His last days were ones of misery.

Robert Gunkel, once an intimidating figure with a grip of steel, was all but bed-bound in the New Jersey nursing home where he spent the final weeks of his life. Weakened after a risky operation to remove a cyst pressing on the right side of his brain, the 87-year-old Korean War veteran could no longer stand.

Those caring for him were supposed to turn him every two and a half hours to prevent dangerous pressure ulcers — what most know as bed sores. But his son, Roger Gunkel, recalled long stretches of time that would go on by before anyone at would check in on him after his father arrived there late last year on Christmas Eve.

“The aides were so scarce,” said Gunkel. “There was probably one aide to every eight to 10 rooms.”

It was his mother who first discovered the open wounds on her husband two weeks later, Stage 2 or 3 ulcers, which only confirmed to them he most likely had been left unattended in bed for long stretches of time. Gunkel said there was a rapid decline in his father’s health. He was in constant pain and his blood pressure started plummeting. Infection and sepsis set in, the son said. His father was rushed to the emergency room, and finally sent home to die. On Feb. 5, he was gone.

Choking back emotion, Gunkel believes his father’s suffering was exacerbated, and perhaps his death hastened at PowerBack Rehabilitation in Moorestown, by a shortage of nurse aides and others he had expected to take care of his dad. “They were very, very understaffed.”

Anyone who has spent any time in a nursing home has a story to tell. About a loved one suffered while waiting for help to go to the bathroom. Or someone who went hungry because there was no one to feed them. A call bell that went unanswered for hours.

And in New Jersey, federal data shows nursing homes are particularly understaffed.

One-in-four of the more than 360 nursing homes in the state had staffing issues, according to reports issued this year by the Centers for Medicare & Medicaid Services.

They revealed 25 percent were rated “below average” or “much below average” in the number of nursing personnel available to take care of residents — a ranking that takes into account that some nursing homes have sicker residents and may therefore need more staff than other nursing homes whose residents aren’t as sick.

Half of those same facilities had poor health inspection reports as well.

At the same time, those self-reported numbers by the nursing homes themselves may not be a true picture.

New payroll data now being collected by the government, which provides a more accurate picture of the number of staff on duty, has revealed large staffing fluctuations from day to day in nursing homes across the country.

That includes skeleton staffs on weekends or low-staffed days when people do not show up for work or take vacation, or when the number of patients increases.

Meanwhile, a heated debate continues in Trenton between the nursing home industry, the union representing its workers, and legislators, over a heavily contested bill that has already been killed once through a governor’s veto, over whether to require minimum staffing levels in New Jersey nursing homes.

There are about 44,000 nursing home residents in New Jersey, according to the AARP.

Those on the front lines, the people who work in those nursing facilities, say they’re in a bad place.

FEELING OVERWHELMED

On a good day, Margaret Boyce said she takes care of 15 to 16 elderly people in the New Jersey nursing home where she has worked for 17 years.

On a bad day, when others call out sick, or get pulled to cover other floors, there may be upward of 20 to 25 residents who need to be washed up or showered, fed, and sometimes changed if they have soiled themselves. Others, all but abandoned by family or battling thoughts of depression as they contemplate death, just want to talk to her. Or perhaps want nothing more than to hold her hand.

The 61-year-old certified nurse aide often feels overwhelmed.

“It’s heart-wrenching. I see it in their eyes. I want to talk to them,” she said in a cheerful, Caribbean-lilted voice she brought with her from her native Trinidad. “But I don’t have the time to listen, because I have to rush.”

She asked that her employer not be identified for fear of possible retribution. Records show that it received average overall and staffing scores, although the average hours of care per resident per day by nurse aide is 1 hour and 36 minutes where she works.

That may seem low, but the New Jersey average is 2 hours and 6 minutes, according to federal data.

“The employers don’t want to hire staff and they keep us working short,” she complained.

Boyce, a union delegate for 1199 SEIU United Healthcare Workers East who makes $14.67 an hour, works on a long-term care unit with patients who cannot do anything for themselves. And when staffing is short, she said it’s hard to keep up with everyone’s needs.

