Advocates want public involvement when nursing homes change ownership

Some of the most sizable and troubled nursing homes in the state of Vermont have struggled for much of this year to provide sufficient care under new ownership, logging violations that included a death, injuries and neglect of residents.

The slate of investigations and new operators’ previous track records have raised questions about how Vermont vets prospective operators and protects residents, under a longstanding process that was supposed to be only temporary.

Corrective plans and subsequent inspections have recently led the facilities to achieve compliance with state regulations. But advocates say there should be policy changes to improve the state’s review process of new ownership, to preempt and root out the problem of poor care.

Genesis HealthCare, a large-scale nursing home operator and private-equity-backed company, sold off six of its nine Vermont nursing home facilities in the past year to little fanfare before filing for bankruptcy this summer.

Genesis had a questionable track record operating in the state in recent years and had been trying to sell its Vermont holdings for years. Facilities under Genesis ownership in Burlington, Berlin and St. Johnsbury were the subject of one of the largest nursing home-related settlements in state history in 2020 after a resident died and two others were hospitalized.

In 2023, the state granted iCare Health Network a contract to operate the former Genesis-owned Bennington Health & Rehabilitation Center. Under the state contract, the new operator agreed to serve people who would typically not be taken in by other nursing homes due to complex mental health challenges or being formerly incarcerated. iCare took over the facility in September 2024 and renamed it MissionCare at Bennington.

This past December, Allaire Health Services, led by CEO Benjamin Kurland, assumed control over former Genesis facilities in St. Johnsbury, Springfield and Rutland. Stellar Health Group owner Ari Erlichman took over facilities in Berlin and Burlington after gaining state approval.

Under a provisionary — but longstanding — ownership transfer process overseen by the Agency of Human Services, these nursing home operators were approved out of the public eye.

With somewhere between 91 and 126 licensed beds at each facility, these nursing homes are all considered large scale, and therefore the care and system breakdowns reported at the facilities affect a sizable swath of the state’s elderly population, said Kaili Kuiper, the state long-term care ombudsman for Vermont Legal Aid.

Since the ownership transfer dates, the rate of complaints reported by residents received by Vermont Legal Aid’s Long-Term Care Ombudsman Project shot up at four of the six facilities, and rose across the board by an average of 25%, according to a data analysis by VTDigger.

Pamela Cota, assistant director for the Division of Licensing and Protection, which inspects facilities to ensure compliance with state and federal guidelines, said the division will investigate complaints and issue citations when substantial evidence of deficiencies are found.

“We expect all of our homes to be in compliance all of the time, so whenever we’re citing a violation, that means that there’s something broken,” Cota said. “We don’t allow for a grace period.”

Nursing homes are typically required to draft corrective plans that are submitted to the state when the facility fails to meet minimum care standards. The division then accepts the plans and conducts a follow-up inspection to ensure changes are implemented before a facility can be considered back in compliance, Cota wrote in an email.

Given the gravity of the situation reported at some facilities this year, Cota said the division has imposed new measures to ensure the safety and care of residents.

“We evaluate each case and really look to what enforcement actions might assist the facility in achieving and sustaining that compliance,” Cota said in an interview.

Death at MissionCare

At MissionCare at Bennington, a resident died from lithium toxicity, according to a March inspection by the state Division of Licensing and Protection. The inspection stated that the resident regularly received lithium carbonate medication despite the resident displaying signs of toxicity.

The facility’s failure to contact doctors, conduct lab work and amend its care plans for the resident put “all residents at risk for serious injury or death because of the noncompliance,” according to the inspection.

David Skoczulek, a spokesperson for iCare, wrote in an email that the company disagrees that “any action by the facility violated state or federal law in this case,” although he wrote that changes were implemented following the incident.

In order to gain state approval, Skoczulek noted that iCare had qualified under the state’s regulatory standards and was considered capable of “delivering secure, stigma free and high quality care” to residents with state-determined “specific service needs.”

“We are honored to be entrusted with this mission and to partner with the State of Vermont to address this critical care gap,” Skoczulek wrote.

Kuiper said she could not comment on the operator’s legal liability for the death, but said that long-term care facilities are supposed to implement measures to prevent lithium toxicity.

