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Long before the coronavirus began sickening Kingston Healthcare Center’s residents and staff, state and federal officials knew the Bakersfield nursing home had serious problems.

During multiple visits last year, state inspectors identified 85 violations at the home, including failure to provide dental care to a resident with rotten teeth, allowing pressure sores to develop in another resident and serving whole hot dogs to a resident at risk of choking, according to one inspection report posted on Nursing Home Compare, Medicare’s consumer website.

Last August, a lack of appropriate precautions led to the death of a 79-year-old man, who fell and hit his head so hard his roommate said “his head bounced,” another inspection report states. The California Department of Public Health fined the facility more than $100,000; the nursing home is appealing.

Regulators have labeled Kingston a “special focus facility” for a year and a half now — a label the federal government reserves for only the most troubled nursing homes, which face the possibility of being forcibly closed. Still, when the pandemic hit, Kingston’s troubles only escalated.

By this week, 52 Kingston health care workers and 112 residents at the 184-bed facility had tested positive for COVID-19, according to a tracker on the facility’s website. State data as of June 11 shows that 18 Kingston residents have died of the virus, accounting for more than a third of all virus-related deaths in Kern County.

More than 40% of California’s COVID-19-related deaths are estimated to come from nursing homes. While highly rated facilities can experience outbreaks, too, many homes with track records of poor care are now operating with significantly less oversight.

On March 23, just as outbreaks began devastating nursing homes around California, the federal government ordered state inspectors to halt in-depth annual inspections to minimize the spread of the virus and focus on hot spots and infection control. Long-term care ombudsmen, who normally field complaints and advocate for nursing home residents’ needs, were told to stop entering all facilities beginning March 16. With limited exceptions, family members, who provide emotional and physical support along with careful scrutiny, haven’t been inside for even longer.  

That leaves a population that is already extremely vulnerable to abuse and neglect — as well as to the ravages of the coronavirus — effectively cut off from the people tasked with protecting them, advocates say.

According to a CalMatters’ analysis of state data, 73 of the state’s 1,224 nursing homes have had more than 10 deaths due to COVID-19, as of June 11. Taken together, that small group accounts for more than 55% of the state’s total nursing home deaths.

“I can’t think of any other time like this, where all of the layers of oversight are missing,” said Tony Chicotel, a staff attorney for the nonprofit California Advocates for Nursing Home Reform. “My guess is there’s lots of terrible neglect going on that is harming people to levels that are akin to the virus, but we just don’t know. And not knowing is very frustrating.”

Chicotel and other advocates say they are especially concerned about facilities that were already struggling with infection control, staffing shortages and other problems before the pandemic. Many of these facilities, including Kingston, have told the state they will use a state waiver to exempt them from staffing requirements, according to the California Department of Public Health.

Before the health crisis and the pause on routine inspections, the department inspected all skilled nursing facilities about once a year to enforce state and federal regulations, and to follow up on complaints as needed. The inspection teams scrutinize a home for everything from nutrition to cleanliness to safety.

The department says it has continued to send inspectors into facilities to oversee infection control and to evaluate “immediate jeopardy” complaints — the most serious incidents that could harm or even kill a resident.

According to data recently released by the Centers for Medicare & Medicaid Services, state inspectors have been onsite at almost 95% of California nursing homes since March 1, compared to a national average of 54% of homes. 

But Chicotel says those visits do not involve the same in-depth attention as routine survey inspections, in which he said three to five investigators typically spend a few days talking with residents and family members, interviewing and observing staff, and inspecting the kitchen and the grounds. 

By contrast, he said, infection control visits focus on handwashing, personal protective equipment and isolation of infectious residents. He also said inspectors haven’t been routinely citing violations or taking enforcement actions during these visits. 

In a report released this week, his organization said the state’s recent infection control surveys have not led to meaningful enforcement. In one example it cited, state inspectors found no deficiencies at Magnolia Rehabilitation & Nursing Center in Riverside on April 7; the next day, county health officials evacuated the facility due to a large outbreak and staffing crisis. In the case of Kingston Healthcare Center, state inspectors entered the facility on April 13 and found it in compliance with infection control regulations. Within a few weeks, dozens of people were infected. 

Charlene Harrington, a professor emeritus at UC San Francisco who studies skilled nursing facilities, said not conducting in-depth surveys — and not having family members or ombudsmen inside the facilities for months — has likely cost many lives.

“We have so many deaths that could have probably been prevented,” she said. She’s especially concerned that nursing home chains with poor track records may have had their quality of care deteriorate with this reduced oversight.

Representatives of the California Department of Public Health recently wrote in an email to CalMatters that “CPDH staff have been onsite at skilled nursing facilities more frequently during the pandemic than during regular pre-pandemic routine oversight.” 

In May, the department sent a letter to all nursing homes requiring them to submit specific plans within 21 days about how they will prevent the spread of COVID-19. The letter said inspectors will visit all facilities every six to eight weeks to evaluate how well these plans are being implemented and to identify any practices that could endanger patients. Department representatives said in an email that they will begin these inspections this month and next.

