [owners] chose to not only not pay the staff and put them in a bad position.”
Waiting until the last minute to move residents put them at risk, she said.
Moore said business operators should be able to tell when their holdings are running out of money. She said the owners should not be able to own and operate nursing homes in Missouri.
Residents and their families have since been reunited, and city agencies have been able to help residents get new belongings, Moore said.
But trauma from such a move could have consequences for those who used to live at Northview Village. Nurses at new facilities may not understand former residents’ needs, especially if they are lacking the proper medical records, she said.
“You often see an increase in deaths after something like this, because of loneliness, isolation, things that might happen as a result of that new environment,” Moore said. “Maybe new care teams do not really understand what the old care team wrote in the medical records. In some of these cases, I think we still are missing medical records for some of these residents.”