COTTAGE GROVE – The first conversation was far from easy, but it was inevitable – Sue can accept that. The time had come for her to move into an assisted-living home. Her husband had taken his life the year before, and the daily upkeep of bathing, picking up her prescriptions and cooking meals became too difficult to manage on her own. She’d reached the age she could admit to herself she needed help.
“I couldn’t really live alone,” she said, months later, stretching back into her La-Z-Boy. “I came in and it felt like a really good place. It felt like home already.”
Her daughter, Gina, was hesitant. They toured facility after facility, weighing pros and cons – rationalizing each shaky breath with a checklist of new questions – What’s the food like? How many nurses are there? Is a hospital nearby? What will Medicaid cover? How quick will they call me? Will she be happy here? Will they care for her like I could?
Eventually, they landed on Magnolia Gardens in Cottage Grove – a graying building on a residential street – with sunshine seeping through its windows and towering, woodsy pines out front. It’s a contained neighborhood with all the usual fixings – wandering cats, smiling neighbors and a lush, flowering garden.
For years, the caregivers at Magnolia Gardens embodied a philosophy that defined their service: treat older people as family, in facilities that feel like home.
“When we came here, Mom left feeling like she wasn’t going to be put somewhere to die. And that was the most important thing,” Gina said. “She knew she’d have the ability to be independent, but also have the help that she needed on a daily basis.”
The first six years were easy and manageable. Gina would visit her mom often, inviting friends to the dining room because the food was “restaurant quality.” Inside the bright building, the common areas were graceful and warm – colorful artwork here, freshly folded linens there. It was a perfect fit.
Sue settled in, watching birds through her room’s wide bay windows and painting landscapes with her new friends. She even joined a widows’ support group, closing a painful chapter and starting anew.
“At the time, it was the absolute right decision,” Gina said. “But would I put her in Magnolia today?” she asked in late 2022. “No. I wouldn’t.”
Last year, Magnolia Gardens was ranked among the 10% of facilities in the state with restrictions on its operating license, according to the Oregon Department of Human Services Office of Aging and People with Disabilities (APD). According to Fred Steele, Oregon’s long-term care ombudsman, Magnolia Gardens is well-known to state health advocates for “abuse and neglect complaints.”
And in July of 2022, the state found residents were in “immediate jeopardy” in the $3,600- to $6,000-a-month facility, as outlined by license conditions acquired by The Chronicle via a public records request.
Since acquiring Magnolia Gardens in 2019, Mosaic Management Inc. has paid nearly $30,000 in fines to the state on abuse and neglect charges at the Cottage Grove operation, according to data from ODHS.
Missy McAllister is the director of operations for Mosaic Management, and oversaw the improvements and compliance standards for Magnolia Gardens.
“I want to make sure that our residents know, while it’s frustrating and it’s been a tough six months in that community, we remain committed to them,” she said in mid-2022. “We’re standing with all of the leaders of the community and helping them get through it.”
Since the release of the licensure survey in 2022, Mosaic Management has hired additional staff and consulted with state-appointed registered nurses to update internal policies and procedures, McAllister said. “We now have outside state-approved consulting agencies conducting audits of each of our communities so that we can assure a third party is evaluating our systems, resident care and staff training programs. This allows for more oversight and support for the executive directors.”
And while today, Magnolia Gardens is in full compliance, meaning there are no restrictions on its operating license, Gina will be the first to tell you something still feels off.
“I still have the feeling that she’s not getting the care that she was when we first moved her in,” she told me.
State Intervention and Compliance Survey
Late into the Covid pandemic, Gina and Sue started reporting what they were seeing to Adult Protective Services (APS). In February of 2022, a full audit, formally known as a licensure survey, was conducted by the Oregon Department of Human Services Office of Aging and People with Disabilities.
“The APD has oversight of licensed nursing, assisted living and residential care facilities, including those with an endorsement to provide memory care – as is the case with Magnolia Gardens Memory Care,” said Elisa Williams, communications manager for ODHS. “Our priority is ensuring that licensed long-term care facilities are following regulations to ensure the safety and well-being of Oregonians who are counting on them.”
The regulatory framework for conducting these surveys is a fairly new one — first passed in 2017 and updated by a companion bill (SB 266) in September of 2021. The implementation of SB 266 is still being ironed out in a state rules committee.
The companion bill increased ADP regulatory mandates, establishing for the first time in Oregon law a mandate for ADP to be proactive in investigating licensing violations other than abuse or neglect, and to prioritize the health, safety, and welfare of residents in their regulatory approach. The surveys act as snapshots, a record of the challenges facing facilities at any given time, rather than a continuum of allegations.
In the 2022 ODHS survey obtained by The Chronicle through a public records request, Magnolia Gardens Senior Living received 13 violations – including failures to report and investigate abuse, medication administration and providing adequate staffing requirements to meet the “scheduled and unscheduled needs” of its 108 residents.
