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Piedmont Gardens community life director Jenevieve Francisco, second from right, joins residents Karen Nelson, left, Lee Wiley, second from left, and Barbara Zimmerman, right, as they inspect plants at the rooftop garden at the facility in Oakland on March 31. Experts say visiting residential care facilities and observing daily life \u2014 including staff interaction and activities \u2014 can reveal more than inspection reports alone.<\/p>\n
Yalonda M. James\/S.F. Chronicle<\/p>\n
In Daly City, a woman broke a tooth after she was dropped while being moved to her nursing home bed. In Fairfield, a woman with dementia escaped from her nursing home and wandered across a busy street to a parking lot, where she was found wandering and asking for help.<\/p>\n
A man in Hayward died after staff missed his respiratory medication two days in a row. In Santa Rosa, a resident was found with maggots in his infected toe, which had to be amputated.<\/p>\n
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These are a small sample of the violations and complaints that were recorded over a three-year period in California\u2019s licensed health care facilities that offer skilled nursing to long-term residents. And though these examples are exceptional, they underscore challenges that are industry-wide.<\/p>\n
Residential facilities that provide nursing care are responsible for supporting the nation\u2019s most vulnerable populations, but they sometimes are poorly run to the point of putting residents\u2019 lives at risk. And for individuals and their loved ones, finding a safe place to live when they can no longer remain at home can feel like a fraught path marked only by red flags.\u00a0<\/p>\n
The Chronicle earlier this year launched a searchable database to help families and others more easily scrutinize nursing homes and similar residential care facilities and determine which ones may be problematic.\u00a0<\/p>\n
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<\/p>\n Add Preferred Source<\/p>\n <\/a><\/p>\n Article continues below this ad<\/p>\n The database, which includes every state inspection report and complaint for licensed facilities in California from 2022 to 2025, includes more than 80,000 violations, which range from severe incidents that led to deaths to claims of poor nutrition and fights among residents.<\/p>\n<\/p>\n What inspection reports can \u2014 and can\u2019t \u2014 tell you<\/p>\n Of the state\u2019s nearly 1,200 licensed skilled nursing facilities, only 22 reported no infractions over that three-year period. Not all nursing homes are licensed skilled nursing facilities; some are known as residential care facilities for the elderly, which provide minimal assistance, such as meals and supervision, but no medical care. These facilities are not included in the Chronicle database.<\/p>\n Whether a facility has a perfect record or no record at all, people should try to visit a home, ideally multiple times, before they move in, industry experts said. The state\u2019s inspection process isn\u2019t perfect, and especially when it comes to staffing, it can be difficult to identify shortfalls from the reports alone.<\/p>\n Article continues below this ad<\/p>\n But the inspection reports and complaints can expose bad actors, especially if consumers know which violations to watch out for, experts said.<\/p>\n Everyone wants to avoid a worst-case scenario \u2014 a preventable death. But they should also want to avoid bed sores and falls. And they deserve, in their home, to be treated to delicious and nutritious food, appropriate care and an environment safe from abuse or other harm.<\/p>\n Piedmont Gardens resident Elsie Allen-Lesler, left, stretches as she watches instructor Ziv Porat, not pictured, during gentle movement hour at the facility in Oakland. Piedmont Gardens is a \u201clife plan community,\u201d where residents can move between levels of care as their needs change.<\/p>\n Yalonda M. James\/S.F. Chronicle<\/p>\n \u201cThe most common way you find out about these problems is through these reports,\u201d said Charlene Harrington, a professor emeritus in the School of Nursing at UCSF who has studied nursing homes for decades.<\/p>\n But the bad reports, she said, are \u201cjust the tip of the iceberg.\u201d<\/p>\n Article continues below this ad<\/p>\n The California Department of Public Health\u2019s Center for Health Care Quality is responsible for inspecting and recording citations in the state\u2019s health care facilities, including nursing homes. Violations typically are identified through routine inspections or complaints filed with the state.<\/p>\n Inspection and complaint reports are available online<\/a>, though they\u2019re not always easy to find or understand. UC Davis runs a website, Cal Long Term Care Compare<\/a>, that incorporates the reports and other factors into overall scores.