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Nursing Home Troubles Show Flaws In State Oversight

by Lisa Chedekel and Lynne Tuohy
The Hartford Courant

November 18, 2007

Carrie Tondalo wasn't a complainer.

Confined to her bed in the Haven Health-Soundview nursing home in West Haven, wasting away from a lack of food and water, she urged her worried daughter, Charlotte Ciccarelli, not to complain to the nursing home staff.

"She was so parched all the time, she would drink a gallon of water when we came in to visit," Ciccarelli said of her mother,an Italian immigrant from North Haven who had worked into her 70s for garment and awning businesses. "But she didn't like us making a fuss. She never wanted to hurt anybody's feelings."

In state Department of Public Health records, Tondalo's demise is starkly recorded: She suffered from bedsores and malnutrition while at the West Haven home in 2003, and was hospitalized in May for dehydration and a urinary tract infection. The nursing home repeatedly neglected to monitor her fluid intake, weight and skin sores in the months leading up to Aug. 19, when she was rushed to the hospital again, with a diagnosis of dehydration and a documented weight of 95 pounds — a 28-pound loss from February. She died a few days later.

In late 2003, state public health officials punished the home for numerous patient-care violations, issuing a detailed "plan of correction" that directed the home to improve its procedures related to weight loss, fluid intake and infection control. The home paid a $1,270 state fine and a $12,600 federal penalty for the violations.

But in the four years since, Haven Health-Soundview has been fined by state and federal health officials six more times for a litany of patient-care violations, including neglecting bedsores and ignoring patients' care plans. The most recent citation, in May of this year, included an incident in which a nurse's aide left a sandwich within reach of an elderly woman with swallowing problems, whose care plan specified that she not be given access to solid foods.

The woman choked to death.

The home paid another fine.

It was a predictable cycle.

A Courant review of state and federal records shows that Haven Healthcare, which owns 15 nursing homes in Connecticut and 10 in other New England states, has been fined more than 45 times in the last three years for serious patient-care deficiencies — at least 30 times by the state health department and 15 by the federal Centers for Medicare & Medicaid Services, which imposes penalties for gross violations.

Many of the health violations, such as allowing residents to develop bedsores and become dehydrated, show up year after year in inspection reports, even after state and federal health officials have levied fines for those deficiencies. But the chain — one of the three largest in the state — has escaped more serious sanctions, such as a loss of government funding or operating restrictions, even in cases where the lapses in care led to patients' deaths.

Haven Healthcare's troubled record affords a window into a state and federal regulatory system that is reluctant to pull funding or licenses from nursing homes or to prosecute cases of neglect. A study earlier this year by congressional investigators found that federal overseers imposed only minimal penalties on nursing homes that were repeatedly cited for patient-care deficiencies.

Although the other large chains also have been cited for serious violations, Haven Healthcare stands out because it has faced the heaviest state fines, litigation and debt claims in the last three years, and runs a home with the highest number of patient-care violations, according to records.

But most of the state penalties imposed on Haven have been below $1,000 — significantly less than the amounts allowed by statute — with no requirements that the chain make long-term improvements in care. And even in cases where the state has used its arsenal, the impact has been short-lived.

The chain's latest inspection results offer striking evidence of the ineffectiveness of Connecticut's enforcement efforts.

The most recent federal data show that in the last 15 months, 10 of Haven's 15 homes in Connecticut have been cited for a total of 23 patient-care deficiencies ranked in the most serious categories — violations that cause harm to residents or that pose an immediate jeopardy to residents' health and safety. Nationally, fewer than one in five homes are cited for such serious deficiencies.

Ten of Haven's homes have a higher number of patient-care deficiencies than either the state or national average, with the chain's home in Waterford cited for 44 violations — the highest in the state, according to the most recent data. The three Haven homes that have been subject to stringent "consent orders" from the health department in the last three years all have cycled back out of compliance, repeating the same or similar violations.

