How penalty eluded consumer detection

Northpointe Healthcare Centre in Fresno was levied a massive $912,404 fine

The inspection report painted a bleak picture of life inside Northpointe Healthcare Centre in Fresno: Residents grimaced in pain from bedsores. Staff told inspectors they were stretched so thin they sometimes skipped treatments and failed to distribute medications. One resident was hospitalized with sepsis after missing four doses of an antibiotic, the report stated.

After multiple visits in early 2018, state inspectors slapped the 99-bed facility with an “immediate jeopardy” deficiency, the type reserved for the most egregious incidents in nursing homes. Then the federal government levied a massive fine: $912,404, the largest penalty given to any California nursing home in at least a decade, according to a CalMatters analysis of federal data.

For years, consumers had little way of knowing that fine even existed.

As COVID-19 ravaged nursing homes across the country — killing more than 9,300 residents in California, and sickening thousands more — elder care advocates, consumers and policymakers have cried out for greater transparency and accountability.

But state and federal systems responsible for overseeing nursing homes often fail to publicize critical information, a CalMatters investigation has found. Government websites that promise basic information about nursing home quality can actually obscure it, lulling consumers into a false sense of security. Licensing and ownership information available to the public can prove opaque and misleading. Fines — even massive ones like Northpointe’s — have been frequently difficult to find.

Information about nursing home quality has become so opaque at the federal level that the Centers for Medicare & Medicaid Services offered four alternate explanations to CalMatters for its processes — then suddenly reversed itself last week and started posting previously missing fines.

For consumers, the operating

reality in California often boils down to a callous precept: Let the buyer beware.

“I’m terrified to get old,” said Coreen Arioto of Ojai, whose father was a patient at Northpointe prior to his death in September.

Despite her own training as a nurse practitioner and her husband’s work as an anesthesiologist, both were missing critical information when deciding where to place her father, she said.

In theory, plenty of safeguards exist. The state and federal governments have complementary roles in overseeing nursing homes. Every nursing home that receives federal money is routinely inspected by California’s Department of Public Health. The state inspection teams are tasked with ensuring that facilities meet both federal and state standards; the teams also conduct complaint investigations. They are empowered to cite nursing homes for everything from abuse and neglect to dirty kitchens to breakdowns in infection control.

Often, there is plenty of give by the state in how it treats those nursing home fines — even for serious violations. As reported earlier this month by CalMatters, the state frequently settles lawsuits by facilities and winds up downgrading the violations and lowering the fines.

Despite such compromises, fines are among the most important indicators consumers have about a facility’s quality, said Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform. He also lists staffing levels, ownership information and data about COVID-19 outbreaks and vaccination rates as key indicators to check.

He characterized the Northpointe fine omission as “dangerously misleading to the public.”

“This is crucial information. It should be front and center,” he said.

Penalty details remain murky

Consumers looking for long-term care might have been reassured by last year’s rollout of the new searchable federal healthcare website, Care Compare. In a September 2020 press release, the federal Centers for Medicare & Medicaid Services sang the praises of its new online platform.

“With just one click, patients can find information that is easy to understand,” the announcement read.

But the website has had inexplicable data gaps — including the Northpointe fine — that even agency representatives could not consistently explain.

In reality, understanding what actually happens within California’s 1,200 nursing homes has required consumers to do a lot of digging.

After CalMatters began investigating the “missing” Northpointe fine in August, the news organization submitted public records requests to state and federal agencies; analyzed government data; interviewed nursing home advocates, former facility staff members and family members of residents; and combed through hundreds of pages of inspection reports, medical records and correspondence between the facility and public agencies.

Even so, details of the extraordinary fine remained murky.

Aside from the sheer size of that federal penalty, Northpointe was not an isolated case.

CalMatters looked at California nursing homes with federal fines totaling more than $100,000 a year, beginning in 2018. Of those 50, only 14 — less than a third — were discoverable on Care Compare. The missing fines could be found elsewhere, but consumers would have needed to know how to navigate the more obscure and complex federal Quality and Certification Oversight Reports website.

According to the federal government’s own data on that site:

One Orange County nursing home faced a fine of more than $500,000 in 2019. Earlier this month, consumers still wouldn’t find any record of it on Care Compare. A Pasadena home fined more than $280,000 in 2020 didn’t show up, either.

And a Central Valley home facing a fine of almost $190,000 this year? As of Dec. 7, it wasn’t there.

All this has abruptly changed. Since CalMatters informed the agency last week it was planning to publish this story, many of the large fines — including Northpointe’s — suddenly became visible on Care Compare. The New York Times also published an investigation Dec. 9 about the agency’s secretive processes, including the website’s lack of transparency around serious violations and inspection reports.

“If it weren’t for the news (media) calling, nothing would ever happen,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, who has been advocating on this issue. She said she gives the federal agency credit for eventually being responsive: “This was brought to their attention in a very strong way, and they fixed this problem.”

Until recently, the federal agency had given a variety of explanations for its data lapses. In several different emailed responses, representatives said that it must not have the data; the data should be findable in the archives (it wasn’t); it had been more than three years since the Northpointe fine. The agency repeatedly refused to put anyone on the phone.

