Wrong doses. Missed doses. Medication errors in group homes pose grave risks.

by Jean Rimbach and Ashley Balcerzak, NorthJersey.com

Katherine Anne Moronski was excited about the next phase of her life.  

After seven years at a therapeutic boarding school in Massachusetts, the young woman with autism — known affectionately as Katie — was going to live at a group home in New Jersey near her family. 

It was, her mother said, going to be “the year of yes.” 

“She was going to take advantage of every opportunity that was offered to her,” Lynne Moronski said. 

In June 2024, two days after moving into a home run by Broadstep in Newton, Katie was dead.

She was 21 years old.  

Katie’s death was ruled an accident. The cause according to her autopsy: “Acute intoxication due to Bupropion, Olanzapine, Fluoxetine and Lorazepam.”  

The first three drugs were part of Katie’s regular medication regimen, which the group home is responsible for dispensing. Records show the lorazepam was administered in a hospital emergency room in response to a seizure.  

“She envisioned a future for herself,” Lynne said. “As we get really upset, obviously, it's not just that she died, it's that she was overdosed, and that's just really tough to take. That someone else took away her future is just really difficult for us to palate.”  

RHA Health Services, which owns Broadstep, did not answer questions about Katie’s death.  

Lynne said when she and her husband, Sean, received the autopsy report “things really spiraled for us.” One of Katie’s doctors told her to get a lawyer. Another remarked, “What a stupid way to die.” 

“And she’s right,” Lynne said. “What a stupid way to die.” 

Huge responsibility

Group homes are not required to have nurses or other licensed medical professionals dispense medications or oversee their delivery. The same workers who provide other routine care — bathing, feeding and changing clothes — are also responsible for dispensing prescription and over-the-counter drugs, keeping records and reporting mistakes. 

Many group home residents have a complex mix of prescriptions for their physical and behavioral needs. Katie’s medications numbered about 30, taken at varying intervals throughout the day, some on an as-needed basis. 

Dispensing medication is a “huge responsibility” being put on frontline workers — called direct support professionals, or DSPs — who have no license or certification at stake, said Vincent Giardina, a former chief of investigations for the Department of Human Services, the state agency that oversees the group home system.

“People who are not medical professionals sometimes don't understand the importance of keeping good records, keeping track of the medication, making sure people are getting what they need,” he said. 

In addition to being autistic, Katie was bipolar and struggled with depression and obsessive compulsive and attention deficit hyperactivity disorders. She was also prescribed medications for asthma and constipation. And she was allergic to dairy and nuts, so anaphylaxis — a life-threatening allergic reaction — was also a concern, and EpiPens had to be kept on hand. 

And like many group home residents, Katie could not administer her own medications.  

Her mother, a nurse, was diligent about supplying the group home with information in writing and in person. Lynne recalled that it took hours to compile the extensive medical and educational history the program required. 

“I wanted to be absolutely sure that they understood the complexity of Katie's routine,” she said. 

But Lynne couldn’t know the extent of medication errors in New Jersey’s group home system. 

The state and group homes confirmed 1,620 cases of medication errors and medication going missing from 2019 to 2024, according to data obtained by NorthJersey.com through a public records request. Of those cases, 57 were listed as having a “serious effect,” and another 1,305 a “potentially serious effect.” 

Medication errors confirmed in NJ group homes, 2019-2024

The state and group homes confirmed 1,620 cases of medication errors and medication going missing from 2019 to 2024. Of those cases, 57 were listed as having a “serious side effect,” and another 1,305 a “potentially serious side effect.”

And since incident reports are not public, the specifics of these cases are unknown. 

Additionally, New Jersey releases few details on deaths in group homes, so it’s impossible to say how many of these mistakes may have been fatal. State data showing the causes of group home deaths from 2019 to 2024 show no overdoses or “acute intoxications,” but the most frequent cause listed — for a quarter of the more than 1,000 deaths — was simply “other.”  

State licensing reports, police records and other documents reviewed by NorthJersey.com show a range of dangerous and persistent errors and issues surrounding both the dispensing and oversight of medication in group homes:  

• Residents receive incorrect doses. Workers follow outdated prescriptions, don’t write down doctor’s orders correctly or are careless.  

