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Chronic abuse at Inglewood-Centinela nursing home
INGLEWOOD (MNS) — Reva McKissick was admitted into the Centinela Skilled Nursing & Wellness Centre in Inglewood for recuperation and rehabilitation following discharge from Centinela Hospital Medical Center, where she was treated six weeks for a severe body infection.
McKissick (not her real name) was progressing steadily, according to family members (who requested anonymity) until the evening of July 25, when something went terribly wrong.
“We visited her on Monday, July 25 at 8:30 p.m., to find her sitting in a wheelchair in a seemingly catatonic state, trembling uncontrollably, mumbling jibberish with her eyes rolling back in her head,” her husband recalled. “My two children and I had last visited her Saturday, July 23, two days prior, and left her in good spirits. She was fine. We were shocked to see her in this condition.”
An on-duty nurse entered McKissick’s ward simultaneously with her family. “She appeared nervous,” McKissick’s husband recalled. “I asked the attendant what was wrong with her and she replied, ‘I took all of her vital signs and she appears normal.’ I asked her rhetorically, pointing to my wife — ‘does she look normal to you? She trembling and her eyes are rolling back into her head!’”
McKissick’s spouse took matters into his own hands and called 9-1-1 because the attendant, whose identity he failed to get due to the confusion at the time, could not secure an ambulance to transport his wife to receive emergency care because the facility’s staff doctor couldn’t be reached for approval.
“The attendant said any move would be to the facility’s contract hospital — Hollywood Presbyterian — 45 minutes away.
“I told her Centinela Hospital was across the street — ‘why take her all the way to Hollywood Presbyterian?’” the husband recalled. “The attendant seemed like she didn’t know what to do. That’s when I called paramedics because my wife appeared to be getting worse. I didn’t want to risk it.”
The owner of Centinela Skilled Nursing & Wellness Centre, Los Angeles billionaire Schlomo Y. Rechnitz, 45, who has a net worth of $204 billion according to his personal bio, owns a slew of nursing homes in California — 81 in total — the state’s largest chain under the name Brius Healthcare Services. Many of the nursing homes were acquired through bankruptcy court.
Rechnitz controls about 1 in every 14 nursing home beds in California, exerting a monumental impact on quality of care in the state. Time and again over a 12-year period, Rechnitz’ nursing homes have been the subject of controversy for allegations of abuse and wrongful deaths in at least two of his facilities.
Geneva Hilton, 68, was admitted into Centinela Skilled Nursing & Wellness Centre in 2014. Five weeks later, she was dead. Her daughter, Czersale Hilton, who sued Centinela West claiming elder abuse and negligence, said her mother’s death didn’t make sense.
“I was shocked. Of course, I was shocked, because the last time I spoke to my mom, she was herself,” Hilton told CBS2/KCAL9 in 2014, shortly after her mother’s death. According to the lawsuit, her mother “was admitted for rehabilitative care following a hospitalization for chest pains.
Her daughter said, “her lungs were clear and she was in good condition.”
But five weeks later, she was rushed to a hospital in critical condition, suffering from pneumonia, dehydration and a critically low body temperature of only 80 degrees.
McKissick’s and Hilton’s stories parallel, except one, still lives and breathes, and the other is deceased. The incriminating evidence as it relates to McKissick, a recent victim of negligent nursing care under Brius is all too familiar.
McKissick’s spouse learned the morning after she was rushed to Centinela Hospital Medical Center, she suffered a urinary tract infection, a bacterial intestinal infection, pneumonia, an accelerated heart rate, and a fever of 104 degrees.
“My wife called me at home, July 25 at 9:30 a.m., complaining that she wasn’t feeling well, that she had thrown up her breakfast after a nurse gave her a small amount of a liquid protein.
“After throwing up, she told me that shortly after taking the liquid protein she began experiencing pain in her abdomen, diarrhea, and a terrible headache,” the spouse said.