On Dec. 7, an unnamed federal spokesperson told CalMatters via email that

the Northpointe fine was missing because it was too old: “Care Compare is a consumer-focused site which is intended to give consumers a representation of the condition of a facility in the recent past.” The agency failed to respond to followup questions from CalMatters. The fines appeared on Dec. 8.

When questioned about the sudden change, a spokesperson for the agency emailed yet another explanation to CalMatters on Tuesday: Prior to last week, the agency had not been posting any fines on Care Compare if nursing homes were not making payments on them — including if the amount owed was being withheld from Medicare payments to the facility.

Edelman called the agency’s newest explanation “shocking and appalling,” saying it seemed to reward facilities’ “bad behavior.”

Said elder care advocate Chicotel: “Sounds like facilities had a perverse incentive not to pay their fines.”

Nurse wept over conditions

Prior to Northpointe’s federal fine, state inspectors filled 131 pages with details about conditions inside the facility in January and February of 2018. These included:

A black organic material that staff suspected was mold was growing on the kitchen wall.

Without the right insulin

needles, staff were improvising, using a tactic one pharmacy consultant told inspectors should be left for emergencies.

A resident told inspectors her bedsores caused tremendous pain: “Most of the time no one does anything for them, that’s why they don’t heal,” she said. “It’s horrible you can’t get anyone to help you.”

According to the state’s report, an on-call nurse wept during her interview. Residents were at risk of harm, she told inspectors: “I am overwhelmed and I am not coming back.”

On Jan. 25, 2018, the inspectors issued the “immediate jeopardy” penalty, reserved for those findings that could cause serious injury or death.

“I’m terrified to get old.” Within weeks, the federal Centers for Medicare & Medicaid Services threatened to cut off Medicare payments to the facility if the deficiencies were not corrected, according to correspondence the agency provided to CalMatters. But it still took months for the home to resolve the concerns, the documents show, during which time the facility accrued significant daily fines.

In September 2018, an attorney for Northpointe sent the federal agency a letter agreeing to give up the facility’s right to a hearing in exchange for reducing the penalty — but without admitting to any of the accusations.

“Northpointe submits this Waiver in order to avoid the cost and uncertainty of litigation,” the attorney wrote.

The federal agency agreed to a 35% reduction — to $593,000, the correspondence from October 2018 shows. Northpointe failed to pay it, a spokesperson for the federal agency said, and the facility was informed in August of this year that it owed an additional $170,000 in interest.

In its letter, the federal agency said it would withhold the cost of the penalty from its ongoing payments to Northpointe.

A spokesperson for the federal Centers for Medicare and Medicaid Services said in a Dec. 7 unsigned email to CalMatters that it will use “all available avenues at the agency’s disposal” and would withhold all Medicare payments “until the total amount is collected.”

Mark Johnson, an attorney who represents the chain of nursing homes that includes Northpointe, said in an emailed response that the facility “addressed all alleged deficiencies from 2018 to the satisfaction of the Centers for Medicare and Medicaid Services and the California Department of Public Health.” He said the facility is now in compliance with Medicare and Medicaid regulations, “and there is no pending intent to terminate the facility’s participation” in the programs. He

declined to answer further questions about the fine.

Northpointe’s administrator did not respond to multiple calls and emails requesting comment.

Website a ‘complete mess’

While problems with Care Compare were largely invisible to the public, elder care advocates say they have long been raising alarms about the site and its predecessor, Nursing Home Compare.

They say Care Compare also wasn’t posting fines that were under appeal, effectively rendering significant penalties invisible to the public. But fines weren’t posted in other cases, too, CalMatters found in its analysis.

“I think it’s a complete mess, that’s what it’s turning out to be,” said Edelman of the Center for Medicare Advocacy, before the data was updated last week.

Compounding confusion for consumers: The state of California doesn’t publicize any of these federal fines, including Northpointe’s — even though its own inspectors are typically the ones identifying facilities’ serious violations. The federal government doesn’t publicize state fines, either.

Charlene Harrington, a professor emerita of nursing at the University of California, San Francisco, who studies long-term care, says she would like to see both the Centers for Medicare & Medicaid Services and the

California Department of Public Health list all federal fines and then note which ones are under appeal.

“The consumers have been complaining about that forever,” she said.

“If it weren’t for the news (media) calling, nothing would ever happen.”

The California Department of Public Health, whose workers conducted the 2018 inspection on behalf of the federal agency, posts state fines on its consumer website, Cal Health Find. State penalties assessed against Northpointe totaled $19,000 in 2018; the state has not fined it since.

Department representatives said via an unsigned email that the state does not post federal fines because it is not regularly informed of final decisions made at the federal level. This would make publishing them on Cal Health Find “sporadic and inconsistently reported,” the email said. The department declined to make anyone available for an interview for this story.

In Northpointe’s case, the uneven information available to the public has not been limited to fines. The state and federal government report wildly different COVID-19 case numbers for the same facility. The Centers for Medicare & Medicaid Services was reporting this week that the home had 122 resident cases; the California Department of Public Health had that number at 42.