• People with disabilities are not given critical medication to prevent seizures, control aggressive behaviors or reduce anxiety. Withdrawal from some can be life-threatening. 

• Medication goes missing, whether through poor organization or because workers steal controlled substances with significant street value.  

• Medication is not always stored or handled properly. Workers keep dangerous substances in unlocked areas, pop pills from their packaging out of order, or sort multiple residents’ drugs all at once — increasing the likelihood of mix-ups.  

• Medication records are shoddy. Workers fail to date and initial medication packs or have someone else record that meds were administered without confirming they were actually given. Some homes didn’t have required medication logs. 

• Group homes don’t have records that show workers completed medication training or took the required tests that evaluate skill and knowledge. Sometimes, the trainers aren’t qualified to conduct classes.  

Paul Aronsohn, the state’s ombudsman for individuals with intellectual or developmental disabilities, said while it would not be feasible for a nurse to administer all medications, “at a minimum, a nurse should be overseeing the process.” 

He pointed to New York, which requires unlicensed direct care staff to be supervised by a registered nurse who visits at least once a week. The nurses are responsible for developing a plan for residents in need of nursing services, including those who require medication for diagnosed conditions. 

“It is wrong and dangerous that the state does not require the involvement of nurses in the administration of medication in group homes,” Aronsohn said. “This is particularly troubling in that this requirement exists in practically every other setting for every other community — in schools, in assisted living homes, in prisons.” 

“New York requires nurse involvement,” he added. “New Jersey should, too.” 

The Moronskis met with Assemblywoman Aura Dunn, R-Morris, who in response introduced a bill in March requiring a nurse — or a certified medication aide working under the supervision of a nurse — to administer medication in group homes and supervised apartments.  

“We're asking service providers that are not skilled in the medical field to dispense medication,” said Dunn, who is a co-chair of the Legislative Disability Caucus and whose 35-year-old brother lives in a group home. “But we have to recognize that this is also a vulnerable population that requires this level of oversight."

“We're talking about [what in] many cases could be lethal medication, if mis-dispensed,” she added.  

Providers say it’s not that easy.  

“Where are the nurses? We can't find nurses,” said Valerie Sellers, head of the New Jersey Association of Community Providers. “And if they're there, they're going to work for much higher pay than they're being offered in this community.” 

Sellers said a better solution may lie in technology. She said some agencies put medication dispensing machines in residents’ rooms. But it’s not many, she said, and those that do secured grant funds. 

“A great way to reduce medication errors is for the state to provide those [machines] in all group homes,” she said. “That would be a good use of state dollars.” 

Serious consequences

Giardina calls some medication errors “near misses” — nobody got hurt but someone could have “if it was a different medication and a different person." 

Other times, such errors lead to hospitalization, permanent injury, dangerous behaviors and — as Katie’s case underscores — death.  

Michael McCarthy Jr. was twice brought another resident’s psychiatric medication when he lived at a Wayne home run by Broadway Group Homes, events his parents observed firsthand. And a caregiver at Beacon Specialized Living tried to convince 21-year-old Tommy Schiavone to take twice his prescribed dose of ADHD medication, clonidine.  

“I had to stop them,” said Tommy, who is autistic. “They seemed careless. Luckily, I know what medication I take.” 

Tarar Cassel, who is autistic and nonverbal, was not as fortunate. 

Tarar had an ulcer on her toe that was getting worse. She scratched at the lesion until it bled and the bones were dislocated at the end of her toe. 

Her podiatrist wrote her a prescription for an antibiotic cream to be applied daily to two toes, and an antibiotic pill to take three times a day. But staff at her Community Options group home in Mount Laurel did not apply the antibiotic cream, medical records obtained by NorthJersey.com indicate.

A week later, doctors called her mother. One of Tarar’s toes had to be amputated to stop the infection from spreading. The tendon was visible. Tarar was screaming in pain.  

“I was in a state of instant shock,” said her mother, Patricia Cassel White, in an interview with NorthJersey.com before she settled a lawsuit against the company. “Community Options knew nothing. You couldn’t get anything out of them. They said, ‘We don’t know. She’s been walking like this for a long time, like her foot was hurting. We thought she bumped her toe on a chair.’   

