David Thompson was living at the Midnight Mission on Los Angeles’ Skid Row when he secured a bed several years ago at a South Pasadena nursing home. For a man who had been homeless for 35 years, the arrangement seemed like a stable step forward.
Instead, he discovered that South Pasadena Convalescent Hospital was visited regularly by local police, summoned to the facility to break up fights or investigate alleged drug-dealing and thefts by residents. Thompson, injured decades earlier in a car wreck, recalled how the nursing home had lots of younger patients with no apparent disabilities.
One resident was known to pack a gun in his wheelchair, he said, a story that is corroborated in state documents. Another patient, he heard, smoked meth in the bathroom – a situation also detailed in state inspection records. Thompson said he kept to himself when fights broke out.
“They had so much stuff going on in there,” said Thompson, 79, who since has moved out of the South Pasadena facility and into another nursing home. “I guess the police chief got tired of it.”
The turmoil inside South Pasadena Convalescent Hospital became painfully public in November 2014, when one of Thompson’s smoking companions – 57-year-old Courtney Cargill, a mentally ill resident – left the facility unsupervised, doused her body with gasoline and lit herself on fire. After prodding from the local police chief, and a surge of community outrage, the California attorney general’s office opened an investigation into the facility and whether anyone should be held criminally accountable for her death.
The gruesome case also has shined a light on the divergent population groups that inhabit California’s 1,250 nursing homes – and the risks associated with serving such a wide mix of patients.
Where once skilled nursing facilities were universally thought of as “rest homes” for the frail and elderly, a growing proportion of California nursing home residents are younger, more able-bodied patients, many diagnosed with mental illness. Some residents, like Cargill, enter facilities with long-standing drug and alcohol problems. Others, like Thompson, have histories of homelessness. Still others are newly released from prison.
Facilities have been able to tap these clients’ Medicare and Medi-Cal benefits and, in many instances, provide long-term housing at government expense.
“The homes that we have known as havens for the frail elderly, as you can see, are no longer safe havens,” said Tippy Irwin, executive director of San Mateo County’s ombudsman services.
Instead, she said, many facilities now have what she described as a “dangerous mix” – old, young, mentally ill, convicted felons, street people in desperate need of care, and younger clients with chronic illnesses, brain injuries and drug abuse problems.
“I don’t think people have a clue,” Irwin said. “I don’t think people give nursing homes a thought unless they’re actually faced with having to use one.”
Between 1994 and 2014, the population of California nursing home residents under age 65 grew by nearly 40 percent, while the number over 65 shrank by 11 percent, according to a Sacramento Bee review of state data. Today, 1 in 5 nursing home residents in California is under 65.
In California, the number of nursing home residents with serious mental illness also is on the rise. In 2014, the Golden State ranked fourth in the nation for the percentage of nursing home residents diagnosed with schizophrenia or bipolar disorder, behind Illinois, Missouri and Louisiana, according to data collected by the Brown University School of Public Health. The rate of schizophrenia and bipolar disorder in California nursing homes increased by about 60 percent from 2000 to 2014, to 1 in 7 residents, the data show.
Quality of care appears to be a casualty in the changing patient mix.
A Bee analysis of California facilities found that nursing homes with a relatively high proportion of younger patients tend to have more health deficiencies per bed and lower patient-staffing ratios than homes at the other end of the spectrum with few young patients. Having more young patients also corresponded with lower quality ratings from the federal government, which ranks facilities from one to five stars.
California facilities with the highest proportion of young patients received an average of 2.9 stars on the federal government’s rating system in November 2015. Facilities dominated by elderly residents averaged 4.2 stars.
South Pasadena Convalescent Hospital, for instance, had a two-star rating when it was decertified in January 2015, losing its critical Medicare and Medi-Cal funding. In the preceding months, local police said they were averaging 60 service calls a month to the facility. About a third of the residents were under 65 in 2014, well above the statewide average.
The facility was owned until recently by the state’s largest nursing home owner, Shlomo Rechnitz of Los Angeles, and his principal company, Brius Healthcare.
“The reality is, some of the worst nursing facilities tend to admit some of the most demanding residents,” said Eric Carlson, directing attorney of the National Senior Citizens Law Center. “They’re not as competitive and, because of that, they’re more likely to get a little lazy on their admission standards and often times admit people who are inappropriate for that setting.”
In California, nursing home residents and staff are feeling the strain.
