From KKD: Nursing Homes Unmasked in Cal. Part 1

NURSING HOMES UNMASKED
 http://media.sacbee.com/static/sinclair/Nursing1c/index.html
Bonnie Nidiver of Paradise holds a photo of her late husband, Eugene, 88, a World War II Navy veteran who was active in his community. He died in June 2011, 10 weeks after he sought rehabilitation at Cypress Healthcare Center for injuries from a fall.PAUL KITAGAKI JR. / THE SACRAMENTO BEE
Bonnie Nidiver of Paradise holds a photo of her late husband, Eugene, 88, a World War II Navy veteran who was active in his community. He died in June 2011, 10 weeks after he sought rehabilitation at Cypress Healthcare Center for injuries from a fall.

First of three parts

One nursing home chain operating in California racked up abuse complaints last year at a pace seven times the statewide rate.

A large competitor placed one in every 15 of its long-term residents in restraints.

Still another corporate giant whose nursing homes dominate the Sacramento region experienced high nursing staff turnover at 90 percent of its facilities.

If you’re a consumer anguishing over the placement of a loved one needing full-time nursing, how would you know this?

The short answer: You wouldn’t.

As the population ages, and more families face the daunting task of choosing long-term care, consumers remain largely in the dark about the ownership of many California nursing homes – and their track records.

While industry officials contend they are intensely regulated by both the state and federal government, no single agency routinely evaluates nursing-home chains to gauge the overall care provided by their facilities.

Data are available for individual nursing homes, as federal, state and nonprofit groups keep records that chronicle staffing levels, bedsore rates and use of antipsychotic drugs, among many issues. But in California, the agency charged with overseeing these skilled-nursing facilities, the Department of Public Health, makes no effort to measure quality of care throughout a chain, or determine whether corporate policies and practices are contributing to any patterns.

Some companies doing business in California go to great lengths to create complex business structures, building layers of limited liability companies and partnerships with curious relationships to one another. The tangled corporate webs make it difficult for consumers and government regulators to identify who’s running the operations – and who should be held responsible when things go wrong.

“It’s a huge maze to try and figure out who owns what. And that’s deliberately done.”

– Charlene Harrington, professor emerita of sociology and nursing at the University of California, San Francisco

“It’s a huge maze to try and figure out who owns what,” said Charlene Harrington, professor emerita of sociology and nursing at the University of California, San Francisco, who has spent 35 years researching the nursing-home industry.

“And that’s deliberately done.”

Yet knowing who owns what can be critical for fragile patients seeking long-term care, according to a Sacramento Bee investigation, which analyzed thousands of federal and state records detailing the ownership of the state’s 1,260 nursing homes.

In addition to identifying owners with at least a 5 percent stake in any California-based facility, The Bee also examined government and industry data to determine how the largest owners and their facilities performed on 46 measures, including quality-of-care indicators, staffing, complaints and deficiencies found during inspections. The analysis took into account the federal government’s star-rating system, as well as rankings determined by the nonprofit California HealthCare Foundation. State and federal inspectors logged most of the measures, although nursing homes self-reported patient care and staffing data.

Clear differences emerged among the state’s biggest operators. In the same way that restaurant franchises or department-store chains deliver similar experiences to consumers – for better or worse – The Bee found that some large nursing-home companies also produce systemic results.

Among the findings:

▪ In California, 25 for-profit nursing-home chains control about half of the state’s 120,000 licensed beds. The Bee found 10 of those chains – including the two largest, Plum Healthcare Group and a network owned by Shlomo Rechnitz of Los Angeles – performed below statewide averages last year in more than half of the examined quality-of-care categories, which gauge the incidence of problems such as pressure sores, infections and falls. Twenty of the top 25 chains fell below state averages in at least three out of five staffing measures.

▪ Some large chains have facilities suffering from the same care issues, despite being located hundreds of miles apart. For instance, within Plum Healthcare Group, which operates more nursing homes in the Sacramento region than any other company, 90 percent of the company’s 42 homes statewide last year had higher than average nursing-staff turnover. About 65 percent of the facilities owned by Longwood Management Corp. have higher than average rates of patients in restraints.

▪ Among the 25 largest chains doing business in California, the lowest performing in The Bee’s analysis are EmpRes Healthcare Management LLC and LifeHouse Health Services. Facilities owned by these chains consistently fell below state averages on most measures, and both owners were more likely to log complaints and federal deficiencies than most of their large competitors.