“These are the people that are supposed to be watching her?”  

The state Department of Human Services investigated and substantiated neglect.  

“According to Ms. Cassel’s [medication administration record], Bactroban was not administered after 8/5/20. This contributed to Ms. Cassel sustaining a major injury, the amputation of her right fifth toe, on 8/12/20, due to osteomyelitis,” a state official wrote. “Remedial action by the agency was not taken.” 

Community Options does not comment on specific cases, said Executive Vice President Svetlana Repic-Qira, citing health care privacy laws.  

“We maintain a robust internal auditing system, including reviews of medication records, staffing ratios, and financial transactions,” Repic-Qira wrote in a statement. 

Jacquelyn Kaminski was hospitalized after having nearly 30 seizures within five hours when she lived at Broadway Group Homes in Wayne because she did not get her epilepsy medication. 

Her bloodwork showed low levels of her anti-seizure medication, and her parents took photos of her pill packs that still contained medication for days that had passed. 

Broadway executives did not return requests for comment. RHA Health Services, which owns Broadway and Broadstep, said in a statement after it acquired the two companies in 2023, "We began integrating and implementing RHA’s systems, including quality and compliance processes.” 

A state investigator found that staff had recorded giving Jacquelyn medication for days the pills were still in their packs. One worker admitted to initialing medication records even though they didn’t dispense the medications or confirm they were given, which violates company policy. On some days when Jacquelyn was in the hospital, group home staff still recorded that they administered her medication. 

Parents say they have seen dangerous behaviors return when prescribed medications aren’t dispensed. 

Adam Morris, 44, who is on the autism spectrum, has post-traumatic stress disorder and an intellectual disability. He’s worked for more than 20 years at a Wawa, where he is affectionately known as the mayor.  

He is charming and is a hard worker, but also suffers from extreme anxiety. When stressed, he can have aggressive outbursts, bite himself until he bleeds, and hit himself and others. He is prescribed lorazepam — a benzodiazepine — three times a day to reduce anxiety. 

“Adam needs it,” said Debra Flagg, his mother. “If Adam doesn't get it, he turns into a totally different person, and it's scary.” 

But through the years his lab results have periodically come back negative for benzodiazepines, documents show. A nurse practitioner first alerted Debra to the problem in 2019, amid a perplexing upswing in dangerous behaviors and trips to the emergency room.   

She’s been mindful of lab results ever since, wary of any changes in Adam's behavior. Last year, after he was punched in the face during a fight with a housemate and taken to the hospital, Debra filed a police report saying she did not believe the staff at his P.I.L.O.T. Services group home in Voorhees was giving Adam his medication. Photos show he had a black eye and a self-inflicted bite on his arm. 

Just three weeks earlier, Adam had tested negative for benzodiazepines when he was also taken to the emergency room, this time after becoming so frustrated he tried to harm himself by biting his arm, hospital records show. 

“Most often times when Adam is like that, when he's that escalated, those urine screens are showing negative,” Debra said.  

Allen Samuels, executive director of P.I.L.O.T., said he could not speak about individual cases. 

“We are very familiar with families’ concerns, and we take those seriously,” Samuels said. 

Not giving a prescribed medication is “just blatant negligence,” said Dr. Andrea Iannuzzelli at Rowan Medicine’s Regional Integrated Special Needs Center. 

Drugs such as lorazepam have another danger. 

“Benzodiazepines are one of those medicines that withdrawal is life-threatening,” Iannuzzelli said. 

Similarly, lab work for JayQuari Johnson-Hogan, 28, came back repeatedly with low levels of two of his prescription medications — lorazepam and clonazepam — while he lived at a Friends of Cyrus home in Monroe. At the same time, his self-injurious behaviors, which include intensely hitting his head, increased.  

JayQuari, who has autism and is nonverbal, had multiple hospitalizations related to his care at the home, including for severe dehydration, constipation and malnutrition, records show.  

“The self-injurious behavior, the extreme anxiety that he was exhibiting, he wasn’t exhibiting at all in the hospital once they got him on his medication,” said Tisha McKenzie, his aunt and legal guardian. 

