Jill Hernandez knew something was wrong as soon as she got the request from a Lodi nursing home.
A new resident had just arrived from Vintage Faire Nursing and Rehabilitation Center in Modesto – a woman with no family and with severely impaired mental skills. The Lodi home asked Hernandez to represent her in making decisions about her care.
“How did she get there? Who signed her out?” asked Hernandez, the long-term care ombudsman program director for San Joaquin County, where Lodi is located.
Hernandez met with the woman. Then she complained to the California Department of Public Health, prompting an investigation of Vintage Faire.
The story widened. The Modesto home had shipped a total of seven long-term residents in March to two sister nursing homes in San Joaquin County, according to state records. One resident said she had only 15 minutes to decide whether to go.
Vintage Faire failed to notify most families and friends of the transfers. At least four of the residents, all women, were diagnosed as severely mentally impaired.
One mentally challenged woman later told a state investigator that she walked the 38 miles from Modesto to Lodi, demonstrating by moving her legs back and forth, records say. Another woman said that “she did not know why she was there, how she got there or where she was.”
“It was shocking to me that someone would do that, that a facility would just send them out like that,” Hernandez said in an interview.
Her complaint led to a state finding that Vintage Faire had transferred the residents “without medical justification as necessary for resident welfare, needs or safety,” a violation of federal regulations. The fine: $2,000.
A key question remains unanswered: Why did Vintage Faire want to transfer those patients?
The facility won’t comment, citing the fact that it has appealed the citation.
But according to hundreds of records obtained by The Bee under the state Public Records Act, the home’s staff told some residents and families that it was removing long-term residents to make room for more short-term patients.
“It says that right in the citation. It’s pretty darned explicit,” said Tony Chicotel, staff attorney with California Advocates for Nursing Home Reform, or CANHR, a San Francisco-based nonprofit. He said he has seen similar cases at other homes.
Chicotel said “short term” is code for higher-paying Medicare patients and that long-term refers to residents on low-paying Medi-Cal insurance for the poor.
Andrew F. Torok, general counsel for Covenant Care, which owns Vintage Faire and more than 50 other facilities, would not comment on the transfers by Vintage Faire. But he said his company doesn’t engage in transferring long-term residents for monetary gain.
“That’s not how we operate,” Torok said. “Our culture is one of doing the right thing, for the right reason. It would be absolutely unthinkable that we would do something like this.”
In a corrective plan sent to the state, the facility said it would assure “safe and proper discharges in accordance with federal requirements.” It promised to audit long-term care discharges for three months and review patterns of noncompliance.
On average in California, Medicare pays nursing homes roughly three times the daily rate that Medicaid pays. That’s because Medicare pays for short-term, intensive rehabilitation after a hospital stay while Medicaid – known as Medi-Cal in California – pays for long-term care.
Last year, a typical Medicare stay in a nursing home lasted 51 days, according to Medicare data. A Medicaid stay could last several years, often until a resident’s death.
State records do not show if the seven residents were on Medi-Cal.
Deborah Pacyna, a spokeswoman for the California Association of Health Facilities, said she is not familiar with the Vintage Faire case and could not comment. She cautioned, however, against assuming a single example could signal an underlying trend.
“We reject any allegations that patient admissions or discharges are tied to payment sources,” Pacyna wrote in an email.
Patients later evaluated
The woman known as Resident 1 had lived at Vintage Faire for nearly 15 years when the home approached her.
An aide told state investigators that the woman was asked if “it was OK to transfer her, and she said it was.”
So Resident 1 was placed in a van on March 27, bound for the Arbor nursing home 38 miles away in Lodi.
Her story, and that of the six other transferred residents, is described in the July 6, 2015, citation that the state issued to Vintage Faire. The citation refers to them as Residents 1 through 7 to protect their privacy.
The day after Resident 1’s transfer, a state evaluator visited Arbor and talked with the woman in her new room, filled with Barbie dolls, toy firetrucks and a dollhouse-sized firehouse. The woman stated “fireman” and pointed at the firehouse.
