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'How many people will have to die?': Coronavirus worsens gaps in nursing home care

Santa Cruz Sentinel - 2/21/2021

Feb. 20—SANTA CRUZ — John Tipton survived the Santa Cruz Post Acute coronavirus outbreak in November. As the youngest resident of the skilled nursing facility, a 63-year-old man with a brain tumor, he was the only one to be transported to the hospital at that time and make it out alive.

But he almost didn't survive an unnecessary halting of his medications in late 2020 that made him lose all pituitary function, his wife Leslie Tipton claims. Pituitary loss stems from hormone deficiencies and can result in stunted growth, blood pressure and reproduction among other effects, according to the Mayo Clinic.

"They directly endangered his life," she said.

John Tipton's wife, who has barely seen him in the last eight months due to visitation rules changing around the virus, said she plans on suing Santa Cruz Post Acute. She will join the family of a Watsonville Post Acute resident who died, Donald Wickham, in seeking accountability from congregate living facilities through legal means.

Multiple individuals have come forward to the Sentinel after the publication first published information around Wickham's wrongful death and neglect case. These personal stories intersect with the issues meriting federal and state deficiencies recorded at three of the county's largest skilled nursing facilities: Santa Cruz Post Acute, Watsonville Post Acute and Pacific Coast Manor.

These are their stories of alleged neglect.

Santa Cruz Post Acute

Leslie Tipton calls herself the nursing home "parrot." She said she isn't afraid to go to the ombudsman and report the horrors she says she has seen — such as her husband's mustache growing into his mouth, his diaper sodden, old food left on his window sill. But when she files a complaint with the licensing agency, the California Department of Public Health, things are cleaned up and it's as if nothing happened, she said. That's until the next time Leslie Tipton finds alleged signs of neglect, such as sores left unaddressed on the legs of a man who needs help moving them.

"They gaslight you and tell you things aren't true," she said of the leadership of the 149-bed facility on Capitola Road. "The ombudsman is the only voice. The patients feel like they're in prison."

Some deficiencies show proven errors in care, such as an instance reported in January 2020 when a resident's arm and catheter lengths were not measured, leading to a complication. In the same federal deficiency, an inspector mentioned incidents of oxygen administration mismanagement.

Santa Cruz Post Acute administrator Rusty Greiner said that management actually made an effort to support and incentivize staff so that residents were hydrated and taken care of. For the first 10 days of the facility's outbreak, Santa Cruz Post Acute needed no outside help; later it used additional help to keep staffing levels greater than the state requirement.

"Is it perfect? No," Greiner said. "It's not your in-house team. But we used the registry company the local state office gave to us."

In late December, John Tipton returned to the facility from Dominican Hospital and was soon found unconscious, his wife said. Dominican Hospital, and all other hospitals caring for congregate living facility residents that have fallen ill to the coronavirus, are cleaning up the messes of those homes, Leslie Tipton believes. They then return to the facility, and the cycle begins again.

"It's like a bizarre hamster wheel," she said then.

Deficiencies found months after the Centers for Disease Control issued virus-related guidance for congregate living facilities that Santa Cruz Post Acute did not have an infection control program. In November, the Cal Health Find database shows, inspectors found that nurses were not cleaning their hands, the machines they used or the surfaces in the rooms properly. There was low staff attendance at trainings that didn't cover the state of personal protective equipment or COVID-19 numbers; one nurse was unable to dilute disinfectant correctly, likely as a result.

"The state did two infection control surveys in the middle of our outbreak," Greiner explained. "When you look across the board at other facilities, it's not uncommon to get a D-level deficiency because... it's very easy to find something during the middle of an outbreak. We work hard not to get deficiencies and none of them were categorized as causing harm to someone, which is something that should be considered."

Approximately 71 state and federal deficiencies have been identified at Santa Cruz Post Acute since the beginning of 2018. A Feb. 1 state inspection shows that the facility's Skilled Nursing Facility Mitigation Plan for COVID-19 is up-to-date with no compliance issues for its 90 current residents.

Pacific Coast Manor

Duane Sondgroth used to sit alone in his bed most days when he contracted COVID-19 unless one of his family members came to visit through the window, his daughter Gigi Sondgroth told the Sentinel. A 79-year-old man with Alzheimer's, Duane Sondgroth doesn't often make a fuss when the nurses who work at his skilled nursing facility allegedly leave him without a bath or shower, without food and sometimes without the simple luxury of seeing a face he knows.

But one of his daughters became frustrated and spoke up when she felt he was being neglected.

