Is a nursing home a safe place? The question is not, is a nursing home a nice place? Not much room for argument there. Nursing home are not popular places. The question here, though, is it is a safe place?
It seems not, certainly not if the home is operated by Brius Healthcare, the largest chain of nursing homes in California, with 81 facilities statewide, and a handful in Nevada and Texas. This chain – increasingly the typical organizational form in the for profit nursing home industry – is owned by the southern California tycoon, Shomo Rechnitz; Brius controls 1 in 14 nursing home beds in California, an empire with facilities from San Diego to Eureka.
Rechnitz, who purchased his first nursing home in 2006, is called an entrepreneur and philanthropist by admirers; he is a supporter of Jewish and Israeli enterprises, but considers himself nondenominational; he also bankrolls right-wing California politicians. His business depends on funding from the government – Medicaid and Medicare. Rechnitz, a success story for many, a rising star in the ranks of West Coast billionaires, is now in trouble, as is his industry. Shlomo Rechnitz and Brius face charges from the media, the state Attorney General, the police, nursing home reformers, patient advocates and the National Union of Healthcare Workers (NUHW).
The important new report, “California Nursing Home Chains By Ownership Type: Facility and Residential Characteristics, Staffing and Quality Outcomes in 2015,” written Leslie Ross and Charlene Harrington, UC San Francisco professors, while not focused on Brius, spells out the issues in great detail. More new information is also available from the California Association for Nursing Home Reform (CANHRA). The Sacramento Bee has an investigative report on nursing homes available on line and now NUHW has put up its own website, documenting Brius’ misdeeds and supporting its members own fight for decent contracts – BriusWatch.org.
The nursing home industry was transformed in the 1950s and 60’s, as small, non-profit providers were increasingly replaced by for-profit companies and these flourished through to the end of the century, fueled by revenues from Medicare and Medicaid. Since then, however, the industry has been in slow decline, despite the continuing aging of the population; still in 2015 there were 15,640 nursing homes in the US with 1.5 million residents. California has 1200 nursing homes located in 56 of its counties.
The shift to for-profit chains has taken place in this context; private owners now increasingly rely on consolidation – increasing market share – in place of actual growth; aggressive chain managements, Brius excels here, acquire failing facilities at bargain-basement prices often through bankruptcy proceedings. These facilities most often already have quality problems – problems which persist and often worsen under Brius.
Today, the deepening crises in mental health and homelessness present possible new clients, as well as, of course, new problems. The number of mentally ill and young residents living in California nursing homes has risen over the past number of years, creating a volatile population mix that produces safety and patient care challenges for traditional elderly nursing home residents and nursing home staff. According to the Sacramento Bee report, California for-profit nursing home owners admit acute-care and non-traditional residents which can yield as much as $800 per day for those with Medicare. Thus the chains have targeted services to post-acute care and rehabilitation – services that receive the highest Medicare reimbursement at the expense of long-stay residents.
Seventy-five percent of California nursing homes are now owned by chains. These chains have cut nursing levels and reduced support staff, and overseen an unmistakable decline in quality of care and life for clients, as well as the working conditions, wages and benefits of its employees.
Of all the areas with “serious quality problems” examined by Ross and Harrington, staffing is singled out; and the fact that California’s “Medicaid reimbursement rate methodology has only weak incentives to increase staffing and has very limited financial accountability standards and reporting requirements.” The result – “dangerously low staffing levels” are endemic in the industry.
They also note that all the evidence suggests that “high staffing levels, especially RN staff, have been associated with higher quality of care…”
Studies, including these, show, not surprisingly, that “facilities with the highest profit margins have been found to have the poorest quality” and, again not surprisingly, that “government and business interests have been supporting the for-profit nursing home industry that controls the long-term care field to the disadvantage of non-profit organizations and home-and community based services.”
Back to Brius. “What we’re seeing at the Brius locations is quite concerning,” says Molly Davies, administrator for Los Angeles’ Long-term Care Ombudsman Programs, the programs that investigate nursing home complaints. “We have seen patterns of poor care, patterns of substandard care in some of these facilities.
“The dangerously low staffing levels in many California nursing homes have resulted in many serious quality problems.” The result? Davies says that in far too many cases her staff has witnessed what can only be seen as a “flagrant disregard for human life.”