“We have pretty solid survey outcomes for the most part,” McAllister said, speaking to the contents of the ODHS survey. “It [the survey] affected staffing and morale from the resident standpoint and staff standpoint. You can understand their frustration. (Residents) don’t understand that there is a crisis across the nation, this isn’t isolated to one community. But all they see is there’s not enough health care and staff isn’t trained well enough. We just have to keep doing everything that we can to combat these big issues, and support each community as much as we can.”
The survey tells the story in great detail: Covid-positive patients going untested and participating in group meals and activities. Medication administration being skipped or missing.
McAllister says in response to the survey that staff at Magnolia Gardens have been “retrained on the medication delivery system” and that “there was some confusion” on the shower documentation system. “We felt confident that our residents were getting showers, but the documentation doesn’t show that,” she said.
The survey also describes a lack of oversight when it came to “high support” residents’ needs. In one instance, a single resident admitted as a “frequent faller” was found by caregivers, on the ground, after falling “unwitnessed” six times in one month – resulting in numerous trips to the emergency room, pain, abrasions, a head injury and hip surgery.
Another documented violation relates to staffing shortages and employees working “universally,” and “out of role,” cleaning the dining hall, showering patients, serving meals and administering medication without proper licensing.
“It’s been a madhouse around here lately,” the OHDS survey states, referencing a Magnolia Gardens employee whose name was redacted.
McAllister says in response to the survey that Mosaic has been “increasing staffing levels, increasing wages and benefit packages across the board.”
After the February 2022 survey was released, Mosaic’s leadership team was given time to address the issues, as per ADP policy. In July 2022, another DHS team was sent to evaluate Magnolia Gardens, as a follow-up to the February survey, resulting in the restriction of its memory care facility. Those restrictions were outlined in an amended “notice and order imposing license condition,” from July, obtained by The Chronicle through a public record request.
“The facility’s failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety and welfare of its residents,” the notice reads. “In addition, DHS finds that the residents of the facility are at risk of immediate jeopardy. That is because the facility’s failure to comply with DHS’ rules has caused or is likely to cause serious injury, serious harm, serious impairment or death to a resident or residents.”
• The notice described five violations, including:
• Failing to have sufficient staff to meet the scheduled and unscheduled needs of residents.
• Failing to carry out medication orders as prescribed.
• Failing to assist residents with bathing.
• Failing to establish and maintain infection prevention and control protocols.
• Hav[ing] a training program that includes methods to determine competency.
The notice on Magnolia Gardens’ license to operate its memory-care facility prevented Mosaic from admitting new residents and ordered an ODHS-approved registered nurse consultant review and evaluate internal systems as well as maintain a presence in the facility.
“When facilities demonstrate a pattern of being out of compliance, or have a serious incident that indicates systemic issues, ADP may put a condition on their license or enter a letter of agreement with a facility on changes that need to be made,” Williams said. “In some cases, these measures can require that a facility bring in an outside consultant to provide the facility with oversight and guidance until it can get into compliance.”
McAllister describes the relationship between Mosaic and ODHS as a collaborative one, saying, “We try to treat them like we would any other customer. We try to be communicative and honest and when they ask something of us it’s our priority to get that done.”
Today, with the support of State Intervention, new leadership at Magnolia and hard work from caregivers, the notice was removed in March 2023 from Magnolia Gardens. For McAllister, it’s a reminder of her commitment to residents.
“These things do happen,” she said. “And we’ve got a lot of people and a lot of resources that are helping the community move forward.”
Mosaic steps in, staff, residents feel the impact
In 1995, Carmen Young founded Magnolia Gardens, planting 12 magnolia saplings on the property to commemorate its groundbreaking. In 2019, once Young was on her way to retirement age, an offer to sell materialized from Mosaic Management Inc., a private-equity corporation based in Salem.
Today, Mosaic houses over 600 residents and employs roughly 550 staff — operating assisted-living homes up and down the West Coast, in Idaho, Oregon, Washington, Montana, and California.
The deal was finalized. Mosaic was brought in to run the home’s day-to-day operations.
Staffers recall that in early meetings the company said it wouldn’t institute significant changes – but many felt a disconnect.
Ona Secord worked at Magnolia Gardens for 10 years, staying on through the management transition. She followed in her mother’s footsteps, who worked at Magnolia before her.
Ona describes the act of caring for elders as intimate, compassionate and important.
“If you’re a good caregiver … your love and compassion for them is what makes you stay and put yourself through so much,” she said. “It’s nice getting to hear their stories of childhood and to see the world through simpler times. Understanding the struggles they’ve been through really makes you appreciate the things you don’t have to (deal with).”