A Bee examination of more than 1,000 pages of inspection records, federal deficiencies and state-issued citations revealed a range of problems directly related to patient mix. Embedded in the dry, single-spaced recitations are descriptions of violent clashes, life-threatening lapses and safety fears expressed by fragile residents.
In March 2014, a nursing home in Pomona owned by Longwood Management Co. was issued the state’s most severe penalty, a Class AA citation, and $100,000 fine. Four years earlier, a 91-year-old resident in a wheelchair had been attacked at Chino Valley Health Care Center by a 46-year-old patient with mental health issues, including an anxiety disorder and “persistent anger,” according to state records. The elderly man was rushed by helicopter to a hospital, where surgeons amputated his right arm. He did not survive.
The facility appealed, and the state agreed to drop the fine to $65,000.
In Bakersfield, a female resident told state inspectors in October 2014 that her roommate at Corinthian Gardens Health Care Center had threatened to “slice my throat open with a knife while I slept.” She complained that the roommate, whose diagnoses included schizophrenia and bipolar disorder, rammed her wheelchair into family members during visits and cursed at them. A prior roommate reported the woman had kicked, hit, pinched and bitten her.
The 237-bed facility, operated at the time by Prema and Antony Thekkek of Alamo, was decertified last year by the federal government.
Mentally ill residents have been victimized, too.
A review of numerous deficiencies and citations issued to facilities in connection with mentally ill residents revealed a host of dangerous breakdowns – medication errors; suicidal patients left unmonitored; patients slipping out of “locked” units and wandering into traffic; and care plans neglected or ignored.
“They’re much more likely to be victims than perpetrators,” said Leslie Morrison of Disability Rights California.
In suburban Los Angeles, one nursing home resident with a history of hearing voices, urging him to cut his wrists, slashed his left forearm with a razor in 2012. The patient, who was diagnosed with schizophrenia and depression, later told investigators that staff at Verdugo Valley Skilled Nursing & Wellness Centre passed out razors to “everyone,” according to state records. One witness reported seeing uncovered razors lying out in the open in shower rooms a day after the incident. The one-star facility also is owned by Rechnitz.
In 2014, health inspectors determined that six mentally ill residents had been in “immediate jeopardy” at Serrano South Convalescent Hospital in Los Angeles after regularly getting drunk at the facility. One resident reportedly had been leaving the facility “unnoticed” to buy liquor at a nearby store, and all six patients – who were taking psychoactive medications and narcotics – were mixing alcohol into their juice and soda, a dangerous combination given their prescription drug regimens, according to federal inspection records.
“If nursing homes are going to be taking these folks, they need to have programs and services that meet their needs,” said Molly Davies, who heads Los Angeles County’s ombudsman program.
Stefan Friedman, a spokesman for Rechnitz and Brius, said the company has stepped up to help the “increasing number of patients in California who have a primary medical diagnosis and a secondary psychiatric diagnosis.” Verdugo Valley is among the company’s facilities that contract with a national firm, CHE Senior Psychological Services, to provide a level of mental health care that is “rarely seen in a nursing facility,” Friedman wrote in an email.
Any implication that Brius is simply looking to fill beds, Friedman said, “has not a shred of merit.”
A ‘volatile environment’
In Los Angeles County – where 34,000 live in skilled nursing, a third of the state’s nursing home population – Davies has seen all kinds of residents mixed together.
Davies, who heads the county’s ombudsman program, said tensions can build in homes combining three distinct populations: older, dependent adults who need nursing home care; residents with a primary mental health diagnosis and no apparent skilled nursing need; and able-bodied individuals with no obvious need for nursing home placement at all. Residents in the last category often need drug and alcohol treatment, she said.
Davies recalled one incident where a resident, who had a diagnosis of “generalized weakness” and orders for physical therapy, scaled an 8-foot wall in a successful bid to leave the facility.
Davies said her staff will fight for the rights of all nursing home residents, whether they are old, mentally ill, drug-addicted, homeless or on parole. But some residents don’t need this level of care, she said, with nursing homes being used like a hotel or transitional housing.
The result can be a “volatile environment for all involved,” she said.
For many, the chief concern is facilities that regularly admit mentally ill residents without the ability or staffing to care for them. Some advocates contend nursing homes have become a de facto solution for the chronic shortage of more appropriate treatment options.
“I don’t think we in California have done a good job of developing that community mental health system,” said Morrison, director of the investigations unit at Disability Rights California. “So you have people who have a chronic mental illness for whom there is no good community-based (option) … And they end up in nursing homes.”