In addition, the most recent federal surveys show that nursing staff levels in at least 13 of Haven's 15 homes fall below both the state and national staffing averages. But in a state where minimum-staffing rules have not been updated in more than 25 years, the chain has rarely been penalized for understaffing or directed to increase staff levels.

The federal inspection figures are months old, in some cases, and may not reflect current conditions.

Haven Healthcare, also known as Haven Eldercare, has been targeted since 2004 in at least seven lawsuits filed by families, including Tondalo's, who claim their loved ones died or were seriously injured in Haven homes because of negligent care. Earlier this year, Haven settled two of those lawsuits for a total of $783,000, and a third for an undisclosed amount.

The families who have filed suit worry that more patients will suffer if the chain's problems go unchecked.

"It was not a haven. It was hell," said Susana Aceituno of White Plains, N.Y., who is suing Haven's former home in Greenwich for neglecting to supervise her husband, Oscar, 78, who was paralyzed after wandering away from the home in May 2004 and falling down an embankment. "They destroyed my life. They destroyed his life completely."

Deeper Problems

Haven's patient-care problems also point to larger issues of state oversight.

In the last three years, the chain has spiraled into debt, with creditors seeking more than $20 million in unpaid bills for medication, oxygen and other supplies. But despite repeated signs that the chain's financial management could be hurting patient care, the state health and social services departments have been reluctant to intervene.

Last year, health officials learned that Haven's nursing home in Jewett City had run out of heating oil one night in December 2005, leaving residents to huddle in blankets, after the oil company suspended deliveries because of the company's repeated delinquencies, according to records.

In January 2006, Connecticut Light & Power warned the state that it was cutting off electric service to six Haven homes, after a yearlong effort to get the chain to pay its overdue bills. Haven paid the debt, reassuring state managers that it had no other financial issues "related to vendors, mortgages [or] utilities," according to notes from a February meeting.

But the Middletown company's financial issues have filled court dockets around the state. At least 12 creditors have sued Haven Healthcare since 2005. Officials in Maine, where Haven owned a home until 2005, say the company owes that state at least $1.5 million.

Records show the chain has collected millions in Medicare reimbursements for pharmaceutical supplies, but has not used that money to pay its pharmacy bills. Meanwhile, company CEO Raymond Termini used assets of Haven Eldercare, the chain's corporate parent, to buy a lakefront house in Middlefield in 2003 and to launch a record company in Nashville in late 2005. His Category 5 Records, housed in a $2.1 million building Termini purchased last December, boasts two-time Grammy winner Travis Tritt.

Last week, state Department of Social Services officials said they had begun examining Haven's finances in recent months "to determine whether the company's financial condition constitutes an emergency situation that warrants the appointment of a receiver to safeguard resident health and safety."

Attorney General Richard Blumenthal said his office also was involved in what he described as a "far-reaching investigation into possible fraud, including Medicaid and Medicare fraud," in conjunction with federal officials. He said one aspect of the investigation was whether Haven's "other financial enterprises could have siphoned away [government] funds from patient care."

In interviews last week, Termini and Haven's chief financial officer Michael Lipnicki insisted that no Medicaid or Medicare funds had been misused, and they blamed the company's financial troubles on the state's "inadequate" Medicaid funding. Termini denied that the company's financial issues had ever affected patient care, saying they were the result of bad hiring choices in some facilities.

Termini acknowledged that he had used assets from Haven Eldercare to finance the record company and buy a house on Lake Beseck, but said he had done nothing improper. He said the money for Category 5 came from refinancing Haven homes in other New England states, which he decided to invest in "non-health care companies," in the hopes they would someday generate a return to the nursing-home chain. He said he purchased the Nashville building with his own money.