Friends of Cyrus founder and CEO Kamelia Kameli said the company does not comment on individual cases. “We take allegations of abuse, neglect, or exploitation very seriously,” Kameli wrote. 

When JayQuari moved out, Friends of Cyrus gave his new agency, EIHAB Human Services, outdated prescriptions for his helmet and medications — and provided few refills, according to emails to the state.  

“EIHAB is now in the position that immediate medical appointments have to be made to get new scripts to assure his medication is delivered in a timely manner,” an EIHAB employee wrote in June 2024.  

Missing medications

Skipped dosages could occur due to carelessness, such as running out of needed medications.  

Lisa Rollins said when her son Kai lived at an APluscare group home, he came home for a visit without his epilepsy medication. It turned out the group home didn’t have any, she said. 

“They didn’t order my son’s medication on time, so he didn't have it — that could have caused him to have a seizure,” Rollins said. 

At her insistence, the staff got it from a pharmacy and brought it to her at 11 p.m. — with the three other residents in the van, she said, because there wasn’t enough staff to leave them at the group home. Her son’s epilepsy medication was two hours late, she said. 

NorthJersey.com called, emailed and sent a certified letter to APluscare asking for an interview. 

A director said privacy law prevents the company from speaking about residents.   

“We can however confirm that the allegations described in your letter are simply not true,” said Anndrea Yetter, senior compliance director.   

Other times, drugs go missing, including controlled substances with street value, such as the benzodiazepines Adam and JayQuari rely on.  

The state and group home companies confirmed 258 incidents involving missing controlled substances from 2019 to 2024.  

While details of those incidents are not public, NorthJersey.com found cases where group homes reported missing medications to police, as well as notations about missing and unsecure medication in licensing and other records. 

For example, there were three reports of missing or stolen drugs — including lorazepam, oxycodone and unnamed narcotics — at a Community Options group home in East Greenwich in 2020 and 2021. The 30 missing oxycodone pills — an addictive pain reliever — were delivered to the group home but were never entered into the tracking system.

The nurse who called the police didn’t know who had been working that day. 

Two other Community Options homes in Little Egg Harbor and Ewing reported missing controlled substances to police in the two previous years.  

Last year, the director of a Friends of Cyrus group home in Cherry Hill reported the theft of medication after a worker was captured on video going through a resident’s medication box and appeared to be removing items.  

When the box was checked, two types of drugs — 60 pills in all — were missing, one of them a controlled substance that is used for seizures and panic disorders. The director told police that he believed the worker would “attempt to sell the medication on Facebook because she had posted pictures of illegal narcotics and other drugs in the past with intent to sell.” 

A lack of security when storing medications plays a role in such cases. It also increases the likelihood that residents, too, can get hold of dangerous substances.

In 2024, state data shows, three group home residents attempted suicide with medication. There were also three overdoses that were not suicide attempts, which the state defines as consuming a large dose of medication that likely led to a serious toxic reaction. 

A state report showed that workers at PennReach used a butter knife to access a locked medication closet in Long Branch. And last year in Linden, inspectors found that Partnerships for People stored medication in an unlocked mini-refrigerator that did not work and was growing mold. Most medications were not labeled. 

Even in the brief time Katie Moronski was at Broadstep, some of her medication — Metadate, a controlled substance similar to Ritalin — went missing, her mother said. 

There is no record of a police report for missing drugs at her group home during that time. 

Choosing Broadstep

At 21, Katie was aging out of the children’s system of care and her time at the Chamberlain International School in Massachusetts was fast coming to an end. 

The Moronskis, like other families, were not able to just pick a company they liked for their daughter. Rather, they had to wait for an agency to express interest in Katie.  

Two programs run by RHA Health Services — a for-profit company owned by a private equity firm — responded. One of them was Broadstep.   

It was not a decision the Moronskis made in haste. In addition to peppering the program with questions, they wanted assurances Katie could go to private tutoring and continue to see her own physician. They toured Broadstep’s day program and saw the nurse’s office. They went to a dinner party at a group home where Katie interacted with residents and was observed by behaviorists.  

Katie also did an overnight visit at the Newton home where she would live all too briefly. She connected with another resident, a woman who was middle-aged but happy to watch Disney princess movies. Katie was eager to make a friend. 

