Esther Hernandez was supposed to come home.
When she had trouble walking in September, Hernandez’s family placed her in Windsor Gardens Convalescent Center, a National City nursing home, to help her regain mobility. The 94-year-old was expecting to return to her family’s San Ysidro house within a few months.
By the last week of February, Windsor Gardens closed its doors to prevent visitors from carrying in COVID-19, and Hernandez’s relatives could only interact with her through phone calls and window visits. When the family celebrated Mother’s Day with their matriarch on video chat, Hernandez was happily blowing kisses to her daughter, granddaughter and great-grandson — just 6 years old — from her nursing home bed. But her family noticed something was wrong.
“She was asking for water, saying she was thirsty,” said Rebecca Niebla, Hernandez’s granddaughter. “She had this look on her face that something was bothering her.”
Four days later, Hernandez tested positive for COVID-19, her granddaughter said. At the next video get-together with her family, she couldn’t stay awake.
Niebla said that even though Hernandez looked like she was in pain, no staff members at the 98-bed facility checked on her during the six hours the family could see her during their video call that day.
That was the last time Niebla spoke with her grandmother before she died on May 16.
“We’re very upset, very concerned about everything that happened at that place,” Niebla said.
Hernandez’s death certificate says her primary cause of death was cardiac arrest, but her granddaughter believes COVID-19 was a contributing factor.
Windsor Gardens has had 17 residents die from COVID-19 and 62 have been infected, according to state public health data. In addition, 24 healthcare workers at the nursing home have tested positive and at least one has died.
Elder care advocates, researchers and attorneys agree the struggle to control COVID-19 in nursing homes has been exacerbated by years of staffing cuts that increase profits but sacrifice patient care. Now, scaled back teams of nursing home employees are left scrambling to tend to overwhelming volumes of sick patients, increasing the risk the virus will spread uncontrollably and the patients who contract it won’t get the care they need.
An inewsource analysis of federal data shows 84% of San Diego’s skilled nursing facilities don’t have enough nursing assistants, and 63% don’t have enough registered nurses to meet minimum staffing levels recommended by researchers.
Reporters scoured state and federal inspection reports, databases and lawsuits to examine the histories of the 12 San Diego nursing homes with the most coronavirus cases, including Windsor Gardens. All have faced lawsuits or citations in the past three years accusing leadership of insufficient staffing practices.
inewsource found none of the facilities have enough aides to meet staffing levels that experts recommend, and 11 don’t have enough registered nurses. One is facing a COVID-19 lawsuit from a former resident’s children who claim the 73-year-old’s death was a consequence of reckless understaffing that left the home unprepared for the pandemic.
The families of nursing home residents told inewsource they have filled in the gaps created by staffing shortages, helping change and feed their relatives and advocating for them to receive the services they need. Now, they can no longer visit their loved ones, and they fear what could be going on inside.
Windsor Gardens did not grant an interview for this story or respond to emailed questions about the pandemic or Hernandez’s death.
“We have known for a long time that this was in our future, kind of like an earthquake,” said Philip Lindsley, an attorney at the San Diego Elder Law Center. “We’ve always known an infection like this — not a day-to-day type infection, but a pandemic-type infection — will be coming.”
Lindsley, a San Diego native, founded the center in 1997 to advocate for the elderly. Over that time, he said he has seen staffing problems at nursing homes continue to escalate.
“What you have is a foreseeable perfect storm,” Lindsley said.
The biggest expense
At The Shores Post-Acute near Linda Vista, registered nurses spend less time with patients than is typical, federal data shows: Residents get 15 minutes of care a day compared to the national average of 41.
That’s less direct care than at almost all other nursing homes in the county.
Since May, state and federal regulators have cited The Shores four times and substantiated nine complaints against the facility. The complaints alleged the nursing home’s staff are unqualified, improperly use protective medical gear, do not follow infection control procedures and do not provide a safe living environment.
When state inspectors investigated the complaints on May 1, they found a used medical gown overflowing from a hallway waste bin onto the ground, and a second gown on the floor of a patient’s room in front of the door.
“This failure had the potential to cause spread of infection throughout the facility,” the inspection report says.
Plus, 14 residents and 18 healthcare workers at the nursing home have tested positive for COVID-19.
In a new study that will publish in August, California researchers found that nursing homes without an adequate number of registered nurses were twice as likely to have COVID-19 outbreaks compared to well-staffed facilities, said lead author Charlene Harrington, professor emeritus at UC San Francisco.
The state doesn’t have a required number of patient hours for registered nurses, but Harrington and other experts recommend they spend at least 45 minutes a day with each resident, otherwise the quality of care begins to decline. Most nursing homes, including 63% in San Diego County, don’t meet that recommendation.
“They’re trying to keep their staffing levels low, especially RN staffing, because they’re the most expensive,” Harrington said. “Then they try to pay the lowest wages and benefits they can get away with, and that’s all to increase their profits.”