The state department said via email that it had contacted the federal agency and believed the lower number was correct. But the federal agency has not changed its data.

Even the correct spelling of the facility’s name is hard to pin down — Medicare’s website has Northpointe; the California Department of Public Health shows North Pointe and the facility’s website itself says North Point, but also makes reference to NorthPointe.

Lawmakers fume over state’s lapses

Northpointe was on the state’s radar long before inspectors submitted their findings in 2018.

The facility is one of 18 homes highlighted in a CalMatters investigation published in April that detailed the state’s controversial treatment of its second largest nursing home owner, Los Angeles businessman Shlomo Rechnitz, and his web of companies. The story described how Rechnitz and his companies, including Brius, have been allowed to buy and unofficially operate Northpointe and the other 17 facilities for years while their license applications remain in “pending” status. In five more cases, the state has allowed Rechnitz and his companies to operate facilities for which the state has outright denied their licensing applications.

As reported by CalMatters, the state’s handling of these 23 nursing homes reveals a licensing process plagued by indecision, confusion and misleading public information. As a result, consumers looking for ownership information for most of these facilities on Cal Health Find, the state’s website, would instead find information about the previous owners.

Both federal regulators and the California Department of Public Health refused to allow anyone to be interviewed for this story, responding only via unsigned emails. Northpointe is not the only one of these homes to face significant scrutiny in recent years. In October, the Centers for Medicare & Medicaid Services released an updated list of “special focus facilities” — a label the federal government reserves for only the most troubled nursing homes that face possible, forced closure. Four of the 23 homes are listed as candidates for the remedial program.

Chicotel of California Advocates for Nursing Home Reform said that, while Cal Health Find does have valuable detail for people who know how to look for it, the site’s lack of information about chain ownership is “a massive disservice to the public.”

This year, state lawmakers have increasingly voiced concerns about the process that allows Rechnitz and his companies to operate homes with pending and denied licenses — and about transparency and oversight of nursing homes more generally.

Assemblymember Al Muratsuchi, a Los Angelesbased Democrat who has been championing nursing home issues, called the lack of transparency about fines “a glaring omission.”

Assemblymember Jim Wood, a Santa Rosa Democrat who chairs the Assembly Health Committee, became emotional during a heated legislative hearing in October on nursing home oversight.

“Where is the proactive, patient-centered, public safety approach here? Where is that?” he asked representatives of the California Department of Public Health. “Because I don’t feel it right now.”

Like the federal agency, the state Department of Public Health also refused to allow anyone to be interviewed for this story, replying only via unsigned emails. In response to questions about the Northpointe fine, its unnamed spokesperson wrote that the department bases its decisions about licensing applications in part on how well facilities have complied with state or federal laws. While the department puts greater weight on the most serious violations and citations, it takes all of them seriously, the email said.

The department is aware of the Northpointe fine, the email said, but the state considers financial penalties “inconsistent” as a measure of determining licensing eligibility.

Johnson, who represents Rechnitz and Brius, has in the past declined to answer detailed questions about state licensing issues. But, over email, he has expressed frustration about the state’s inconsistent treatment of Brius homes — approving some, denying others, and leaving still others in pending status.

‘He wasn’t ready to go yet’

Coreen Arioto didn’t know any of Northpointe’s backstory when her 80-yearold father, Harry “Punky” McClellan, first arrived at the facility in March of this year. Not the inspections. Not the fine. Not the licensing.

All she knew was that her father, who had spent 32 years fighting fires for the U.S. Forest Service, needed more care than she could provide. But a month earlier, after a physical therapy session left him in extreme pain, he had fallen. He’d already been to the emergency room three times.

Prior to his fall, Arioto said her father had been doing well in retirement: driving himself, serving on a nonprofit board, working on a family history project. His wife, Susan McClellan, said they almost never fought during 60 years of marriage. “He just made me a better person,” she said.

Arioto, who is a nurse practitioner, spent a few months as a patient at Northpointe after she suffered a stroke in 2019 at 57. Her husband, an anesthesiologist, had researched the facility, she said, but hadn’t turned up any red flags. And the facility was listed as affiliated with Kaiser, she said.

Her time at Northpointe had not been perfect, she said, but she had managed to advocate for herself. And she still knew some of the staff. So sending her father there seemed to make sense. But during his weeks at the facility, his condition worsened, she said.

On April 13, facility staff dropped McClellan at the Kaiser Fresno physical therapy department for a routine visit, according to an account by Arioto and medical records shared with CalMatters. Arioto says they left him in a hallway, where he was discovered by Kaiser staff.

The physical therapist’s notes from that day describe McClellan as somewhat shaky but “alert and able to answer questions.”

“He is very uncomfortable sitting in a wheelchair due to pressure sores on buttocks and just wanted to lay down on his bed,” the physical therapist’s notes say.

“The consumers have been complaining about that forever. If it weren’t for the news (media) calling, nothing would ever happen.”

— Charlene Harrington, a professor emerita of nursing at the University of California, San Francisco