BriusWatch.org has gathered the evidence for us, the details in human lives. Here are examples, all shocking, all inexcusable:
In 2009, Rechnitz purchased an abandoned tuberculosis sanatorium in Fresno County, then converted it into a nursing home. In 2011, a state investigation found numerous health hazards at the aging facility. Surveyors cited bathrooms with standing water and toilets brimming with fecal matter; the poorly maintained sewage treatment system downhill from the home resulted in workers having to manually dispose of feces in garbage bags.
Inspectors also detailed a gastrointestinal illness that swept through the facility in September and October, sickening numerous residents and staff. One 75-year-old resident, who contracted salmonella during the outbreak while recuperating from a mastectomy, died in late September following a wound infection.
Inspectors found that staff lacked the training to properly change her dressing, and she was admitted to an acute care hospital with sepsis, a life-threatening blood infection, state documents show.
Doctors discovered that a foam sponge used in the dressing had been left behind by staff and was growing into her skin; she died within a week. (Sacramento Bee, June 13, 2015)
In Montrose, CA, a 30-year-old paraplegic man living at the Brius’ Verdugo Valley Skilled Nursing and Wellness Centre died three months into his stay. In July of 2010, Armando Reagan had begun bleeding profusely and cried out to nursing home staff for help. Fifteen minutes later his sheets were soaked and a pool of blood had collected on the floor.
By the time paramedics arrived and transported him to a nearby hospital emergency room his breathing was labored and heartbeat rapid. He died there within an hour. The Los Angeles County coroner reported Reagan died from hemorrhagic shock due to chronic infections stemming from an old wound and from neglect by the nursing home. (Kaiser Health News. October 27, 2014)
In Roseville, CA in 2012, 82-year-old Genine Zizzo entered Brius’ Roseville Point Health and Wellness Center in good health and only needing physical therapy after a fall at home. Ten days later, she was transferred to an acute-care hospital in a coma and later died of multiple organ failures. Her family alleges that the nursing home used anti-psychotic medicines as a form of chemical restraint, which led to her death. (ABC Local News Sacramento, June 17, 2015.)
In November 2015, Courtney Cargill signed herself out of a suburban Los Angeles nursing home. and took off on foot.
Cargill scribbled her initials on the sign-out sheet at Brius’ South Pasadena Convalescent Hospital and declared her destination: “Library etc.”
Instead, Cargill – a 57-year-old resident known by nursing home staff to be suicidal and delusional – walked unsupervised to a nearby service station and bought a plastic jug and gallon of gas. She walked a quarter-mile to a second service station where, at 8:05 a.m., a surveillance camera recorded her heading to the back, stripping off her clothes, dousing her body with gasoline and lighting herself on fire.
She walked away, down the sidewalk and into a neighbor’s driveway. Cargill died at a Los Angeles hospital less than 24 hours later, with second- and third-degree burns over 90 percent of her body.
Prior to this, staff observed Courtney Cargill “having hallucinations, hearing voices and talking to herself;” nevertheless she requested and obtained an unsupervised pass to leave the nursing home for up to four hours a day.
“There is no evidence,” according to the family’s attorney, “that Courtney’s physician made a determination that Courtney was capable of safely being on an independent, unsupervised pass, as required by the facility’s policy…Instead of providing mental health services, defendants took money from Courtney to house her in a ‘room and board’ fashion, content to let her smoke cigarettes and watch TV all day.” (Pasadena Star, October, 8, 2015).
Five weeks after Geneva Hilton, 68, was admitted to Brius’ Centinela Skilled Nursing and Wellness Centre, West (Inglewood, CA), she was dead. According to CBS News in Los Angeles, Geneva Hilton entered the nursing home with clear lungs and in good health. Five weeks later, she was suffering from pneumonia, dehydration and a body temperature lower than 80 degrees.
During the investigation, a CBS reporter went undercover into the facility where he heard patients moaning aloud and his producer noticed the smell of human waste. Czersale Hilton, Geneva Hilton’s daughter, is suing the nursing home, alleging elder abuse and negligence. She joins a growing list of others suing Rechnitz and/or Brius over patient abuse and neglect. (CBS Local, Los Angeles CA, May 17, 2016.)
A Brius nursing home in South Pasadena ran afoul of the state partly because it recruited convicted felons, probationers, rapists and robbers as patients.
Instead of a median age of about 75 years old, residents at the former South Pasadena Convalescent Hospital had an average age of 37, Police Chief Arthur Miller said. He accused the former nursing home of sending recruiting teams to Los Angeles to get new patients.