“I was very concerned about my wife’s severe condition and didn’t seek to speak with administrators of nursing home regarding her condition,” said the spouse, who was at his wife’s bedside daily in her first two weeks of hospitalization. “My number one concern was for her. Over the first few days in the hospital, her conditioned worsened and she was moved twice for more intense critical care and observation by the hospital staff.
“The attending nurses said she had a number of serious medical conditions and was being closely watched by several medical specialists,” the spouse recalled. “It was very stressful for us while she was in intensive care.”
The Compton Herald sought to speak with Renee Porter, administrator of Centinela Skilled Nursing & Wellness Centre, who told McKissick’s spouse she would initiate an investigation into the events that led to McKissick’s critical turn of events, but successive attempts to reach her were unsuccessful.
Rechnitz’s companies earned $500 million in taxpayer Medicare and Medi-Cal insurance payments in 2014, but his nursing facilities routinely face allegations of neglect, abuse, and wrongful deaths, elder-care expert Molly Davies told CBS2/KCAL9 in their 2014 investigation.
“We see the same persistent problems. So that speaks to me of an unwillingness to make the necessary changes,” Davies said.
Centinela Skilled Nursing & Wellness Centre is not the only nursing home connected to Rechnitz with multiple complaints about repeated noncompliance with industry laws and regulations pertaining to the skilled nursing industry.
According to the most current 2015 Medicare nursing home profile, Centinela Skilled Nursing & Wellness Centre has an overall rating of 2 out of 5 stars in a 5-Star Gold Rating standard. But the nursing staffing and health inspection categories both got only 2 stars, a sub-standard score for Medicare. Overall the facility was rated by the county as “Below Average,” and a staffing rating of “Poor.”
Between 2004 and 2016, the County of Los Angeles Department of Health has received 36 statements of complaints and was found by successive investigations by the County Department of Health to have 250 wanton deficiencies
While the Inglewood facility may be one of the most notorious of Rechnitz’s 81 nursing homes in the state, it is not the only one operating amid a host of complaints and deficiencies.
A facility Rechnitz once owned, the South Pasadena Convalescent Hospital, was decertified by the federal government in 2013, losing its eligibility to receive Medicare revenue. That occurred after a patient there set herself aflame.
The FBI raided two other Rechnitz’s facilities — the Alta Vista Healthcare & Wellness Center in Riverside, and the Verdugo Valley Skilled Nursing facility in Montrose for severe issues. No charges have been filed against the former, and a 58-year-old male patient died at the Verdugo facility.
The California attorney general filed involuntary manslaughter charges against Verdugo Valley and two staff supervisors.
Rechnitz’s spread of nursing facilities grew rapidly after acquiring his first facility in Gardena, Calif. in 1996. According to a spokesperson for Rechnitz, he has “rescued 59 institutions from insolvency, and preserved 6,000 jobs, while providing life-aiding services to thousands of Californians.”
The spokesperson said Rechnitz “has gone above and beyond what is necessary to deal with the challenges of the industry.”
The attorney general tried unsuccessfully to block Rechnitz from acquiring more nursing homes according to Patricia McGinnis with the California Advocates for Nursing Home Reform, who was incredulous about Rechnitz’ ability to continue acquiring nursing homes. “If that’s the case, why are you giving out more licenses to this company?” she asked, in an earlier interview with CBS2/KCAL9.
“Under [Rechnitz’] particular company, we’ve had more closures and more decertifications in such a short period of time than any time that I can think of in the last 30 years,” McGinnis told the broadcast news station.
Brius Watch: Lawsuits and chronic pattern of substandard care
Nursing home residents and family members allege that Brius’ profit-driven approach to long-term care has led to a chronic pattern of substandard care. This pattern has resulted in a string of government sanctions and has exposed Brius to a series of lawsuits, including several actions filed by the California attorney general. For example, in August 2014 the California attorney general filed an emergency motion to block Brius’ acquisition of 19 distressed nursing homes. In a separate case, the attorney general brought felony involuntary manslaughter charges as a result of the death of a resident at one of Brius’ nursing homes.