“She reported to us in the morning that she was very happy with what she saw and that she could see her new life there,” recalled Lynne. “So, we stopped the search and went with Broadstep.” 

Looking back, Lynne said dealing with Katie’s medication was “the most stressful” part of the process. 

Broadstep wanted a 30-day supply of each of Katie’s medications upfront. And they required paper prescriptions — not electronic, a system Lynne didn’t see as modern.  

She was also uneasy about the way pills would be dispensed. 

At the Chamberlain school, Katie’s morning, noon, evening and bedtime medications were in pre-sorted pill packs, each labeled with the date and time they were to be administered, as well as the number and type of pills. 

Lynne provided Broadstep with pill packs from Chamberlain, along with each of Katie’s individual medications. 

“There are several days of pill pack meds, which are easier to administer than the individual ones,” Lynne wrote to the admissions coordinator a day before Katie arrived. “I trust that you’ll be able to handle all the individual pills for 30 days. I hope your pharmacy uses pill packs going forward: it’s safer.” 

When Katie arrived at the group home on June 22, a Saturday afternoon, Lynne emphasized that Katie could not administer her own medications, pointing to the prescription. She reviewed how the pill packs work with the residential supervisor.

“I also covered personally how the pill packs work, that the pills are listed on the front. You can look at them through the back, and it's got her name on it, and it's got the date on it, and it's got the time on it,” Lynne said. 

Lynne said she felt Broadstep was an “established program” with medical professionals and that “they’ve done this before.” 

“We did our best,” she added. “We had a right to believe that they would administer medication as prescribed.”  

Training and oversight

Not all group home staff members are trained to dispense medications.

Those who are trained take a recently updated six-unit online course in the basics of medication administration, including how to read labels, deal with pharmacies and prevent and document errors.  

The state Department of Human Services, which oversees the group home system, didn't answer specific questions about the medication training and any recent changes. It also would not allow reporters to view the training, claiming the department was unable to provide access.  

The online training is followed by an on-site competency assessment. The evaluator does not have to be a nurse or other medical professional, but must have experience dispensing medication to individuals with developmental disabilities. An annual reassessment is also required by the state. 

Licensing inspections and other documents obtained by NorthJersey.com raise doubt that workers completed training or were properly assessed before dispensing medications.  

At Bancroft in 2022, there was no record that four workers took the training and that 18 completed the required competency assessment. At Broadstep that same year, there was no evidence 16 workers took the competency assessment. 

A former Bancroft employee sued the company in 2023, claiming she was told to certify that a worker demonstrated an understanding of the proper procedures for medication administration when she hadn’t seen the assessment.

“Indeed,” the lawsuit reads, “to her knowledge the staff had not completed the necessary training at all.” 

A representative for Bancroft said the company could not speak about specific lawsuits, and said Bancroft’s state ratings have since improved.  

“We take the training of our staff and the well-being of the people we support very seriously,” wrote Rebecca Fuller, senior director of marketing and communications at Bancroft.  

Workers told NorthJersey.com that staff members, some young and inexperienced, distracted by cell phones or in a rush to complete tasks, can deviate from procedures and make mistakes.  

“They take shortcuts and set themselves up for failure,” one group home manager said. 

Some workers pop medications from blister packs into cups for multiple patients in advance, rather than one medication, one patient at a time, she said. Or they record that all medications have been dispensed before handing them out, quickly clicking through computerized forms. 

After making a medication mistake, providers are required to contact the resident’s doctor or pharmacist for direction.  

State records show that medication errors at some companies are frequent and, in some cases, excessive. 

At PennReach, inspectors found that 92% of its group homes and supervised apartments had “medication administration issues” in 2022. 

One resident’s chart had 197 documented errors in four months. In 27 instances, the resident received only one of their two prescribed doses. And in a Paterson apartment, workers recorded that they administered medication to a resident on days he was in the hospital and not at the group home. 

But Krystall Odell, CEO of PennReach, said what’s written in state reports “doesn't always show you a whole picture of what's going on.”  

“If you are hit on something with the medical records, what it can be is that it was a vitamin that somebody didn't mark off,” Odell told NorthJersey.com. “That's marked exactly the same as if it's heart medicine. We get people who might be good at caregiving but aren't really good at the paperwork, and that, frankly, is usually the problem. We brought everything into compliance.” 