“In that lower age population, there were convicted felons, probationers, drug users, rapists, robbers,” Miller said. “Traditionally police officers do not go to convalescent hospitals on a routine basis, especially to handle the crimes that I just described. … The staff at the time were not equipped for it. The hospital was not equipped for it, and it wasn’t licensed to do that type of rehabilitation.” The facility was closed. (Pasadena Star, October 20, 2015)
Between October 2015 and January 2015, three of Rechnitz’s facilities, including South Pasadena, were decertified by the federal government, an economic kiss of death that is extremely rare.
This punishment strips a nursing home of its crucial Medicare funding until it can demonstrate improvement, or is closed or sold. Since 2010, the federal Centers for Medicare and Medicaid Services has decertified only six out of more than 1,200 nursing homes in California.
Rechnitz controls his California nursing homes through a web of 130 companies. He has an ownership stake in many other companies, including a pharmaceutical company, two medical supply corporations, and a management services business.
This complex structure serves to conceal the nursing homes’ ownership and shield Brius, its owner, and its assets from lawsuits. Rechnitz’ 81 nursing homes and assisted living facilities operate under as many different names, and each is managed and owned by parent companies that also have different names. This allows Brius to operate below the radar. The name Brius does not appear in the Department of Public Health’s database of licensed nursing homes. It also potentially allows Brius’ owner, Shlomo Rechnitz, to profit at multiple stages of his corporation’s convoluted healthcare delivery system.
I spoke with two Certified Nursing Assistants (CNA) who work at Brius’ Novato Health Care Center in Marin County, a large facility with 180 beds.
Sue Journette, is a CNA; she’s worked for Brius for nine years. Ida Bantilan, also a CNA, has worked there for ten years. They both make the long commute to (very) upscale Novato from Vallejo, a North Bay city still recovering from the long recession of 2008. “There’s no question of living anywhere near here,” says Journette. As with many co-workers, they were born elsewhere, Journette in Thailand and Bantilan in the Philippines.
They both belong to the National Union of Healthcare Workers; both were active in NUHW’s recent successful organizing campaign at the Novato site.
They each explained economic issues in bargaining now underway. There had been no raises since 2011, though management had come up with 30 cents an hour, a bribe they thought. CNA’s started at about $14 an hour, they were making more, $16 and $17 an hour. It was “not nearly enough,” many co-workers work two jobs, often in two separate nursing homes.
“The housekeepers make less,” according to Bantilan. ‘and so do the janitors,” adds Journette, “and the laundry workers and kitchen staff, their work is hard.”
The real issue for them, however, was staffing. Management reduced employees’ work shifts from eight hours to 7.5 hours with no reduction in the workload. This meant they each had responsibility for nine or ten, sometimes as many as twelve people. Bantilan explained: “I start their day. I get them up, shower them and clean them up, dress them, try to make them look nice and get them to breakfast. Many of these people are long term, many have dementia. They can be difficult.”
The new shift schedules also made the work harder, according to Journette. “When we come on, the last worker has already gone. We get no report, no sharing information, no explanation of what’s going on with the resident. No continuity.
“This work is not easy because so many of our people are sick, they are old, they are in bad moods, they are not feeling good, they miss their homes, their families. Many cannot walk…some have HIV…yes, the work is also dangerous, many injuries” I asked if they agreed with reports that this work was amongst the most dangerous of US occupations. They did, “It’s the lifting moving, pushing, pulling. Back stress.”
They came back to pay. Bantilan: “It is important. When you work two jobs, you’re tired. You’re in a bad mood before you begin. Then, no one wants these jobs, they can’t get replacements, so when someone doesn’t come in, you can be forced to do another shift.
“Sometimes when they do find replacements, it doesn’t work. They don’t offer training. Or maybe a day, or two days. We’ve all met someone new in the morning, only to learn later that they left in tears before lunch.”
Journette and Bantilan learned of the NUHW when they were told of the strike last year at the San Rafael facility. That’s also when they learned that they were all employed by Brius.
The National Union of Heathcare Workers is a new California union, born in the wreckage of SEIU’s trusteeship of its California local United Healthcare workers in 2009. It has grown dramatically since then, now to 12,000 members, mostly hospital workers. This includes 1,000 new members in the last six months alone, the result of victories including at Kindred’s Bay Area Hospital, the Oakland Children’s Hospital and Tenet’s Fountain Valley Hospital & Medical Center, Orange County’s largest for-profit hospital.
NUHW prides itself in being worker-led, democratic and militant – and in not being afraid to take on employers, whatever the size, in California several of the country’s largest hospital corporations (Kaiser, Tenet, Dignity, Kaiser, Sutter). NUHW sees its origins in the long history of trade unions; its own roots are in the drive for industrial unionism in San Francisco in the 1930s.