“Resident 1 nodded her head or said ‘yes’ to questions but was unable to respond in complete sentences,” according to state records. She was interviewed to assess her cognitive ability, scoring 0 on a scale of 0 to 15. Any score of less than 7 is considered “severe cognitive impairment,” the records state.
Two other transferred residents scored 5 and 3 on the same scale.
Another woman, Resident 4, a Cantonese speaker and a resident since 2007, is described in records as “severely impaired – never/rarely makes decisions.”
A man described in the state records as her “responsible party” said Vintage Faire contacted him the day she left, to say she was being transferred and that the home was “getting rid” of long-term residents. He said her relatives could not easily visit her in Lodi because of transportation problems.
Her family had visited her frequently in Modesto, speaking in Cantonese and bringing home-cooked food that she ate with them in the dining room, where she always ate, records say. In Lodi, she ate most meals in her room.
Resident 7’s friend found her missing just two days after bringing her fresh laundry. Vintage Faire had moved her to Arbor without notifying the friend, who held power of attorney for her health care needs. The facility’s staff said they could not locate the paperwork.
“They just sent her. She was not prepared,” the friend said.
Arbor’s staff wrote in her clinical record that she described herself as depressed and frustrated, saying, “Things just aren’t going well for me.”
Vintage Faire’s director, who is not named in state records, told investigators that she received a call in March from the company’s regional director of operations, telling her that another facility had some open long-term beds and that any resident who wanted could transfer there.
The home’s director said she told two social services aides to make the offer to alert, oriented residents. The aides were not adequately trained, she added, and she should have supervised them.
Massive changes are sweeping nursing homes nationally as the so-called silver tsunami of aging baby boomers demands more medical care.
Industry officials and senior advocates agree that those changes mean more seniors are receiving Medicare short-term care in long-term facilities statewide.
But while the industry calls such care an essential role for those facilities, some advocates say it has the potential for squeezing out long-term residents covered by much lower Medi-Cal disbursements.
Seniors often receive Medicare-financed rehabilitation after being hospitalized for strokes and hip and knee surgeries.
For many nursing homes, that has opened the door to charging Medicare increasingly higher rates for physical and occupational therapy, including “ultra high,” the most expensive of five categories of Medicare-financed therapy.
Ultra-high therapy rates range from less than $500 to nearly $800 per day. By comparison, Medi-Cal pays $110 to about $275 per day, depending on location.
In California, the share of Medicare patients in nursing homes has stayed at roughly 14 percent, an analysis by the Center for Health Reporting shows. At Vintage Faire, Medicare paid for 22 percent of its patients.
What has grown significantly, however, is the share of short-term patients receiving “ultra high” therapy.
In 2014, the share of nursing home Medicare patients receiving such therapy stood at 58 percent nationally and 66 percent in California.
The same year, 72 percent of Medicare patients at Vintage Faire received “ultra-high” therapy. Overall at the 56-home Covenant Care chain, the share was 83 percent.
Vintage Faire appeal pending
The full story of the seven Modesto residents will not be told until Vintage Faire’s appeal is heard and decided. And that may not be soon.
In summer of 2008, the Modesto facility appealed two unrelated citations, totaling $1,700. More than seven years later, those twin appeals still have not been resolved.
Chicotel is still bothered by the $2,000 fine, which he calls too small to make nursing homes change their ways.
The $2,000 is the highest fine the Department of Public Health could issue for that type of citation, spokesman Corey Egel said. Larger fines are imposed only when a violation directly leads to a death or presents “an imminent danger of death or serious harm.”
The state could have at least fined Vintage Faire $2,000 for each resident, Chicotel said. “It’s probably what they spent on canned pears in the course of a year.”
Schoch and Campbell are staff writers for the California HealthCare Foundation Center for Health Reporting at the USC Annnenberg School for Communication and Journalism. Modesto Bee staff writer Ken Carlson contributed to this story. Schoch can be reached at email@example.com. Campbell can be reached at firstname.lastname@example.org.