A California Department of Public Health dashboard shows no skilled nursing facilities in Santa Cruz County are reporting resident or staff COVID-19 cases. At Pacific Coast Manor, however, residents are still allegedly in a perilous situation.

The family members of residents and former employees detailed more than 20 allegations waged against the Wharf Road facility, which the Sentinel sent to Covenant Care. Heidi Stone, Covenant Care’s regional director of business development, did not specifically address any of the alleged misconduct.

“The care and well-being of our residents is our paramount priority at Pacific Coast Manor,” Stone wrote in a statement. “We are proud to have received five stars out of a possible five stars from Medicare for Quality of Resident Care, as well as an overall rating of five stars. Pacific Coast Manor is the highest rated skilled nursing facility in our area of service.”

Following former executive director of Pacific Coast Manor Marise Goetzl’s sudden retirement after the Sentinel’s first article on neglect at the facility, four families approached the publication to talk about their experiences. Several had filed complaints with the California Department of Public Health that were shared with the Sentinel. Some had contacted Covenant Care itself. At least two families went to court to battle the administration of Pacific Coast Manor.

Mistreatment

It was Gigi Sondgroth who first spoke up in late 2020 about the solitude her parents felt before and during the COVID-19 health crisis. Her father Duane would be left staring at the wall, with no entertainment, during the height of the facility’s fall outbreak, she said.

This is similar to Kathie Pieper’s story about her mother, Arlene Pieper Stine, who spent the last few months of her life in the middle bed of a room at Pacific Coast Manor. She had an 8-foot by 8-foot box of her own space to exist in. She died just one week before the initial Sentinel article was published Feb. 20.

“They wouldn’t even open her window so I could say hello during COVID,” Kathie Pieper said.

Crystal Andrade, a previous dietitian aide for the facility and the granddaughter of late resident Maria Martinez, said the inactivity was occurring pre-COVID-19 — the facility was known in its field, she said, for letting patients to become bedridden from a lack of engagement and exercise.

“I talked to several families before COVID-19 and they would say that their mom or grandma or aunt would be laying in bed and they would end up with bedsores,” she said. “If we weren’t there to take (my grandma) out onto the patio … if it wasn’t for my uncle or my mom being there to take her out and go to bingo, (staff) wouldn’t have done it for her.”

Those that needed help from certified nursing assistants to clean themselves up or use the bathroom relied on help that they said hardly came. Helene Luna, who quit when she found out the administration hadn’t notified her of a requirement to renew a license, alleged a failing staff-to-resident ratio worsened the conditions.

“I stepped in as much as I could and I felt like some of the staff wasn’t,” Luna said. “There were clients or residents who hadn’t been changed for numerous hours … There were times I’d go to try to change a client, get them up on a bedpan and their B.O. was just awful. They weren’t getting bathed.”

Improper cleaning, illustrated by a practice where nursing assistants allegedly put a dry brief under a mattress saturated with bodily fluids, led to a history of urinary tract infections (UTIs) for Martinez, current resident Angela “Lola” dela Riva and another current resident whose family asked they not be named for fear of retribution from Covenant Care.

“I went to the doctors (with her) and I have photos. She had fungus growing under her arms and they looked at her (private area). There were dried tissues because they use it to apply (medicine),” dela Riva’s 16-year-old granddaughter Liliana Maya delaRiva said. “They didn’t even clean it.”

In her first three years as a resident at the facility, Martinez’s doctors recorded 19 UTIs, medical paperwork contributed by her family shows. Approximately half of the urine tests done on her detected E.coli, a bacteria found in the GI tract that can cause UTIs. Her son Eddie Martinez said that by the time she died in December 2020, doctors at nearby hospitals had treated at least 30 UTIs.

Both families had to consult the State of California Health and Human Services Agency in 2016 when their mothers were released to the facility but the facility did not accept them back. This practice, called “hospital dumping,” is when a nursing home leaves a resident without future housing, stuck at the hospital until they can figure out arrangements.

