Where do patients go when a troubled nursing home closes? Often, nowhere better

When the Eagle Crest nursing home in Carmichael began notifying residents this summer that it would soon be closing, executives assured family members in writing that loved ones could be accommodated at other company-owned homes.

Genesis HealthCare Inc., one of the nation’s largest nursing home chains, similarly assured the state it would evaluate the relocation needs of each remaining resident at Eagle Crest. The 126-bed nursing home only recently closed.

What the $5 billion corporation based in Pennsylvania didn’t mention in its relocation plan is that its string of nursing homes in California tends to have more serious problems and worse federal ratings than other skilled nursing facilities in the state, according to a Sacramento Bee analysis of federal data.

Eagle Crest in suburban Sacramento was among the chain’s worst-performing facilities nationwide, teetering toward decertification while federal regulators kept it on a consumer-beware list for three years.

Now, with many of the former Eagle Crest residents shepherded off to other Genesis homes, The Bee’s analysis found that the troubles at Eagle Crest were not isolated at all.

One Genesis facility in Willows, 85 miles northwest of Sacramento, became the destination for seven Eagle Crest residents, despite a scathing inspection earlier this year in which its patients were found to be in “immediate jeopardy,” according to documents from the California Department of Public Health. The Willows Center has the lowest possible rating from the federal government.

The March inspection revealed that a certified nurse assistant with a known criminal history of abusing others had gone on to abuse, neglect and mistreat five residents at the facility. One male resident claimed the nursing assistant put a blanket over his face and held it there “so I can’t breathe,” according to the survey documents.

“I can’t use my hands good, so I can’t defend myself,” the resident reportedly said.

A female patient said the nursing assistant had “scared and bullied” her because of her incontinence, refused to give her ice chips and flickered her room lights at night for no apparent reason. Inspectors found no evidence the allegations had been thoroughly investigated, nor did the facility report the incidents to the state, as required, the documents show.

The Eagle Crest closure highlights the precarious nature of the nursing home business in California, and the upheaval for residents when a facility shuts down – forcibly, or by choice.

“Moving residents from one troubled nursing home to another puts their lives at risk,” said Michael Connors of California Advocates for Nursing Home Reform, based in San Francisco. “It should never happen.”

Connors said it is common for operators, even those with dismal track records, to capitalize on their own closures and funnel residents right back into their own facilities, regardless of location, quality of care, or a patient’s specific needs and desires.

‘Safely relocated’

Of the 67 patients who remained at Eagle Crest in its final operating days, 33 were transferred to the company’s own facilities in Sacramento, Stockton, San Leandro, Fresno and Willows, according to the California Department of Public Health. The majority of those patients – 18 – found new homes at American River Center in Carmichael.

“Eagle Crest staff worked personally with each patient and his or her family to identify an alternative care option to meet his or her needs,” said Genesis spokeswoman Jeanne Moore. “All patients have been safety relocated at this time.”

The Carmichael and Stockton facilities earned higher marks from regulators than the 76-bed home in Willows. However, a Bee analysis shows that Genesis HealthCare has struggled in California to consistently deliver quality care.

Federal inspectors logged 44 serious deficiencies at Genesis’ California homes during the last 3½ years for violations that caused actual harm, or immediate jeopardy, to the health and safety of patients. The rate of serious deficiencies per 1,000 beds at Genesis homes was about 60 percent higher than the rate at other California nursing homes during that period.

The company, based in Kennett Square, Penn., controls 38 health facilities in California, of which 29 are traditional nursing homes. Most are in Southern California. That nursing home count includes Eagle Crest but not the company’s six behavioral health nursing centers that cater to the mentally ill.

Nationwide, Genesis HealthCare said it had 473 skilled nursing facilities in 34 states at the close of last year, according to company documents filed in 2016 with the U.S. Securities and Exchange Commission.

The SEC documents show that Genesis’ business model is built on accepting the sickest and most fragile residents. The company states that its marketing efforts are focused on “high-acuity patients” who are recovering from strokes and other debilitating illnesses and conditions.

Those patients also come with the highest Medicare reimbursement rates.

Despite a practice of accepting the sickest of the sick, The Bee found that nurse staffing levels at Genesis’ traditional nursing homes in California were below the statewide average.

Poor inspection results have contributed to poor ratings, The Bee found.

The average federal rating at Genesis’ 29 traditional skilled nursing facilities in California is 2.9 stars, significantly lower than the statewide average of 3.7 stars. (Genesis’ average rating rises to 3.2 stars if its behavioral health nursing centers are included.)

The federal government rates nursing homes from 1 star, or much below average, to as high as 5 stars, considered to be much above average. The scoring is based on health inspections, staffing levels and quality measures collected by the facility (http://sacb.ee/bARa).

Federal data show that 14 percent of Genesis’ California homes are rated 1 star. One of its 2-star homes in Los Angeles also is being targeted by the federal government for closure, which would trigger yet another round of transfers for residents.

Genesis blamed its lackluster federal ratings on changes to the rating methodology and the company’s acquisition in early 2015 of Skilled Healthcare Group Inc., whose facilities “generally had poorer than average star ratings,” according to the company’s Dec. 31, 2016, SEC filing. Most of Genesis’ California nursing homes were once owned by Skilled Healthcare. Those facilities have continued to log multiple serious deficiencies following their acquisition by Genesis.

Earlier this month, Genesis spokeswoman Moore told The Bee that the company’s facilities actually had improved their star ratings since 2015. About 65 percent of its California facilities – including behavioral health nursing centers – are rated 3-star (average) or above, up from 53 percent in 2015, Moore said.

Problems persist, however. The U.S. Centers for Medicare & Medicaid Services recently declared its intention to kick the company’s 159-bed Brier Oak On Sunset facility in Los Angeles off its Medicare rolls, effective Aug. 28, because of persistent compliance issues. The company is challenging the government’s termination notice, court records show.