▪ Below-average staffing or high turnover were issues in nine out of 10 of the state’s largest nursing-home chains in 2012, the most recent year staffing data are available. The state’s largest chain, headed by Rechnitz, earned poor or below-average staffing ratings from the nonprofit California HealthCare Foundation in about 80 percent of its 54 homes. Even so, Rechnitz recently was given a federal judge’s blessing to purchase 19 more facilities.

Oversight of California nursing homes, and their owners, has waxed and waned over the years. In 2001 and 2002, under then-Attorney General Bill Lockyer, the state aggressively pursued chains by prosecuting two of the largest nursing home owners: Sun Healthcare Group of Irvine, and the California subsidiary of Beverly Enterprises Inc. In both cases, the state got permanent injunctions requiring that they improve care.

By contrast, the Department of Public Health was hauled before legislative leaders earlier this year amid charges it was dismissing hundreds of nursing-home complaints without adequate investigations. Assemblywoman Mariko Yamada, D-Davis, grilled health officials at the hearing and requested an audit of how the department regulates long-term care facilities.

“The state is not doing its job in protecting its most vulnerable residents,” said Carole Herman of the Sacramento-based Foundation Aiding the Elderly, who filed a lawsuit last year against the Department of Public Health charging it failed to promptly investigate nursing-home complaints.

Attorney Mark Reagan, legal adviser for the California Association of Health Facilities, said government oversight of nursing homes is intense on both the state and federal levels. “You have a very robust range of investigative entities that look at every element,” he said.PAUL KITAGAKI JR. / THE SACRAMENTO BEE
Attorney Mark Reagan, legal adviser for the California Association of Health Facilities, said government oversight of nursing homes is intense on both the state and federal levels. “You have a very robust range of investigative entities that look at every element,” he said.

Mark Reagan, legal adviser for the California Association of Health Facilities, the industry’s trade group, disagrees that there is any shortage of government oversight – or that chainwide performance is overlooked.

Reagan’s organization can recite at least 17 local, state and federal entities that oversee some aspect of nursing homes in California, from licensing to funding to food safety to criminal investigation.

“Government regulators do look broadly,” Reagan said, describing how government oversight of the industry has mushroomed over the past 10 to 15 years.

“You have a very robust range of investigative entities that look at every element,” he said.

Government oversight, though, does not necessarily help consumers connect the nursing-home dots. A family wanting to examine chainwide quality patterns faces a herculean task.

The Bee, for instance, spent months untangling federal Medicare and state records to identify owners and assess their facilities’ performance as of the end of 2013. Even then, the findings continued to shift as chains consolidated and transferred ownership of individual homes, and glaring gaps in government data collection became evident.

The reality is, most average consumers – in the midst of a family crisis – are unlikely to slog through voluminous public records and cumbersome statistics when hunting for a nursing home, said several elder-care advocates.

“People make relatively uninformed decisions in a lot of cases,” said Eric Carlson of the National Senior Citizens Law Center.

“That’s not to blame them,” he said. “It’s just the situation in which they find themselves.”

The bottom two

In California, more than 100,000 people live in skilled-nursing facilities, often transitioning from the hospital. Most of them are women, and most are older than 75. They come for a variety of reasons: a broken hip that requires care and rehabilitation; recuperation from serious surgery that needs daily monitoring and pain management; a chronic heart condition that leaves an individual too frail to dress or use the bathroom; the helplessness that comes with the final stages of Alzheimer’s.

From the outside, the facilities look similar: typically beige, low-slung buildings tucked into quiet neighborhoods or perched alongside busy urban thoroughfares, American flags flapping from tall poles.

What happens inside varies dramatically.

Among the top 25 players, two nursing-home chains stand out as the lowest performing in The Bee’s analysis: EmpRes Healthcare Management LLC, based in Vancouver, Wash.; and LifeHouse Health Services, headquartered in Culver City.

Together, the two companies operated 20 homes statewide last year, including 11 in Northern California, and consistently fell below the state average in numerous measures The Bee considered. Over the last 31/2 years, LifeHouse lagged state averages in 40 out of 46 measures, which gauge such critical aspects of care as staffing levels, patient welfare, complaints and deficiencies. EmpRes fell below in 39 of those measures.

Formerly known as Evergreen Healthcare, EmpRes was sold to its employees in 2008 and became one of the country’s first long-term care companies to be 100 percent employee-owned, according to its website. The chain had 11 nursing homes in California last year, the majority in Northern California, including Tracy, Vallejo and Chico.