“You’re busy. The nurse is busy. I may have someone in the bathroom, but you can’t leave them in the bathroom by themselves. If you have a stroke patient, you can’t tell them to hurry up,” she said. “Some are incontinent. When you go to change them, your heart is breaking. You think about your mother. About your brother and sister. You choke on your tears.”

Sometimes she thinks about quitting. But she says she cannot.

“It’s my passion," she said. “I love caring for people.”

COMING UP SHORT

New Jersey Health Commissioner Shereef Elnahal said it is hard to pin a judgment overall on the industry, but conceded there is a staffing problem in certain nursing homes in the state. “Where we have found that, we have held them accountable,” he said.

The department has issued 34 citations for staffing alone in the last couple years.

Critics, though, maintain that New Jersey’s nursing homes “continue to be woefully understaffed.”

Families for Better Care, a non-profit advocacy organization, said the state ranked 45 nationwide in the amount of direct care service hours provided per resident. In its own analysis, the Texas-based group said nursing home residents here received 34 minutes less direct care daily, when compared to the country’s top-ranked states, or an average 2.27 hours of direct care staffing hours per resident. Alaska was highest with 4 hours of direct care.

“You have to question the enforcement” of the staffing requirements, said Brian Lee, executive director of the group. The state minimum in New Jersey is 2.5 hours, according to the Department of Health.

How states like New Jersey can otherwise score so well in the ratings issued by Medicare, yet still fare so poorly on staffing, is a mystery to Lee, who claimed nursing homes are “cash cows” with money to spend. Although home operators have long complained Medicaid reimbursement is abysmally low, he insisted that is not the case.

“They like to keep the profits close to the vest — to give it back to shareholders instead of staff,” Lee said.

The cost of nursing home care keeps going up.

New Jersey is the seventh most expensive state for nursing home care, according to a study, by SeniorLiving.org, based on the most recent data from the 2018 Genworth Cost of Care Survey. The average cost of a semi-private room in New Jersey is $10,646 per month or $127,752 per year, the study found. That compares to the national average of $7,441 per month or $89,297 per year.

A private room costs in New Jersey costs even more: $11,863 per month or $142,356 per year. Nationally, a private room averages $8,365 per month or $100,375 a year.

A number of long-term care facilities in the state are now being bought up by big companies, such as Genesis, or by investors.

A Department of Health spokeswoman said as part of its inspection process, the state reviews staffing plans and interviews employees and residents to determine if the facility has the appropriate staff in accordance with New Jersey regulations. If they do not, citations are issued. The facility is then required to submit an acceptable plan of correction which includes a process to correct the deficiency as well as preventing it from happening again.

Assistant Health Commissioner Stefanie Mozgai explained that part of the state’s annual survey involves reviewing medical records. Surveyors also will shadow staff and watch them treat patients.

“It’s not just looking at those numbers, it takes being there talking to residents. It’s a really comprehensive process,” she said.

Those representing the interests of state’s nursing home facilities, in response, say while staffing is “unquestionably a component of quality care,” it is not the only one.

The Health Care Association of New Jersey, a trade group for assisted-living and nursing home operators, said staff that is “compassionate, caring, respectful of their patients, and knowledgeable about the individual care required for each of them are very important indicators of quality.” Yet the group said the emphasis of quality should not rest solely on the number of staff, but instead on the “competency of skills and the heart of staff,” that come together to provide the highest quality of care.

At the same time, the association said it was important to note as well that New Jersey suffers from a serious shortage of certified nursing assistants. A survey of its members found some facilities have as many as 18 openings.

“We’re doing very well in staffing," asserted association president and CEO Jon Dolan, who said 80 percent of their costs can be attributed to staff. “Our top challenge has been for people to understand the workforce challenge.”

Still, nursing home aides, the foot soldiers who help provide basic daily health care — including assisting patients with bathing, eating, going to the bathroom, changing those who are incontinent, and often serving as surrogate family — say staff shortages are rife.

AT THE BEDSIDE

At the nursing home where Jerry Christensen works, there are typically four nurse aides such as her assigned to 46 residents. When someone is pulled to work elsewhere, or doesn’t show up for their shift that day, they get assigned more patients.

