Diagnosis: Eviction

An out-of-state company mismanaged its Mill Valley nursing home, then closed it down, casting dozens of elderly patients to the winds. Within months, 10 of them were dead.

One was a Jewish immigrant who survived the Holocaust. At least three fought as U.S. soldiers. Others were European immigrants and Americans who came of age during World War II, watching from vantage points on both sides of the Atlantic.

In their waning years, all came to live in a nondescript, single-story building at 505 Miller Ave., a 120-bed nursing home in Mill Valley.

The setting was ironic. Testaments to the North Bay's reverence for the young, fit, and pretty surrounded the Mill Valley Healthcare Center. A couple doors away a company made mountain bikes, like the ones seen in soft-drink commercials. Farther up the street was a town plaza where breezy clothing boutiques, designer health-food stores, and sprightly coffee shops formed the palette of West Coast chic.

In this cradle of youth-obsessed sensibility, a horrible thing happened this spring.

After managing the nursing home incompetently -- and some say negligently -- a Massachusetts corporation washed its hands of the Mill Valley Healthcare Center and cast out its occupants. In just two years, under the management of Lenox Healthcare Inc. of Pittsfield, Mass., the community that these elderly patients had carved out for themselves was torn asunder and scattered to the winds.

Lenox Healthcare's owners did not respond to repeated requests for interviews from SF Weekly. But court filings, state inspection reports, and interviews with former patients and their family members show that, under Lenox's reign, conditions at the home deteriorated to such a miserable level that at least one family member says she was warned by local paramedics to "get her mother out of there" for her own safety.

Care became so bad, so swiftly, following Lenox's purchase of the home in 1997, that the state of California suspended Lenox's license to provide for Medi-Cal-funded patients eight months after the company took control of the facility.

Then -- so promptly and efficiently that some suspected it was by design -- Lenox attempted to evict all 70 of the patients whose bills were paid by Medi-Cal, the least profitable for the company. When a judge stopped Lenox from doing that, the company eventually decided to simply close the home down. All of the patients were told they must leave, and the Mill Valley Healthcare Center was shuttered and sold. It stands empty to this day.

Whether there was some grand scheme to Lenox's behavior -- some design to maximize profits -- or this was an act of colossal strategic bungling by an otherwise shrewd company, remains unknown. The answer, perhaps, will emerge from the lawsuits soon to come from former patients and their families.

Almost from the time Lenox instructed orderlies to start packing patients' belongings into black plastic bags and hired ambulances to take them away -- some at night -- suspicions have lingered that Lenox planned the scenario all along.

"How can a company like Lenox, that has facilities all over the country, fail to correct problems like that, unless they didn't want to correct them?" asks David McGahey of Sausalito, whose mother lived at Mill Valley. "I thought it was rather brutal the way they did it."

In comments to the local Marin County press, former Lenox Vice President James Hardee was quoted as saying that his company did not purposefully seek to purge the home of Medi-Cal patients.

And Hardee's replacement, Joyce Hogue, said that while she had no firsthand knowledge of Lenox's actions at Mill Valley, she found the idea "hard to believe."

The story did not end when Lenox emptied out the home.
Within three months of their evictions, 10 people -- some of whom had lived at the center for years without life-threatening health problems -- died. Eight of those were possible victims of a syndrome known as "transfer trauma," according to an official with the Marin County Department of Health and Human Services. Sometimes, current medical understanding of this phenomenon holds, older patients who have been forced from their homes and routines become so distraught that they simply give up living.

It's not possible to prove, definitively, that the closing of the Mill Valley Healthcare Center killed anyone. Perhaps there are other reasons why some of its former patients withdrew, or stopped eating, or willed themselves to die.

That will be for the courts to decide.

As brutal as a forced eviction is for anyone, for the elderly it can amount to a death sentence. Medical science calls the condition "transfer trauma" -- a wave of disorientation and despair so intense that it can kill.

Marcella Adamsky is a San Francisco clinical psychologist and expert on the syndrome. For people at an advanced age, she says, stability -- familiar people, surroundings, routines -- are important elements for sustaining life. An elderly person's first move, from their private home to a nursing home, is almost always traumatic, Adamsky says.

If there's another, subsequent forced move, it can be deadly. California law recognizes the potential trauma involved with evicting elderly nursing-home patients. State law requires nursing-care providers to be especially careful when transferring patients. They are supposed to provide counseling and other services to help ease patients into their new homes. Lenox's critics say no such help was provided for the former patients at Mill Valley.

"They finally carve out a niche, a home, and when they least expect it, an outside force demands that they move," Adamsky says. "This is disturbing for older people, especially for people who have been in the same environment for a while."