Pacific Coast Manor noted “a change in health” for Martinez and “problematic behaviors” for dela Riva as excuses to discharge them. Both were eventually readmitted, as they were not properly noticed and did not execute a bed-hold period, appeal documents from the dela Rivas show.

“Appellant reminded Facility of its obligation to provide the care and services required by its residents, and that readmission rights do not apply only to those residents that ‘act ok,’” wrote Administrative Appeals staff from the California Department of Health Care Services.

It happened to the Martinez family again in 2019 when Goetzl, according to a family-supplied letter to the facility from California Advocates for Nursing Home Reform (CANHR) staff attorney Anthony Chicotel, tried to condition the matriarch could return if her son agreed to never visit again.

“In other words, Pacific Coast Manor shamefully forced Mrs. Martinez and her son to waive their rights to visit with one another before permitting Mrs. Martinez to return to her home,” Chicotel summarized.

Unpreparedness

COVID-19 infections ran rampant at least in part due to loose or nonexistent infectious control protocols. As recently as November, the facility was cited for federal deficiencies around its prevention and control program. In February, Stone of Covenant Care said that the facility’s most recent deficiencies were just around an aid dropping a piece of paper during the inspection and a housekeeper not using an alcoholic anti-bacterial before putting on gloves.

To help bulk up its short staff, Pacific Coast Manor allegedly brought in student nurses from Capitola and San Jose during the health crisis. One of them contracted COVID-19, which spread to both residents and administrators such as Goetzl — who admitted her positive test to Eddie Martinez as she continued to work with residents, sick or not.

“Right then and there, it’s her job to have someone do temp checks or check for symptoms of COVID,” Andrade said of Goetzl.

Some student nurses allegedly didn’t mind the severity of the situation. According to another Martinez granddaughter, Vanessa, she would see the group congregate without masks at her place of employment, a restaurant in Capitola, and other local eateries.

“(Goetzl) told me, ‘I’m sorry, we are required to have them here’ and I asked why and she said, ‘We are running out of nurses’ and I said, ‘What do you need nurses for if you’re killing people? Who are they gonna take care of?’” Eddie Martinez said.

Text messages to Eddie Martinez from a CNA that did not reply to requests for comment confirmed the extended stay of the student nurses after federal and state COVID-19 funding had been disbursed to skilled nursing and other patient-based facilities. She apologized to him, calling the move the worst thing imaginable for the facility’s residents.

“It was all about the money, obviously,” dela Riva’s daughter Osa Hidalgo de la Riva added.

Transmission peaked when residents were moved from their usual rooms to new ones, an alleged idea from the administration to consolidate patients into a COVID-19 wing and non-COVID-19 wing. Dela Riva’s room was in the designated COVID-19 wing, so she was moved and the Martinez matriarch was put in her place. After Martinez died, dela Riva was allegedly moved back into her room before the woman’s things had even been collected.

“They were moving negative people into previously contaminated rooms,” daughter Laura Ann delaRiva said. “My mom had had several people die in her bed and they (brought) the dying into her room. They died next to her three times in a row. My mom tested positive within a week.”

The Martinez family alleges that the nurses did not attend to their mother regularly the second time that a staff CNA exposed her to COVID-19, letting her oxygen levels drop dangerously low. Records from Dignity Health confirm a positive COVID test on Dec. 8 when she was admitted again for acute respiratory failure. At the time, notes from a doctor indicated she was experiencing severe sepsis on top of her pneumonia because of the UTIs; one week later, she died.

“I teared up wondering how much she was suffering,” Eddie Martinez said.

“You saw her in the coffin, that’s how much she was suffering,” his sister Antonia Martinez said as she sat beside him, tearing up. “You couldn’t recognize her.”

Kathie Pieper lost her mother’s spirit before she lost her physical presence. A woman who had once been the first in the U.S. to complete a marathon but had stopped finding the will to live, Pieper Stine was depressed in the end, just as records showed Martinez had been for some time. Neither of the women, their children indicated, received counseling. Kathie Pieper offered to pay staff to stay with her mother for a semblance of company.