Termini's management of Haven's funds has stirred a legal fight from his longtime partner, the Rev. Edward Doherty, who filed documents this month in Superior Court in Middletown, alleging that Termini and another partner improperly diverted Haven Eldercare's assets to the record label, the lakefront home and a food-service business. Doherty, who founded the Roncalli chain of nursing homes that grew into Haven Healthcare, accused Termini of committing "dishonest acts" in running the company and refusing to provide him with business records that he needs in order to prepare his will.

Termini downplayed the dispute, saying he had consulted Doherty about Haven's financial investments. But he said Doherty was "not entitled" to the records he was seeking.

Termini conceded that the company's recent patient-care record was troubling, but noted that some Haven homes had no serious deficiencies in the most recent inspections and that problems in Waterford and other troubled homes were being addressed.

He said he had come back to Connecticut full time from Nashville this summer to rebuild the struggling chain and had begun pouring millions into hiring new staff, settling debt and making other improvements.

"We're fighting really hard to turn the company around," he said of the chain, which promotes itself as "A Safe Place to Be." "I'm hopeful the next round of [inspections] will bear the fruits of our labor."

Pulling Punches

Regardless of the reasons behind Haven Healthcare's financial problems, responsibility for policing the possible consequences falls with the Department of Public Health.

From a distance, Connecticut's enforcement efforts look impressive.

The state has one of the highest percentage rates in the country of nursing home inspections that result in findings of serious patient-care deficiencies, according to federal data. The state health department bears responsibility for inspecting homes and determining what state and federal penalties should be imposed for violations.

But a closer look, through the lens of Haven Healthcare, shows that while the state has been aggressive in identifying violations, it has been reluctant to impose the harsh penalties allowed by law and unsuccessful in policing long-term improvements in patient care.

Records show that 10 of Haven's homes — in Torrington, Waterford, West Haven, South Windsor, Norwich, Jewett City, Farmington, Rocky Hill, Danielson and East Hartford — have been fined multiple times in the last three years by the federal or state government, or both. The West Haven, Torrington and Waterford homes have been cited at least five times each since 2004. Each time, the homes paid the fines and agreed to make improvements, then cycled out of compliance again, sometimes repeating the same offenses.

The most recent federal inspection data show that three Haven homes have at least 24 deficiencies each — double the state average number of violations per home, and triple the national average. The homes in Jewett City, New Haven, Norwich, Rocky Hill and Waterford all were cited for two or more serious violations that caused harm to residents; Waterford also was cited for four deficiencies that caused immediate jeopardy to residents' safety, the highest level of severity.

Among the most frequently cited violations are failures to prevent bedsores, also known as pressure sores, and dehydration — avoidable conditions considered consequences of chronic understaffing.

In the past year, at least nine Haven homes have been cited by the state for failing to prevent and treat bedsores, and five have been cited for failing to monitor residents' fluid intake, state records show. In the most recent federal surveys, 10 Haven homes were found to have a higher percentage of long-stay, high-risk residents with pressure sores than the state or national average, with homes in Cromwell, West Haven, New Haven and Farmington having more than double the national rate.

Despite the deficiencies, Haven Healthcare has continued to receive millions in Medicaid and Medicare funding — more than $130 million last year — making its own decisions about how much to spend on staffing. The chain now has 1,890 beds in Connecticut.

By law, state and federal health officials have the ability to come down hard on nursing homes that put residents' safety in jeopardy. The state Department of Public Health can fine homes up to $5,000 for violations that present an immediate danger of death or serious harm to any resident, and up to $3,000 for violations that pose a likelihood of harm. The state also can terminate nursing home licenses for serious deficiencies or enter into consent orders that carry even larger fines and that require specific improvements.

Federal rules allow for fines of up to $10,000 a day for conditions that place residents' safety in immediate jeopardy. The state also can recommend that funding for new admissions be withheld when homes fail to correct deficiencies, or when serious violations are found in multiple surveys.

But records show state officials have rarely imposed such strong penalties on Haven Healthcare, even in cases where poor care has contributed to death or serious injury. Most of the fines imposed by the state to date have been significantly less than the amounts allowed by state law.