<\/p>\n What to know before choosing a nursing home<\/p>\n Several types of facilities are included in the reports, from acute care and rehabilitation hospitals that look after people for a few weeks after surgery to communities that offer lifelong care. Many facilities offer staggered levels of care \u2014 for example, residents may start off living independently, then receive part-time nursing and later move to a ward for patients with dementia.<\/p>\n Article continues below this ad<\/p>\n Costs can be the biggest hurdle for most people in need of nursing care. Medi-Cal will cover care for low-income residents in California, though not all facilities accept Medi-Cal, and in many places the waiting list for those beds is long. Otherwise, residents must pay for the care \u2014 which is typically several thousand dollars a month \u2014 themselves or with private insurance.<\/p>\n The Chronicle database showed that smaller facilities tend to have higher rates of violations per bed than larger homes, but industry experts said in general, bigger isn\u2019t necessarily better or safer. Rather than size, many experts are more interested in whether a home is for-profit vs. nonprofit, in large part because the former tend to be more likely to scale back services or have problems hiring and retaining staff, Harrington said.<\/p>\n \u201cThe bigger homes, a lot of them are for-profit and some of them look quite nice. They have new buildings and chandeliers and nice living rooms, and people get taken in by that,\u201d Harrington said. \u201cBut they don\u2019t realize there\u2019s no staff. And that\u2019s fine if a person goes in and they\u2019re pretty independent. But if they need very much help, or if they start needing a lot of help, there may not be the help they need. And that\u2019s a big problem.\u201d<\/p>\n Lillian Fujimoto, 83, has been healthy enough to remain in her Kensington home, but her husband fell earlier this year and ended up in two nursing facilities to recover. The experience of finding a place for him and visiting him every day opened her eyes to some issues she\u2019d never considered before, she said.<\/p>\n Gym instructor Kathleen\u00a0Dzubur works with resident Carrie Stoltzfus at Piedmont Gardens in Oakland.<\/p>\n Yalonda M. James\/S.F. Chronicle<\/p>\n In particular, there often didn\u2019t seem to be enough staff at the first facility, she said. One day they forgot to give her husband a shower. They were slower than she would have liked to respond to issues he was having with a roommate. \u201cThere just weren\u2019t enough people attending to patients,\u201d Fujimoto said.<\/p>\n \u201cHonestly, if we could afford it financially, I would probably try to stay out of a nursing home,\u201d Fujimoto said. \u201cI think they all tend to be short-staffed.\u201d<\/p>\n Daniel Wittman, executive director of the nonprofit Piedmont Gardens in Oakland, agreed that staffing is a challenge industry-wide, but he added that it\u2019s possible to attract and retain staff as long as that effort is prioritized. Piedmont Gardens is a \u201clife plan community,\u201d meaning many residents live independently when they move in and can graduate to more advanced care as needed. The community received 26 violations from 2022-25, according to the Chronicle database.<\/p>\n One resident, Wittman said, is over 100 years old and has lived there for 30 years. She and her family have built a relationship with the staff at Piedmont Gardens, he said. That\u2019s something to look for when people visit potential homes \u2014 the interactions between staff and residents, who should be well supported and treated with respect.<\/p>\n \u201cDon\u2019t just look at the brochure or the website \u2014 you\u2019ve got to visit to see and feel the vibe,\u201d Wittman said. \u201cDo people seem to be fairly happy and comfortable?\u201d<\/p>\n Major red flags to watch for<\/p>\n Industry experts said staffing is by far the most consistent problem across facilities, but there are many loopholes and nuances to the regulations that make it difficult to cite operations. Often, experts said, facilities are given multiple chances to fix staffing issues before they\u2019re issued a citation. Formal staffing violations are not common, according to the Chronicle database.<\/p>\n But experts note that the worst violations \u2013 the ones that lead to death or physical harm \u2013 almost always are due to not having enough staff or not having staff trained for certain kinds of care.<\/p>\n For example, bed sores, or pressure ulcers, tend to develop when there are not enough staff to help residents frequently change positions and keep their skin healthy, clean and dry. Or if a facility has reported repeated falls, that\u2019s another warning sign that they don\u2019t have enough staff to help residents get around.<\/p>\n \u201cWhenever I see pressure ulcers, I know there\u2019s something more to look into. That tells me they are not lifting the patient up or switching them or keeping them clean,\u201d said Dr. Ria Paul, a Stanford geriatrician. \u201cAlso unwarranted falls \u2014 why did that happen?