In 2011, the California attorney general’s Office announced the indictments of Verdugo Valley Skilled Nursing & Wellness Centre and its former administrator on charges of “felony abuse and neglect after the death of a patient.” According to the press release, a Los Angeles County criminal grand jury handed down indictments in June of 2011, saying the actions of the facility and the administrator “caused the death” of the resident.
The former nursing home resident, who had a history of severe mental illness, had made several attempt on his life while at the long-term care facility before killing himself in 2009 by pulling the pin on a handheld fire extinguisher, putting his mouth on the nozzle before pulling the trigger, sending the contents therein racing down his throat. In 2012, the state’s attorney general office agreed to drop the charges in exchange for placing the facility under a three-year court injunction requiring ongoing monitoring, according to press reports (Los Angeles Times, 2011).
In 2012, federal agents from the FBI, IRS, California Department of Justice, and the U.S. Department of Health and Human Services carried out a raid on a South Pasadena nursing home operated by Brius at the time. From 2010 to 2012, local police officers responded to 65 calls for police service at the nursing home, many of which included criminal investigations (Pasadena News Now; Pasadena Star News).
In 2014, the California attorney general filed an emergency motion seeking to block Brius’ acquisition of 19 nursing homes due to its “history of failing to comply with laws and regulations enforced by [the Department of Health Care Services] and the federal Centers for Medicare and Medicaid Services.”
Aug. 28, 2014 – California attorney general refers to Shlomo Rechnitz and Brius as a “serial violator of rules within the skilled nursing industry.”
In October 2014, Raymond Foreman, a former resident at one of Brius’ nursing homes, filed a class action lawsuit in Los Angeles County Superior Court on behalf of himself and current and/or former residents at Brius’ California nursing homes alleging that Shlomo Rechnitz, Brius, and the network of long-term care facilities under their control “did not devote sufficient financial resources to the proper operation of their skilled nursing facilities, did not devote sufficient financial resources to protect the health and safety of residents and ensure resident rights were not violated, and instead diverted those resources to create ill-begotten profits.”
Oct. 7, 2014 – This class action lawsuit alleges Shlomo Rechnitz, Brius, and Brius’ California nursing homes of violating its nursing home residents’ rights.
In 2014, the California Department of Public Health called for the immediate temporary suspension of Brius’ license to operate Wish-I-Ah Healthcare & Wellness Center (Auberry, Calif.), the suspension of operations at the facility, and, following the conclusion of legal proceedings, a full revocation of its license to operate the facility. This call came after significant issues such as the death of one of the nursing home’s residents as a result of poor staff training, badly maintained facility infrastructure that included a badly functioning sewage system that forced staff to handle human waste physically, and residential living conditions that placed nursing home residents in peril.
Nov. 13, 2014 – State of California alleges “a pattern inimical to health, morals, welfare, and safety of its patients” at Wish-I-Ah Healthcare and Wellness Center (Auberry, Calif.).
In the spring of 2015, according to this Sacramento Bee article, Brius’ South Pasadena Convalescent Hospital (South Pasadena, Calif.) was hit with 24 state citations and $195,000 in fines. The California Department of Public Health imposed the penalties for multiple violations including:
Unsanitary and unsafe living conditions, Failing to prevent the development of pressure sores, Failing to identify hazards and risks to residents, and, Failing to ensure that each resident receives adequate supervision and assistive devices to prevent incidents. The latter two failures resulted in one mentally ill resident checking herself out from the facility and committing suicide. South Pasadena Police Chief Art Miller, denounced the facility as a “cesspool” and a “community menace” while it was under Brius’ control.
In August 2015, the California attorney general filed involuntary manslaughter charges over the death of a nursing home resident who allegedly received “grossly negligent” care at Brius’ Verdugo Valley Skilled Nursing & Wellness Centre (Montrose, Calif.) (Sacramento Bee, Arrest Warrant). According to the Sacramento Bee investigation, Verdugo Valley is one of Brius’ most problematic facilities, earning the federal government’s lowest one-star rating. Officials logged 42 federal health deficiencies at the facility during the most current inspection cycle, according to data from the Centers for Medicare and Medicaid Services. Only three of the state’s roughly 1,200 nursing homes had more health deficiencies during that period.
