ORINDA — In an ongoing investigation into Orinda Care Center authorities have found evidence of “chronic” understaffing, “insufficient” amounts of personal protective equipment, like face masks, and a sexual assault against a patient with dementia that was never reported to police, according to the investigator’s reports.
Although no criminal nor civil charges have been filed against the center or its owners, authorities said in court recordsthat they are proceeding with an elder abuse investigation into the center.
“I believe the conditions, lack of staffing, misuse of personal protective equipment, suspected sexual assaults, and overall neglect is evidence of elder abuse and likely produced great bodily injury or death to the elder and dependent residents of the Orinda Care Center,” Contra Costa District Attorney Inspector Sean Eriksen wrote earlier this month in an application for county records of an April inspection of the center.
Late last month, prosecutors in the Contra Costa District Attorney’s office confirmed that investigators were working with regulators to probe “multiple COVID-19-related deaths of elderly residents of the Orinda Care Center” and that they are looking for possible instances of neglect, but provided no other details at the time.
“Orinda Care Center has not been contacted by the District Attorney, but we would welcome cooperating with authorities and rebutting these inflammatory allegations as the investigation proceeds,” said Dan Kramer, a spokesman for the Orinda Care Center, without saying which allegations the company would rebut.
At least four patients died from COVID-19, although after county health officials in April declined to continue providing an accurate death count for the facility, and the state health department will not share specific death or case figures if the total is less than 11, the actual number of dead is unclear.
The facility had 40 confirmed cases among patients and another 31 among healthcare staff. The facility currently has no more positive cases of COVID-19.
The investigation has thus far consisted of witness interviews and document reviews, as well as information gleaned from news reports about the center. An April 9 county health inspection found that the center is, on average, short three to four nurses per shift — as well as multiple reports of lacking amounts of protective equipment such as gloves, masks and gowns.
One witness — a former housekeeper — told investigators that rooms with patients with COVID-19 were marked simply with blue tape, and that he saw nurses traveling between the rooms of infected patients and those of uninfected residents without restrictions.
The witness also told investigators he saw management preparing for an April 9 inspection by taking all of the home’s available personal protective equipment, or PPE, and displaying it throughout the center.
At the end of the county’s inspection, the face masks and other PPE were rounded up and locked away in a closet, the staff member claimed. Still, a county health official told investigators on April 9 that the amount of available PPE at the home was “insufficient,” according to court records.
On Feb. 13, 2019, a nurse witnessed an unidentified housekeeper touching the genitals of a partially-paralyzed man who suffered from dementia. The housekeeper, caught in the act, allegedly yelled, “I shouldn’t be doing this,” and was fired eight days later but was never reported to the Contra Costa Sheriff or Orinda police, according to investigators.
According to emails between county health officials and the nursing home obtained by this news organization, at least part of the reason for the staffing shortage during the outbreak was due to mixed messages healthcare workers were getting from county health workers in March and April. Officials from Orinda Care Center and its operating group, ReNew Health Group, wrote to county health staff noting that workers were not coming into work after being told at drive-through testing stations that they needed to isolate after being tested.
County health officials later responded to clarify that people without symptoms could continue to work as long as they did not have symptoms, and that staff who tested positive but remained asymptomatic could still go to work but could only care for COVID-19 patients.
Nursing homes across California and the rest of the country have been hard hit by COVID-19. In California, at least 21,599 residents and healthcare workers have contracted COVID-19, and at least 2,524 have died, according to the most recent state health data. Staffing shortages fueled by low pay in the industry, as well as a lack of available personal protective equipment and testing have compounded a situation in which asymptomatic staff members can easily spread the virus through the close contact required in nursing facility settings, experts say.
But well before COVID-19 swept through nursing facilities across the country, there has been a history of problems at nursing homes run by the owner of the Orinda Care Center, Crystal Solorzano, state health records show.
As recently as August, state inspectors found the Orinda Care Center did not meet minimum staffing requirements on 16 out of 24 days that were monitored, according to California Department of Public Health records. Inspectors found that dietary staff at the facility could not describe or demonstrate the correct procedures for sanitizing cookware and tableware. They also found that staff were storing expired and current medications together — sometimes without refrigerating those medications that required it.
In December, the California Department of Public Health took the rare step of denying Solorzano’s applications to operate facilities on the basis of her other facilities’ past records.
According to state records, the state denied applications submitted by Solorzano to operate skilled nursing facilities in San Jose, Canoga Park and Glendora because inspectors found 97 federal regulatory violations in facilities she owned, managed or operated between October 2016 and October 2019, as well as 46 violations of state requirements and three administrative penalties for failing to meet minimum staffing requirements.
Among the deficiencies the state cited in its denial to Solorzano was a February 2019 sexual assault and rape of a Glendale facility resident inside her room by a nursing assistant. The state also cited a 2018 inspection at her San Bernardino facility where inspectors found staff did not notify a doctor about patients’ injuries, including a fall that left a resident with a fractured hip, among many other violations.
Solorzano has appealed the denials of her facility applications, the spokesman, Kramer, said in April.
In the denial letters, state health officials also noted that the state had revoked Solorzano’s nursing home administrator license because she provided fraudulent college transcripts in applying for it. She is still allowed to own nursing homes without the administrator’s license.
Kramer told this newspaper in April that Solorzano’s administrator’s license was not revoked but rather the state sent the letter in error, noting that a hearing on the license revocation is scheduled for September where “we plan to present information on or before that date fully exonerating,” her.
Staff writer Thomas Peele contributed reporting.