James Cook, a 47-year-old stroke survivor who lives in a Trenton long-term care facility, was preparing to head to the Statehouse earlier this month to lobby for nursing home reforms when he realized he wasn't going anywhere.
The elevators in his building, Trenton Gardens Rehabilitation and Nursing Center, were once again out of service. Cook, who uses a wheelchair, could only stare out his third-floor window as the ACCESS Link van that provides public transportation to people with disabilities was forced to leave without him and another member of the nursing home's residents' council for the short ride to the capitol building.
"It was important for me," he said of the missed trip.
Laurie Facciarossa Brewer, who serves as New Jersey's Long-Term Care Ombudsman, saw no shortage of irony in the situation. She noted that Cook and a fellow resident had been planning to talk to legislators during AARP's "Legislative Day" to speak one-on-one with elected officials, including efforts to push a long-stalled nursing home transparency bill sponsored by state Sen. Joseph Vitale, D-Middlesex and other legislation aimed at long-term care abuses.
Both Cook and the second resident were unable to attend because they were basically trapped on their floor, she said, urging state regulators later to cite Trenton Gardens for what she called "a safety hazard and a stunning violation of the residents' rights in this building."
Trenton Gardens is a poorly regarded nursing home that most recently garnered only 1-star -- considered "much below average" in the U.S. Centers for Medicare and Medicaid Services' 5-star rating system. Its previous owners sold the rights to the license to operate the facility to a new entity two years ago, according to the state Department of Health. Earlier this year, the department halted admissions there over failures to report a number of physical altercations and several incidents of opioid overdoses, records show.
That curtailment order has since been lifted.
Meanwhile, a state survey team has been onsite conducting a recertification survey since December 2 and was aware of the elevator issue that has since been resolved, said a department spokeswoman. Separately, she said the department's Crisis Operation Team, which is deployed when a facility is in economic crisis or facing serious health and safety violations, has been on the scene since October.
A message left with a receptionist at Trenton Gardens was not returned and multiple emails to the nursing home's administrators went unanswered.
One of the major efforts by Facciarossa Brewer and other advocates in the waning days of the lame duck Legislature has been passing the Vitale bill, (S1948), which would impose greater financial transparency on the industry. It would require identifying all the owners of a nursing home, as well as all the owners of any third-party entity exercising substantial management control over the home.
First introduced in the 2022-23 session, the bill was shelved without ever posting to the full Senate. Reintroduced last year, it was co-sponsored by eight other Democrats.
While there are other reform measures pending before the Legislature, the transparency bill took on new life after an investigative series earlier this year by NJ Advance Media and its sister newsrooms in other states that looked at food spending by nursing homes across the country and payments by long-term care operators to related companies they also controlled.
The reports involved a data analysis of the more than 10,000 federal cost reports filed each year by every nursing home in the nation. The analysis found that more than a quarter of all nursing home operators spent under $10 a day to feed their residents -- less than what it costs to buy a Quarter Pounder with cheese, fries and a Coke at many McDonald's.
The stories found that the use of side businesses with related or even overlapping owners has become widespread. While legal, advocates say it often blurs where the money went, although in some cases, critics say operators have siphoned funds intended for resident care to their personal and business interests.
At a budget hearing in May, state Human Services Commissioner Sarah Adelman said they found nursing home operators did not spend rising government aid to improve resident care and quality.
"And I think you saw some of that articulated in the news stories," Adelman told legislators, also citing the NJ A pieces.
Earlier this month, the Office of the State Comptroller issued a new report that found what it called "a troubling pattern of mismanagement, self-dealing, and profiteering" at the Deptford Center for Rehabilitation and Healthcare and Hammonton Center for Rehabilitation and Healthcare -- two troubled nursing homes in South Jersey that share ownership.
Investigators for the state agency said staff disregarded call bell, and left one resident sitting in their own urine and feces for hours. Management ignored pleas for assistance from nurses and staff. Two residents were allegedly sexually assaulted, the comptroller's report said.
But while all this was happening, the comptroller said the operators of the two long-term care facilities pocketed millions of dollars.