People like Astrid Lindman, a Swedish nanny who came to America when she was 55 years old. The former Chicago nurse's aide, the San Francisco I. Magnin employee who loved hats, who loved flowers, who grew up dreaming of living someday in the United States, had made a home at the Mill Valley Healthcare Center before it closed.

After she was forced to move, according to her daughter, Lindman found herself in a strange Colma nursing home which was not her home, and which she did not want to make her home. Lindman apparently decided to die.

"She stopped eating and drinking. She just shut down. She wouldn't interact with us. She completely shut down," says Agneta Lindman, a San Francisco hairdresser who immigrated from Sweden with her mother in 1962. "She kept saying 'This isn't my house.' " Lindman was 91 years old and heart failure was formally ruled the cause of her death.

Sheila McGorty monitors nursing homes as the long-term care ombudsman for the Marin County Department of Health and Human Services. McGorty believes that Lindman's was not the only death possibly connected to the closing of Mill Valley Healthcare Center.

Although confidentiality rules prohibit her from providing the patients' names, McGorty says she believes she watched other deaths from transfer trauma, and that as many as eight deaths can be attributed to the home's closing.

"One I witnessed, she was a very fragile senior, but very vital. She was very, very social. She would sit in the main room in the lobby and always greet people. She was 88 years old, but she was stable," McGorty says. "She had no medical conditions other than the fact that she was a fragile elder. I talked to her family and explained to them that ... if they did move her, she wouldn't live. That was her life at the Mill Valley home. She had no husband, no children, and she'd re-established the Mill Valley group as her second family. At the time of the evictions, members of her family were out on vacation. So the staff at Mill Valley moved her.

"I followed people as they moved. I followed her up to the new facility where she had been placed. She was in a corner room. I said, 'Do you want to meet some of the people here?' She didn't want to. She didn't want to eat lunch, and she went to bed. At dinner time, she didn't eat dinner. She curled up in a ball. I went in Monday, and she had died. She never got out of bed. A week later, the woman who had been across the hall from her was transferred and died."

For 30 years investigations by journalists, regulators, and advocates have chronicled a legacy of suffering in America's nursing homes. California has seen more than its share of complaints about inadequate staffing, improper use of medication, and in many cases, direct physical abuse.

A study by the federal watchdog General Accounting Office released last summer showed that one-third of the nursing homes in California had received citations for problems that endangered, and in some cases killed, patients. Federal and state officials all but look askance at the abuses, the report concluded. As a result, homes can cause patients to die, or suffer egregious harm, with little fear of serious repercussions from regulators, the report charged.

Indeed, for all of its failings in caring for patients at the Mill Valley Healthcare Center, Lenox Healthcare Inc. was fined a grand total of $1,000 by the state of California, for not having hot water, and the fine was waived.

Over the years, there have been myriad attempts at nursing-care reform -- there's one such battle going on right now at the Sacramento Statehouse -- but nothing ever seems to change.

Nursing homes have repeatedly been hit with lawsuits: Berkeley attorney William Taylor, who has made his living for the past 18 years suing old-folks homes, plans to file a class-action lawsuit against Lenox this summer over problems at the Mill Valley facility. (Although he initially agreed to talk with SF Weekly, Taylor changed his mind, and instructed his clients not to grant interviews.)

According to advocates for the elderly, things are likely to get worse. As the restructuring of the health-care industry turns nursing-home patients into commodities, firms are going to ever greater lengths to cut costs. As wave after wave of mergers and acquisitions sweep over the nursing home industry, care is becoming leaner by the year, says Pat McGinnis, director of California Advocates for Nursing Home Reform.

Mass relocations like the one at Mill Valley aren't rare either.
The Mission Villa nursing home in San Francisco, for example, decided this spring to stop providing care to Medi-Cal patients, and attempted to evict the low-income patients formerly under its care.

"There was no care plan, no transfer plan. They were dumped in the new facilities, and the new facilities were unprepared to deal with these people," says Prescott Cole, an attorney for California Advocates for Nursing Reform in San Francisco. "This kind of stuff happens a lot. The story just marches on. This wasn't an aberration."

Nursing-home entrepreneur Tom Clarke is the owner of Massachusetts-based Lenox Healthcare, Inc. the second-largest privately owned nursing-home chain in the country. Clarke's company is at the forefront of a trend in which nursing-home care is evolving from a smattering of mom-and-pop enterprises to a hugely profitable national industry.

Clarke began building his empire in 1990, after he was dismissed by Berkshire Medical Center in Pittsfield when the western Massachusetts hospital accumulated tens of millions of dollars in debt following an expansion into the nursing-home market, according to an article in the Boston Business Journal.