“We certainly would expect there the recommended testing to be done and completed,” Kuiper said. “It’s a horrible tragedy that this person died because no one caught that she was suffering from lithium toxicity.”

MissionCare at Bennington is currently in compliance as of September, Cota wrote in an email.

‘Widespread system failure’ at Allaire

The three Vermont facilities now run by Allaire Health Services have faced a string of problems in recent months as well, including resident neglect, medication errors, staffing shortages and the rollback of COVID-19 protocols, state inspections show.

St. Johnsbury Center for Living and Rehabilitation was found to have “immediate jeopardy” level violations due to neglect cases and “widespread system failure” that put residents at a “serious risk” of harm and death, according to a July state inspection.

The facility faced chronic staffing shortages and lacked systems for care planning, medication management and lab services. The July inspection also found breakdowns in communication among staff, residents, physicians and state officials, leading to delayed care, unresolved complaints and other failures.

According to the inspection, the director of nursing confirmed to the inspector that she heard about a reported incident in which a certified nursing assistant allegedly slapped a resident across the face, but did not think it was necessary to notify the state. The administrator then told the inspector that she filed a state report in June, but there was no record of the report being received by the state a month later.

The July inspection found widespread lack of care plans and treatment for residents with diabetes at the facility. In one case, a diabetic resident was denied insulin by a previous medical director, who told the state inspector it is a “dangerous medication” for nursing home residents, according to the report.

That incident came after a different St. Johnsbury nursing home resident with diabetes was hospitalized due to dangerously high blood sugar levels, after a staff member refused to seek medical attention for the resident, according to an inspection report in May.

In an April inspection, staff members also reported that the St. Johnsbury facility’s medical director told staff not to test residents and to stop testing themselves for COVID-19 in March after an outbreak in January, and COVID-19 personal protective equipment and N-95 masks were removed from the facility.

The vice president of operations told surveyors that the previous medical director “did not believe in COVID” and told “staff to pull the precautions and stop testing the residents for COVID and to treat symptoms like the cold,” according to the inspection.

Due to the repeated problems at the St. Johnsbury facility, Cota said, the division implemented an “extended survey” of the nursing home in July to identify system-level issues and violations that caused immediate jeopardy to residents. Once the state completed the extended inspection, Cota said the St. Johnsbury facility laid out an “extensive quality improvement plan” on Aug. 12, so the division did not impose a direct corrective plan.

As of Sept. 3, the St. Johnsbury Center for Living and Rehabilitation was found in compliance by the state after an unannounced follow-up inspection, according to Cota.

At the Rutland Center for Living and Rehabilitation, state inspectors found in August that a resident with dementia and a co-occurring mental health diagnoses was physically abused by a licensed nurse assistant. While receiving care, the resident hit the assistant, and the staff member responded by striking the resident across the face, according to the inspection.

A resident was hospitalized for a fractured hip, according to a state inspection in June, after the Rutland Center for Living and Rehabilitation failed to place nonskid strips on the resident’s room. The inspection also found that the facility failed to store drugs and food properly and implement hygiene practices.

The Rutland Center for Living and Rehabilitation was found in compliance in September, Cota wrote in an email.

At the Springfield Center for Living and Rehabilitation, a licensed nurse withheld a resident’s pain medication, did not treat their wounds and inserted a silicone catheter even though the resident had a potential allergy to silicone, according to a state inspection in March. Adult Protective Services were called after the report, but the licensed nurse continued to work at the facility during the investigation.

The grievance policy was not updated after the ownership change to Allaire, according to the inspection. No residents surveyed knew how to report a grievance and several residents reported fear of retaliation if they reported their grievances.

Under the new ownership, the facility’s digital tracking systems were not updated, meaning employee records were not up to date and admissions records for patients were delayed. There were additional problems at the Springfield facility with lack of dental care, lack of trauma-informed care, lack of review of treatment plans, food safety violations, and residents receiving non-medically necessary medication, according to the March inspection.

After the “systemic” issues found in March at the Springfield Center for Living and Rehabilitation under Allaire Health Services, the division imposed a direct plan of correction requiring an independent consultant to offer weekly reports on progress, Cota said. The Springfield Center for Living and Rehabilitation was found in compliance in July, Cota wrote in an email.

Allaire spokesperson Suzanne Anair wrote in an email that the operator is known for turning around troubled long-term care facilities in other states.

