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Operation Guardians - Inspections find problems at two San Fernando Valley nursing homes

Contra Costa Times
Susan Abram, Staff Writer

Residents at two San Fernando Valley nursing homes suffered from untreated bedsores, were at risk of contracting infections or were drugged when they didn't have to be, according to state inspection reports released this week by a nonprofit advocacy group.

The Motion Picture Television Fund in Woodland Hills and the Tarzana Health and Rehabilitation Center in Tarzana were two local nursing homes among 14 statewide that were inspected recently by the state's Operation Guardians team, which works under the auspices of the state Attorney General's Office.

Among problems detailed in the findings were pressure ulcers that were allowed to fester, sloppy medical record keeping, overuse of antipsychotic drugs even though patients were not diagnosed with depression or mental illnesses, and infection-control problems.

"The findings in these nursing homes are shocking, disturbing and they are an indictment of the poor care of these particular nursing homes," said Michael Connors, spokesman for the California Advocates for Nursing Home Reform.

The group filed a state public records request to obtain the reports. The information can be found online at

"The public would not have any way of knowing that these exist at all," Connors said.

An inspection conducted on March 7 at the Motion Picture Television Fund, for example, found that one patient suffered a deep tissue wound near his right hip and another on his left foot. Both pressure ulcers occurred because of "inadequate skilled nursing assessments and interventions" and "not having an appropriate pressure relieving mattress in place." Another patient had never received wound care for an advanced stage bedsore on her left buttock.

The MPTF has been struggling with financial problems in recent years, and was on the verge of closing in 2009, after board members announced a $10 million a year shortfall. But the fund is now engaged in a $350 million fundraising drive, and on Wednesday media mogul Rupert Murdoch announced a $20 million contribution to the effort.

The home, founded in the 1940s, provides nursing home and hospital care to actors, camera operators, set designers and others from the entertainment industry.

MPTF officials said the state inspectors had visited at a time when long-term care patients were being moved as part of an effort to place them all on the same floor of the building.

"In many cases, we feel that the conclusions of the inspectors, on an abbreviated visit to the facility, represent half-truths and with the benefit of a longer and more comprehensive interaction with our care team they might have seen a different picture," Bob Beitcher president and CEO of the MPTF, said in a written statement.

"Nevertheless, we are taking each and every one of their findings seriously and will be bringing in outside, experienced health care experts for a more extensive review of our practices both in long term care and dementia care."

At Tarzana Health and Rehabilitation Center, inspectors found that one patient was being given four different anti-psychotic medications for various mental issues, but there was no documented diagnosis of dementia or any mental illness.

Another patient had been admitted to Tarzana in February with quadriplegia, chronic obstructive pulmonary disease, epilepsy, and other ailments, but on March 6, when inspectors had visited, the patient had yet to be examined by a doctor. Inspectors also found there was not enough staff to help residents who needed help eating breakfast.

A call for comment Wednesday to administrators of the Tarzana facility went unanswered.

Operation Guardians was created in 2000 by then-Attorney General Bill Lockyer. The team's goal is to find Medi-Cal fraud within those nursing homes that take patients on Medi-Cal. While there, inspectors observe deficiencies and report them to the California Department of Health Services, which can prompt additional investigations and possibly citations and penalties.

The group has inspected 14 facilities across the state - including Golden Cross Healthcare and Sunrise Convalescent Hospital in Pasadena - since 2010. But budget cuts have limited the team's ability to travel, said Lynda Gledhill, a spokeswoman for Attorney General Kamala Harris. The team also visits nursing homes that have triggered many complaints.

"We have seen an increase in overall incidences of neglect and overmedication," Gledhill said. "It's a priority of this attorney general to make sure our most vulnerable residents are treated well."

The California Association of Health Facilities said the Operation Guardian findings do not reflect the care provided by all nursing homes, which serve some 300,000 patients a year.

"There is no excuse for poor treatment and neglect. However, this report focuses on outliers and does not reflect the high standard of care provided at most of the state's skilled nursing facilities," the group said in a statement Connors said there is no excuse among nursing home operators for such deficiencies, even those who service Medi-Cal patients. Nursing homes receive high reimbursement rates from the government.

He also said CANHR will continue to press state, county and local officials on the importance of consistent inspections. In addition, the group also will continue raising awareness about the misuse of anti-psychotic drugs.

"We've been making a federal case about that concern," Connors said. "The main challenge is there are so many people who are affected by the misuse of these drugs - 25,000 each day in California, and that doesn't even include assisted living facilities."