\u201d<\/p>\n Other violations tied to staffing could include medication problems, including over-medicating or making mistakes, and repeated hospitalizations, which suggest staff are not able to provide an appropriate level of care. Another common and concerning violation is for elopements, or patients with dementia who leave the site without staff being aware.<\/p>\n According to the Chronicle database, in the Bay Area the most common citations are for building code violations, some of which could be serious, such as blocked fire exits or wheelchair ramps that are too steep.<\/p>\n Across the Bay Area, more than 3,500 building code violations were reported at nursing homes from 2022 to 2025; one 87-bed home in Solano County recorded 58 building code infractions over that time period, though none was considered serious.<\/p>\n Second to building code violations, problems with quality of care, infection control and medication or pharmacy services were the next most common, with roughly 1,000 of each type of infraction reported over the three-year period.<\/p>\n Instructor Ziv Porat leads Piedmont Gardens residents in gentle movement hour at the facility in Oakland. Activities and amenities like gardens and social spaces are part of what prospective residents often consider when choosing a facility.<\/p>\n Yalonda M. James\/S.F. Chronicle<\/p>\n \u201cBasically, if you\u2019re seeing a lot of the same citations over and over again, to me that\u2019s some sort of system failure, like there\u2019s no oversight,\u201d said Angie Perone, who directs UC Berkeley\u2019s Center for Advanced Study of Aging Services.<\/p>\n And these violations can be alarming. Quality of care infractions can be particularly upsetting. There\u2019s the woman in Daly City who broke a tooth in a fall, for example. Plus a man in Oakland suffered a broken femur while being moved from a wheelchair to a bed, and a woman from another Daly City home broke all five toes when she fell.<\/p>\n Infection control violations may appear minor, but for vulnerable residents these can signal bigger problems. Inspection reports that show sloppy intravenous line protocols, for example, or repeated bladder infections among residents should draw concern. Violations can also be as severe as the man with the maggots in his toe.<\/p>\n Medication violations can be due to staff not labeling drugs correctly, using appropriate protocols to deliver them, or skipping doses. But one of the most common and problematic infractions is for over-medicating \u2014 that often signals that staff are using drugs to control patients.<\/p>\n Elopements also come up often in the state reports. These are residents, usually with dementia or other cognitive issues, who wander off and cannot be found. \u201cNot keeping track of patients who have dementia, like cases where people try to escape and get away when nobody\u2019s watching \u2013 that\u2019s a severe problem,\u201d Harrington said.<\/p>\n Another common infraction: fights among residents. These can range from petty-sounding complaints \u2014 a man threw a cup of water at his roommate \u2014 to events that sound like brawls, with residents slapping and punching and drawing blood.<\/p>\n Ideally, industry experts said, people seeking nursing home care should be able to choose a place that feels comfortable and livable. They should not have to worry that their basic needs will be met. And so beyond looking for infractions, experts recommend looking for a place that feels like home.<\/p>\n \u201cYou can\u2019t conger up culture,\u201d said Wittman, of Piedmont Gardens. He said many potential residents are less interested in health care services on site than they are about the gym and art studio and vegetable garden. \u201cThey want a community.\u201d<\/p>\n \u201cUsually when people are looking for a nursing home they ask me, \u2018What do I look for?\u2019 And I would say you\u2019ve got to walk around the place, you\u2019ve got to smell it,\u201d he said. \u201cLook at the staff and how they interact with residents. Do people seem happy and comfortable? You\u2019ll feel and see those differences.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"Piedmont Gardens community life director Jenevieve Francisco, second from right, joins residents Karen Nelson, left, Lee Wiley, second…\n","protected":false},"author":2,"featured_media":566320,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[59],"tags":[3805,2356,2788,241574,97,252,253],"class_list":{"0":"post-566319","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-health-care","8":"tag-bay-area","9":"tag-california","10":"tag-data","11":"tag-graying-bay","12":"tag-health","13":"tag-health-care","14":"tag-healthcare"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/566319","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=566319"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/566319\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/566320"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=566319"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=566319"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=566319"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}<\/p>\n
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