"After many attempts of me trying to get staff to open the blinds in his room so I could check on him and say I love him, and give him hope while my mom was in the hospital, they would yell at me and say they didn't have time for that," Gigi Sondgroth recounted with frustration.

Gigi Sondgroth's sister, Hollie Thayer, disagreed with this telling of the story, adding that she spoke with staff to come to an understanding about what had happened.

"I feel like my sister came in in the ninth inning and ran in and said, 'Hey, this is all wrong,'" said Thayer, who was the caretaker for her parents until it was emotionally too much to handle more than a year and a half ago. "She doesn't know what happened in the first eight innings. She just walks in at the end and says, 'All hell's broke loose, they're terrible.' But you don't know what led up to that."

Thayer did, however, agree some incidents or practices should have been communicated to the family earlier, such as when bed baths were implemented with residents because of a described county warning to nurses not to shower residents and ruin personal protective equipment.

"The showers were also a concern for me... one of the head nurses was amazing, she took the time to talk to me cause I was like, 'Well, my dad hasn't been showered or changed,' and then they explained to me about the masks and the steam," Thayer said. "I would have appreciated the communication at that time so we made that clear."

Their father had contracted COVID-19, and the 99-bed facility insisted on moving their mother Sandra Sondgroth to try to preserve her health, Gigi Sondgroth alleges. The anguish of being apart after more than 50 years of marriage would sooner kill them, she claimed. Within a week of the separation, Sandra Sondgroth also contracted COVID-19 and had to be taken to Dominican Hospital, she said. The 73-year-old remained there for multiple weeks, as she was dehydrated and had a definite urinary tract infection when she arrived. This is more severe than an October 2020 federal deficiency against Pacific Coast Manor for an incident in which a resident was left in a high-stress state after her urine sample was not collected, as a physician requested when it was determined she had a urinary tract infection.

Since the start of 2018, the facility has been cited 26 times for state and federal deficiencies.

Heidi Stone, the spokeswoman for Pacific Coast Manor's parent company Covenant Care, explained the facility was required to separate the couple.

"We strongly encourage involvement from families, including window visits," Stone said. "We have virtual visits using iPads. (It's) all for resident wellness. Pacific Coast Manor conducted 70 window and virtual visits with families over the six-week period surrounding the COVID-19 outbreak."

In December, the Sondgroths were told that their matriarch only had a few days to live because she was "unresponsive," their daughter said.

"When I stopped by she perked up and started getting better," Gigi Sondgroth said. "The doctor called my sister and said that (the facility) was not used to patients having a family that actually cared... (Staff) did not realize that we are a very close family and want to be here for our parents."

The care Gigi Sondgroth described her father was (or was not) getting aligned with a February 2020 federal deficiency cited against the facility in which an inspector observed call lights, used by residents to ask for medical aid, were out of their reach. One resident waited 45 minutes for medication, and another mentioned that staff regularly took a long time to help or were not replaced when someone called out sick. One resident was left without a urinal for an extended period of time; another resident with a serious diagnosis of epilepsy did not have their vital signs assessed for nine consecutive days. This was one of the 26 state and federal deficiencies identified at Pacific Coast Manor since the beginning of 2018.

When asked about the deficiencies over the last three years, Stone pointed out the facility's five-star Medicare rating.

Stone also stated that there are protocols in place to protect residents, even those who do not have family nearby to advocate on their behalf.

"I do feel like this has been an opportunity if there's anything that can come from it, for us to come closer, staff and employees," Stone said. "We've got so many team members, from van drivers to housekeeping to activities, that are really trying to come together to bring some comfort and be a voice for our residents."

The outbreak that occurred at the end of last year inside Pacific Coast Manor's walls killed 15 residents. As some were dying, the facility received a federal deficiency around its infection prevention and control protocols. An inspector noticed nurses not using their PPE correctly, avoiding hand hygiene and sweeping and mopping around beds. It appears the inconsistencies began in July when the state cited the facility for acts such as the facility's director of nursing, dietary manager and dietary aid not wearing or pulling down facemasks in the facility.

Stone said that the facility's most recent deficiencies were just around an aid dropping a piece of paper during the inspection and a housekeeper not using an alcoholic anti-bacterial before putting on gloves. According to the state, an inspection was done Feb. 1 — just like Santa Cruz Post Acute — that also yielded findings of no issue with its Skilled Nursing Mitigation Plan for COVID-19 for its 60 current residents.

Watsonville Post Acute

Wickham, 94, was the last resident of Watsonville Post Acute to die following the skilled nursing facility's coronavirus outbreak in October, according to previously extended death data from the County of Santa Cruz. One by one Wickham watched and, because of his dementia, somewhat understood when fellow residents succumbed to the symptoms of COVID-19 until he died.

