The first sound Karen Adams heard as she walked into the room at Braemoor Health Center in Brockton was her mother screaming in pain.
Marie Crean had fallen two days earlier and broken her left hip, but no one at the nursing home had noticed.
A pressure sore soon developed on the 85-year-old’s left heel because her leg was nearly immobile after the fall last year. But that, too, was overlooked by Braemoor staffers, and spread “like wildfire,” Adams said. Crean died two months later, on Aug. 2.
State regulators investigated Crean’s care at Braemoor and cited the nursing home for failing to provide timely evaluation and treatment after her fall.
“There was no documentation of an assessment having been performed in response to [Crean’s] complaints of pain,” investigators concluded. By the time Crean was taken to the hospital two days after her fall, her level of pain was “10 out of 10 (on a scale of 0-10, zero being no pain and 10 the most severe pain),” investigators found.
Crean’s treatment at Braemoor casts a new spotlight on Synergy Health Centers, the owner of the Brockton nursing home. Synergy’s rapid expansion since December 2012 — it won state approval Monday to acquire its 11th Massachusetts nursing home, in Salem — has been matched by mounting complaints.
More broadly, Crean’s experience raises questions about the state health department’s oversight of the 414 nursing homes in Massachusetts, and the thousands of frail residents who live in them.
A Massachusetts law passed last summer requires the health department to establish a public hearing process before nursing homes are sold or closed, yet state health officials have not put that into effect. The department is still working on rules to implement the law.
Synergy has acquired four of its Massachusetts nursing homes since that law was passed. State health department spokesman Scott Zoback said in a statement the department is closely monitoring Synergy.
At Braemoor, Adams had a clear vantage point to view what was happening inside: Not only is she Crean’s daughter, she also was working at Braemoor when her mother was admitted there.
The 58-year-old Halifax resident, with more than two decades’ experience working in nursing homes, didn’t want her mother to go to Braemoor because she worried that the new owners were cutting too many corners and that overwhelmed nurses were unable to provide high-quality care in the nursing home, licensed to care for 120 residents.
But Adams said it was the only nursing center near the family’s South Shore home with an available room in late April 2014. Her mother needed a few weeks of rehabilitation after being hospitalized for a urinary tract infection.
Crean, a spirited woman who raised four children and loved to dance, had worked as a grocery store cashier until she was 79. But in her later years, she had diabetes, which left her legally blind. Then dementia crept in and her hearing faded.
Reluctantly, Adams placed her mother in Braemoor, but derived a measure of comfort hoping Crean might get extra attention because her daughter worked there.
“You usually take pride where you work, and you figure [a family member] would get better care,” Adams said. “But this was a disaster.”
Braemoor’s executive director, Paula Topjian, did not return phone calls from the Globe. Synergy’s spokesman, Uri Turk, declined comment.
Synergy bought Braemoor in July 2013, and Adams said the new company’s administrators quickly began pinching pennies.
The nursing home, she said, would run out of alcohol pads used when drawing blood, and administrators suggested staffers improvise using hand sanitizer instead.
Adams said administrators told nurses not to worry about completing their daily written reports detailing each patient’s care if they didn’t have time at the end of the overnight shift and to simply provide an oral update to the morning staff.
At the same time, Adams said, Braemoor was admitting an increasing number of short-term rehabilitation patients because the company received more money to treat them. But no extra nurses were hired to care for them, she said.
By fall 2013, Adams said she called regulators in the state health department to relay her concerns, but little seemed to change.
“Maybe if they had really come in and checked, this would not have happened to my mother,” Adams said.
Zoback, the Department of Public Health spokesman, said the agency “inspects and monitors nursing homes within the available legal framework.”
“We will continue to closely monitor Synergy Health to ensure resident safety,” he said.
Adams worked the overnight shift at Braemoor, then would visit with her mother in the morning, as nurse aides roused Crean for breakfast.
A nurse who found Crean lying on the floor in her room at Braemoor in May 2014 wrote in a report that Crean was not injured and had no pain. That’s what Adams said she was told when a nurse called her at home that evening, a night she was not scheduled to work.
The day after Crean’s fall, Braemoor staffers sent her to routine physical and occupational therapy sessions, even as she complained that her left hip hurt, and the therapists voiced concerns about her apparent pain and mounting agitation, state records show.
Nurses finally ordered a hip X-ray for Crean. But the requested X-ray was for the wrong hip.
It wasn’t until Adams returned to work and found her mother screaming in pain two days after the fall that Braemoor officials sent Crean to a hospital. There, doctors determined she had broken her left hip and needed surgery.
State investigators cited the nursing home for deficient care and ordered administrators to file a plan with state regulators detailing how the nursing home intended to prevent similar incidents.
Braemoor’s plan stated that it retrained staff on how to detect “nonverbal indicators of pain” in patients with dementia, and how to assess patients for injuries after a fall.
Adams left her job at Braemoor soon after her mother’s fall and made plans to care for her mother at home as soon as she recovered strength following the hip surgery. Meanwhile, the family visited Crean frequently at Braemoor to keep a close eye on her.
By three weeks after the surgery, Crean appeared to be gaining strength. Adams, who joined her mother for dinner one evening at Braemoor, said she told nurses she would help get her mother ready for bed. When Adams removed Crean’s socks, she discovered a quarter-sized pressure sore on her mother’s left heel, with skin so deteriorated it was black.
Nurses were supposed to be checking Crean’s feet daily, according to patient records, because diabetes raised the risk of foot infections and other complications. The records also indicate medical workers were supposed to be rubbing cream on Crean’s heels twice a day to help prevent pressure sores.
On each shift, nurses signed off that Crean was receiving foot care, yet no one apparently noticed the skin rotting on her left heel. Furious, Adams removed her mother from Braemoor and brought her to her home, caring for her mother with help from hospice nurses.
“The staff did not consistently document that diabetic foot care was completed,” a state investigation of Braemoor noted. But with several inconsistent entries in Braemoor’s nursing logs, investigators said they were “unable to determine” whether Braemoor was at fault for Crean’s pressure sore, according to the final report issued in February.
The rotting skin around Crean’s pressure sore proved relentless, and poor circulation related to diabetes exacerbated her condition. The family followed her wishes that no aggressive treatments, including amputation, be taken, and Crean died at home in August, surrounded by family.
Adams said she doesn’t entirely blame Braemoor’s nurses for the cascade of errors in her mother’s care because she knows firsthand how overwhelming the workload became after Synergy took over.
The facility has been through five directors of nursing and three administrators in the past two years, an upheaval that has been hard on staff, said Marion Salisbury, a Braemoor nursing supervisor who recently retired.
Adams’ former colleagues may have made mistakes, but Adams said, “I blame the owners for not paying to have [enough] staff there.”
Meanwhile, financial reports filed by Synergy indicate that four companies owned by Synergy’s founder and chief executive, Avi Lipschutz, received more than $600,000 in “management fees” from Braemoor last year, and another related company received $300,000 for rental fees.
“My mother worked her whole life,” Adams said, tearing up as she thought about her mother’s final months. “Finally, something happened to her, and that’s the best [treatment] she got, after a lifetime of work.”