It also prides itself as being not just for its members but also an advocate of patients and the public. It has from its beginning supported free, universal healthcare. It’s less than a year now since NUHW therapists and social workers won their hallmark victory at Kaiser, winning a contract that featured fundamental advances in mental health care, above all in staffing.
Sal Rosselli, the President of NUHW, sees its long-term goal as an industrial union of healthcare workers, all healthcare workers in one union, even as its priority now is hospitals.
NUHW staff readily admit that organizing nursing homes is difficult: the work units tend to be small, turnover is high, employers are for the most part fiercely hostile to unions. Still workers want unions, all investigations report this. “So what can we do.” asks Rosselli, “when workers come to us? We can’t turn them down.”
It’s informative here to recall that nursing home and home care workers were important in the 2008/9 dispute that wrecked United Healthcare Workers (UHW-SEIU), then 150,000 strong. Today, SEIU-UHW is half its former size, it is factionalized and scandal-ridden: long-term workers have been shifted out to another local and nursing home workers have been abandoned altogether.
Until, trusteeship, UHW policy had been “Stronger Together,” a strategy based on uniting healthcare workers and using the power of the best organized to support the interests of the least.
In 2008, however, the national SEIU leadership wanted long term care workers organized separately, isolated from the unions far more powerful hospital workers. At the same time, they proposed an “organizing strategy” they called “The Alliance.” This would ally the union with nursing home management (yes, people like Rechnitz) – the purpose to lobby Sacramento for increased Medicaid funding for the industry. In return, the employers would give SEIU “neutrality,” that is, a “free” hand in organizing – but (the catch) only when and where the employers agreed. The Alliance would also sanction secret negotiations, long term contracts (one contemporary SEIU contract in Washington State was for ten years), no right to picket, no right to strike.
There was another component, worth mentioning. The agreement would oblige the union to press for tort reform that would limit the patient’s rights to sue nursing homes, even in cases of neglect, abuse and death, an issue of the greatest importance to nursing home management, as we have here seen.
One last point: The Alliance mandated the union to oppose patient advocates’ demands for staffing minimums (and any legislation relating to the nursing homes without industry approval).
The Alliance meant, in no uncertain terms, willfully disregarding the crisis in staffing that existed then and continues, all the worse, to this day. It also meant no free speech for caregivers, the “gag rule” and specifically it meant nursing home workers could not advocate for patients – patients who often had literally no one else in their lives.
The recent Sanders campaign revealed for all the massive support that exists today for “real” health care reform – for universal coverage based on need, not on ability to pay and not for profit. The American nursing home industry is, perhaps, the extreme example of our healthcare system in crisis, and of everything that’s wrong with it.
These “homes” are 21st century sweatshops for the millions who staff them, they are “homes” which are not homes; it is an industry that warehouses and isolates our most vulnerable and removes them from sight– and for a profit.
“We love our patients, we would not do this work if we didn’t,” Journette and Bantilan agree, emphatically. “We need the union because we need rights to do our work right; so the residents, they rely on us, they so often have no one else. They need the union, too.”
And on it goes…now Humboldt County.
On September 8, the residents of the Eureka Rehabilitation and Wellness Facility… [were told] why that facility and two others locally may be shutting down, forcing almost 200 patients into an uncertain future, and possibly into care hundreds of miles away.
The potential closure of the facilities — Eureka, Seaview and Pacific Rehabilitation and Wellness — would cut the number of local skilled nursing beds by more than half and came as a surprise to many patients and caregivers. The management company for all five of Humboldt’s major facilities — Rockport Healthcare Company [Bris] – did not notify patients before the information leaked to local media in late July. (North Coast Journal, Sept. 15, 2016) NUMW members at St Joseph’s Health have joined the movement to keep these facilities open.
Note: Just last week, the federal government has taken steps to protect patients. The Health and Human Services Department has ruled that it will refuse Medicaid payments to nursing homes that demand that patients and their families sign agreements that restrict their right to sue and instead force them into corporate friendly binding arbitration.
Cal Winslow is author of Labor’s Civil War in California (PM Press) and co-editor of Rebel Rank and File (Verso). His most recent book is E.P. Thompson and the Making of the New Left (Monthly Review). River of Fire: Commons, Crisis and the Imagination will be available from Pumping Station Press in November. He is Director of the Mendocino Institute and lives with his family near Caspar on the Mendocino Coast.