Aug. 13, 2015 – California AG files felony complaint for arrest warrant of Verdugo Valley Skilled Nursing & Wellness Centre, LLC, the nursing home’s director of nursing, and its nurse supervisor.
Aug. 14, 2015 – California AG accuses Verdugo Valley Skilled Nursing & Wellness Centre, LLC, of involuntary manslaughter; the nursing home’s Director of Nursing with dependent adult abuse causing death; and the nursing home’s nurse supervisor of dependent-adult abuse causing great bodily harm for its grossly negligent care of a nursing home resident.
In August 2015, the attorney general’s Bureau of Medi-Cal Fraud and Elder Abuse charged the former top nursing home administrator and nurse manager at Mesa Verse Post Acute Care Center (Costa Mesa, Calif.) with four misdemeanor counts each of inflicting injury on an elder adult and failing to report elder abuse (Sacramento Bee, 2015).
According to the Los Angeles Times, in February 2016, the family of a 78-year-old former resident at Brius’ Mesa Verde Post Acute Care Center (Costa Mesa, Calif.) filed a “wrongful death lawsuit alleging elder abuse, negligence and neglectful hiring and supervision.” The lawsuit, filed in Orange County Superior Court, states that the Brius nursing home “took the money, accepted the known responsibility for him and then failed miserably to provide Sebastian his required care that needlessly resulted in his death.”
Chronology: Brius litany of patient care violations
Molly Davies, the administrator for Los Angeles’ Long-Term Care Ombudsman Program, refers to the chronic pattern of substandard conditions her staff has observed at Brius’ nursing homes as evidence of the company’s “flagrant disregard for human life.”
In August 2015, the California attorney general’s office files criminal charges in connection with patient deaths at two Brius nursing home facilities: Mesa Verde Post Acute Center (Costa Mesa, Calif.) and Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, Calif.).
Late in 2014, Wish-I-Ah Healthcare & Wellness Center (Auberry, Calif.) shuts its doors after being decertified in November 2013. The nursing home’s decertification marked the first time since 2008 that the California Department of Public Health (CDPH) had issued a suspension order against a skilled nursing facility. The state’s formal allegations are based in part on separate reports made by inspectors at CDPH and California’s Office of Statewide Health Planning and Development. According to the state’s allegations, inspectors cited the nursing home for such deficiencies as a resident’s death and a poorly maintained sewage treatment system that forced nursing home workers to dispose of human waste in garbage bags manually.
Nov. 13, 2014 – State of California alleges “a pattern inimical to health, morals, welfare, and safety of its patients” at Wish-I-Ah Healthcare and Wellness Center (Auberry, Calif.).
In 2015, a nursing home resident at Brius’ Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, Calif.) dies of acute respiratory failure days after being transported by ambulance from the nursing home to an emergency room at a nearby hospital. State officials find that the nursing home was directly responsible for the former nursing home resident’s death.
The nursing home receives an “AA Citation,” the California Department of Public Health’s most severe penalty. According to the surveyor’s report, the nursing home failed to ensure that the resident, who had a history of respiratory problems, was assessed for signs of respiratory distress daily; failed to notify a physician when the resident became unresponsive and had breathing that became labored; and failed to call 911 paramedics promptly when the resident’s health condition showed a significant change.
Nov. 2014 – Geneva Hilton, 68, was admitted into Centinela Skilled Nursing & Wellness Centre in 2014. Five weeks later, she was dead. Her daughter, Czersale Hilton, who is suing Centinela West claiming elder abuse and negligence, said her mother’s death “didn’t make sense.” She said her mother was admitted for rehabilitative care following a hospitalization for chest pains. But five weeks later, she was rushed to a hospital in critical condition, suffering from pneumonia, dehydration and a critically low body temperature of only 80 degrees.
Nov. 4, 2015 – Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, Calif.) receives an AA citation from the California Department of Public Health in connection with the death of a nursing home resident.