California does have a specialized treatment system for a small percentage of mentally ill nursing home residents. The state has certified 26 skilled nursing facilities as “special treatment programs,” serving people with chronic psychiatric impairments. But because these programs make up less than 2 percent of the state’s total nursing home beds, regular skilled nursing facilities also are admitting these patients – some more aggressively than others.
So which homes admit the highest numbers of residents with mental illness? And how do they fare?
You’ll get no easy answers from state regulators.
The California Department of Health Care Services, charged with administering the state’s mental health programs, does not keep data on nursing home residents with mental illness, according to an email from Anthony Cava, a department spokesman. He referred the matter to the California Department of Public Health.
The Department of Public Health, which inspects skilled nursing facilities and responds to complaints, says it doesn’t have any data, either.
The federal Centers for Medicare and Medicaid Services doesn’t publish such data by individual facility. But it does offer a snapshot of what’s happening on a statewide level. In 2015, about 11 percent of California nursing home residents were diagnosed with schizophrenia; 5 percent with bipolar disorder; 34 percent with depression; and 22 percent with anxiety disorders, according to federal data.
All these diagnoses are on the rise in California nursing homes, except for depression, which has fallen about 2 percentage points since 2011.
Elder care advocates are quick to point out that people with mental health problems can, like anyone else, require skilled nursing – care for a broken hip, perhaps, or recuperation from pneumonia. The question, they say, is whether the mix is well-managed and safe for everyone.
Barbara Trigueros of San Diego is suing a Southern California nursing home over the care her mentally ill mother received, culminating with her hospitalization in February 2014 for a serious head injury and broken femur.
Her mother’s diagnoses include schizophrenia and bipolar disorder, and she is physically disabled, confined to a wheelchair.
In December 2012, her mother, Emma Davidson-Pugh was admitted to Glendora Grand, a one-story complex 25 miles east of downtown Los Angeles. With 342 beds, Glendora Grand is the state’s second-largest for-profit nursing home, billing itself on its website as “the premier skilled nursing facility in the San Gabriel Valley.”
The facility currently has two stars from the federal government, a below-average rating.
Over a four-month period in 2013, Davidson-Pugh, now 77, left Glendora Grand unattended at least five times, according to the lawsuit, which accuses the facility of abuse and neglect. Four of those times, the suit contends, Trigueros’ mother was found steering her motorized wheelchair alone down West Arrow Highway, a five-lane urban stretch lined with auto-body shops, warehouses and small businesses.
“She was going out on her own – anything could have happened,” said Trigueros. “It’s not called a highway for nothing. The cars were speeding up and down there.”
The lawsuit also alleges that Davidson-Pugh was injured in at least three falls that resulted in hospitalizations.
Judith Tishkoff, the attorney representing Glendora Grand in the case, said she and the owners declined to comment because of the pending litigation. Federal records identify the facility’s owners as Vicki Rollins and William Nelson.
The family’s San Diego attorney, Jake Stipp, said the lawsuit boils down to a basic concept.
“They’re just not watching out for these people,” Stipp said. “They’re taking in patients they really have no capability of caring for.”
Industry leaders acknowledge the shifting demographics. Deborah Pacyna, spokeswoman for the California Association of Health Facilities, the industry trade group, said it “is an evolving issue and we continue to evaluate the impact on patient care.”
“Our first concern is the safety of our patients and staff,” she wrote in an email. “Our concern centers around a patient mix that places a frail elderly person in the same environment as a younger resident with mental illness or behavioral issues.”
As one remedy to separate groups, some larger companies are designating specific buildings in which to house residents with behavioral issues or mental health diagnoses, she said.
Pacyna said one factor in the growth in younger patients is the number of active baby boomers seeking short-term rehab after hip and knee replacements.
She also cited the Affordable Care Act as a driving force. She said the act, signed into law in 2010, has had an “unintended consequence” of allowing younger, more challenging clientele to access Medi-Cal benefits and enter nursing homes. This new population also includes convicts released into community settings under prison realignment, she said.
“Because of the Affordable Care Act, people who never had health insurance are now accessing medical care,” she stated.
Others contend the trend started well before the law, noting most of its provisions took effect in 2013 and 2014. They point to another motive: corporate profits.
A patient with Medi-Cal, the state’s public health insurance program, nets a facility an average of $195 a day, according to the industry’s trade group. A coveted Medicare client coming in with federal benefits and high needs could generate as much as $800 a day.