PennReach does not have an electronic medication system — it relies on paper records, which Giardina and other experts say can lead to errors.  

“When you use the paper and pen system, a lot of things can go wrong,” Giardina said.  

A lack of oversight and auditing is frequently noted in state reports as a cause, especially when the problem is pervasive. 

Allies Inc., one of the state’s largest group home providers, has been cited for widespread errors in dispensing medication and recordkeeping for years. By 2022, the state found systemic issues at as many as 50% of Allies sites. One year, inspectors noted that "many prescriptions were either expired or missing,” and medications weren’t dispensed according to physicians’ instructions.  

Allies did not respond to multiple calls, emails or a certified letter request for comment.  

How each group home is run — who it can serve, staffing levels and whether there will be nursing oversight — is dictated by a key form called the program description.  

The program description on file with the state for Katie’s group home hasn’t been updated since 2009 — and bears the name of a previous owner.

It says a part-time RN or LPN assigned to the home will visit “at least weekly to provide oversight of medication administration” and report any issues to a nursing supervisor. A schedule for the home puts a nurse on site two hours a day, five days a week. Arranging medical appointments for residents and certain specialized training for the staff — such as giving insulin injections — is also part of the job. 

But nurse involvement in training and oversight isn’t always thorough, and nurses may be stretched thin, interviews and documents show. 

A nurse, for example, claimed in a lawsuit that she was generally assigned to oversee 15 to 20 group homes when she worked at Devereux Advanced Behavioral Health, among the largest group home providers in New Jersey. She often traveled for hours per day between sites, working up to 60 hours a week for about $69,000 per year. 

Leah Yaw, senior vice president at Devereux, said she could not comment on the lawsuit, which has been settled. But she noted that the company having nurses on the ground goes “above and beyond any requirement of the state or any regulation.” 

“We like to have nursing support rotating through, because it's helpful to our individuals, it's helpful to the staff on the ground,” Yaw said. 

State guidance is nearly silent about precisely when a nurse is required to be present at a group home, but the state standards do say feeding tubes are the responsibility of nursing personnel. 

An additional state policy directive from 2018 made clear that a host of medical procedures and monitoring — such as injecting insulin, taking blood pressure and monitoring catheters — may be done by unlicensed workers as long as they have training. 

Charmaine Cohen, a former manager overseeing supervised apartments run by Beacon Specialized Living, said the nurse she worked with was “very good at her job” but was “definitely given more work that one nurse could have realistically handled.” 

The nurse would not have had time to administer medications for all the residents she oversaw. Cohen said she helped the nurse with auditing. 

And any training the nurse provided Cohen she could then teach to staff. Sometimes that training was no more than pamphlets and a manual, she said.  

Beacon Specialized Living would not comment on specific cases, but Lisa Coscia, its president, wrote in a statement, “We continue to strengthen our training, reporting and prevention systems.”  

Providers say group homes are generally not staffed by nurses unless a resident requires medical care for a specific condition — usually the more fragile residents who are in medical group homes.  

Katie Moronski's group home was for people in general good health who might have medical issues that can be controlled by diet, medication and monitoring.  

Katie's last day

On Monday, June 24, Katie’s second morning at the group home, her mother, Lynne, got a series of phone calls from the program while she was at work in Philadelphia. 

In the first call, an employee said some of Katie’s medication — Metadate, which is similar to Ritalin — had gone missing.  

Frustrated, Lynne went for a walk, leaving her phone behind. She missed another call from the group home saying Katie’s “behavior was a little bit off.”  

Back at her desk, Lynne picked up the next call and suggested the staff take Katie to urgent care, where she would be seen more quickly than at a hospital emergency room. 

“They said the nurse had told them to go to the ER, and I didn't get the impression that there was any urgency, because she said that Katie couldn't describe what was bothering her, other than she wasn't feeling well,” Lynne said. 

At urgent care, Katie was rushed to an examining room. She was in obvious signs of distress — incoherent, sweating and unable to breathe.  

Urgent care called an ambulance immediately to transport Katie to nearby Newton Medical Center. 

The attending physician called Lynne from the hospital to get Katie’s medical history.  