Clarke swiftly built a sprawling, 16-state nursing home empire worth $400 million. According to financial documents prepared by Lenox Healthcare and filed with the Commonwealth of Massachusetts Department of Public Health, the company's growth strategy appears voracious. Company ledgers show that Lenox acquired at least 36 nursing homes in 1996, either buying the buildings outright, or buying the business and its license, and leasing the building. In 1997, Clarke acquired another 17 nursing homes in California. Clarke's acquisitions around the country have been financed through a crazy quilt of limited partnerships, financing corporations, and acquisition trusts with names such as Stockbridge Investment Partners Inc., Pinellas Healthcare Investors Inc., Walkulla Acquisition Inc., and Monterey Investments, Inc. Most of the holding companies are either wholly or majority-owned by Clarke and his wife, Linda.

Like Clarke's other California nursing home investments, the Mill Valley Healthcare Center was owned by Lenox Healthcare Inc., 100 percent owned by the Clarkes. The California homes were each structured as independent entities, limiting liability to the assets of each individual home.

Lenox's strategy appears to be one of classic, 1990s-style leveraging. While apparently profitable enough to fuel a stunning expansion drive, the strategy hasn't been without drawbacks. A $100 million lawsuit filed in Florida, for example, charges that a Lenox subsidiary there, York Hanover, failed to provide such basics as hot meals and clean sheets to its elderly patients.

The bottom-line strategy appears to also have had immediate practical effects at the Mill Valley Healthcare Center, which rapidly spiraled downward after it was bought by Lenox.

Almost as soon as Lenox took over the home in 1997, the facility suffered an exodus of employees, residents say. For the types of wages ordinarily paid at nursing facilities such as Mill Valley Healthcare, workers simply could not afford to live in Marin County.

Lenox acknowledged the problem in a memo to patients and family members a year after it took over the home. "Since acquiring the operating rights of Mill Valley Healthcare Center on March 1, 1997, Lenox Healthcare Inc. has experienced great difficulty in recruiting full-time staff members to care for our residents," read the letter, which was printed on Lenox letterhead and included the tag line "Lenox Healthcare Inc.: Caring for People."

According to family members of former residents, the turnover immediately spawned problems at Mill Valley Healthcare Center. Patients in some cases were not fed, or were given food they could not safely eat, according to allegations in affidavits filed along with a lawsuit in 1997 that sought to stop Lenox from evicting patients. Other claims said one man's body was left dirty with feces; and several patients became speckled with bed sores because workers weren't turning them frequently enough. Some were left unbathed. Others were improperly medicated, the affidavits say.

"It is deeply disturbing to see the level of care here deteriorate so badly. Every day, it seems, there is a new nurse or employee taking care of us. Many of the good staff, who were also friends, have left. I do not know who will be caring for me tomorrow or whether the care will be provided," lamented former Mill Valley patient Elfriede Pennington in a court affidavit. "If I were not mentally alert, asking questions, and looking after my own care, I would probably have suffered greatly from mistakes made here."

Nancy Devlin of Corte Madera recalls in an interview seeing a man die while she was visiting her mother at Mill Valley, a story she also related in a sworn affidavit accompanying the Lenox lawsuit.

"I saw a man die right in front of my eyes," she says. "One man was in his room facing the door. He was coughing, and then I walked and looked at him and he didn't look good, but how am I supposed to know that he's choking or whatever? I said something to the nurse and they finally went in and they're running around to look for oxygen, but they didn't have the mask with the oxygen, and they couldn't find the mask. Finally they find the mask. By the time they found the mask, the man was gone. While they were trying to get him going, some guy was trying to pound on his heart. The nurse said, 'Let's call 911,' but another nurse said, 'Let's wait.' Finally they called 911, but by the time the Fire Department got there, he was gone. The fireman said to me, 'You'd better get your mother out of this hellhole.' "

In October 1997, eight months after Lenox had bought the home, the state Department of Health Services inspected the facility and found it had too small a staff and inadequate food service. Restraints were being improperly used on patients, the inspection found, and there was insufficient treatment of bed sores. A follow up visit in April, 1998 showed that Lenox had not corrected the problems.

On May 8, state officials ruled that the home would be barred from receiving Medicare and Medi-Cal payments starting May 28.

Less than a week later, Lenox Healthcare Inc. sent out letters to patients that read "Notice of Intent to Discharge." The company told its Medi-Cal patients that they had 30 days to vacate the premises.

After the eviction notices went out, bedlam ensued, family members of former patients recall.