“You still have to strip beds, cut fingernails. They send us out on doctors’ calls. We take care of the daily needs of someone who is disabled, handicapped, or critically ill,” she said. “We bathe them, we shower them, and we change them.”

She gets paid $13.67 an hour.

Christensen also asked not to identify the nursing home where she works over concerns of retaliation. But federal reports show the facility, which has 235 beds and on a typical day cares for 186 patients, had a below average staffing ranking. Nursing aides there provided an average 1 hour and 50 minutes daily patient care per resident, compared to a statewide average of 2 hours and 6 minutes.

“We never have enough staff,” said Christensen. “There’s always something to do.”

At the same time, like Boyce, she said the residents become part of her extended family.

“We are their family,” she said. “They get dropped off here and their family doesn’t see them for years. We sit next to them. We cry with them. We pray with them. They want someone to talk to. Someone to hold their hands.”

One of her residents has a mother and father. She said he’s been at the nursing home for the past five years and they’ve visited him twice.

A BATTLE IN TRENTON

With New Jersey’s low ranking for nursing aide-to-patient ratios, unions have fought for changes in the law since 2015 to get more improve staffing levels, with little success.

A bill passed both houses of the Legislature three years ago that would have set limits of up to eight patients for every certified nursing assistant during the day shift, 10 residents in the evening and 15 during the overnight shift. The bill died when Republican Gov. Chris Christie declined to act on it.

Nursing home workers with 1199SEIU United Healthcare Workers East demand Assembly action on staffing legislation earlier this year. Michael Mancuso | NJ Advance Med

After Democratic Gov. Phil Murphy took office in January 2018, the measure was reintroduced. But in a surprise concession to nursing home operators last month, its sponsors rewrote it to weaken the proposed staffing requirements and give a pass to nursing homes facing “hardships.”

The industry said it supports the changes.

The Health Care Association of New Jersey said the measure creates staffing ratios that include all direct care staff – not just certified nurse aides.

“This shouldn’t be about one category of employee. It’s about how to most effectively bring all needed services to bear on behalf of those unable to care for themselves. These ratios, which include nurses, meet or exceed those of other states with staffing ratios because they accurately represent the care environment today and in the future,” the association said in a statement.

However, union officials charge the bill was jammed through the Assembly Appropriations Committee without prior notice that it was even up for a vote.

“Had we known, our members would have been there to vehemently oppose the amendments which completely gut the bill,” said Bryn Lloyd-Bollard, a spokesman for 1199 SEIU United Healthcare Workers East.

While the bill includes nursing numbers in the staffing ratio, Lloyd-Bollard said nurses are not expected to feed, bathe or turn patients in bed and other tasks expected of nursing aides. He said counting them would not improve the daily care of residents.

“By adding these new job classes into the mix, even though the ratios were reduced slightly —from 1 to 8 on the day shift in the original bill to 1 to 6.5 in the amended version — it dilutes the ratios to such an extent that most facilities wouldn’t have to make any changes whatsoever to their existing staff complement,” he said.

The minimum staffing ratios would not apply to pediatric nursing facilities, and any nursing home could apply for a “hardship waiver” from the Department of Health if they could demonstrate they had tried to hire more aides.

Lloyd-Bollard called the changes “an affront to the thousands of nursing home residents and caregivers who are fed up with the unsafe and degrading staffing conditions that run rampant in our state’s for-profit nursing home industry.”

Evelyn Liebman, associate state director for the AARP-NJ, said her group has been actively supporting the legislation that has been moving through the legislature to establish the minimum staffing ratios.

“Staffing levels are key to providing safety as well as quality,” she said.

And she does not support the amended bill that would allow nurses to count as part of the ratio for direct care staff.

“The argument nursing home operators have made is there is a shortage of direct care staff. But take a look at the numbers,” Liebman said, noting the governor in January signed a law to address the shortage of certified nurse aides by allowing those licensed in other states to work in New Jersey without having to repeat their training. The law opened up a pool of 140,000 CNA’s in New York and Pennsylvania to supplement the 56,500 CNA’s already working in the state.

“Perhaps they need to pay them more. They have such responsibility for the lives of our most valued citizens,” she said.

Elnahal, the state health commissioner, would not comment on the legislation, but said staffing should be viewed in the context of clinical needs.

