(Editor’s note: This story has been revised to remove the current name of a nursing care facility because the incidents that were reported there occurred under a previous owner.)

The incident in a bathroom at a nursing care facility in Morris County involved a confused and disoriented nursing home resident who would not get up from the toilet.

According to a federal inspection report, the unidentified patient required “extensive assistance” in most daily activities and a nurse’s aide asked for help from another aide, who stood over the resident and immediately turned to physical force.

"The abusive CNA (certified nurse aide) began to pull the resident’s hair and pull the nipple on the resident’s breast to get the resident to stand up,” inspectors said.

No one reported what happened for five days. The aide who witnessed it had been “afraid” to step forward, investigators said.

Nursing home abuse is an often-hidden secret in many of the places that families trust to take care of their elderly. At times unnoticed by overworked and frequently overwhelmed staff who may miss or simply ignore maltreatment by others, abuse in long-term care facilities typically has few witnesses. Victims with minds clouded by dementia often are unaware of how they received bumps, bruises or even broken bones.

But a NJ Advance Media analysis of federal nursing home inspection reports filed with the Centers for Medicare and Medicaid Services shows abuse-related citations nationwide are on the rise, jumping to 4,107 in 2018, up from 3,083 in 2016.

It is likely just the tip of the iceberg, advocates say. A report in June by the Office of Inspector General for the U.S. Department of Health and Human Services said nursing homes fail to report nearly 1 in 5 of potential cases of abuse.

In New Jersey, there were about 30 complaints investigated by federal regulators last year involving abuse allegations, most calling out a facility’s failure to quickly notify the state Department of Health.

Yet that was only a small fraction of the 353 complaints just for physical abuse alone reported last year to the state through a hotline maintained by New Jersey’s Long-Term Care Ombudsman. Laurie F. Brewer, the state’s ombudsman, believes the actual number of incidents involving abuse and neglect in the state are “dramatically” undercounted. Some residents are reluctant to report any problems, she explained, fearing retribution.

“You are in the most vulnerable position in your life at the end of your life. People are fearful of reporting, especially people who don’t have family members,” she said. “It’s heartbreaking. The thousands of people who don’t have regular visitors or have friends who come visit them, they are the most vulnerable.”

An examination of state and federal nursing home inspection reports since 2016 turned up few cases classified by investigators as significant threats to residents.

Roosevelt Care Center at Old Bridge, for example, was cited earlier this year for failing to report incidents of altercations between residents to the N.J. Department of Health. The April report detailed a number of physical attacks by a nursing home patient who hit, kicked and scratched other residents, staff and visitors.

But there were reports of outright intimidation or deliberate mistreatment of residents by workers — as well as assaults by agitated residents — deemed to represent "immediate jeopardy” to the health or safety of those living there.

Among them included Riverside Nursing and Rehabilitation Center — whose owners also hold an interest in the troubled Wanaque Center for Nursing and Rehabilitation in northern New Jersey where 11 children died in a viral outbreak last year. The Trenton nursing home, ranked at the bottom by federal regulators as “much below average” in both overall and health inspection ratings, was cited for abuse deficiencies in a 2016 report.

According to that report, a resident was forcibly held down and dragged down the hallway and away from the nurse’s station, all while the individual was yelling and thrashing on the floor. The episode was caught on surveillance video. A unit manager walked away and could be seen throwing her hands up in the air. A nurse’s aide later said she was frustrated with the resident, who she said was very difficult to care for, the report said.

And in another 2016 incident at the nursing care facility in Morris County, an unidentified nurse aide reported the abuse of a resident in the shower. According to the federal report, inspectors recounted “the resident was yelling, and the abusive CNA (certified nurse aide) began hitting the resident and grabbing the resident’s face. The CNA who was assisting the abusive CNA in the shower stated that the resident screamed because of the cold water, but that the abusive CNA slapped the resident’s face and held the resident’s mouth shut.”

An earlier version of this story gave the current name of the facility where these incidents occurred. That name has been removed because the facility was being operated under a different name by a previous owner at that time.

Riverside Nursing officials in a statement said they responded as soon as they learned of the abuse allegations.

“When notified of this regrettable incident from three years ago, management immediately terminated all personnel involved for not following our standard of care and staff received additional training," said Daniel Engelson, the administrator of the nursing home. "This incident does not reflect the level of professionalism of our staff.”

Middlesex County, which operates Roosevelt Care Center in Old Bridge, said the nursing home was not cited because of deficiencies in intervention or quality of care, but because the incident between two residents was not reported in a timely manner.