The doctor called again to say they were performing CPR. 

“I said I was very confused, because she's 21. What do you mean you’re doing CPR?” Lynne recalled. “I was very upset. She said that she would call me back. And she did — to say that they were unable to resuscitate her.” 

Hospital records show a quickly escalating crisis. Katie arrived shortly after noon, appearing ill, with mottled skin, an “altered mental state” and shortness of breath. 

“The group home staff states the patient woke up this morning and felt fatigued and had difficulty breathing,” the records show. 

Katie was seen immediately and put on intravenous fluids. She was given steroids and a treatment to open her airways. She had a rapid heart rate and rapid, shallow breathing. Medical staff members had trouble drawing blood, common when someone lacks oxygen.  

As they were preparing to intubate Katie, she had a seizure; that’s when the lorazepam later found in her system was administered. By 12:48 p.m. they had begun CPR. It continued through multiple rounds of epinephrine, which can restart the heart.  

Katie never regained a pulse. She was pronounced dead at 1:18 p.m. 

Lynne and Sean’s distress and confusion escalated when they saw Katie’s body at the hospital. She was blue, indicating hypoxia, a lack of oxygen. 

“Blue — blue like a Smurf blue,” Lynne said. “We were trying to figure out: Why is she so hypoxic?” 

Lynne told the attending physician she wanted an autopsy. 

“She was glad that I had asked, because it had happened so quickly that she couldn't determine what the problem was,” Lynne said. 

'We're heartbroken'

In the aftermath of Katie’s death, questions multiplied; frustration and anger grew. 

The medical examiner told Lynne there was no obvious cause of death, and ruled out an allergic reaction, which was top of mind. 

Lynne didn’t know Katie had been taken to the hospital by ambulance until she looked at the medical claims. And she found no mention in the records that Katie’s extensive list of medications had been provided to urgent care or hospital staff.  

“When you take a young adult who's in a group home or in a school to a medical facility, you should be bringing a list of their medications so that the doctor can understand the bigger picture,” Lynne said. “I'm just very, very disappointed, because I think that they could have gleaned more information about her history from it.” 

A visit to the group home two weeks after Katie’s death to retrieve her belongings was unsettling on two fronts. 

Lynne recalls the residential supervisor greeting them with “Hey, how y'all doing? It's a great day.”  

“I was so upset. And I said, 'You know, we just lost our child. She died. We're very upset,’” Lynne recalled. “I just felt that it was really callous.” 

More disturbing, the unused medications that were returned set off alarms. They showed obvious signs of tampering, photographs show.  

Pill packs for dates after Katie’s death had been opened — and resealed with tape.  

The half dozen packs of Katie’s bedtime medications were supposed to have seven pills each, but had only five.  

There were 20 olanzapine pills in an envelope stapled to one of the blister packs. The imprint on the loose pills didn’t match the pack it was stapled to.  

RHA Health Services’ only response to NorthJersey.com’s questions about Katie’s death included a statement: “We are committed to providing high quality services in safe and healthy environments for the people we serve, who are at the center of everything we do.” 

“The state of the medications when given back to my clients were the epitome of disarray,” said Paul M. da Costa, the Moronskis’ attorney, “and called into serious question the conduct of the Broadstep employees as it relates to the management and dispensing of prescribed medications.”  

And there were the autopsy and toxicology reports, revealing the senselessness of Katie’s death. 

Two of the drugs cited by the Morris County Medical Examiner’s Office as contributing to Katie’s death were prescribed antidepressants; a third was prescribed to treat her bipolar disorder.  

At least one of those drugs was in her bloodstream at a concentration in the range where there have been fatal overdoses, a toxicology report shows. 

“What is most disturbing and bordering on unbelievable is that there were three of Katie’s prescribed medications that were in acute overdose status based on her autopsy, which gave her exponentially higher probability of dying from the reckless care of the group home staff, as opposed to it only being one prescribed medication in overdose status,” da Costa said.  

It remains unclear precisely what happened that day. Four staff administered medication to Katie in the two days she was at the group home, including the residential supervisor.

It appears unlikely that Katie could have ripped open blister packs on her own, da Costa said — she had a hand tremor. Even so, medications should be secured by the group home, according to licensing standards. 