No one from EmpRes responded to phone calls, a letter and emails from The Bee, directed to the Vancouver home office.

The company faced negative publicity this year following allegations that a 93-year-old woman was sexually assaulted by a certified nurse assistant at Evergreen Arvin Healthcare, a skilled-nursing facility southeast of Bakersfield.

In May, two of the woman’s grandchildren filed a lawsuit against the facility, three associated limited liability companies and 11 company officials, alleging that the elderly woman “died an agonizing and horrible death” last year as a result of her injuries, according to court documents. The lawsuit claims the facility administrator and others knew of accusations that the nurse assistant had sexually assaulted another resident days earlier, but that he was not suspended or disciplined.

“Defendants, and each of them, failed to staff the facility appropriately and allowed a situation to develop where a known sexual predator was on premise(s) in the guise of caring for the residents,” the lawsuit states.

The California Department of Public Health investigated the Arvin facility and issued a $20,000 fine, determining the facility had failed to protect its residents from sexual assault. The facility also was given a Class A citation, a penalty reserved for violations that pose imminent danger to residents.

Within the EmpRes group, The Bee found, the rate of complaints from patients and family members was above the statewide average. The rate of federal deficiencies cited by inspectors related to patient medication also ranked high: Nine of the company’s 11 homes had more deficiencies related to drug administration for each patient bed than the statewide average over the last 31/2 years.

The impact of medication errors on fragile patients can be devastating, as evidenced in records kept by the Department of Public Health.

Earlier this year, an EmpRes nursing home in Oroville was fined $50,000 by the state after failing to give a resident daily antibiotic injections in March 2012, as ordered by her doctor. The patient’s infection worsened and she developed septic shock, dying two days later. “We might have been able to prevent it if she had gotten the first shot,” the physician was quoted as saying in a state report.

The facility, Olive Ridge Post Acute Care, was cited for failing to protect residents from serious medication errors and was issued an “AA citation,” the most serious penalty the state can level against a nursing home.

Another medication error resulted in an AA citation at a different EmpRes facility in Lake County. Last year, Evergreen Lakeport Healthcare was fined $100,000 after a nurse mistakenly gave methadone to a patient in August 2011. The nurse, who had confused one patient with another, realized her mistake 15 minutes later, but the staff did not call 911 for another eight hours, state inspectors found. The patient died shortly thereafter.

In issuing the AA citation, the state determined that the mistakes were a direct cause of the woman’s death. It was the third time the Lakeport facility had been cited for medication errors since 2009. The Oroville facility also had been cited previously for making a medication mistake.

The Bee found that, for each patient bed, EmpRes’ ratio of registered nurses was about 13 percent lower than the statewide average.

Harrington, the UCSF scholar and registered nurse who has studied nursing-home chains, said repeated medication errors within an ownership group suggest the chain doesn’t have enough nurses. They also may lack the right mix of nurses, she said.

Charlene Harrington, a UCSF professor emerita of sociology and nursing, has researched the nursing-home industry for more than three decades. “It’s a huge maze to try and figure out who owns what,” Harrington said.PAUL KITAGAKI JR. / THE SACRAMENTO BEE
Charlene Harrington, a UCSF professor emerita of sociology and nursing, has researched the nursing-home industry for more than three decades. “It’s a huge maze to try and figure out who owns what,” Harrington said.

Many companies slash costs by reducing the number of RNs, relying instead on lower-paid licensed vocational nurses with considerably less training to handle medications, Harrington said.

“They do it to save money,” she said. “… LVNs don’t have the expertise to be taking care of these complex residents.”

Two ends of the spectrum

The home page for LifeHouse Health Services, headquartered in Culver City, features a smiling celebrity spokeswoman – actress-singer Shirley Jones – pictured alongside a bubble of text: “Warmth. Comfort. Experience. Professionalism. That’s so rare these days, but that’s LifeHOUSE!”

There’s another side to the LifeHouse story.

Nursing turnover at LifeHouse’s nine California nursing homes was nearly double the statewide average in 2012. About 1 in 8 of its long-term patients was reported to be in moderate to severe pain last year, also double the statewide average. And the chain had persistently high rates of complaints and deficiencies compared to state averages.

The company’s San Jose Healthcare Center was fined $30,000 last year by the state for failing to meet minimum levels of nursing staff care.

