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Operation Guardians - Surprise nursing home inspection exposes 'resident neglect'

Bay Citizen
Katharine Mieszkowski

Two Bay Area facilities among 14 statewide criticized by state for lapses in care

On Jan. 19, 2010, state inspectors found a resident lying in "a feces-soiled diaper with old, dry stool" inside a "filthy" Vallejo nursing home.

When the inspectors from the California Department of Justice notified staff, it took an hour for the patient to be changed.

“This is unacceptable nursing care and considered resident neglect,” according to the inspection report.

“They can’t get help even when a Department of Justice inspector directly notifies the staff. What does that say about what happens in the facility when they’re not there?” said Mike Connors, an advocate with California Advocates for Nursing Home Reform. The nonprofit organization obtained reports from surprise inspections at 14 nursing homes in the state through a public records request and posted them on its website last week.

The California Department of Public Health said in a statement that it has initiated an investigation of the Vallejo nursing home, Springs Road Healthcare, as a result of the inspection. The health department, which is the regulatory agency that oversees nursing homes, does its own investigations to substantiate allegations, issue violations and impose penalties. But the department would not say what it had found at Springs Road Healthcare, which is also known as Evergreen Healthcare Centers of Vallejo.

For now, the nursing home has a three-star rating on the federal government's Nursing Home Compare site, which ranks nursing homes. The rating for Springs Road Healthcare is unlikely to change unless the state's health department takes action.

Since 2004, the department has fined the nursing home a total of $55,800 for 18 violations of patient rights, patient care, safety and staffing, according to the department's website.

And since the surprise inspection, the long-term care ombudsman, a federally funded watchdog, has received 66 complaints about the facility.

“That’s pretty high,” said Joan Parks, administrator of Ombudsman Services of Northern California, which provides advocacy services for residents in long-term care facilities in 13 Northern California counties, including Solano where the nursing home is located. “I am not surprised at all with what (inspectors) saw on that day.”

Parks attributes the problems at Springs Road in part to turnover among administrators at the facility. “That high turnover is costly, and the ones who are paying are the residents,” she said.

Officials from the nursing home refused to comment on the state’s findings or any administrative turnover at the facility.

“We feel privileged to care for our residents,” said Jonathan Allred, general counsel for EmpRes Healthcare Management, which provides management consultation services to the nursing home. “Striving to provide a safe and secure environment for our residents remains our upmost priority at all time.”

The surprise inspection of Springs Road Healthcare was one of 14 conducted at various nursing homes by the California Department of Justice's Bureau of Medi-Cal Fraud & Elder Abuse in the past two and a half years. The inspections are part of the bureau's Operation Guardians program.

The inspection reports reveal problems ranging from life-threatening deficiencies in patient care to signs of neglect, including many call lights out of reach of patients, peeling wallpaper and unshaven residents.

Lynda Gledhill, a spokeswoman for the state attorney general’s office, said all the reports have been referred to the state’s Department of Public Health.

Springs Road was not the only Bay Area nursing home visited by Operation Guardians' inspectors. During a surprise inspection at Winsor House Care Center in Vacaville on March 18, 2011, inspectors examined the care six patients received. “There were deficient facility practices in the areas of pain management, infection control, physical restraints, weight loss and nursing services in general,” Kathryn Locatell, a doctor with the Operation Guardians team wrote in a report.

Officials from the nursing home refused to comment.

Although inspectors uncovered numerous problems at the different nursing homes, the California Department of Public Health said it can confirm that it has cited three facilities – Windsor Redding Care Center in Redding, Braswell's Hampton Manor in Yucaipa and Plott Nursing Home in Ontario, Calif. The department said in a statement that it "is in the process of gathering all those deficiencies that have been issued related to the Operation Guardians facilities."

The attorney general’s office has taken legal action against one nursing home mentioned in the Operation Guardians reports, seeking a civil injunction against Braswell’s Hampton Manor. The court-ordered injunction “allows us the power to monitor the facility for five years,” Gledhill said.

It is rare that a nursing home is actually shut down for violations. "I've been doing this for 22 years, and I think that there have been two nursing home closures," said Parks of the ombudsman's office. She said that closing a home is a last resort because "many residents experience transfer trauma," which can be fatal. "The older we get and the more demented one is, the more difficult any kind of change can be."

Despite the problems uncovered by the Operation Guardians program, the number of inspections performed by the state Department of Justice has dropped dramatically in the past six years. When asked about the drop in inspections, state Department of Justice officials said in 2010 that there had been no conscious effort to diminish elder abuse cases.

Correction: A previous version of this story incorrectly stated the date of one of the state inspection. It was Jan. 19, 2010. Also, Winsor House Care Center was misspelled, and the California Department of Public Health said it can confirm that it has cited three facilities.