By Sarah Ravani, San Francisco Chronicle, July 3 2020
The Contra Costa County district attorney’s office has found evidence of elder abuse, including a suspected sexual assault, at a 47-bed Orinda nursing home where nearly every resident and many workers became infected with the coronavirus in April, records reveal.
Search warrants with an investigator’s report obtained by The Chronicle allege that Orinda Care Center had chronic staffing shortages, locked away protective equipment and allowed other dangerous conditions in which a patient with dementia was reported to have been sexually assaulted.
“Based on my investigation, I believe the conditions, the lack of staffing, misuse of personal protective equipment, suspected sexual (assault), and overall neglect is evidence of elder abuse and likely produced great bodily injury and death to the elder and dependent residents,” wrote the district attorney’s investigator, Sean Eriksen, who completed his investigation in June.
A spokesman for the office of District Attorney Diana Becton declined to comment because the case is still under investigation. No criminal or civil charges have been filed against the nursing home or its owner.
The privately owned Orinda Care Center had one of the largest outbreaks at any nursing home in the county in April, when 40 residents and 31 staff members were sickened. At least four residents died, but because the state doesn’t specify the number of deaths under 11, it’s impossible to know the exact number.
Orinda Care Center, which has a lengthy list of health and safety violations, is owned by Crystal Solorzano, who runs 11 other facilities throughout California. Solorzano also has a long record of regulatory violations against her, including fraud that led regulators to revoke her nursing home administrator’s license. State law nevertheless permits her to own such facilities.
“Orinda Care welcomes the opportunity to cooperate with authorities and to rebutting these inflammatory allegations as the investigation proceeds,” Dan Kramer, a spokesman for Orinda Care Center, said Thursday.
In May, the district attorney’s office joined state law enforcement and regulatory agencies to investigate COVID-19 deaths at the facility.
Deaths at nursing homes and assisted-living facilities account for nearly half of all COVID-19 deaths in the state, public health data show. Since March, 2,588 residents and workers have died at nursing homes and 422 have died at assisted-living facilities.
The allegations of dangerous conditions highlighted in the county’s investigation don’t surprise nursing home experts who say such problems are more prevalent at private, for-profit nursing homes like Orinda Care Center.
“These are private companies,” said Charlene Harrington, a nursing professor at UCSF. “They’re trying to make money, so they are cutting corners as much as they can.”
An April 9 county inspection found that, on average, Orinda Care Center was short three to four workers per shift. The pandemic exacerbated a “severe lack of staffing,” the inspector said, because workers infected with the coronavirus could no longer show up for their shifts.
Daniel Peddycord, the Contra Costa County public health director, told investigators he believes a lot of the failures at the center were “a direct result of poor staffing” because the nursing home didn’t properly supervise patients.
“If they don’t have enough staff, they don’t get the work done,” Harrington said. “People aren’t getting taken to the toilet, they’re left in bed all day, they’re not helped with eating.”
A staffing shortage also strains the current workforce because they have to rush “from patient to patient, and they don’t have time to wash their hands between patients,” Harrington said.
In addition to staffing shortages, Eriksen noted that management locked away personal protective equipment. Eriksen interviewed a former worker who said little was done to quarantine patients with the virus.
The former worker told Eriksen that “personal protective equipment was staged throughout the center” when county and state health workers came to inspect. After the inspection, management collected masks, face shields and gloves and locked them in an office, according to the investigator’s report.
Patients with the virus slept in rooms across the hall from residents who didn’t have it. No barriers separated the two groups, and staff often floated freely from room to room, the report said.
Eriksen also combed through public records and inspection reports and found the center failed to protect a resident from sexual assault by an employee.
The alleged assault occurred on Feb. 13, 2019. A nurse walked in on a housekeeper holding a resident’s penis. The housekeeper, who was not identified, removed the hand and said, “I shouldn’t be doing this.”
The resident had dementia and was paralyzed on one side of his body. The housekeeper’s employee file showed that the person had been previously investigated for sexual abuse, but complaints were “unsubstantiated.” The nursing home fired the housekeeper a week after the incident, according to the search warrant.
The Contra Costa County Sheriff’s Office and Orinda police had no report of the incident, Eriksen wrote.
Orinda Care Center has a long record of violations, according to state regulators. Last year, the nursing home failed to meet sanitation protocols and proper staffing requirements, among other violations, state records show.
During an inspection in July 2019, dietary staff “could not describe or demonstrate the appropriate procedures for sanitizing tableware and cookware,” leaving residents “at risk for food-borne illness,” inspectors wrote.
Other inspections last summer found that the Orinda facility stored active and expired medication together, and some medications were not refrigerated properly. Investigators responding to complaints discovered that staff had misused antipsychotic drugs for residents.
The facility filed a “plan of correction” for many of the violations, but no enforceable actions were taken in incidents last year.
The owner of Orinda Care Center, Solorzano, owns 11 long-term care facilities near Los Angeles and in the Bay Area. Solorzano’s other Bay Area nursing homes include Lake Merritt Healthcare Center in Oakland and Redwood Healthcare Center in Oakland.
In May 2019, state health officials revoked Solorzano’s nursing home administrator license because she provided fraudulent college transcripts in applying for the license, according to the revocation letter. An administrator’s license is needed to serve as an administrator at a nursing home, but it is not required to own such facilities.
Solorzano is scheduled for an appeals proceeding in September.
Last year, she applied to operate three other California long-term facilities, including one in San Jose, but was denied in December. Officials found 97 federal regulatory violations above a certain severity level and 46 citations for state licensing violations from the past three years.
“Allowing unfit operators to run nursing homes during the pandemic is a recipe for disaster,” said Michael Connors, an advocate at California Advocates for Nursing Home Reform.