Problems Dogged Veterans Home

Times Staff Writers

When the California Veterans Home opened its doors seven years ago amid imported palms and a man-made brook in Barstow’s high desert, its nursing facility was hailed as a high-class operation by many of the state’s aging soldiers and their supporters.

It was only the second skilled nursing center for veterans in the state -- and the first in Southern California, where two-thirds of California’s veterans live.

But just a few years after its opening, its promise was tarnished. Regulators cited and fined the facility for alleged substandard conditions, patient abuse and a spate of preventable deaths. Federal authorities temporarily pulled its Medicare and Medi-Cal funding. At least five administrators came and went. Critics, including Gov. Gray Davis, demanded reforms.

Last week, Secretary of Veterans Affairs K. Maurice Johannessen announced that the skilled nursing section of the home would be closed altogether, and its 90 residents moved to either Yountville or the state’s newest home in Chula Vista. Officials said they hoped to take action before further fines were imposed.


A day later, on Friday, regulators with the state Department of Health Services imposed a $100,000 fine -- the highest possible -- against the home for the death of an 80-year-old man who they said was not promptly treated for an infected hernia. It was the second fine in two months stemming from a patient death. Two such violations within a year’s time spark revocation of a home’s license under recently passed state law.

“We have no choice now,” said California Department of Veteran Affairs Undersecretary Tom Kraus, as he left a meeting at the facility Friday with administrators, residents and their families. “We’re closing.”

The entire veterans’ home is not closing. There are 278 residents who can care for themselves or need only limited nursing care. They will remain at the home, but the skilled nursing portion, where round-the-clock care is required, will cease operations.

The rapid rise and fall of such an eagerly anticipated and critically needed nursing facility has left residents, families and staff members feeling betrayed. Elderly or disabled patients will be uprooted, loved ones will no longer be able to visit easily and many employees, who complained they were overworked before, will be out of work altogether.

Former boosters of the facility mourn the loss.

“There was a time when it was highly thought of -- a hallmark of state veterans’ homes,” said Thomas R. Langley, the home’s second administrator, who stepped down in 1998 citing health reasons. “I was very proud of the home.... I will never forget seeing those old vets sitting outside watching the sun rise over the desert.”

Troubles Surface

In fact, problems, including inspections that yielded evidence of patient abuse and staffing deficiencies, began not long after the home opened its doors in 1996. (The inspections were conducted by the state Department of Health Services, which regulates nursing homes -- including those like the Barstow facility, which are run by the state VA).


By 1999, enough trouble had surfaced that the California Department of Veterans Affairs launched its first internal review of the Barstow home. But it was the events of the following year that drew the concern and dismay of top government officials, including Davis.

The home was cited in three patient deaths, and federal officials withdrew the facility’s certification for Medicare and Medi-Cal funding -- an unusual move that deprived the home of about $80,000 per month in reimbursements. The U.S. Department of Veterans Affairs yanked funding too, citing poor medical care and record-keeping, medication errors and high administrative turnover.

A routine state inspection that year also uncovered an unusually high number of failings at the home, including untreated bedsores, unexplained bruises, use of antipsychotic medication without consent and theft. Five residents reported having money stolen -- one man was robbed of $800 locked in his nightstand -- but administrators did not promptly investigate, inspectors found.

One of the men who died was Paul Stevens, 76, a World War II Army drill sergeant who choked to death on a piece of broccoli Feb. 11, 2000.


Officials at the home insisted he had died of a heart attack, but autopsy findings revealed otherwise. The home was also cited for altering medical records related to Stevens’ death and for retaliating against a doctor who declined to corroborate the heart-attack explanation, according to state Department of Health Services records.

In March of 2000, one 78-year-old diabetic man died after his blood sugar level soared and a physician wasn’t promptly summoned. That led to a $25,000 fine.

Another death, in May of the same year, also resulted in a citation and $10,000 fine. A 62-year-old diabetic patient had refused food or finger pricks to check his blood glucose level, but the staff made no attempt to intervene or call a doctor, according to inspection records.

Probe Ordered


Davis, an Army veteran who has described himself as the “best friend” of California veterans, personally ordered an investigation into Stevens’ death.