Last week, the state suspended the license of Golden Cross Health Care in Pasadena, evacuating more than 60 residents because of “ongoing and serious quality care concerns,” some COVID-related, the Los Angeles Times reported.

Deborah Pacyna, a spokeswoman for the California Association of Health Facilities, an industry trade group, said nursing homes are receiving a great deal of attention from family members and the media. In addition, she said, no skilled nursing facility wants to be known for having bad outcomes for residents. 

 “They’re under more scrutiny than ever before,” she said.

A troubled history

Kingston Healthcare Center, a large facility on a tree-lined street a few blocks from I-99, is one of at least 73 California nursing homes that have had more than ten deaths directly linked to the pandemic, according to a CalMatters analysis of state data.

Kingston Healthcare has struggled for years. It is one of only six federal special focus facilities in California; these homes face losing critical Medicare and Medi-Cal funding if they don’t fix serious problems. One other special focus facility, Alexandria Care Center in Los Angeles, has had 22 deaths due to COVID-19 as of June 11, according to state data.

 Kingston has been on the government’s list before — it spent 15 months as a special focus facility beginning in 2012, when it was under different ownership and named Parkview Healthcare Center, according to the Internet Archive. Since at least May of 2017, the nursing home has been owned by Dr. David Silver, a Beverly Hills rheumatologist, according to the California Department of Public Health. (The federal government traces his ownership of the facility back to December 2015, the Medicare website shows.)

Silver is also CEO of Rockport Healthcare Services, which oversees nursing homes for Shlomo Rechnitz of Los Angeles, owner of Brius Healthcare Services and one of the state’s largest nursing home owners. Silver told Kaiser Health News in 2017 that he had replaced the Bakersfield facility’s top management and staff who resisted a new approach — “We were not happy with the level of patient care,” he was quoted as saying.

Still, problems persisted. In 2019, the state received 129 complaints and reported incidents about Kingston, compared with an average of 40 for other nursing homes, according to the California Department of Public Health. The state recorded 85 survey deficiencies–or problems that can harm residents–for Kingston last year, compared to an average of 26 for other homes.The 79-year-old man’s death from a fall resulted in a rare AA citation, the most serious violation for California nursing homes.

Silver and Kingston Healthcare did not respond to multiple requests for comment for this story.

Ucedrah Osby of Bakersfield initially thought her uncle, Clyde Cooper, seemed reasonably happy at Kingston. She would visit occasionally, finding him in a courtyard smoking cigarettes with other residents. He seemed proud to introduce her to his friends.

“Everybody was really nice and they seemed to be caring,” she said.

Clyde Cooper, who lived at Kingston Healthcare Center in Bakersfield, died of coronavirus. Photo courtesy of Ucedrah Osby

Cooper, 76, had worked as a chef in a diner, among other jobs, prior to becoming disabled, Osby said. After he had a stroke, he was in and out of Kingston. His passions were “cigarettes, Pepsi and the Lord.”

Osby said she first realized something was amiss at Kingston earlier last month, when she saw news footage of ambulances leaving the facility.  She called and left messages, she said, but said no one returned her calls. After a week, she said she finally reached someone who told her her uncle had been transported to a hospital a week earlier—the staff member didn’t know which one, Osby said. After calling various state and local agencies, Osby said she finally heard back from a case manager at Bakersfield Heart Hospital who confirmed that her uncle had COVID-19. A few hours after that, she said, a doctor called.

“Your uncle’s not in good condition,” she says the doctor told her. “He’s on a ventilator. I need the family to make a decision today.”

“I said, ‘Wait a minute. I just found out where he was, and now you’re telling me to pull the plug?’”

If it was my dad,” she said the doctor replied, “I would send him to the Lord.”

Cooper died later that night.

Matt Constantine, Kern County’s director of Public Health Services, said that because his department has no regulatory authority over skilled nursing facilities, he only began paying attention to Kingston after the facility reported to the county that staff weren’t showing up for shifts. Constantine said his department worked to find emergency medical technicians, paramedics and other health workers that they could send into the facility — as well as to provide personal protective equipment and training. The county eventually asked the state for help, and the Department of Public Health last month sent a medical assistance team made up of about 35 staff members, Constantine said.

By then, infections were already racing through Kingston. Constantine said he thinks intervention should have happened earlier.

Clearly when you have residents that are dying, clearly that’s a strong indication that there are concerns,” he said. “We need to do more. This should be a wake-up call.”

Poor infection control

The federal government has created a nursing home rating system of one to five stars, ranking the homes from “much below average” to “much above average.” 

Those ratings alone don’t necessarily predict outbreaks. The Life Care Center in the Seattle area, where a widely documented COVID-19 outbreak killed more than 40 people, had a five-star rating from Medicare. It has since been accused of violating federal infection control standards and is facing a fine of more than $600,000, according to The Washington Post, citing an April letter from the Centers for Medicare & Medicaid Services.

But poor ratings have helped signal which facilities might fare poorly during the pandemic. CalMatters’ analysis found that about half of the 73 homes with more than 10 COVID-19 deaths received an overall rating of “below average” or “much below average” from Medicare. Statewide, about 30% of all homes have those lower ratings.