Anair acknowledged that problems at the St. Johnsbury facility are “disappointing” and that the Allaire team has “implemented a rapid improvement plan to address all issues.” Allaire has changed regional leadership and is working with staff to place focus on improving care for residents at the St. Johnsbury facility, Anair wrote.

Anair wrote that the Rutland facility staff member who was found to have physically abused a resident was vetted in accordance with the state and federal protocols and received training. The facility reported the incident immediately to proper authorities and takes resident safety seriously, she wrote.

The nursing homes in St. Johnsbury, Springfield and Rutland struggled under Genesis’ ownership due to short staffing, failing compliance standards and leadership turnover, but the facility is working to stabilize operations and implement better systems, according to Anair.

Injury, staffing shortage at Stellar

Premier Rehab and Healthcare at Berlin — renamed from Berlin Health and Rehabilitation Center under Genesis — is still in the federal special focus facility program due to persistent quality issues under Genesis ownership.

The facility under Stellar Health Group continues to face serious problems. A May inspection found that staff failed to notify family until a resident’s bedsore “deteriorated to an unstageable pressure injury with necrosis.”

In February, inspectors reported that the facility lacked adequate staffing, leading residents to wait long periods of time for medication, personal care and assistance with daily activities. One new resident said they had been confined to a bed for an entire weekend and forced to use a bedpan due to a policy requiring a physical therapy evaluation before staff could help a resident move.

Other findings included inadequate trauma-informed care, a 43% medication error rate, improper drug storage and staff giving residents unnecessary medications with long-term side effects.

Erlichman wrote in an email that the Berlin facility recorded its “very first successful survey” in years in August. Stellar Health Group is hopeful that “after one more strong survey, Berlin will come off the Special Focus Facility list as early as February,” Erlichman wrote in August.

Yet, the since released August inspection describes several violations. A resident diagnosed with a traumatic brain injury and identified as a flight risk escaped the Berlin facility through a window. The resident was found with scraped knees and with a headache after falling down a hill, and was brought to the hospital.

A physician assistant did not maintain hand hygiene standards when assessing a resident with a pressure ulcer on their tail bone, according to the inspection.

The state inspector also found residents were served unpalatable, cold food; medications were stored improperly; two residents were given drugs to take unsupervised; and required emergency-preparedness exercises were not regularly implemented at the Berlin facility.

When asked about the inspection, Erlichman wrote that every violation is concerning, but the total of only six citations “represents a significant improvement and clear progress for the facility.” The facility consistently had around 20 violations in recent surveys as a special focus facility, and the average U.S. nursing home receives around 10 federal citations per inspection according to 2024 data, he wrote.

Richard Mollot, executive director of the Long Term Care Community Coalition, said that comparison to average violation count is less important to note than the actual harm to residents caused by violations cited. The violations described in August, including lack of infection control and adequate monitoring of residents, indicate “serious failure,” Mollot said.

Cota said the division had required an independent review of Premier Rehab and Healthcare at Berlin along with a corrective plan. The facility is in compliance as of September, Cota wrote in an email.

Premier Rehab and Healthcare at Burlington, Stellar’s other facility, reported physical assaults between residents in a May inspection, but was found in compliance with regulatory requirements in July, Cota wrote in an email.

One of Stellar’s other long-term care facilities in Vermont — Birchwood Terrace in Burlington, which was not formerly owned by Genesis — has become “a jewel of Vermont’s nursing homes,” and “every resident deserves the same kind of stability, attention, and dignity that Birchwood represents,” Erlichman wrote.

Birchwood Terrace has an overall one-star rating, out of five, for health inspections, staffing and quality measures and was fined $128,000 in 2024, according to the federal Centers for Medicare and Medicaid Services website.

In response to the ratings, Erlichman said the period that caused the low score was “truly an outlier in what has otherwise been a pristine record,” and the facility has seen improvement by completing an inspection recently with “only two minor tags.” The state Division of Licensing and Protection found Birchwood Terrace in compliance in September.

The positive change at the two former Genesis facilities is “palpable” after the operator changed leadership and staff and started planning building renovations, Erlichman wrote in August.