The state Department of Veterans Affairs hired an outside firm to help clean up the operation at the end of the year. The firm, Marina del Rey-based Country Villa Health Services, operates 21 skilled nursing facilities and one assisted living home in Southern California.

Eldon Teper, Country Villa’s chief operating officer, walked in on Jan. 1, 2001, and found a poorly organized facility where nurses did not take responsibility for patient needs, he recalled last week.

The skilled nursing portion of the Barstow facility didn’t even have its own administrator, Teper said. Country Villa hired one.


“We spent thousands of hours in that facility bringing them into compliance,” said Teper, whose contract expired in October of that year. “When we left they were in good shape.”

The facility won back its federal VA funding, along with its Medicare and Medi-Cal certification, in February 2002. Brenda Klutz, director of licensing and certification for the Department of Health Services, said last week that her department believed things were looking up.

But within a few months, the skilled nursing administrator hired by Country Villa left. Then, last month, regulators cited the facility -- and fined it $95,000 -- for what they termed another avoidable death. Billy D. McGowen, 78, an Army combat veteran with two Bronze Stars and a Purple Heart, was hospitalized Nov. 4 with an irregular heartbeat, according to state records. A doctor prescribed a drug called amiodarone to treat it.

When he was readmitted to the veterans’ home, a staff physician prescribed another drug, digoxin. The two drugs are toxic when combined. McGowen slowly deteriorated and died Dec. 4, according to inspection records. Some of these most severe violations can be “single tragic errors that may or may not be indicative of systemic errors,” Klutz said. “We were concerned there were systemic problems.”


The problems mounted. Last month, California Highway Patrol officers, who perform some investigations of state government, recommended criminal charges be filed against three staff members at the facility -- including its former administrator -- after the workers broke the finger of Tom Joyner, a disabled veteran, in December. They had been struggling to snatch his cigarette, which he was smoking in violation of regulations.

The administrator was reassigned to other duties at the home. All three employees remain at the Barstow facility while the San Bernardino County district attorney’s office considers criminal charges.

‘This Is My Home’

“I was scared of them for a while,” Joyner, 52, said from a patio at the facility Friday as he and his sister smoked and discussed his upcoming move to Chula Vista.


Joyner, who is paralyzed on his left side, struggled for words and showed that he was clearly conflicted over the closure. “It’s not right. This is my home. The nurses here are good.”

About the same time Joyner and his sister were conversing, state regulators issued a $100,000 fine against the facility in the case of 80-year-old Otho Lee Duckwiler. He had died Jan. 9, three days after he began vomiting. Staff did not call a physician so were not aware that he had an infected hernia until it was too late, state health services department records show.

A state law that took effect in 2001 quadrupled maximum fines. The new law also triggers license revocation if a home receives two preventable-death citations in a year.

Some workers, family members and others say problems at the home are exacerbated by a staffing shortage, a consequence of the home’s relative isolation.


Representatives of the California State Employees Assn., which represents the home’s nursing staff, say 16 registered nurse positions are authorized for the facility, but only six are filled. There are four vacancies for licensed vocational nurses.

One licensed vocational nurse is responsible for 46 residents, said Vidal Salas, the union’s labor representative in Rancho Cucamonga, while “ideally, there should be two LVNs per 45 residents as well as a registered nurse on hand to help.”

For those whose relatives have died due to what state officials consider poor care, news of the latest citations and fines is especially galling. Brenda Albitre, the 52-year-old daughter of McGowen, one of the veterans who died in 2000, said her family has been pursuing legal action in the hope that no other family would suffer the way hers did.

“I think it’s time to take drastic measures,” Albitre said.


She said she was unaware of problems at the home until it was too late. The staff had been warm and friendly, she said.

Her father, a “fun dad” with a quick wit, had chosen the place himself, drawn to the desert climate and pictures in the brochures. At first, he seemed to enjoy it.

But when Albitre visited him about three weeks after his hospitalization, he had lost his appetite and his verve.

“He always had a sense of humor, which is what I didn’t see the last time I saw him,” she said, choking back tears. “I didn’t realize why.”



Times staff writer Carl Ingram contributed to this report.