Normally, the state requires the overall amount of care provided by all nursing staff — including registered nurses, assistants and others — to total at least 3.5 hours for each patient every day. Eleven of the 12 nursing homes with the most COVID-19 patients asked for waivers for the upcoming fiscal year to keep their staffing levels below the minimum requirement.
When the pandemic began, the California Department of Public Health officially waived the requirement indefinitely. The decision outraged advocates, who believe the standards were not strict enough to begin with and who think it will cause the virus’s spread to accelerate.
Most care at nursing homes comes from a group of employees called certified nursing assistants, who help residents with daily tasks such as feeding, bathing and walking. Researchers believe patients need at least 2.8 hours of direct care from nursing assistants every day.
About 84% of San Diego’s nursing homes don’t reach that recommended benchmark, inewsource found, including The Shores.
The Shores didn’t answer messages about its response to the pandemic.
“What they do is cut staff to the point that they become less like a healthcare facility and more like a warehouse for human beings,” said Mike Dark, a lawyer for California Advocates for Nursing Home Reform. “That has nothing to do with how committed and hardworking nursing aides are. It’s that they’re being asked to see 10 or 12 or 15 residents an hour.”
Last year, the average nursing assistant in California earned $17.61 an hour, according to federal labor data, adding up to an annual salary of about $37,000.
Dr. Aram Harijan, who provides wound care services to two dozen nursing homes in the county, said many employees work at more than one facility to supplement their income, making them possible vectors who are spreading the virus — and possible victims.
Harijan’s friend, a 44-year-old San Diegan employed by two nursing homes, died from the virus soon after she volunteered to work with COVID-19 patients.
“There’s a real human toll, you know?” Harijan said. “I didn’t know what to do with myself for about a week.”
In early June, Harijan had to self-quarantine because a patient he treated at a dialysis center contracted the virus. Although he later tested negative, the doctor said, “I wouldn’t be shocked if I get COVID before the end of the year.”
San Diego County doesn’t publicize the number of healthcare workers who have contracted or died from the virus, but state data shows that 72% of the county’s nursing homes have had infected employees and 34% have had infected residents.
As a result of widespread outbreaks, many nursing home employees have been forced to stop working because they became sick or were exposed to those who did. The state requires healthcare workers with COVID-19 to self-isolate for at least 10 days after developing symptoms.
“That would be obviously ideal for people to work in one facility, but we can’t tell people, ‘No, you can’t take up another shift,’” said Deborah Pacyna, a spokesperson for the California Association of Health Facilities, a nursing home trade association. “We can’t stop people from making a living.”
Legal records and inspection reports reveal what can happen when nursing home staff are not vigilant or are too busy to address each patient’s needs.
In late 2019, a stranger walked into an unlocked door at Balboa Nursing and Rehabilitation Center in Hillcrest without being seen by staff, raped an 88-year-old woman and fractured her arm, according to federal inspection reports. Staff didn’t come help the victim until her roommate was heard screaming.
The victim sued the nursing home for $25 million, claiming the facility’s night shift was intentionally understaffed by managers “with the purpose of reducing ‘overhead’ and maximizing profits,” leaving nobody to monitor the entrance when the man walked in.
At least 43 residents and 23 healthcare workers at Balboa have tested positive for COVID-19. Its administrator did not respond to multiple requests for comment for this story.
So far, one lawsuit has been filed against a San Diego nursing home, The Springs at Pacific Regent, in response to a resident’s death from COVID-19.
In the May lawsuit, the two daughters of 73-year-old Lenard Hugle Jr. allege leadership at The Springs was motivated by profit to understaff the nursing home for years.
“These are patients who are unable to leave the facility, are not ambulatory — they are literally trapped,” said Gil Purcell, the attorney representing Hugle’s family and a senior partner at Brayton Purcell LLC. “Juxtapose that with the good intentions of the family who believe they have placed their loved one in the care of a facility that has the caliber of service to protect them. How devastating to discover that’s not the reality at all.”
Hugle was admitted to the La Jolla nursing home in February after a stroke. Because there were not enough workers to test residents, disinfect surfaces and isolate sick patients, he contracted the virus from his roommate in April, the lawsuit says.
Hugle had scarred lungs from a disease called asbestosis, an underlying condition that made him especially vulnerable to COVID-19. He died shortly after he tested positive for the virus.
“These large corporations say one thing and do another,” Purcell said. “They need to be held accountable.”
Shaun Alkema, the administrator of The Springs, would not answer questions over the phone and never responded to repeated emails.
In 2019, The Springs was cited by federal inspectors after at least five residents reported difficulties getting prompt help from staff and the nursing home took no documented steps to address their concerns.
The Springs has also been cited three times since 2017 for failing to perform proper background checks on at least five employees. That includes a citation in February after inspectors discovered an employee who had worked there for a decade never received a background check. The inspection report said the nursing home’s violation constituted a “failure to implement abuse prevention.”
“If there is a staffing problem, it is always a systemic problem. It has nothing to do with the individuals working there,” said Natalie Holm, a managing attorney in a San Diego law firm who specializes in elder abuse. “There’s also under-training or lack of qualifications, and that also has to do with the management and who they’re electing to hire and how they’re training those people.”