Its sister facility in Paradise, the Cypress Healthcare Center, also was fined $15,000 last year for missing state-ordered staffing minimums. The Paradise facility was fined another $10,000 last year and picked up a Class A citation after an unsteady 76-year-old resident was brain-injured in a fall while going to the bathroom unassisted.

Joseph M. Earley III, a Paradise attorney who has filed lawsuits against both EmpRes and LifeHouse, said in an interview that LifeHouse is “woefully inadequate,” especially in the area of staffing. Between January 2012 and December 2013, Earley filed four lawsuits against Cypress Healthcare, all alleging problems with staffing or quality of nursing care. In each case, the patient had died.

“Their focus is far too much on profit,” Earley said. “They’re taking money out of the facilities that could be used to add staffing or increase pay rates.”

Bruce Ward, chief administrative officer at LifeHouse, said such criticism “is unfair and ill-informed.” He said LifeHouse “uses an organization structure highly similar to the organization structures used by virtually all middle- to large-size organizations with multiple health care facilities” and that it “delivers consistent, high quality of care.”

“It is far easier for plaintiffs’ attorneys to criticize health care, and secure hundreds of thousands of dollars in fees to do so, than it is to deal on an ongoing basis with the actual demands of skilled nursing care,” he said.

Ward said the company specializes in taking over and improving bankrupt or near-bankrupt homes. Those homes tend to have “high turnover, deferred maintenance and a range of other challenges,” he said.

“LifeHouse has worked hard and spent millions of dollars to improve those facilities,” he added.

Ward said the state’s method of measuring nursing turnover captures a large number of temporary and occasional employees who are hired to meet short-term needs. LifeHouse performs better on maintaining permanent employees, he said, pointing to a separate state measure that tracks long-term employee retention.

The high average rate of residents who report being in pain at LifeHouse facilities, he said, reflects the company’s practice of accepting more patients with debilitating conditions. He said the company has appealed the state’s findings at its Paradise and San Jose homes, and that subsequent state audits of the homes have found no similar problems.

Homes owned by Shlomo Rechnitz, the state’s largest operator, fell below state averages on 35 of the 46 measures The Bee considered. Rechnitz did not respond to interview requests. However, in written responses, his legal and public-relations advisers emphasized that Rechnitz and his principal company, Brius Healthcare Services, have taken over numerous troubled facilities suffering significant patient-care issues.

“This should be taken into account when looking globally at the performance of all Brius facilities,” the advisers wrote.

They also noted that the federal government gave Brius high marks, on average, for meeting several quality-of-care measures.

At the top of The Bee’s analysis, three large nursing-home chains – the Ensign Group, North American Health Care Inc. and Generations Healthcare – consistently performed at or above the state average in numerous categories over the last 31/2 years. All three are based in California.

Generations Healthcare, for example, had one of the lowest rates of nursing turnover among the large chains. And it had fewer complaints and deficiencies than most of its large competitors.

Headquartered in Newport Beach, the company was started in 1998 by Thomas Olds Jr., who was a founding partner of another chain, Covenant Care Inc. Generations began with one 89-bed nursing home and has expanded to own 19 facilities in Northern and Southern California, 17 of them nursing homes. Nine of its 17 skilled-nursing facilities earned five-star ratings from the federal government for excellence in 2013, the highest stamp of approval, while another six facilities received four stars.

Olds attributes low nursing turnover and other successes to his intimate involvement in operations, treating employees well and a clearly stated operating philosophy that “expects extraordinary results.”

“Once your employees see you doing the right thing, then they’re committed to being a part of that,” he said.

Did Plum deliver?

In February 2011, as Sacramento continued its slow climb out of the recession, an announcement rippled through the state’s nursing-home world.

After 50 years in business, Rocklin-based Horizon West Healthcare Inc. was being acquired by a relative newcomer, Plum Healthcare Group LLC. The San Marcos company, founded in 1999, was about to become the Sacramento area’s predominant nursing-home operator – assuming control of 12 Horizon West facilities in the four-county region, and another 15 elsewhere.

At the time, Horizon West was in trouble: hefty regulatory fines. Accusations of Medicare fraud. A stunning $29 million jury award in the death of a 79-year-old resident of an Auburn facility.

A 2011 news release stated that Horizon West had “hand-picked” Plum because of the company’s “excellent track record of mobilizing facility staff to achieve quality patient care and regulatory compliance …”

Plum co-chief executive Mark Ballif told The Bee in February 2011 that his company would bring “a really strong compliance record … We’re eager to bring that to the table.”