DEADLY CONSEQUENCES

Staffing shortages like those described by Roger Gunkel in the death of his father are often at the root of litigation alleging negligence or malpractice.

“We probably allege it in almost every case we bring,” said attorney Thomas S. Howard of Hackensack, who has brought a number of nursing home neglect and abuse cases.

He said one needs only to look at outcomes as evidence of insufficient staffing.

“Take the most common problem in nursing homes is that 10 to 30 percent develop pressure ulcers, or bed sores. You probably don’t have a nurse or nurse aide going to work in the morning saying ‘I hope my patient gets a pressure ulcer,’” Howard remarked. “So why does it happen? Because they don’t have the time.”

It takes time and staff to regularly turn a patient every two and a half hours, which is what needs to be done to avert pressure ulcers. When bed sores develop, it is a direct consequence of not having enough staff to prevent it, the attorney explained.

“Falls as well. Patients fall. I’ve seen so many cases where a nurse ran in and the patient had already fallen. It’s a staffing issue," he said.

In some cases, the result can be tragic. In a case being heard in Superior Court in Hunterdon County, the family of a man whose clothes ignited after dropping a lit cigarette while sitting in an outdoor patio area of a Lebanon senior care center has filed a wrongful death lawsuit against the facility.

According to the lawsuit, William Trivigno, who was 75, suffered third-degree burns and died a day later after being flown to the burn center at St. Barnabas Medical Center. There were no staff members around at the time and another resident, who was confined to wheelchair, was unable to unlock the door that led back inside to seek help.

An attorney for the family declined comment.

Gunkel’s family has not yet decided whether to file a lawsuit, but has requested medical records from PowerBack Rehabilitation in Moorestown, the nursing home where they said Robert Gunkel developed pressure ulcers during his stay there that led to his hospitalization, and ultimately, they believe, to his death.

Robert Gunkel, before he was hospitalized.Photo courtesy of Roger Gunkel

PowerBack’s staffing rating by the Centers for Medicare & Medicaid is two out of five stars, or below average. According to federal data, the amount of time spent by nurse aides with patients at PowerBack was about half the national average.

A spokeswoman for Genesis Healthcare, the parent company of PowerBack, took issue with the staffing numbers, saying there was an error in the number of patients they had reported, making it appear that they had more patients per staff than was the actual case.

“Essentially, discharge data was not updated so it appears we had more patients per day than we actually had during that period,” said Lori Mayer. “The facility only has 124 beds. As a result, the CMS 5-Star rating for staffing was not accurate.”

She said the short-term care facility serves a higher acuity patient than most skilled nursing facilities, and has more staff taking care of them.

“In actuality, our direct care staffing hours per patient day is much higher than the state average,” Mayer said. “I would also like to point out additional facts that are not included in the rating that are important to consider as well."

She said PowerBack in Moorestown employs three physicians and four full-time nurse practitioners.

"These individuals are not included in the state’s staffing rating,” Mayer said. “You will be hard pressed to find this level of medical oversight in any stand-alone, sub-acute, skilled nursing facility in New Jersey or nationally.”

Roger Gunkel, though, complained that in his father’s first six days at the facility, not far from the family’s small home in Delanco in Burlington County, his dad saw a physical therapist once, and they had him doing arm exercises — instead of helping him regain use of his legs. And even that was a struggle. He said the therapists wanted the aides to have him in a wheelchair and ready to go to therapy at an assigned time, and the aides would fight, arguing they couldn’t leave him in the wheelchair because he was a fall risk.

“His legs were so weak because he was laying down all the time,” Gunkel said.

He and his brothers helped turn their dad, but claimed the nurse aides were never a help at all. The family was at the nursing home during the day, but he did not believe anyone checked on his father for many hours, after they left. It wasn’t until the pressure ulcers were discovered that he said his father finally became a priority there.

By then, it was already too late, according to Gunkel. Over a few short weeks, he said his father’s health rapidly declined, with his blood pressure bottoming out. He was brought to the hospital, and they finally brought him home under hospice care, where he passed away a week later.

“I got to hold my father’s hand for the last time and say goodbye,” said Gunkel.

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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