“She didn’t have many body aches at first, she didn’t get real severe symptoms but she did lose her appetite,” Kathie Pieper said of her mother’s bout with COVID-19 in late 2020. “I think COVID led to her (downfall). With nobody else being able to go in and give her any care, she just never recovered from it.”

Separation

The families allege that administrators did everything they could to divide residents from their loved ones. The dela Riva, Martinez and Pieper families had to call the front desk and ask for nurses to find and provide cell phone chargers they say were hidden purposefully so that FaceTimes and phone calls happened less frequently.

Perhaps, they claim, it was so that family members who could not come to visit did not know how bad things had truly gotten. Pieper Stine went from happily greeting residents in the parlor and fighting for those without families during care meetings with staff to calling her daughter in the middle of the night to plead for a way out of the skilled nursing facility.

“She said, ‘I want to go home, I gotta get out of here,’” Kathie Pieper recalls. “She said, ‘People are dying. You better come and get me.’ She was screaming… it was just so heartbreaking.”

Communication was even more difficult for those who barely spoke English. Her family alleges that Martinez was regularly assigned nurses who did not speak Spanish, her first and beloved language.

While the resident asked them not to make a big deal of the discrepancy, they said, tensions between the administration and the Martinez and dela Riva families escalated when only their mothers’ windows were made to be permanently shut, with locks on the screens. They claim they saw white families hand things to their relatives through the windows for weeks afterward.

“We don’t want to make it so much a racial issue, but in a way it was,” Eddie Martinez said.

Some listened to their family members and didn’t make a big deal of what they witnessed. Martinez warned her children and grandchildren of stirring up trouble, allegedly promising she was OK as she laid with her toenails unclipped and other necessities unaddressed. But those who pushed for their residents through acts such as asking staff members to flip their badges to the front, so names were visible, faced retaliation through alleged means such as demeaning nicknames over the PA system. Retaliation, in Eddie Martinez’s case, meant a temporary restraining order.

The son was first dragged to court over the supposed harassment of staff members, but especially a specific CNA, when text messages offered to the Sentinel show that they had a cordial, friendly relationship. She even offered to make sure he and his mother FaceTimed after Goetzl took him to court and only let him come back to check on his mother with conditions. Character testimonies in his favor included active employees from Pacific Coast Manor.

The families tried not to let the obstacles deter them and prioritized focusing on calling or coming in to care for their families. All the while, staff tasked with caring for them had very little motivation to do good work. They cared about the residents, but behavior from higher-ups made it hard to want to stay, according to former employees.

“When I would go there, she had her favorites and would just say hi to whoever she was comfortable saying hi to,” Andrade said of her old boss Goetzl. “I told her, ‘I don’t think it’s fair that you… act like other people are invisible.’”

Goetzl allegedly created an environment of fear — fear that, in a competitive work environment, people would lose their jobs and fear that, if things ended on bad terms, she would call around and make sure they never got a job in the industry locally again. This happened to a maintenance director just two months before the pandemic hit, Roger, a former maintenance employee who requested his last name not be included, alleged. That was the fourth maintenance director he had outlasted.

Luna said many were guilt-tripped into working doubles on their day off. Most of those individuals, Roger said, hadn’t gotten a pay raise in years. But they endured the abuse, allegedly listening to instructions to hand over their phones and never reach out to residents who were hospitalized or discharged from the facility.

Roger drove a bus for the facility that transported residents to and from medical centers; he had never once been provided with any kind of emergency training.

“They’d have me pick up people and I’d kind of catch on at the hospital and say, ‘Why does everybody have gowns and gloves on?’ And (hospital staff) would say, ‘Didn’t they tell you? They’ve got (contagious) C. diff.’ They wouldn’t fill me in, I was going in there blind. I learned the hard way. I had to protect myself.”

What mattered most to the administrator, Antonia Martinez said, was a good CDPH inspection.

“Her license mattered more than the lives of those people,” she said.