Among the lawsuits filed by families is one that charges Haven's Windham facility with failing to properly monitor the blood sugar level of Rosalie Laroe, an 80-year-old Ashford woman who had diabetes.

Laroe was admitted to the Windham home on Jan. 29, 2003, with a plan of care requiring that she be closely watched for signs of hypoglycemia. But the nursing home staff neglected to notify a physician when she showed signs of low blood sugar, state records say.

In late March 2003, finger-stick tests showed Laroe's sugar levels were falling. A family member reported on March 24 that Laroe was having trouble breathing. On March 27, the staff noted that Laroe's pulse rate was weak and her coloring was pale, but failed to notify a doctor.

Two days later, Laroe was found unconscious in bed, with a critically low blood sugar level. A nurse on duty "shoved [glucose] medication into her mouth, causing Mrs. Laroe to suffocate to death," the lawsuit filed by Laroe's family charges. She died at Windham Hospital on April 14 of aspiration pneumonia and complications from hypoglycemia.

The state fined the home $935 for the lapses in care, records show. The home also paid a $2,000 federal fine.

This March, Haven Health agreed to pay the Laroe family $555,000 to settle its lawsuit.

Laroe's son, Brian Laroe, and the family's lawyer, Vincent DeAngelo, declined to discuss the lawsuit because of a confidentiality agreement. But Brian Laroe said he still has trouble understanding what happened to his mother, who went into the Windham home for a short stay while her husband, who took care of her, was being hospitalized.

"She was only supposed to be there temporarily," he said. "But the way they treated her, it got bad. … She'd yell for help, in her loud voice — they didn't like that. They'd make her wait a half-hour or an hour when she called them."

Laroe said he was discouraged to learn that the state had imposed only a minimal fine on the Windham home for the events that preceded his mother's death.

"It seems like just a slap on the hand," he said.

Earlier in 2003, state inspectors had cited the Windham home for similar lapses in care, involving the staff's failure to notify a doctor that a resident's wound was bleeding profusely. The home had agreed to revise its policies to ensure timely notification of physicians.

A review of state records found other cases in which the state cited Haven homes for negligent care, but imposed only minimal fines and did not require any major improvements.

In 2004, for example, Haven's home in West Hartford was cited for two incidents that contributed to deaths. In one case, a resident with dementia who was identified as being at a high risk for falling fell 17 times in seven months, with injuries ranging from bruises to a broken jaw. After falling for the 18th time, the resident became weak and died.

For that incident and another involving a resident who became dehydrated and died, the state fined the home just $950, records show. Federal officials imposed a $3,000 fine.

In October 2006, a Haven home in East Hartford was cited for allowing two residents to become dehydrated to the point they needed hospitalization. The state fined the home $615.

Also last October, Haven's Rocky Hill home was cited for failing to notify a physician of a resident's abnormal blood sugar level. The resident was found unresponsive and having seizures. The home paid a $280 state fine.

In November, the Rocky Hill home was cited for failing to monitor the fluid intake of three residents who became dehydrated. The state fine: $755.

State public health officials said they weigh a number of factors, including the scope of the problems and the home's previous violations, in setting fines. Joan Leavitt, chief of licensing and investigations for the state health department, said the dollar amount of fines is less important than "what we do with the providers to bring them into compliance."

"It isn't all dollar amounts. It's what we put in to improve quality of care," she said.

Recently, a former medical director of three Haven nursing homes stepped forward to criticize the chain's quality of care. Dr. Cornelio Hong, who served as medical director of Haven's Norwich, Jewett City and Waterford homes, said he had complained last year to both Haven management and the state health department about "the inadequate health care being provided by the Haven facilities," according to a lawsuit he filed in October that seeks $13,000 he claims the company owes him.

In the suit, he charges that the chain reneged on paying him because he was a "whistle-blower" about poor care.