The five facilities with the most deaths so far all have one- or two-star ratings, the lowest categories. Redwood Springs Healthcare Center, a Visalia home with a 1-star rating, has reported the highest number of deaths with 29; 121 residents have tested positive, state data show.

Redwood Springs is administered by Plum Healthcare Group, a large chain based in San Marcos. Plum spokesman David Oates said in an emailed statement that the safety and well-being of patients and staff “are our highest priorities during this national emergency.”

He said Plum facilities have been “meticulous and prompt” in adopting the practices and protocols directed by county, state and federal agencies. Administrators at the various Plum facilities don’t know exactly how any of the outbreaks started, he said.

“However, we know that the virus is very contagious and could have been in their system for some time,” Oates said.

Elder care advocates say the problems facilities face controlling the spread of the virus reflect years of under-staffing and inadequate procedures for preventing the spread of infection. According to a Service Employees International Union analysis of Medicare data, nearly 70% of California nursing homes did not have and were not implementing an infection control program on their latest inspection prior to the pandemic.

Cedar Mountain Post Acute, a 95-bed facility in Yucaipa, has had 91 residents test positive for COVID-19 and 21 resident deaths, as of June 11, state data show. Cedar Mountain, which has a three-star rating from Medicare, or “average,” has had multiple documented problems with infection control in recent years, according to inspection reports posted on Nursing Home Compare.

In July 2018, state inspectors found that the facility’s washing machine had broken and that staff did not have access to adequate clean sheets and towels, the inspection report states. The facility was fined $14,875 for putting residents’ health and safety in immediate jeopardy. Five months later, Cedar Mountain was cited again for infection control lapses because staff did not wash hands between administering medications to different patients, according to the December 2018 report. And in February, on the eve of the pandemic, the facility was cited again for violating infection control procedures after staff failed to wash hands while treating residents’ wounds.

Cedar Mountain did not return calls for comment.

Pacyna, of the California Association of Health Facilities, said that many large outbreaks began prior to more recent guidance mandating that everybody inside facilities should wear masks. Prior to that, she said, facilities were told not to wear masks because of the need to conserve their supply. She said guidance on testing has also been evolving.

“I think facilities are doing the best they can given the instructions that are given and the equipment and testing that is available,” she said.

Families worry about neglect behind closed doors

Coronavirus is not the only threat to nursing home residents. Falls, bed sores, choking, abuse and neglect have been problems long before the pandemic. Long-term care ombudsmen and family members around California say they are deeply worried those problems are worsening behind closed doors, in the absence of traditional safeguards. They also worry about the psychological impact of prolonged isolation for residents confined to their rooms full time. 

“I am growing very concerned,” said Leza Coleman, executive director of the California Long-Term Care Ombudsman Association.

Coleman said local ombudsman programs around the state are already receiving more complaints from hospitals, paramedics and other first responders noting increased bad outcomes, more falls, more dehydration, more cognitive issues.

“They’re receiving the complaints, but how do you investigate the complaints?” she said.

At the same time, at a state Assembly hearing about nursing homes last week, Kim McCoy Wade, director of the Department of Aging, which includes the office of the state long-term care ombudsman, said abuse calls from the homes were down 43 percent – a figure  she says “does raise questions and concerns.” Shelter-in-placer orders also led to a dramatic drop-off in child abuse reports early on in the pandemic. Advocates contend such declines in complaints don’t reflect fewer problems, but rather less oversight. Family members commonly file complaints on behalf of nursing home residents, and now aren’t inside the facilities.

Pacyna, of the California Association of Health Facilities, said her organization has established a work group to find a way to help make family visits happen safely, but that state and federal authorities will ultimately determine what is allowed.

Some family members enter facilities daily to provide hours of care and attention for their loved ones – clipping their fingernails, coaxing them to eat, holding their hands. Being suddenly locked out for months has felt terrifying. They worry about what is happening in their absence; they also fear retaliation if they speak out.

Carole Herman, who runs the Sacramento-based Foundation Aiding the Elderly, said she’s been inundated with requests for help from people concerned about loved ones inside getting dehydrated or developing bedsores.

One of Herman’s clients said she, her sister and other family members normally spend eight to ten hours a day caring for her father, who is in a San Jose nursing home with late-stage Alzheimer’s disease. After the family was shut out of the home in March, they regularly video chatted with him. Over time, they noticed he seemed to be growing weaker. It turned out her father hadn’t been eating or drinking, and was severely dehydrated, she and Herman said.

“Our system is broken, but this situation makes it even worse,” Herman’s client said.

  Molly Davies, Los Angeles County’s long-term care ombudsman, says she hopes the pandemic will force a public reckoning with longstanding problems in the industry.

I think we all have to take responsibility for the absolute substandard care that we have allowed in nursing homes for decades,” she said. “Shame on us.”

CalMatters COVID-19 coverage, translation and distribution is supported by generous grants from the Penner Family Foundation, Blue Shield of California Foundation and the California Health Care Foundation.

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Jocelyn Wiener writes about health and mental health for CalMatters, exploring the intersection between government policies and people’s lives. She has worked as a reporter in her native California for...