But he was the first to make headlines on a legal front when his son, John Wickham, and his attorney David Spini announced a wrongful death lawsuit against the facility in November. It was the first of its kind in Santa Cruz County.

On March 31, counsel for both the Wickham family and the facility will meet for a case management hearing, according to the county's court case portal. Then, they will discuss allegations that the 95-bed facility was understaffed and that the present staff was inadequately trained to handle the situation, leading to the deaths of 16 total residents.

"Infection control in nursing homes is not some new thing," Spini said upon the complaint filing. "Nursing homes are required to prepare for infectious outbreaks and Watsonville Post Acute had more than six months to follow the law and their own protocols to prevent this deadly COVID-19 infectious spread... Most nursing homes have done just fine, but not Watsonville Post-Acute."

In October, approximately one month after the outbreak began, the facility was cited by a federal health inspector who witnessed a housekeeper not being scanned for a temperature or other COVID-19-related symptoms before he started his shift. Data reporting was also an issue for the facility. By summer, Watsonville Post Acute had failed to report coronavirus data three times since the pandemic began.

In total, the facility has written plans of correction for 37 state and federal deficiencies since the beginning of 2018. Deficiencies dating back to a world before COVID-19 show signs of possible neglect, such as hazardous conditions around supervision to prevent falls, unsafe sprinkler and electrical wire systems in June 2018.

Representatives of Watsonville Post Acute did not return multiple requests for comment through phone calls and emails from the Sentinel. The facility has not been inspected this year.

Issues across the board

Mary Franco, an Aptos resident, has been an advocate entering congregate living facilities to bring up the concerns of families for several years. Since she began acting as an intermediary, Franco has seen unspeakable things — a few of which she previewed in a letter to the editor that ran in the Sentinel.

"...Our seniors are paying the price for gross neglect on top of COVID-19 related issues," she wrote. "Fall accidents going unreported. Malnutrition. Poor hygiene. Gross neglect. Medication errors. Dehydration. State and local licensing, we need you."

Franco has been encouraging those who know of examples of neglect in skilled nursing and residential care facilities to speak up by contacting local and state legislators, calling the agencies that license the facilities and reaching out to an ombudsman that can act as a mitigator. It's not making trouble, she says, but making sure the people in power don't think theirs is a one-off situation.

"Even when a facility and the people in it are trying, corporations and licensing are falling down on the job," Franco said, adding that licensing deficiencies are often just a "slap on the wrist." "All we're asking is to talk. How do we (fix) this together?"

Franco has signed a non-disclosure agreement, meaning that her occupation is not publishable at this time for fear of retaliation. But in her many years of monitoring skilled nursing and residential care facilities, she says there have always been issues. COVID-19 was just the straw that broke the camel's back.

"I have been in every facility in Santa Cruz County," Franco said. "(These issues) existed long before the pandemic, long before me ... Corporations ask administrators to play it mean and lean down to the dollar and they pay the folks who are caring for our seniors and loved ones the lowest (wage) possible.

The fact many of these workers don't have health insurance and have to take on more than one job to qualify for it adds to the issue of infection control, Franco alleged.

"It has to change at a legislative level," Franco concluded.

Creating the change

U.S. Rep. Anna Eshoo, who represents a portion of Santa Cruz County and her other jurisdictions by serving as chairwoman on Congress's Health Subcommittee, is working to make that change. Eshoo, along with some of her colleagues, introduced the Nursing Home Reform Modernization Act of 2020 in December.

The act, Eshoo's office said in a statement, would expand the current Special Focus Facility list to ensure more oversight, enforcement and assistance for all facilities nominated for the Nursing Home Reform Modernization Act program. In addition, it would increase educational resources for all underperforming facilities and establish an independent advisory council to touch base and give updates to the U.S. Department of Health and Human Services.

"COVID-19 has torn the veil off every system in our country and laid bare the need to reform and strengthen America's nursing homes," Eshoo said to the Sentinel. "With this devastating clarity, we can move forward to correct what's wrong and do what's right. I will not let these issues go unaddressed. My colleagues and I are committed to passing legislation to provide resources and oversight to protect residents and staff and demand accountability."

Eshoo made a point in a statement around the act that Franco also desires to bring to the forefront: the number of individuals lost when a virus attacked facilities with infrastructure that didn't stand a chance. Santa Cruz County congregate living facilities have recorded the deaths of more than 140 residents, the county's data dashboard shows.

So what's the breaking point?

"How many people are going to die?" Franco asked.


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