No Success

Only once in the past six years have state and federal officials taken the rare step of suspending government payments to a Haven home in Connecticut for health care violations. And even in that case, the effect was short-lived.

In December, an inspection by state surveyors of Haven Health Center of Waterford found widespread evidence of neglect: Residents were found with bedsores that went untreated or that were covered in urine-soaked bandages. The home was not preventing the spread of infections. A blister on one resident's heel went neglected so long that his leg had to be amputated.

After the inspection, state officials asked the chain's owners to sign a voluntary agreement to stop admissions to the home. Executives of Haven Healthcare said no.

"The President of Haven Health asked [state] managers to take into account the financial resources the ownership is currently putting into the facility," a record of a Dec. 8 meeting says. "The voluntary statement was not signed."

On Dec. 11, state and federal officials suspended Medicare and Medicaid payments to the home, for new admissions only. And in its strongest action to date against the chain, the state in February placed the Waterford home on probation and imposed a $100,000 fine.

But in May of this year, just two months after the suspension was lifted, the nursing home was cited again for some of the same violations, including neglecting a sore on a resident's foot for so long that his toe had to be amputated.

"Multiple issues identified in [the December report] persist," say notes of a May meeting between Haven managers and public health officials.

Nationally, a 2007 study by congressional investigators in the Government Accountability Office found that state and federal sanctions against nursing homes often prompt only temporary improvements, with fines generally so small that some homes viewed them simply as a "cost of doing business."

But other states have had more success in policing Haven Health. Haven owns 10 homes in Vermont, Rhode Island, New Hampshire and Massachusetts.

In Rhode Island, federal and state health officials stopped funding to a Haven home for two months in 2004, after an inspection found multiple deficiencies, including neglect of bedsores. The Rhode Island home is now rated highly in federal quality surveys.

The state of Maine forced the closing of a Haven Health home two years ago, after an inspection found the staff had neglected residents' bedsores and failed to notify a doctor for two days after a resident was injured in a fall. The home closed down two months after the state and federal government halted funding.

The problems cited in Maine and Rhode Island were comparable to deficiencies found in some Haven homes in Connecticut, federal inspection records indicate.

State and federal officials have rarely used their authority to suspend government payments to Connecticut homes. In the last three years, 23 homes have temporarily lost their funding for new admissions, but most of the suspensions have lasted just a few days, with only three lasting longer than 60 days, federal records show.

Several Haven homes, including Jewett City and West Haven, have been cited two years in a row for deficiencies that caused harm to residents. Ironically, while the chain escaped suspensions in those cases, funding to its home in West Hartford was withheld in September because it failed to remedy fire-safety deficiencies found during a June inspection.

Leavitt, of the state health department, said imposing large financial penalties on homes could end up curtailing the level of care those homes provide, or could prompt owners to appeal the fines in court, tying up the department's limited resources.

"If I put on a $35,000 or $40,000 fine every time I issued [a citation], I might be in court a lot more than I have the resources to be," she said. "I'm not demeaning the fines. [But] there's more value in trying to correct the system."

She also said harsher penalties could force homes to close down, reducing the number of available beds.

"We want to keep the places operating," she said. "We have to look at bed availability."

In recent years, Connecticut has rarely forced a nursing home to surrender its license or prosecuted a home manager or caregiver for neglect. Since 2004, the state has forced only two nursing homes to give up their licenses. One of those homes was Hillcrest Health Care of Montville, where state prosecutors for the first and only time brought criminal charges against a home's corporate owner, in a case in which a resident died after suffering from dehydration, malnutrition and an infection caused by bedsores. The owner pleaded guilty to manslaughter charges.

State health officials said in some cases involving Haven Healthcare, the agency may have referred nursing-home employees to the licensing unit for disciplinary action.

Termini and Haven President Anthony Scierka said they have been working hard in recent months to improve care at the Waterford home and others that have been cited for serious violations. They noted that some other Haven facilities have been free of serious deficiencies, and that the chain's occupancy rate remains one of the highest in the state, at about 96 percent.