Did Plum deliver?

Yes and no, according to The Bee’s investigation.

While Ballif recently stated that Plum facilities provide quality care, a deeper dive into the company’s performance record reveals an uneven pattern. A few of the homes ranked among the region’s best, but the chain also was hit last year with higher-than-average rates of complaints for alleged abuse, quality-of-care and patient-rights issues.

Last year, Plum operated 12 of the 62 homes in the four-county region, more than any other provider. But the shadow of Horizon West looms. Eight of those homes ranked in the bottom 24 regionally in 2013 in terms of performance measures analyzed by The Bee – and all but one of those are former Horizon West properties. At the opposite end of the spectrum, three Plum homes ranked in the top 25.

A theme emerged among the poor performers: high staff turnover. All but one of the eight lowest-performing Plum homes saw nursing staff turnover above 80 percent in 2012. Plum’s Lincoln Meadows Care Center in Placer County reported nursing staff turnover of 144 percent that year, the highest rate in the region, with multiple positions turning over more than once.

Concerns over patient safety also emerged as an issue. Plum’s Westview Healthcare Center in Auburn logged 11 abuse complaints last year, more than any other home in the region. Its Auburn Oaks facility saw 41 federal deficiencies related to the life and safety of patients during the last 31/2 years, also more than any other facility in the region.

In an email response to The Bee, Ballif pointed to the federal government’s rating system as evidence that his company overall provides quality care to patients. The federal government uses a five-star system to rank nursing homes based on inspection reports and data self-reported by facilities.

The system, Ballif said, “helps residents and families see a single measure for total quality to inform their choice of facility … The average score across all Plum-affiliated facilities is four stars.” The company has 50 facilities in California, Utah and Arizona.

Locally, two Plum facilities that once were owned by Horizon West – Lincoln Meadows and Westview – each received only one star at the end of 2013 from the U.S. Centers for Medicare and Medicaid Services, a designation that means the federal government considers performance “much below average” based on staffing, deficiencies and quality-of-care measures.

But several Horizon West homes have improved since Plum took them over, Ballif noted. Some of those changes are evidenced by improved federal ratings, while other improvements will take longer to become evident because the federal government uses roughly three years of data when compiling its rankings, he said.

Six of the 11 local homes Plum purchased from Horizon West in early 2011 improved their federal rating between 2010 and 2013, according to government data. The newest federal ratings for 2014 show that Lincoln Meadows upped its status to three stars this year; Westview remains a one-star facility.

And, the latest ratings show, seven Plum facilities in the Sacramento region earned the coveted five stars.

A notorious distinction

In addition to Plum, eight more of the 25 largest chains in California have homes in the four-county region.

One Carmichael home owned by Genesis HealthCare Corp. has been singled out by federal regulators with a stern message: Improve or else.

Carmichael Care & Rehabilitation Center on Fair Oaks Boulevard, recently renamed Eagle Crest, was added this year to a government watchdog list as one of the nation’s most troubled facilities. Only five other homes in California appear on this “Special Focus Facility List” maintained by the U.S. Centers for Medicare and Medicaid Services.

Special Focus Facilities are surveyed more frequently and, if problems persist, are subject to possible fines and other penalties, including termination from the Medicare and Medicaid programs.

The Bee found that Carmichael Care/Eagle Crest ranked near the bottom in performance measures among the Sacramento region’s 62 nursing homes, falling below state averages in 31 out of 46 indicators. Its owner, Genesis HealthCare, has its own badge of notoriety: Last year, it was slammed with complaints of abuse at seven times the statewide average.

The chain, privately held and based in Kennett Square, Pa., recently was ranked by Provider Magazine as the nation’s largest nursing facility company. Genesis acquired Sun Healthcare Group Inc. and its subsidiary, SunBridge Healthcare LLC, in December 2012, picking up Carmichael Care/Eagle Crest in the deal, among many others.

Genesis spokeswoman Jeanne Moore did not respond to specific questions about Carmichael Care/Eagle Crest. She noted that the majority of abuse complaints in the company’s other California facilities came at two of its behavioral-health centers, which house mentally ill patients. She said it is unfair to include those centers when comparing Genesis with other companies.

“Behavioral-health centers are licensed as skilled-nursing centers but cannot be compared to a traditional skilled-nursing center,” Moore said. In behavioral-health centers, she explained, “combative behaviors and resident-to-resident altercations may be more common than in a traditional skilled-nursing center.”