She started as a dishwasher, working her way up through the ranks, eventually filling in as the interim director during the ownership transition.
She said she felt a change within Magnolia under the new leadership, not only in the quality of care but in the hours she was asked to work.
Her longest shift? Twenty-one hours, she says.
Some mornings, she recalls, there were only two nursing aides tending to the 108 residents at the facility.
“Understaffing is huge and the neglect is even bigger, because of it,” Secord said, in August.
The intercom system crashed, the fire alarm only rang in one portion of the building, and diabetic-friendly meal options weren’t readily available, according to the 2022 ODHS Survey.
No longer did the kitchen serve an eclectic variety of main dishes such as popcorn shrimp, crispy french fries, or homemade chicken soup. Now residents were commonly given an option of ground beef and potatoes. Some days, the kitchen was so short-staffed that meals were hours late, Gina said.
“When Mosaic took over … there was no continuity of care, which was devastating for Mom. There was no feeling of being heard. You’re treated like an object, not a person,” Gina said.
The attentiveness of the nursing staff plummeted, she added.
Since the turn of the century, private-equity investment in nursing homes has grown from $5 billion to $100 billion in the U.S, according to research from the Institute for New Economic Thinking.
The research explains that cost-cutting is to be expected in any business, but nursing homes are particularly vulnerable, and staffing often represents the largest operating cost. So, when firms buy a home, they cut staff to cut costs.
“There were a few times it was just me running memory care,” Secord said. “It was just wild. And people didn’t want to pick up shifts – and you’re short-staffed already, it’s a mess. That’s one less bed you can get to. One less shower.”
The issues faced at Magnolia Gardens reflect national trends. According to a recent study published in The Journal of the American Medical Association (JAMA), residents in homes acquired by private equity were 11.1% more likely to have a preventable emergency department visit and 8.7% more likely to experience a preventable hospitalization, when compared to residents of for-profit nursing homes not associated with private equity.
The study determined that nursing homes with fewer nurses bathe residents less often. They fall more, because there are fewer hands to help them to the bathroom or into bed. They suffer more dehydration, malnutrition, and weight loss, and higher self-reported pain levels. They develop more pressure ulcers and a greater number of infections. They make more emergency-room visits, and they’re hospitalized more often.
Another paper, published by the Journal of the American Geriatrics Society, examined 18,000 nursing-home facilities over a 17-year period and found that private equity ownership increased excess mortality for residents by 10%, increased prescription of antipsychotic drugs for residents by 50%, decreased hours of frontline nursing staffing by 3%, and increased taxpayer spending per resident by 11%. That suggests an additional 20,150 lives lost as a result of private equity ownership.
Whereas staffing levels influence costs, occupancy rates determine profits. Firms have an incentive to fill more beds – Medicare pays $585 per patient per day; Medicaid pays $245. Neither adjusts the rate for quality, resident satisfaction, or reputation. If a nursing home can bring costs below the daily rates of Medicare and Medicaid, it can pocket the difference.
And residents notice.
As a diabetic, Sue requires insulin, administered by a qualified staff member, multiple times a day. She says she went days without her medication. Sue is classified as “high risk” for a stroke, so the lack of medication was a serious oversight.
Her daughter was furious.
“They ran out of it,” Gina said. “We’re paying for my mom to be taken care of, and she could have been hospitalized and hurt because they forgot to give her the medication.”
This wasn’t the first time Mosaic Management had been under fire for its labor standards.
In November of 2021, Arryin Andrade, a former Mosaic employee, sued the company for retaliation, arguing she’d been wrongfully terminated. In court documents obtained by The Chronicle, the complaint alleged:
“Over the course of her duties, plaintiff [Andrade] became aware that defendant [Mosaic] was misclassifying several employees (including lower-level employees) as salaried and exempt from state and local overtime requirements.”
According to the complaint, Andrade alleged she then brought the misclassification to her superiors and was told she was “sticking her nose where it doesn’t belong,” and directed to adhere to the defendant’s classification of those employees, regardless of whether Andrade “considered the defendant’s [Mosaic] conduct to be unlawful.” On May 23, 2022, the case was dismissed and the parties reached an unspecified settlement.
McAllister declined to comment on the case but said she “was not involved in any of the allegations or claims.”
Pandemic
Then the pandemic hit, and nursing homes everywhere were a particularly dangerous place to be – not only for staffers, but for residents and families, too.
Visiting wasn’t allowed, and assisted-living facilities across the nation felt the deadly impact of the disease. Recent CDC reports show that 23% of all COVID-19 deaths in the United States were in long-term care facilities. And according to the Oregon Health Authority’s (OHA) November 2022 COVID-19 Monthly Congregate Care Setting Outbreak Report, Magnolia Gardens’ total number of deaths is eight times the state average.
McAllister said that leading a team through the pandemic was the biggest challenge of her 23 years in the industry.