"We received this notice saying their license was in suspense and giving us 30 days to move out. We found out that there were only six beds available in the entire county," says Agneta Lindman. "I asked James Hardee, the Lenox regional director, what will happen for people who can't find beds? He says, "We'll charge you as a private pay person."

Neither Lindman nor the other Medi-Cal patients could afford the $124 per day that the home charged private-pay patients. Medi-Cal reimbursed the facility at a rate of $94 a day. Family members and patients describe the resulting scene as resembling a refugee exodus.

The discharges were eventually halted by a court decree, but not before more than a dozen families, frightened by the eviction notices, immediately moved their loved ones elsewhere. Other patients who didn't have family or friends present were moved out by Lenox before the court injunction to halt the evictions took effect.

"It came unexpectedly. Nobody imagined that they wouldn't be able to do it," recalls David McGahey. "A panic broke loose. People started moving out like crazy."

Some 70 residents effectively stood to be evicted as a result of the order. Family members and health officials say orderlies scooped patients' belongings into plastic bags and boxes. Many were confused and frightened.

"There was this one woman who was a Holocaust survivor, and they put her things in a black plastic bag, and told her they were coming to take her away," recalls McGorty, the nursing-home ombudsman. "There were these three veterans who lived at Mill Valley, and they found each other and became close friends. They used to tell war stories together. Two of the vets were crying. They called an ambulance to take them away at night. At night! When they saw what was happening, the ambulance drivers refused to transport them. They knew that what they saw was wrong."

But the patients, their families, their neighbors and advocates, didn't give up without a fight. And they almost won.

Just as it seemed that Lenox was well on its way to getting rid of all the subsidized patients, a remarkable thing happened. Alerted by family members, Pat McGinnis of California Advocates for Nursing Home Reform recruited pro bono legal help from the powerful San Francisco law firm of Morrison & Foerster. The firm sued to stop Lenox from discharging the Medi-Cal patients. The legal battle was a fierce one, recalls California Advocates attorney Prescott Cole.

"With the money [Lenox] spent on legal fees, they could have brought the nursing home up to code several times over," he says.

Initially, the patients' attorneys prevailed, and a judge ordered Lenox to halt the evictions, though many of the Medi-Cal patients had already been removed.

But when it became apparent that it could not run the home as it wished, Lenox eventually decided to sell the home and allow it to close. This spring, a second round of notices was sent to all the home's remaining residents informing them that Lenox was getting out of Mill Valley.

As it fought Morrison & Foerster attorneys, Lenox also waged battle on another front. According to the "Mill Valley Healthcare Center" file at the California Department of Health and Human Services offices in Daly City, Lenox responded to the collection of state complaints -- an inch-thick sheaf depicting a facility essentially out of control with inadequate staff, missing medical records, and myriad failures to provide proper care -- by challenging inspectors' conclusions. Lenox submitted several watered-down "Plans of Correction" which were summarily rejected by state regulators. The state gave Lenox six months to fix things. The company failed to do so.

"They were given six months to make corrections, and they didn't do that," says Julia Abramson, whose father Larry was the last patient to leave the Mill Valley home. "I don't know why they didn't do it, unless they couldn't care less about their medical certification."

Finally, Lenox was forced by the state to hire a private consultant to manage the home while it looked for a competent buyer to run the facility. Residents and family members at first met this move with skepticism.

But it turned out to be a brief godsend. Under state pressure, Lenox hired Lynn Blair, a Pinole consultant who brought in a top-notch management staff and galvanized the remaining Mill Valley employees.

"That was a period when everything went exceedingly well," recalls Holland Gray, whose partner, Larry Abramson, was a patient at Mill Valley. "They weren't conscientious about anybody's eating until Blair and company came in. They used to put the tray in front of Larry in the room, and if he didn't eat it, they would say he didn't like it. Blair and company started having everybody who could, eat in the dining room. They would write down [the] percentage of food that was being eaten, and knew ... if he needed help eating."

During the patients' and families' struggle against Lenox, an esprit de corps emerged during regularly held family council meetings. As it became clear that Lenox wanted to sell the home, three young women who had been attending meetings came up with the idea of forming a nonprofit corporation to buy and run the center.

The plan portended a truly happy ending. Though the Mill Valley Healthcare Center had gone through a string of private owners during the previous decade, with the attendant varying levels of care, it was widely seen by people in Mill Valley as a community resource. High school kids regularly participated in county-sponsored programs held at the center, and many town residents had parents, aunts, friends there.

At first, family-council members tried to talk an established nonprofit nursing chain into buying the facility.