Genesis has “a zero-tolerance abuse policy at all of its centers,” she said.

While for-profit facilities dominated the ranks of bottom performers in the region in 2013, the top-25 list looks remarkably different: Ten are operated by nonprofits or hospitals.

Eskaton, a Sacramento-based nonprofit, has two of the top-performing facilities in the region, and none of its four facilities had any serious citations over the last three years.

All four are well-staffed compared to most nursing homes in the state. Eskaton’s turnover rate in its skilled-nursing facilities, for instance, was about 21 percent in 2012, compared with more than 70 percent for LifeHouse and Plum.

Todd Murch, Eskaton’s president and chief executive officer, said the company’s ability to retain high-quality staff is “really at the core of excellence.” At Eskaton’s nursing home in Fair Oaks, which recently received the highest five-star rating from the federal government, three of the top administrators have collectively worked at that facility for 22 years, he said.

Todd Murch, president and CEO of Eskaton, said nonprofit nursing home organizations like Eskaton typically staff facilities better, retain employees longer and offer better pay and benefits. Eskaton has two of the top-performing facilities in the Sacramento region, according to The Bee’s analysis. PAUL KITAGAKI JR. / THE SACRAMENTO BEE
Todd Murch, president and CEO of Eskaton, said nonprofit nursing home organizations like Eskaton typically staff facilities better, retain employees longer and offer better pay and benefits. Eskaton has two of the top-performing facilities in the Sacramento region, according to The Bee’s analysis.

“Even in today’s world, there’s still a value of nonprofit ownership in nursing homes,” Murch said. “Statistically, history will show that nonprofits typically staff higher, typically have longer-tenured staff and typically offer better pay and benefits than for-profit nursing homes.

“The tendency of nonprofits to have longer stability and continuity in a community is a big thing.”

Lost in a fog

Up and down the state, consumers who are unhappy with nursing-home care often lay the blame on overworked, undertrained and poorly supervised staff. In civil actions and in complaints filed with the state, patients and family members describe the sometimes-chaotic conditions inside California’s nursing homes.

Unnecessary falls. Soiled diapers that go unchanged. Unanswered call lights. False entries scribbled into charts. Pressure sores that turn deadly when patients are not repositioned.

Attorney Joseph M. Earley III, left, represents Bonnie Nidiver, a longtime Butte County resident. After her husband died in 2011 following a stay at a Paradise nursing home, the widow was reluctant to file a lawsuit, but said she proceeded in the hope of helping others. PAUL KITAGAKI JR. / THE SACRAMENTO BEE
Attorney Joseph M. Earley III, left, represents Bonnie Nidiver, a longtime Butte County resident. After her husband died in 2011 following a stay at a Paradise nursing home, the widow was reluctant to file a lawsuit, but said she proceeded in the hope of helping others.

“Staffing – that’s the thing it almost always comes down to,” said Earley, the Paradise attorney who specializes in elder abuse and neglect.

“If they’d just increase staffing, a lot of these problems wouldn’t happen,” he said. “It always, always comes down to staff.”

The Bee’s analysis found that among California’s 10 largest chains, nine fell below state averages in three out of five key staffing measures in 2012, the latest data available.

The five measures examined by The Bee were nursing turnover and four staff-to-patient ratios, which look at the facilities’ levels of registered nurses, licensed vocational nurses, physical therapists and aides. Overall, the state requires a minimum of 3.2 nursing hours per resident day, but the statewide average in 2012 was actually higher, at 4.1 hours. To earn a superior rating from CalQualityCare.org, the nonprofit industry watchdog, facilities must have somewhere between 4.1 and 6.5 nursing hours per patient day, depending on case mix.

Among the 25 largest operators, three ranked lowest in terms of staffing performance: Rechnitz and his principal company, Brius Healthcare; EmpRes; and LifeHouse. The Bee found that these three chains fell below statewide averages on all five staffing measures.

Ward cited numbers from the first six months of 2014 that showed nursing staffing at LifeHouse’s homes on average exceeded government requirements. Rechnitz’s legal team made a similar argument: “Every single facility has met or exceeded state staffing requirements on a monthly or even weekly basis since acquisition,” they said in a written statement.

EmpRes did not return calls for comment.

In California, elder-abuse attorneys have successfully argued that bad corporate practices – especially in the area of staffing – can spread like an infectious disease throughout a nursing-home chain.