Attorneys for the nursing homes said both facilities had "strong, above-average quality CMS measure ratings" and played a vital role in serving their local communities. They said the comptroller's report overlooks that reality and misstated "both the facts and the law."
At a press conference outlining the allegations against the nursing homes in Deptford and Hammonton, Facciarossa Brewer said New Jersey nursing homes received more than $4 billion in taxpayers' money through Medicaid and Medicare in 2023 alone.
"The public deserves to know where every dollar went. And the harsh truth is that we really don't. What we do know is that many nursing homes routinely divert money away from resident care and into the pockets of owners and owners' families," she complained.
While she said the comptroller's Medicaid fraud division has proven to be a leader in identifying fraud and clawing back misspent public funds from for-profit nursing homes, the state of New Jersey needs to do more.
Part of that, she said, is for the state health department to better monitor conditions in nursing homes and scrutinize their finances.
"When a nursing home is routinely understaffed, we shouldn't just fine them, we should shut down their admissions. We shouldn't allow them to take in new patients or new residents when they can't care for the ones that they have," she said. "We should demand additional disclosures from individuals or entities seeking to purchase nursing homes."
Deptford and Hammonton showed there needs to be more financial transparency for nursing homes, the ombudsman said.
"The legislature should pass Senate Bill 1948, which would require nursing homes to provide audited financial statements not just for the individual nursing home, but for the entire nursing home chain and any related parties," she said. "The legislature needs to act rather than continually passing rate increases for nursing homes with no transparency across the board."
She said she was also troubled the Legislature awarded various rate increases for nursing homes during final closed-door budget negotiations in June. The state set aside $3.6 million, qualifying New Jersey for an additional $3.6 million from the federal government to pay for the higher rates.
"By increasing the bed tax, the intent of the Legislature was to give the nursing homes a ton more money and yet they still can't muster the political will to pass the transparency bill," Facciarossa Brewer said.
Andrew Aronson, president and CEO of the Health Care Association of New Jersey, which represents the state's long-term care industry, argued that nursing homes "are the most financially transparent providers within the health care system."
He noted that long-term care facilities provide quarterly financial reports and three separate types of annual financial reports to the state of NJ, as well as annual reports to the federal government.
"The state Medicaid program has the authority to audit reports for accuracy, and previous audits have shown that the information is accurate and reliable," Aronson said, calling S-1948 "an example of the worst type of government overregulation, imposing duplicative reporting requirements, bureaucratic roadblocks, and unsustainable costs on healthcare providers that divert time, effort, and resources away from patient care."
The real issue, he said, is that New Jersey's Medicaid payment rates lag woefully behind the rates paid in our surrounding states.
"These unacceptably low rates drive staffing shortages, access issues, and undermine quality," he said, noting that his association consistently asks the Legislature to raise Medicaid rates "so nursing homes can recruit and retain staff, expand access, and deliver the level of care New Jersey seniors deserve."
Vitale, meanwhile, said he won't give up on trying to pass the stalled bill.
"I am continuing to push for this legislation," said the Middlesex Democrat and chairman of the Senate Health, Human Services and Senior Citizens Committee, citing in particular the stories by NJ Advance Media that he said, "clearly demonstrates the unquestioned need for my transparency legislation."
Still, the bill remains bottled up in committee.
In the Assembly, Majority Leader Lou Greenwald, D-Camden, said he has not been approached by the AARP or the Assembly sponsor of a companion bill in connection with the nursing home transparency bill. But he maintained he has done nothing to actively oppose it.
After reviewing the bill at NJ Advance Media's request, Greenwald said the bill ought to be changed. Rather than requiring every nursing home to undergo an audit, the state Health Department should do a random number of audits to see if the owner is complying with transparency requirements.
"If the owner is in compliance, the state should pay for the audit," he said. If the owner is not in compliance, the owner should cover the audit's cost, he argued.
"I support absolutely financial transparency," Greenwald added. "Our focus should be on patient safety," protecting state dollars and drawing down as much federal aid to pay for care as possible."