‘Egregious problems’

Regardless of the troubled history of the facilities under Genesis, Mollot said, the owners failed to meet the care and services required under state and federal law to provide on Day One of operations. It’s disconcerting that “very serious and egregious problems” have arisen at the six nursing homes in less than a year, Mollot said.

“The owner is expected to provide care and compliance with longstanding federal minimum standards for every resident, for every single day, and actions can certainly be taken in even the most urgent situations to rectify and address substandard care and neglect and abuse,” Mollot said.

Mollot said the new owners must provide good quality of life and meet minimum care standards under the Nursing Home Reform Act of 1987 in order to receive federal funds.

“The whole point of the federal nursing home law is that you don’t accept residents for whom you cannot provide safety and care,” Mollot said.

Under the federal Centers for Medicare and Medicaid Services evaluation standards, iCare Health Network has a 3.1 star rating, Stellar Health Group has a 2.6 star rating, and Allaire Health Network has an overall 2.3 star rating as operators. Allaire Health Network and iCare Health Network also operate facilities in nearby states of New Jersey and Connecticut, respectively, that have been reported for abuse by the federal government.

Mollot said subpar or even average ratings for nursing home operators raise alarm bells in his work as an advocate for nursing home residents because care violations often go underreported or are not adequately addressed across the country.

“It’s really hard to get a lot of citations in this country,” Mollot said. “When problems are identified, for me, that is really important for the public and for policymakers to be aware of.”

The most recent federal inspection of an Allaire Health Network facility in New Jersey in 2024 found that the facility conducted canine drug searches of residents’ rooms without notifying law enforcement or obtaining consent of all residents. The New Jersey facility is in “full compliance,” and the operator is currently appealing the citations, Allaire spokesperson Anair wrote.

The most recent federal inspection of the Connecticut facility in 2023 found three residents reported sexual abuse from one resident with co-occuring mental health diagnoses. iCare spokesperson Skoczulek wrote the federal inspections did not find “mistreatment by the nursing home or its staff.”

“We feel strongly that a nursing home should not be given an ‘abuse’ deficiency under state or federal law for resident-to-resident incidents that are not reasonably preventable,” Skoczulek wrote in an email.

Skoczulek wrote that the Connecticut facility is currently in compliance with state and federal regulations.

Kuiper said she could not comment on the specific incident, but operators need to provide protections from resident-on-resident violence in any state.

The deluge of violations at the six former Genesis facilities under new ownership come amid broader questions about who should ultimately be responsible for regulating nursing home ownership changes in Vermont.

Long interim process

The state’s nursing home ownership transfer formerly fell under the purview of the Green Mountain Care Board, but the regulatory board passed that responsibility to the Agency of Human Services in 2018 through Act 125, on an interim basis.

The law on nursing home oversight required a working group to recommend a permanent transfer process, but the Legislature has yet to act on those recommendations. Seven years later, the agency still manages the process through temporary rules.

Under the current system, the Agency of Human Services officials take a two-pronged approach to reviewing proposed buyers’ finances and record of care. The agency’s secretary decides whether to approve the transfer after a private hearing with ownership representatives. Members of the public are not allowed to participate directly in these hearings, though the state long-term care ombudsman may submit written comments, Cota said.

The secretary of the Agency of Human Services denied VTDigger’s requests for comment. The Division of Rate Setting, which reviews the financial and administrative capacity, also denied an interview request. But, Division of Rate Setting spokesperson Alex McCracken wrote in response to the inquiry that the three operators “all appear to be for-profit,” and the division did not find any problems with the operators’ financial information.

Through “comprehensive” review of quality care, staffing and information from the federal Centers for Medicare and Medicaid Services documents, Cota said the Division of Licensing and Protection works to understand the “whole picture” of the operators’ track record and “how the homes have either improved or deteriorated over the years of ownership in other states” before making recommendations to the agency secretary.

Genesis had its facilities on the market for years, Kuiper said, and the state was caught between a rock and hard place when approving new nursing home purchasers due to lack of bidders.

Kuiper said Genesis had six of its Vermont nursing homes openly on the market for a number of years to little avail. A 2021 bid from another prospective buyer collapsed after state regulators scrutinized the company’s performance at other nursing homes, Seven Days reported in 2021.

Kuiper said she was not aware of any other operators that threw their hat in the ring other than Stellar and Allaire before the five nursing homes transferred in December 2024.