“The (nursing home) is exercising all of its legal rights to appeal the termination,” said Genesis spokeswoman Moore.

Molly Davies, who oversees the city and county of Los Angeles Long-Term Care Ombudsman Program, said her group wanted Genesis to disclose to Brier Oak patients being uprooted whether their prospective new homes were also owned by the company, so individuals and families could make an informed choice. She said that care problems and staffing shortages inside Genesis-run facilities have “come onto our radar” more recently in the Los Angeles area.

Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, said that oversight systems nationwide have failed to account for chains and patterns of care when residents are relocated.

“It’s a big problem,” she said. “…What good is it going to do for a resident to be sent 80 miles away to another 1-star facility?”

‘Transfer trauma’

A Bee investigation published in 2014 identified distinct patterns of poor-quality care at a number of nursing home chains in California, including Genesis.

Smetanka’s group released a detailed report in November 2016 about nursing home closures, which found that residents face significant obstacles to a successful transition. Patients often have no appropriate options in the immediate area, or are rejected by prospective facilities, the study said.

In some cases, little time is spent on individualized planning and moves become chaotic and frenzied. According to the study, one local ombudsman who observed a facility closure saw belongings stuffed into trash bags, charts and medication left behind, and families left clueless as to their loved ones’ whereabouts.

The consequences can literally be deadly, as fragile residents are susceptible to what is known as “transfer trauma.”

“If a facility decides to close, there really needs to be individualized planning with every single resident,” Smetanka said. “Just saying that a closure is a success when all the residents are moved is not a valid measure of success.”

The study singled out three states – Connecticut, Ohio and Wisconsin – which had created policies and procedures to help overcome some of these barriers.

Ohio, for instance, created a “resident relocation team” with members from various public agencies, who begin planning early for a possible closure. Team members have direct contact with residents and family members, trying to identify the best placement choices for each individual. During chaotic situations, the report said, team members have found themselves on the front lines, directing moving trucks and faxing paperwork.

California, which was not singled out in the report for any “best practice,” does not have a multi-agency relocation team. Federal regulations, however, require that operators closing a facility notify the state and its residents 60 days in advance. And, the relocation plan must ensure that residents are transferred to the “most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs, choice and best interests of each resident.”

Elder-care advocate Connors contends that California has failed to enforce those provisions. He said the California Department of Public Health relies too heavily on nursing home operators to develop and execute their own relocation plans – which he says the state then “rubber stamps.”

“The department’s position seems to be that a closing nursing home can send residents to any licensed nursing home, no matter how far away or how poor its record,” he said.

Patients moved 450 miles

Connors was aghast in late 2014 when the state’s largest nursing home owner, Shlomo Rechnitz of Los Angeles, closed his decaying facility near Fresno following a patient’s death and a 74-page list of deficiencies. About 24 residents reportedly were driven 450 miles to Rechnitz-owned facilities in Humboldt County, along California’s remote North Coast.

Rechnitz and his company, Brius Healthcare Services, created another uproar last year in Humboldt County by threatening to close three of those facilities and accommodate displaced residents in still other of his nursing homes, many miles away. Rechnitz ultimately backed off the plan, closing only one of the facilities, and state lawmakers from the region called for an audit of Brius and to assess whether the company had misused millions in public money. That audit is underway.

A spokesman for the California Department of Public Health said the agency does not have the authority to determine where patients go.

“It is not within the California Department of Public Health’s scope to investigate placement options,” according to an email response from the state. “CDPH does follow up with each resident in their new facility to assess for transfer trauma and ensure the resident is receiving appropriate care.”

The department stated that it had monitored the Eagle Crest residents for transfer trauma, and “did not identify any significant issues during the transfer of residents.”

In that closure, the state approved the company’s relocation plan on Aug. 4. Just six weeks earlier, the state had notified Genesis it was recommending that the federal government decertify the facility at 8336 Fair Oaks Blvd. The Carmichael nursing home had been on the federal government’s “Special Focus Facility” list for three years, a public shaming intended to get a troubled facility to step up or risk losing its government money.

In recommending closure, the state cited an incident in which it had concluded that a 79-year-old Eagle Crest resident with Alzheimer’s disease had been sexually abused multiple times by another resident.

Genesis denied any wrongdoing but told the state it would voluntarily close instead.

Joe Rodrigues, California’s long-term care ombudsman, said he would hope that “families didn’t blindly accept placements at another facility without checking that facility out.”

American River Center, about 2 miles west of Eagle Crest in Carmichael, has received mixed reviews. The facility is rated four stars, or above average, in the federal rating system. But the 99-bed nursing home was assessed as being “below average” in an ongoing statistical analysis by the University of California, San Francisco (http://www.calqualitycare.org/). American River Center took in 18 Eagle Crest residents, state records show.

Creekside Center in Stockton, which accepted three Eagle Crest residents, gets top marks from both rating systems – the only Genesis nursing home in California to achieve those results. Five more residents went to Genesis homes in San Leandro and Fresno. Those homes also got mixed reviews in both rating systems.

Connors said he was appalled that Willows Center received any transfers at all.

Earlier this year, the state issued three calls of “immediate jeopardy” related to the certified nurse assistant with a criminal history, and the abuse allegations. The state found that the CNA had been hired at Willows Center in June 2016 after being found guilty of abusing, neglecting or mistreating others on three separate occasions in 2014 and 2015. During the hiring process, she had disclosed to the facility that she was on probation for the misdemeanor violations, state records show.

“I’d like to know what they told residents and family members about the track record of that facility,” Connors said.

Marjie Lundstrom: 916-321-1055, @MarjieLundstrom