Of the dozen San Diego County nursing homes with the most COVID-19 cases, nine have received “deficiencies,” or citations, in the past three years for failing to have enough staff, inewsource found.
Two of them, Country Hills Post Acute and Avocado Post Acute, each paid $15,000 fines in 2019 for repeated staffing shortages.
“The fact that these nursing homes got all these deficiencies means that they really have problems,” said Harrington, the UC San Francisco professor who also ran California’s nursing home oversight program in 1975.
Harrington said staffing requirements are not the priority of state inspectors during on-site visits.
“They rarely give citations for that,” she said. “So if they got a citation for that, you know it’s really bad.”
A spokesperson for Country Hills Post Acute, where 82 residents and 25 healthcare workers have tested positive for COVID-19, said the facility has not received any citations for staffing shortages since new managers took over in 2019, adding that leadership is taking all the necessary steps to protect residents.
“In light of the pandemic, we have enhanced our infection control protocols in a number of ways,” said Dan Kramer from KPA Strategies on behalf of Country Hills. That includes limiting visitations, screening employees and residents for symptoms, isolating sick patients and restricting group activities, he said.
At Avocado, 110 residents have tested positive for COVID-19 — more than any other nursing home in the county — and 16 have died. At least 40 employees have also been infected.
Debra Sheridan, a spokesperson at IVY Marketing Group, said in a statement on behalf of Avocado that the nursing home has not had any COVID-19 infections originating in the building since June 2, but it is still accepting coronavirus patients who are transferred from hospitals. She attributed the improving situation to widespread testing of all staff and residents.
Sheridan added that Avocado has provided staff with extra sick leave and bonus pay during the pandemic, and said the nursing home has not received any citations for staffing violations since the inspection that led to the $15,000 fine was issued, which occurred in 2017.
“The term ‘unprecedented’ is used so often these days, but it effectively captures the essence of this crisis,” Sheridan said. “Because there’s not been anything comparative in the past to help us understand how the situation would evolve, there have been missteps, errors, and changing protocols.”
Locking out the enforcers
State nursing home regulators suspended on-site inspections in March to quell the spread of the virus, except for visits related to infection control or immediate threats to patient safety. One week later, the county issued a stay-at-home order barring all “non-essential personnel,” including family members, from entering nursing homes.
Inspectors and families are the two main sources of oversight at a nursing home. The relatives of four San Diego nursing home residents told inewsource they worry what’s happening to their loved ones behind closed doors.
Before the lockdown, Rosa Montiel used to spend every day with her sister Lilly, a nursing home resident at San Diego Post-Acute, where the 57-year-old receives treatments for Down’s Syndrome and epilepsy.
Lilly can’t speak or move freely, but she can smile, blink and nod.
“There were hours when she was awake and I could interact with her, and I would hold her hand and we would color, or we would feed her baby dolls. We would feed them with little baby bottles of orange juice or milk,” Montiel said.
“Or I would put music on with Alexa. I would take her hand and her foot, and I would move them like we were dancing. She loved that.”
Rosa, who is five years older than Lilly, became her sister’s caregiver in 1992 when their mother had a brain aneurysm on the same day their father died. Since Lilly came to the nursing home in 2009, Montiel has been her advocate, making sure she is changed, fed and given medication on time.
The responsibility has gotten more difficult since the visitor ban, she said.
Now, she spends nine or more hours every day sitting on a stool and watching her sister through the window. She takes notes on all the staff members who enter Lilly’s room. If more than two hours pass without a nurse shifting Lilly’s bed position — a practice that prevents dangerous and painful sores — Montiel calls the front desk from the dirt pathway outside the building and insists someone check on her sister.
“Don’t tell me it’s going to take three or four hours for a CNA (nursing assistant) to come,” Montiel told inewsource. “You have to have enough people hired in the facility to deal with these issues, with what people’s needs are. These are patients’ rights.”
Nursing home advocates have denounced visitor bans, arguing they make the properties more susceptible to COVID-19 outbreaks, not less, because families are most likely to sound the alarm about staffing shortages or poor infection control.
“There’s a cruelty now in the calculus of cutting off these visitors,” said Dark, the lawyer with the California nursing home reform group. “Now there’s nobody to help them. There’s no staff, there’s no family.”
Mary Comrie, the administrator at San Diego Post-Acute, said in an emailed statement sent by a PR firm that she cannot discuss the specifics of Lilly’s treatment because of health privacy laws, but mentioned Lilly receives round-the-clock care as prescribed by her physician.
San Diego Post-Acute has had one employee who contracted COVID-19, Comrie said, and no infected residents.
Montiel said she knows the lockdown is supposed to keep the virus out, but residents inside are suffering without their families looking after them.
“We need to be able to communicate with our loved ones whenever they need to speak with us, not when the facility can or is willing to or has extra time. They’re always complaining they don’t have enough time,” she said.
“Well, they need to make time.”
inewsource intern Natallie Rocha contributed to this story.
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