Termini said he had no complaints about the Department of Public Health's enforcement program.

"I've never pointed the finger at DPH," he said. "I think they've been fair."

A Predictable Pattern

Inspections of the most troubled Haven Healthcare homes follow a pattern.

State surveyors find violations. The company pays a fine and pledges to correct the problems, sometimes by hiring an independent nurse consultant and agreeing to weekly monitoring. Within a year or two, the problems are back.

Gabrielle Vaillant, a patient in Haven's Danielson home in 2003, got caught in that cycle.

After a March 2003 state inspection, the Danielson home was fined $860 for two incidents in which residents' injuries were ignored. In one incident, an elderly woman who was moved the wrong way by a nurse's aide was forced to wait more than a week, in pain, before she was sent to a doctor and diagnosed with a leg fracture, inspection records show. In the other, a resident who had leg pain and bruising was not sent for an X-ray for 10 days.

At about the same time that the home was paying that fine, Vaillant, 78, slipped while being moved with a mechanical lift. Although she complained of pain when her left leg was touched, the nursing staff didn't notify a doctor until the next day. An X-ray revealed she had broken her leg.

A month later, in May 2003, Vaillant was found lying on the floor of her room. A nurse's aide had lowered a side-rail on her bed and she had fallen out. She broke her collarbone.

The state fined the nursing home $675 in early 2004 for the incidents involving Vaillant, and Haven of Danielson agreed to improve its policies for assessing residents' injuries and using mechanical lifts.

But in 2005, another inspection found a similar violation: A resident injured by a mechanical lift was left in pain for three days before a doctor was notified and an X-ray identified a fracture. The home was fined another $900 by the state and $1,950 by federal officials.

Vaillant's family sued Haven Health, claiming her injuries, as well as a large pressure sore she developed while in the nursing home, accelerated her death in 2004. Haven agreed to a settlement in February, shortly before jury selection was set to begin. The lawyer handling the case, Sandra Baker, would not discuss the settlement because of a confidentiality agreement.

The West Haven home, Haven Health-Soundview, has been cited by the state for multiple instances of neglect of pressure sores and dehydration, dating back to December 2003, when the state issued a detailed "plan of correction" directing the home to improve its patient care. But a year later, in December 2004, the home was again cited for violations, including failing to prevent and treat bedsores and to properly treat residents' injuries, and was fined a total of $9,550.

Two months after state officials again ordered improvements, another inspection found similar deficiencies, and the state and federal governments imposed another $3,900 in fines.

Although state health officials monitored the home through 2006, an inspection in May of this year found some of the same violations, including neglect of bedsores and patients' care plans, and the choking incident involving the woman with swallowing problems. For all those violations, the home was fined $1,350 by the state and $5,000 by the federal government.

The Torrington home was fined $4,000 by the state and $2,600 by the federal government last year for several violations discovered in an April inspection, including inadequate care of pressure sores and administering psychotropic drugs to residents without an appropriate rationale. In a December 2006 "consent order" signed with the state, the home pledged to correct the deficiencies.

This February, a state inspection found many of the same violations.

Haven Health of West Hartford was cited late last year for failing to conduct respiratory assessments after a patient whose cough was not properly evaluated died. In May of this year, another inspection found similar neglect in tending to a patient with respiratory trouble.

The Haven homes that have cycled most frequently in and out of compliance also have had a high turnover in management staff, according to state records.

The homes in Waterford, Torrington, Jewett City and South Windsor have changed administrators at least three times in the last two years; the home in West Haven has gone through four nursing directors since January 2006, according to records. Haven often moves administrators out of homes after serious deficiencies are found, but in some cases, it has shuffled those same administrators to other homes in the chain.

In the last year, at least one Haven home has gone without an administrator. The state cited the New Haven home in an April inspection for allowing the director of nurses to also serve for six months as the home's administrator, a practice barred by state rules. The home was cited for a litany of patient-care violations.