“The quality of care and staffing at Roosevelt Care Center has been deemed above average by the state, which has issued high marks to the Old Bridge Roosevelt Care Center in this regard,” said a county official in a statement. The county has taken corrective measures following a review related to the handling of reportable incidents.

ABUSE NOT REPORTED

Nationwide, the inspector general’s report for the Department of Health & Human Services found that estimated one in five high-risk hospital emergency room Medicare claims for treatment in 2016 were the result of potential abuse or neglect, of beneficiaries residing in a nursing home.

Despite those injuries, many of the incidents were never reported by the nursing homes to regulators, the report revealed. And findings of substantiated abuse were often not reported to local law enforcement as well.

In a New Jersey case garnering national headlines in 2011, the family of a paralyzed, 87-year-old woman beaten by an aide at a North Bergen nursing home only learned of the incident after it was captured on a “nanny cam” they had left in her room at The Harborage Nursing Home after seeking several suspicious bruises on the woman’s body. The video images shows an aid striking Modesta Alvarado in the head two or three times, and violently removing her oxygen mask.

The aide, Julia Galvan, later pleaded guilty to charges of assault. According to court records, she received probation.

“Elder abuse and neglect is a serious problem, with the elderly population expected to reach approximately 84 million by 2050,” said the inspector general in its recent report, noting that a 2008 survey, 1 in 10 elderly persons reported emotional, physical, or sexual abuse or potential neglect. “However, many cases are not reported because the elderly are afraid or unable to tell protective services, police, friends, or family.”

In a separate report last week, the Government Accountability Office found that the number of abuse citations in nursing homes, while relatively rare, doubled from 2013 to 2017. Physical, mental or verbal abuse was most common, followed by sexual abuse. The perpetrators were often staff.

The GAO report, however, said there are gaps in the reporting process. While federal law requires nursing home staff to immediately report to law enforcement and the state any reasonable suspicions of a crime resulting in serious bodily injury to a resident, there is no equivalent requirement that the states make timely referrals for complaints received either directly or through surveys.

FEARS OF RETRIBUTION

State Health Committee Chairman Joseph Vitale, D-Middlesex, who led a legislative hearing into the failed response of the Wanaque Center following last year’s viral outbreak, noted that abuse victims are typically unaware of their rights, don’t have the wherewithal to file a complaint, or are just afraid to say anything.

“It’s the same as domestic violence and sexual abuse. How many incidents are reported?” he asked.

The ombudsman’s office has an army of about 220 volunteers whose job it is to spend four hours a week visiting the state’s more than 360 nursing homes. They help prevent bad things from happening, said Brewer.

Incident of abuse and neglect in N.J. are “dramatically” undercounted, advocates say.Pixabay | File photo

A hotline takes in thousands of calls a year. The overwhelming number of them come not from nursing home residents, but are made by family and friends, workers and former staff members.

If the office suspects a resident has been the victim of abuse, the findings are referred to a regulatory or law enforcement entity for possible further action.

Most complaints almost always circle back to inadequate staffing, Brewer said.

“The better staffing ratios, the better the outcomes for residents. It feeds into everything else.” If not enough aides are working, the more likely that people won’t get timely changes, or (the nursing home) won’t follow the care plan. Mistakes will be made,” she said.

Abuse is not always about bad people working in nursing homes, but rather about poorly trained, under-supervised or overwhelmed people, said Stephen Crystal, a researcher and professor of health policy at Rutgers University. He, too, saw the dividing line between poor care and abuse as most likely tied-in to staffing.

“The best thing we can do to cut abuse is mandate better staffing,” he said.

At the same time, though, Crystal added that not only are those in nursing homes requiring more medical attention than in the past, but new efforts to restrict the use of anti-psychotic drugs — which are especially dangerous for elderly patients — means more nursing home residents are acting out. That, too, requires more and better-trained staff, he said.

Abuse, meanwhile, is not just about violence toward a nursing home resident, said James McCracken, president and CEO of LeadingEdge New Jersey, the statewide association of not-for-profit senior care organizations.

“It can range from neglect, which is a professional’s failure to meet standards of practice, all the way up to the physical stuff,” he pointed out.

What’s important, said McCracken, who served as the state’s Ombudsman for the Institutionalized Elderly, is those providing senior care services ensure they screen their employees, do good orientation and provide good continuing education, to make sure they are hiring care givers.

“That’s the kind of person you need to provide compassionate care,” he said.

Ted Sherman may be reached at tsherman@njadvancemedia.com. Follow him on Twitter @TedShermanSL. Facebook: @TedSherman.reporter. Find NJ.com on Facebook.

Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio. Find NJ.com Politics on Facebook.

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