In 2015, Alameda Healthcare & Wellness Center (Alameda, Calif.) is cited by the California Department of Public Health (CDPH) for failing to implement policies and procedures that prohibited the neglect and physical harm of its nursing home residents. CDPH inspectors cited the case of a nursing home resident who, after initial symptoms of shortness of breath and fluctuating vital signs, died at the nursing home.
Feb. 25, 2015 – A nursing home resident at Alameda Healthcare & Wellness Center (Alameda, Calif.) dies several hours after initial signs of shortness of breath and fluctuating vital signs go ignored.
Feb. 4, 2015 – Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, Calif., Los Angeles County), nursing home resident death (CDPH)
May 26, 2015 – Windsor Healthcare Center of Oakland (Oakland, Calif.), which Brius operated as Brookdale Healthcare and Wellness Centre, LP, neglects several residents, including a paralyzed resident who was sent to an emergency room with open wounds, and covered in feces (CMS)
March 19, 2015 – Gridley Healthcare & Wellness Centre (Gridley, Calif., Butte County), alleged mistreatment of nursing home residents (CMS)
Feb. 25, 2015 – Alameda Healthcare & Wellness Center (Alameda, Calif., Alameda County), nursing home resident death (CMS)
Feb. 19, 2015 – San Rafael Healthcare & Wellness Center (San Rafael, Calif., Marin County), nursing home continues to admit residents amidst Norovirus outbreak at facility (CDPH)
Feb. 19, 2015 – Presidio Health Care Center (Spring Valley, Calif., San Diego County), potential for fire and food-borne illness at nursing home (CDPH)
Jan. 22, 2015 – Alameda Healthcare & Wellness Center (Alameda, Calif., Alameda County), spread of infectious disease at nursing home (CDPH)
Nov. 24, 2014 – South Pasadena Convalescent Hospital (South Pasadena, Calif., Los Angeles County), nursing home suicide (CDPH)
Sept. 19, 2014 – Clairemont Healthcare and Wellness Centre, (San Diego, Calif., San Diego County), resident not able to care for herself was discharged from the nursing home with catheter still in place
July 14, 2014 – Gridley Healthcare & Wellness Centre (Gridley, Calif., Butte County), abuse of nursing home residents (CDPH)
May 16, 2014 – Pacific Rehabilitation & Wellness Center (Eureka, Calif., Humboldt County), nursing home resident lying in own urine (CDPH)
May 15, 2014 – Pacific Rehabilitation & Wellness Center (Eureka, Calif., Humboldt County), care for nursing home resident with skin rash delayed (CDPH)
March 14, 2014 – San Rafael Healthcare & Wellness Center (San Rafael, Calif., Marin County), nursing home resident to nursing home resident abuse; slum-like conditions (CDPH)
Feb. 25, 2014 – Marin County), nursing home’s furnace not working (CDPH)
Jan. 28, 2014 – San Rafael Healthcare & Wellness Center (San Rafael, Calif., Marin County), nursing unit is understaffed (CDPH)
Dec. 20, 2013 – Pacific Rehabilitation & Wellness Center (Eureka, Calif., Humboldt County), 57 nursing home residents placed in immediate jeopardy (CDPH)
May 16, 2013 – Oakhurst Healthcare & Wellness Centre (Oakhurst, Calif., Madera County), nursing home experiences the spread of infectious disease (CDPH)
April 5, 2013 – Alameda Healthcare & Wellness Center (Alameda, Calif., Alameda County), nursing home resident abuse (CDPH)
Dec. 7, 2012 – Novato Healthcare Center (Novato, Calif., Sonoma County), understaffing at nursing home leads to nursing home resident injury; facility fined $1000 (CDPH)
Dec. 4, 2012 – Novato Healthcare Center (Novato, Calif., Sonoma County), nursing home resident chokes; facility fined $1000 (CDPH)
Aug. 1, 2012 – Presidio Health Care Center (Spring Valley, Calif., San Diego County), thawed chicken sitting in blood (CDPH)
BruisWatch.org contributed to this story.