“As beds empty out, some nursing homes are more and more willing to take anybody to fill the beds,” said Janet Wells, a consumer advocate and public policy consultant based in Washington, D.C.
Wells said she once wrote consumer guides on how to choose a nursing home.
“I often thought that one thing we should have begun to put into these publications was, when you’re visiting a facility, look around,” she said. “Who are the other residents? Do you feel comfortable with them? Are there people there who don’t appear to be compatible with your elderly mother?”
Staff feel at risk
Inside some California nursing homes, the changing patient population has created friction, sparking safety concerns for staff and residents alike. The Bee’s review of government inspection reports revealed numerous incidents where workers and residents allegedly have threatened and even abused one another.
In Sacramento, Gramercy Court was issued a federal deficiency in 2014 after a nurse failed to properly report that a resident had threatened to shoot the facility’s administrator. The state cited Braswell’s Yucaipa Valley Convalescent Hospital in 2012 after a resident hurled a blood glucose monitor at a certified nursing assistant. According to state documents, the CNA allegedly taunted the resident, saying: “You’re lucky I’m on the clock, you old hag, get away from me.”
Some residents arrive at facilities addicted and continue their drug-seeking behavior, state records show.
In the Los Angeles area, Santa Clarita Convalescent Hospital was fined $15,000 in 2012 after a resident who had overdosed multiple times admitted to having a friend deliver heroin to the facility and hiding the stash in his socks, according to the Class A citation from the California Department of Public Health.
Maria Martinez, a certified nursing assistant in San Rafael, said she sometimes feels ill-equipped to deal with the evolving patient mix. Martinez has worked 25 years at the San Rafael Healthcare & Wellness Center, which Rechnitz acquired in 2012.
“When you have homeless people coming in who are also alcoholics, you never know how they’re going to react,” she said. “We put ourselves in a lot of risk with some of our residents.”
One homeless man was admitted to the San Rafael nursing home after being discharged from a hospital for treatment of a raccoon bite he got while sleeping under a bridge, she said.
Last August, Martinez and other workers belonging to the National Union of Healthcare Workers staged a two-day strike at the facility, complaining of high staff turnover and inadequate wages. Nursing turnover at the home was 52 percent in 2015, according to state data. The nursing home currently has a one-star rating, the federal government’s lowest mark.
Friedman, Rechnitz’s spokesman, did not directly respond to questions about the strike, staffing or homeless clientele. He did note that the 54-bed San Rafael facility currently has only four patients under 65 with a psychiatric diagnosis.
Frances Salcedo, a longtime social services director at a suburban Los Angeles nursing home, said facilities aren’t always to blame for volatile patient mixes. Acute care hospitals sometimes fail to accurately or fully inform nursing homes about the mental health condition or behavioral issues of patients they refer, she said. The nursing home then may have a hard time discharging a difficult patient without facing penalties, she said.
Advocates for the elderly and mentally ill contend that inadequate staffing is the biggest obstacle to keeping nursing home residents and staff safe, especially with the influx of younger, more mobile patients with complex diagnoses.
In its statewide analysis, The Bee identified the 100 nursing homes with the highest proportion of younger residents and compared them with the 100 homes at the opposite end. Among the homes with the highest proportion of young residents, staffing ratios were lower: 3.7 nurse staffing hours per patient day, compared with 4.2 nurse staffing hours at facilities with mostly elderly patients.
The homes with many younger patients also tended to generate more health deficiencies from federal inspectors. The facilities with the most young patients averaged 41 deficiencies per 100 residents over 3 1/2 years, compared to 31 deficiencies per 100 residents at those with the least young patients.
Glendora Grand, the facility that Barbara Trigueros is suing, is filled with younger residents – 67 percent were under age 65 in 2014, more than triple the statewide average. Trigueros said she was “taken aback” by the patient makeup on her very first visit.
“In the time that Mom had been in facilities, it would be rare to see a young person,” she said. “But I saw quite a number of young people walking around. I didn’t know if it was due to drug abuse, but they were kind of (in a) zombied state, kind of lingering around the nurses station in chairs, talking to themselves.”
The administrator at Glendora Grand, Donovan Mauga, did not return phone messages regarding this story.
Karen Jones, an elder care advocate in San Luis Obispo County, is trying to help nursing home workers be better prepared for the challenging mix of patients.
Jones said too many mentally ill residents check themselves out of nursing homes against medical advice because their behavioral issues alienate staff, who don’t know how to compassionately handle them. Meanwhile, without adequate training, staff members can be vulnerable to physical and emotional abuse from difficult residents, she said.