"We tried to find an established provider and, failing to do so, literally one of our members said, 'Let's roll up our sleeves and do it ourselves.' At first the idea made me laugh. But I came to believe that it really was possible," says Liz Rottger, a Marin County employee who was attending the family-council meetings.

Rottger, Kelly Philpott, a newly minted attorney who had once worked as a programs coordinator at the Healthcare Center, and Julia Abramson, whose father lived at the home, began to meet and scheme. Marin County is flush with nonprofit foundations that just might be willing to fund such a worthy cause, they mused.

"During the month prior to the closure, something very special was happening," Rottger recalls. "This was an opportunity to create a model nursing home in the United States. It would be community owned and operated. Profit margins had to be there, because you can't run something purely on faith, but that wouldn't have been the highest priority. We were going to use models of care with hospice, things that are cutting edge in terms of activities, so people don't feel that they are being warehoused. The idea was to make those residents who were there to the end feel that this was really their home."

Miraculously, the trio managed to gain commitments from nonprofit funding sources to meet the $2 million asking price for the home. They convinced a local realtor to work pro bono as their negotiating agent. While Lenox owned the license and the lease on the nursing home, the actual building was owned by the Auguello brothers, a pair of East Bay real-estate developers.

"Our offer went in. Everything was handled in a very professional manner -- it's not a lot different than when you go out to buy a house. This counter offer came in over the weekend, and I think there was a week that went by before they got back to us," recalls Rottger. "On the 23rd, they called and said they had decided to accept the other offer."

The home was sold to Eve Murphy, who owns a couple of homes in Santa Barbara. Murphy did not return several calls for comment. So it is unclear whether low-income elderly will ever again live at 505 Miller Ave.

The home was closed, its residents becoming a diaspora throughout the Bay Area.

Among the scattered was Dorothy Williams, a gracious, plain-spoken woman in a flower-print dress, who had been head of the Mill Valley Healthcare residents' association.

The final defeat didn't come as a complete surprise to Williams, though she had held out hope. Williams, like her former neighbors at 505 Miller Ave., came of age during World War II. She went to live in Germany in 1950, when her husband worked for the Immigration and Naturalization Service providing visas for the war brides American GIs were bringing home. Because she saw the postwar carnage firsthand, she wasn't left with the American optimistic, triumphal sense of the great war that is the stuff of popular folklore. She knows that all stories, even heroic ones, don't have necessarily happy endings.

"It was very sad, seeing the cities in ruins," she recalls. "It was devastating, seeing the hunger and the deprivation."

Williams moved from Europe to the East Coast, and then to the Bay Area in 1955, where she worked as an accountant for Pacific Motor Trucking Co. in Oakland for 16 years before she was forced to retire after two rounds of heart surgery. She lived for a decade at a Walnut Creek apartment complex for retirees. Then, with the onset of Parkinson's disease and continued heart trouble, she moved to a nursing home. That was hard, she says.

"I hate having to ask for help," she says.
Still, even though she was at the Mill Valley home for less than a year, she quickly made herself a circle of friends. She became head of the center's residents' association, and regularly attended meetings of the center's family council, keeping close track of the ongoing battle with Lenox. After the diaspora, she found a room at the Pine Ridge Care Center in San Rafael, the third nursing home she's been moved to in during the last two years.

She's tried to make friends at her new home, too, but it's difficult.
"I've tried, but they're either asleep, or they're in another world. It's lonely," she says. "That's why I do crosswords and read magazines."

With this latest move she finds that she's losing some of the resilience that got her through life on two continents, through two marriages, through failing health and narrowing possibilities. "The older you get, the more settled you become," she explains. "Some of it is remembering what I had, and what I don't have. It's not being able to do what I want to do; needing help for everything. I used to travel and do everything by myself, and all of a sudden I can't. And then, with this, it feels like I'm being tossed out the door again."

"So I do crosswords. I watch TV," she says.
At around noon, after a lunch of chicken and vegetables -- during which she graciously, charmingly insists that a guest accept a cup of sherbet -- a forlorn wail begins to waft through the air: "Looouuuiiieee. Looouuuiiieee."

"Her husband used to live here, and his name was Louie, and he died. It's very sad," Williams says. "That screaming kicks in in the afternoon and goes all night. Did you see the old picture One Flew Over the Cuckoo's Nest? It's kind of like that."

Williams doesn't speak of Lenox Healthcare Corp. with the sort of vehement scorn some family members, health officials, and elderly advocates do. But she does say that allowing conditions at the Mill Valley Healthcare Center to become so bad they were life-threatening, and humiliating, then attempting to yank fragile, poor people from their homes, is "something I'd never do to another person.

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