“We're heartbroken. We're crushed. We're just crushed,” Lynne said. “You know, after everything that she went through, everything that she managed to achieve, this is the ending? It’s just cruel.” 

Katie

Katie had worked hard to overcome the challenges she faced. She had a tough time being independent and controlling her emotions, and before the Chamberlain school she could scream for hours if she was upset or things didn’t go her way. 

“She always wanted to improve herself, no matter how much she screamed or did the wrong thing. Like she was persistent,” Lynne said. 

While shopping for new clothes for the move to Broadstep, Lynne could see the change. 

“She said very quietly, ‘I don't want to try on any more clothes.' No screaming, no arguing,” Lynne said. “I considered that to be huge progress.” 

Katie had goals that most people take for granted, such as pouring a bowl of cereal without it overflowing, loading a dishwasher, or getting dressed without forgetting her bra.   

Her impulse control was poor, and she could get into trouble if left alone for more than a few minutes, and turn making a cup of tea or coffee “into a huge mess.” 

“It was a little bit like living with Curious George,” Lynne said. “He needs lots of supervision. He’s very sweet, but the minute you turn your back, you know the bathtub is overflowing. He's really trying to do the right thing, but he's also very curious. That is a pretty accurate portrayal.” 

Katie was passionate about horses. She loved to groom them and feed them little candy canes at Christmas. It was with horses that she and her family saw the potential for a career — the director of a horse stable confirmed she was very good at it — and the move to the Broadstep home in Sussex County put her near an abundance of horse farms. 

“She loved art,” Sean said. “She loved drawing. She had a talent for capturing people's faces, and she drew them anime style. She knew her limitations and wanted to get beyond them.” 

Katie pushed herself further after she met academic and scientist Temple Grandin, who has autism, at an event in their hometown of Morristown. Grandin told Katie she needed to be at an eighth grade reading and math level if she wanted to have a future.  

Learning that she was at the sixth grade level in English and the second grade in math, she asked for a tutor. By the time she graduated from high school, Katie had exceeded the reading goal. 

In addition to horses, she had an encyclopedic knowledge of birds — she had memorized the names of birds in the Cornell Lab of Ornithology guide.  

Katie “was very passionate about the underdog,” Lynne said, “whether you were Black or trans or gay.” 

She collected unicorn toys, and her favorite was “Afro Unicorn,” a stuffed animal from a Black, female-owned business. 

“She had incredible moments of clarity that most people don't have, or would surprise the heck out of you,” Sean said.  

At her guardianship hearing, for example, Katie had her lawyer confirm that no one would take away her right to vote, which impressed the judge, Sean recalled. 

And not long before she died, Katie told him: “Dad, I know we're Catholic, but I believe in reincarnation.” 

“And I said to her, ‘Well, I hope you’re right.’” 

An afterthought

It took the state Department of Human Services four months to open an investigation into Katie’s death.  

Sean called it “an afterthought.” Lynne said she was “offended.” 

“It makes us feel that they're only looking to vindicate themselves,” Lynne said, “that they're not really interested in what happened to our daughter or putting new safeguards in place so it doesn't happen to anyone else.” 

The Moronskis were interviewed in November, but the state has not responded to an email from their attorney with questions and photographs of the medications. Officials also have not come to inspect the tampered medications in person.  

“Although it seemed like they were interested in that,” da Costa said, “there's been zero follow-up.”  

The investigator on the case does not have a nursing or other medical license, and the Moronskis were told that it’s almost certain no doctor would be involved. 

No law enforcement authorities have been in contact with the family about Katie’s death. 

Coping with the loss, Lynne said, “is not getting any easier. If anything, it's getting harder as the days drag on.” http://northjersey.com

They miss Katie’s hugs, her inquisitive nature, her five emails a day with the entire message crammed into the subject line. She was, Sean said, “the most genuine person I have ever known.” 

Online tributes from friends and the staff at the Chamberlain school remember her as “a beautiful soul,” a sweet and loving best friend, and a “little angel” who was “always wanting to please, always wanting friendship, always spreading love.” 

“She's been robbed, and we've been robbed,” Lynne said. “We were supposed to be able to watch her grow up.” 

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