Last year, her office secured funding to offer training to nursing home workers on dealing with the mentally ill – an initiative that Jones said was greeted enthusiastically by staff attending the sessions.
“They were starving for the information,” said Jones, head of the county’s ombudsman program.
‘She just couldn’t handle it anymore’
To this day, Casey Cargill isn’t sure why her younger sister, Courtney, wound up in skilled nursing. Cargill said her sister had been fully mobile, joining her for shopping excursions and signing herself out of the facility to wander on foot around South Pasadena.
Courtney had struggled for years with mental illness, abandoning her work as a court reporter and drifting on and off the streets, according to her family. After a series of involuntary psychiatric holds, the public guardian placed Cargill at South Pasadena Convalescent Hospital in November 2013 with diagnoses that included schizophrenia, psychosis, bipolar disorder, depression and anxiety, according to public records and her family.
Long-standing federal regulations require each state to establish programs to screen nursing home applicants for mental illness. This so-called “Pre-Admission Screening and Annual Resident Review” prohibits facilities from admitting individuals with serious mental illness unless the state determines they need that level of care, along with any additional specialized services.
According to the family’s lawsuit, the California Department of Health Care Services informed the South Pasadena nursing home in January 2014 that, based on the screening review, Courtney required multiple services, including psychotherapy, substance abuse treatment and behavior monitoring.
Instead of getting mental health services, the family’s lawsuit contends, the facility “took money from Courtney to house her in a ‘room and board’ fashion, content to let her smoke cigarettes and watch TV all day.”
Cava, the Department of Health Care Services spokesman, stated in an email that department officials “do not know the outcome of the (screening) recommendations” once they are sent to the facility. He referred questions about the case to the Department of Public Health.
Corey Egel, spokesman for the Department of Public Health, said his department would follow up on the other department’s treatment recommendations if a problem were brought to its attention. His department investigated Cargill’s death and fined the facility $20,000.
Rechnitz and his representatives expressed sympathy last year for Cargill’s family but have declined to comment further, citing privacy considerations. At that time, a former spokeswoman for Rechnitz told The Bee that the facility for years “had provided quality health care services to a severely underserved population of patients with few to no options for placement.” The home since has changed hands, and failed last month to regain certification under the new owners.
Looking back, Casey Cargill has concluded that her sister “was pretty much on her own” while she was there.
“For so long, her needs hadn’t been met,” said Casey, 63, who lives in Costa Mesa. “She just couldn’t handle it anymore, I guess.”
On the morning of Nov. 7, 2014, Courtney left the nursing home, alone, bought a gallon jug of gas, stripped off her clothes and lit herself on fire behind a service station five blocks away. She died 19 hours later.
“The cause of death is due to thermal burns,” the Los Angeles deputy medical examiner wrote. “The manner of death is suicide.”
About this story
The Bee used several sources of data in reporting this article.
The statistics on mental health diagnoses among nursing home residents draw on a federal database of health information reported by nursing homes for every resident upon admission, and at least quarterly thereafter. The Centers for Medicare and Medicaid Services publishes statewide data based on these assessments going back to 2011.
The Brown University School of Public Health warehouses some MDS data back to 2000. That historical data also is cited in the story.
Data on the number of residents under age 65 in each California nursing home during 2014 came from the Office of Statewide Health Planning and Development. It reflects only freestanding nursing homes, not the relatively small number of homes attached to a hospital.
Staffing data for 2014 also came from OSHPD. Statistics on the number of health deficiencies at each home, as well as their federal star ratings, came from CMS’ November 2015 data release.
In analyzing the relationship between the proportion of young patients and health deficiencies, The Bee calculated the number of deficiencies per 100 residents during the last three inspection cycles, which cover a period of about 3.5 years. The analysis excluded facilities with fewer than 45 residents.
When looking at the relationship between young patients and staffing, The Bee reviewed nurse staffing hours per resident day in 2014. It excluded specialized facilities that provided subacute and intermediate care, and those that provide care to the developmentally disabled and mentally disordered.
Finally, The Bee focused its analysis on “regular” nursing homes, excluding homes with “special treatment programs” that are certified to care for large numbers of chronically mentally ill residents.
The correlations between higher proportions of younger patients and higher numbers of health deficiencies per bed, lower staffing ratios and lower federal ratings were statistically significant at the 99 percent confidence level.