Nursing Home Called Among Worst in State


Cited for offenses such as letting a patient’s bedsores fester and serving food in dirty dishes, a Ventura nursing home has been named as one of California’s 50 worst nursing homes for the second straight year, according to a report released Wednesday.

The Victoria Care Center, a stately pink-and-brown brick building on Everglades Avenue, had the 11th-worst record of deficiencies and complaints in 1993 among all of California’s 1,200 nursing homes, said the report by nonprofit California Advocates for Nursing Home Reform.

But the executive director of Victoria Care Center said patient care at the nursing home has improved dramatically under new management brought in last fall.

And a local watchdog group confirmed that the elderly patients at Victoria Care Center are getting better treatment.


“I see positive changes,” said Susan Miller, program coordinator for Long-Term Care Services of Ventura County, which acts as an ombudsman for nursing home patients. “I think things have really come around. Things are improving.”

“We have had less complaints,” agreed Lana Pimbley, the Ventura district administrator for the state Department of Health Services, which regulates nursing homes.

In Wednesday’s report, the San Francisco-based watchdog group lists the 50 California nursing homes that had the highest number of patient complaints and citations and deficiency notices from state inspectors in 1993.

The 188-bed Victoria Care Center was the only nursing home in Ventura County to make the list.


State inspectors last year issued four health-and-safety citations against the nursing home and fines of $18,000. Over the same period, the state sent the Victoria Care Center 90 notices of deficient care, more than four times the state average.

In addition, the state health department received 49 complaints against Victoria Care--the second-highest number for any California nursing home, the report says.

The Victoria Care Center also made the advocacy group’s 1992 list of the worst nursing homes in the state. That list ranked nursing homes according to the amount of fines levied. Victoria Care, which was socked with $50,000 in penalties for four citations in 1992, had the 13th-worst record in the state.

Besides having a high number of deficiencies and complaints in 1993, the Victoria Care Center was one of only 50 in the state last year to be cited for a violation that led to a patient’s death, according to the report.


In that case, an 86-year-old woman died two weeks after she was admitted in June, 1993, from blood poisoning caused by infected bedsores.

State inspectors found that nursing-home aides neglected to turn the woman from one position to another. She was too frail to move on her own, and on one occasion was left in a wet bed for 1 1/2 hours, they reported.

“The facility failed to give adequate care to this frail, medically compromised resident,” said the September, 1993, citation, which carried a $10,000 fine.



Two days later, the state fined the nursing home $8,000 for not monitoring and maintaining residents’ diets in accordance with physicians’ orders, said Kim Kelley, a coordinator for the watchdog group.

That same week, Granada Hills-based Twin Oaks Life Care Inc., which owns Victoria Care Center, brought in a new management company to run the nursing home.

The management company--Arizona-based Retirement Community Specialists--hired a new executive director and nursing director, who within several months replaced about 80% of the 200 staff members at the facility, Executive Director Leny Sandbeck said.

Under the new management, nursing home employees received better training and supervision, Sandbeck said.


“We say there was no care before,” said the home’s new nursing director, Sharon Mulkey. “Now we have the best care at Victoria Care.”

One improvement, Sandbeck said, is that Victoria Care has established a formal grievance procedure to encourage patients and family members to voice their concerns directly to nursing home managers.


However, three months after Sandbeck took over, the state issued two more citations: one on Dec. 11, 1993, for letting a patient sustain a 27% loss in body weight over a three-month period, and the other on Dec. 15 for serving food in dirty dishes.


But Sandbeck said both of these citations were less serious than those issued earlier in the year and did not carry penalties. “You can’t correct everything at once,” he said.

Wednesday’s report did not say how many of the 90 deficiency notices and 49 complaints were lodged after new managers took over.

So far this year, the state health department has issued no citations against the nursing home. But inspectors have received 20 patient complaints. Upon investigation, the state found instances of deficient care in five cases, records show. Ten of the complaints were dismissed as unsubstantiated. The remaining five are pending.