“Everyone, at every level, was in survival mode. Trying to minimize the impact on our residents and the impact of the deaths that occurred throughout some of our communities – and how that impacted the people that care for them, let alone families that couldn’t even come in and sit with their loved one while they were passing … I’ve never experienced such a challenge of leading a team in my entire career,” she said.
For Gina and Sue, the pandemic put up new barriers. They were used to checking in every day, sharing meals and swapping updates. The pandemic put a halt to their easy routine. But despite the challenges, the two regularly connected via video chat and stayed close through it all.
“The building was locked down and most people stayed in their rooms because they were afraid to come out, afraid to get sick; at my age, I could die if I got that,” Sue said. “It was really scary.”
During the lockdown, residents were restricted to their rooms. There weren’t enough hands to stop them from falling, let alone to take them outdoors.
ODHS’s regulatory power
Choosing a nursing home involves sifting through reams of information and painstakingly comparing choices with available alternatives. But the decision-making process often occurs during a crisis – after a parent has fallen or suffered some other medical emergency — and tools to simplify the process are lacking.
At the state level, advocates see the challenges at Magnolia Gardens as linked to a larger system, rather than an isolated incident. Steele, Oregon’s state long-term care ombudsman, is an advocate for residents and resident needs across the state.
“When there are numerous complaints and problems at a facility, those issues need to be investigated from a consumer protection mindset – rather than DHS going in, identifying the problem, and then simply telling that facility to follow the law,” Steele said.
Over the past two years, Steele and others have been advocating for DHS to become more of a regulatory agency. Two bills passed in the 2021 Oregon Legislative session were key to the rise in license conditions, advocates say.
Senate Bill 714 created a tool for establishing staffing requirements at each facility, which became paramount after the lingering effects of the pandemic.
“Acuity-based staffing tools help facilities determine the amount of staff time required to assist each resident including the number of staff necessary to meet each resident’s needs and the type/level of staff training necessary to address the level of care a resident requires,” Williams said. “Staffing is something we care deeply about in Oregon, as inadequate staff is often the cause of safety and quality-of-care issues.”
The law removes the flexibility for special scheduling and requires residential care facilities to use the staffing standards predetermined by the state – to assure families that their loved ones receive the care and attention they need.
“There have been staffing shortages and workforce shortages in the caregiving realm for many, many years, pre-Covid. But if you listen to the industry, they make it sound like it’s a new crisis,” Steele said. “Low staffing was a reflection of what had been a lack of regulatory oversight, or lack of regulatory enforcement or a lack of respect for following the requirements in the industry.”
Senate Bill 266, which updated the survey framework used to regulate long-term care facilities, allows for ADP to implement new program elements. “This legislation revised the regulatory authority to take a progressive approach,” Williams added.
The new elements include the qualifications for obtaining a residential care administrator license, standard infection control guidelines, metrics for quality measurement, facility-enhanced oversight and supervision standards and gathering consumer summary statements. Once the mechanics of each of these programs are finalized, training materials will be provided to facilities to assist in the implementation of the new requirements in the hopes of focusing department staff attention on residential care or assisted-living facilities that “consistently demonstrate a lack of substantial compliance” with regulatory requirements, according to the Senate Bill 266 Regulatory Framework Guide.
There’s an active debate over whether nursing-home deterioration is caused by private-equity acquisition, as senior-care advocates contend, or if private-equity firms tend to acquire homes that are already deteriorating.
“From our perspective, it seems that business decisions are being made for profit rather than for care of the individuals,” Steele said in reference to corporate ownership of senior-care facilities in general. “These aren’t all companies that necessarily get into the business to provide services to the consumer. Some are effectively real estate, property, and investment-oriented companies. That’s why it’s important to have a stronger regulatory body to ensure that we can move towards compliance in long-term care as a state.”
Looking ahead
Still, months later, after the survey, the staff increases, the license condition and the numerous Covid-outbreaks – Sue is optimistic. She said the survey system had worked and she noticed tangible changes. Her medication is coming on time. The food is better. More residents are moving in. Management even replaced the carpet in her room.
“Yes, there are problems here. And challenges,” she said. “But the thing that has kept me here is the people. They give me purpose. Some of them can’t speak up for themselves or pay attention. I know I’m needed here.”
Today, nurse-staffing levels are reaching a stable level – but turnover is still a concern for families and residents.
“Nurse staffing is better now,” Gina said. “Some things have changed, and some things are still the same. I still feel like they might have met whatever state standards they needed to during that inspection, but I don’t know that it’s going to be consistent.”
For Ona, the residents are at the heart of why she stayed so long. “I think caregivers and everybody who is a support worker for the elderly have such a dedicated job,” she said. “You’re caring for their life, their life is in your hands. And you have to be compassionate, you have to listen.”