“I recognize that it’s difficult in Vermont, because my understanding was they didn’t have a lot of options,” Kuiper said. “It’s not like they had a wide variety of options and they chose these among a lot of different possible purchasers.”

But the lack of transparency concerns Kuiper, who considered seven years “a long time for an interim process,” and said she’d like to see more publicly available information on the state’s nursing home ownership transfers decision-making process.

While Kuiper said it is premature to make sweeping judgements on iCare Health Network and Stellar Health Group’s ability to turn around their facilities and provide care, she said her office has more concerns about Allaire Health Services given its past track record in Vermont and problems at the facilities it took over from Genesis.

“To be honest, we have more concerns about Allaire,” Kuiper said. “We still want to work with them. We still are hoping we can get better results.”

Kuiper raised red flags to the state about Allaire Health Services’ bid to acquire three facilities. She told the state about problems reported at the Center for Living and Rehabilitation in Bennington — which Allaire already owned — including complaints of excessive heat, lack of necessary supplies, lack of food, and that staff and management failed to rectify reported issues.

Another ombudsman position was created to oversee facilities in Bennington due to the number of complaints at the Allaire facility, and to ensure MissionCare at Bennington residents’ rights are respected and needs are met given the specialized care required there, Kuiper said.

The Allaire spokesperson wrote that the operator has had a “very positive impact on services and outcomes at its Bennington facility and is dedicating itself to making necessary and important changes and improvements at its other Vermont facilities.”

‘Best interest of the long-term care system’

Faced with a longstanding interim process, Cota said there are early plans to introduce legislation to codify the current system under the Agency of Human Services under the Vermont Human Services statute.

Another solution would be to move some of the oversight back to the Green Mountain Care Board, said Sam Peisch, health policy analyst with Vermont Legal Aid. A bill backed by Vermont Legal Aid last session sought to regulate transactions between health care entities.

But Peisch said there was pushback to the bill partially because of the work it took to move the responsibility under the Agency of Human Services years prior. Now, nursing home resident advocates and regulators may need to consider other innovative approaches to improving the nursing ownership transfer process, Peisch said.

While state law provides strong principles to strive toward in the health care system, Peisch said state regulators, legislators and advocates should work toward stronger prohibitions on worst practices in the nursing care industry.

State regulators for nursing homes face a real challenge, and are often under-resourced and overburdened, Peisch said, so the goal of the bill is to create a guide to identify and stop operators engaging in extractive financial practices that lead to low-quality care or harmful consequences for residents.

One restriction would be higher financial penalties when abuse and other violations occur that act as a more meaningful deterrent to operators rather than the cost of doing business in the nursing home industry, Peisch said.

Under a finalizing nursing home ownership transfer review process, Kuiper said representatives of long-term care residents should be included in the process, and “the best interest of the present residents and the best interest of the long-term care system in Vermont” should be part of the finalized review standards of ownership transfers.

In the long run, Kuiper said the state should explore promoting other ownership models and investing in improving the long-term care system in Vermont, because staff at nursing homes facilities can only do so much while “the system that they’re working under is dysfunctional.”

Kuiper would like the long-term care landscape to move away from the large-scale, for-profit model and instead invest in smaller nursing home facilities that are tailored to individualized care. That necessitates more state support for potential providers who find regulatory processes to be a barrier, but are capable of caring for the Vermont elderly population Kuiper said.

“I know there’s a lot of rules and policies that you have to follow that can be really difficult for someone who could be very, very good at the care part,” Kuiper said. “I would love to see Vermont develop more support for people too on the regulatory side.”

In the evaluation of prospective buyers for former Genesis nursing homes, the Agency of Human Services has failed to identify and prevent operators with a history of deficient care from opening shop in Vermont, Mollot said.

The state should strengthen laws and improve the evaluation process to root out operators with a history of poor care, akin to reforms in New York and other states, he said. One concrete step Vermont could take would be to increase transparency and make the entire nursing home ownership transfer process open to the public, Mollot said.

“The fact that these operators have been allowed to enter Vermont and operate facilities which have been found to have substandard care is very alarming,” Mollot said. “Vermont should be doing a much better job — even under its own current written processes — to ensure high-quality care and the absence of abuse and neglect.

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This story was originally published by VTDigger and distributed through a partnership with The Associated Press.