Besides the patient-care deficiencies, there have been other recurring problems. A number of Haven's homes, including East Hartford, Cromwell, West Haven, Farmington, South Windsor and Windham, have been cited by the state in the last two years for poor building conditions, such as damaged walls in patient rooms and moldy bathrooms, state records show. Haven officials said they have addressed those issues.

In addition, four Haven homes — in Jewett City, Norwich, West Haven and East Hartford — have not yet complied with a July 2006 state law requiring that all nursing homes install sprinkler systems. The Haven homes are the only ones in the state still not in compliance, Leavitt said. The law allows the state to fine homes that don't comply as much as $1,000 a day. But no penalties have been imposed, Leavitt said.

Alice Hedt, executive director of the National Citizens' Coalition for Nursing Home Reform, said that when patient-care enforcement is lax, savvy nursing home owners know they can get away with making only temporary fixes.

"The biggest problem we have is what we call 'yo-yo compliance,'" Hedt said. "Facilities will bring about change after an inspection, but they're not being sanctioned in a way that forces them to make any long-term improvements."

State health officials said they are concerned about repeat violations, which they track closely. But Leavitt said she doesn't believe there's "any one answer" to prompting nursing homes to make long-term improvements.

If fines and monitoring fail, she said, "One would have to take another initiative, after a while."

The One-Dollar Man

To date, the lowest fine paid for a patient-care deficiency involved a nursing home in Greenwich that Haven Health managed in 2004.

That case involved Oscar Aceituno, a 75-year-old resident who had been identified as a wandering risk, with a plan of care directing the staff to check on him every hour and ensure that he wore a "wander bracelet," according to state records.

Susana Aceituno had placed her husband of 50 years in the home on May 14, 2004, to keep him safe. At age 75, he had advancing Alzheimer's disease. She said his condition had progressed to the point that she could not even go to the bathroom without first calling a nearby daughter to watch him. She reluctantly decided to put him in a nursing home after police found him wandering on a busy New York expressway.

Oscar was not in frail condition when he was admitted, Susana Aceituno said. In fact, the couple had danced a tango for the other residents on his first day at Haven Health Center of Greenwich, she recalled.

During his stay, Oscar Aceituno repeatedly removed his Wanderguard bracelet and left the building, according to a lawsuit the couple has filed against the nursing home chain. On May 18, Susana Aceituno made arrangements to have her husband transferred to a more secure facility nearby, but canceled the plans after Haven's managers assured her he was adjusting well, the suit says.

Then, on May 30, a nurse's aide noticed Aceituno outside the building and brought him back inside. Twenty minutes later, he bolted outside again, according to state records.

He was found lying in the dirt, with an injury later identified as a cervical cord contusion.

He has since been confined to a wheelchair.

"You have no idea how strong this man was," Susana Aceituno said of her husband, who now resides in another nursing home. "Today, there's nothing there. He doesn't walk. He never walked again. He doesn't talk. He has to be fed. He has diapers.

"I look in his eyes but he doesn't look at me. He looks far away," she said. "This is what they gave me back."

Attorney Joshua Koskoff, who represents the couple, called the facts of the case "egregious," noting that Oscar Aceituno's wandering was the reason the family chose to entrust him to Haven Health.

Like other lawyers who have sued Haven homes, Koskoff said he and co-counsel Tom Rhodes are trying to navigate the chain's complex corporate maze, which consists of numerous limited-liability nursing home corporations.Haven's lawyers already have claimed the Aceitunos sued the wrong entity.

State inspectors cited the Greenwich home in December 2004 for failing to properly monitor Aceituno, who had been identified as a serious "elopement risk." The state imposed a fine of $615.

But because the nursing home was in bankruptcy at the time, the financial manager assigned to the home contested the fine, saying it would create "an undue hardship on the state of Connecticut and its taxpayers."

He sent the state a check for $1.