In Humboldt County, a jury in a class-action lawsuit ordered Skilled Healthcare Group Inc. to pay a jaw-dropping $677 million in damages in 2010 after finding the national chain had violated state staffing regulations in all 22 of its California facilities. The amount later was negotiated down to $50 million.

Emails introduced at trial in Humboldt County illustrated pressure from corporate administrators to keep staffing costs down. After one staff person reported that four out of five facilities fell below state staffing minimums for a week, the president of Skilled replied: “Thanks again for sending this. Nice hour controls. Keep on that overtime.”

In another case, a federal judge in Oakland issued an injunction in 2012 against Evergreen Healthcare, now EmpRes, for chronic understaffing. The judge overseeing the class-action lawsuit ordered that the chain be monitored for 21/2 years to ensure that the homes comply with state staffing requirements.

Earley, the Butte County elder-abuse attorney, argued in court that a management decision about staffing in a LifeHouse facility ultimately contributed to the death of an 88-year-old Paradise man, a fixture in his small community north of Sacramento.

LifeHouse did not respond to questions about the case.

The story begins, as these matters often do, with a calamity.

In early 2011, Eugene and Bonnie Nidiver – married for 60 years – had just returned from a 17-day cruise to Hawaii, and were planning their next cruise to Alaska.

The couple’s plans were upended when Eugene missed a step on a friend’s new deck and fell, breaking his pelvis and left wrist.

Widow Bonnie Nidiver, 86, sits in her late husband’s favorite room in their Paradise home, cradling a family photo. Her husband, Eugene, a fit and active man before his fall on a friend’s deck, enjoyed the light and brightness of this room, she said.PAUL KITAGAKI JR./ THE SACRAMENTO BEE
Widow Bonnie Nidiver, 86, sits in her late husband’s favorite room in their Paradise home, cradling a family photo. Her husband, Eugene, a fit and active man before his fall on a friend’s deck, enjoyed the light and brightness of this room, she said.

Bonnie Nidiver, now 86, describes her husband as a fit and active man who could be seen walking daily, working out three times a week at the Elks Lodge and sharing lunch on Tuesdays with his buddies. A retired Navy veteran who served on the aircraft carrier USS Cowpens in World War II, he was a 50-year member of the Masons and active in the Shrine Club, American Legion and Moose Lodge.

Eugene’s broken bones were treated at the hospital, and on April 6, 2011, he was admitted to a nursing home for rehabilitation. What he got, according to family members and court documents, was an unrelenting series of powerful drugs for sleeplessness and pain that left him confused and disoriented.

Bonnie, who visited the Cypress Healthcare Center daily, said she alerted staff – constantly – to the deteriorating condition of her husband.

“They changed his whole personality,” she said. “He was a non-pill-taker. He wouldn’t even take an aspirin unless he was desperate.”

On May 3, 2011, Eugene fell from his wheelchair but was not immediately reassessed for fall risk, nor was he given any preventive devices or alarms, the complaint states.

Three weeks later, on the night of May 23, 2011, Bonnie recalled how she gave her husband a “good old mushy kiss,” and he told her how much he loved her. It would be their last coherent conversation.

The next day, Eugene fell again, toppling from his wheelchair in the main lobby and breaking his right hip. He was hospitalized and rapidly declined, lost in a fog of pain and medication, attorney Earley said.

Eugene Nidiver died in hospice care on June 16, 2011, 10 weeks after being admitted to Cypress Healthcare Center.

The widow and her son, Scott Nidiver, filed suit in Butte County Superior Court in a case their attorney says revealed the facility’s lack of sufficient, qualified registered nurses “who had the time to actually do the nursing.” Instead of analyzing why Eugene Nidiver was having trouble sleeping, or was agitated and experiencing pain, they simply medicated him with a lineup of sedatives, antidepressants and narcotics, Earley said.

The nursing home agreed to a $400,000 judgment in the case. Earley also had sued the parent company, LifeHouse Health Services LLC, but a judge threw out that case last month. LifeHouse argued it had no liability because it doesn’t hold a health care license and does not provide day-to-day care for individual patients.

The case highlights an issue playing out in courtrooms up and down the state: Who’s really in charge of these facilities? Who calls the shots? And who should be held responsible when things go wrong?

COMING MONDAY: Untangling the ownership web.

Call The Bee’s Marjie Lundstrom, (916) 321-1055.

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