Months before she died, Lourdes Yldefonzo Arganda assured her sister she would be safe in her job at a Marysville nursing home.

Even before the pandemic, she had accepted that her work as a certified nursing assistant — with long and late hours, and low pay — was a calling, her sister Irene Yldefonzo Arganda said.

If anything bothered her, it was that co-workers sometimes could not help patients quickly enough during busy shifts.

“She always wanted to take care of people,” her sister said in a phone interview from her home in Sacramento. “She wants to take care of her patients, but she doesn’t want to be the patient.”

Lourdes, 61, caught the coronavirus in late November amid an outbreak at the Marysville Care Center, a facility with a history of short staffing, where she worked the overnight shift. In one Facebook post, she questioned what she could have done wrong after trying to help as much as she could. She died Dec. 24.

A new state inspection report shows the toll of her concerns about time-strapped staff at Marysville Care Center.

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The 339-page review, released by the state Department of Social and Health Services (DSHS) in late January, paints an especially bleak portrait of the situation inside the facility in the fall, around the time of a major coronavirus outbreak that killed Yldefonzo Arganda and 17 residents.

It is also one of the first deep looks inside a long-term care center since the pandemic began, when lockdowns left families and the public largely in the dark on how facilities were dealing with the twin crises of short staffing and COVID-19.

State inspections had been limited to infection-control issues early in the pandemic, before returning to review neglect and abuse allegations, among others.

Starting Feb. 18, the state plans to deny Medicare and Medicaid payments for all new admissions as a result of inspectors’ findings, and the facility has two months to reach compliance. The facility was fined $18,000 by the state, with the possibility of federal fines.

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One resident had two seizures after staff missed doses of his medication. Another resident, who checked into Marysville Care Center to recover from a fall, was given antidepressants that made her drowsy, despite her family’s objections. She was able to drive and dance with her grandkids before going to Marysville Care Center. But after a few months there, another fall landed her in the hospital, and her dramatic decline was clear.

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“She smelled really dirty,” her son told inspectors, adding that one of her toenails was so long it curled under her toe. “She was skinny and ghost[ly] looking, she had blood on her head and in her hair, she had no idea who I was whatsoever.”

Inspectors found the facility didn’t have enough staff to care for residents, leading to widespread neglect and placing them at the highest levels of risk. Administrators continued to admit new patients despite what the report called “squalid” conditions.

Turnover and insufficient oversight left the building “understaffed and unprepared” when the coronavirus struck, ultimately spreading to 60 people. The state found that corporate leadership knew or should have known about the issues.

Abraham Ritter visits with his mother, Patty Ritter outside the Enumclaw Health and Rehabilitation Center on Friday September 18, 2020. Ritter, who’s mother has been at the facility since 2004, has had concerns about staffing levels and his mother’s care.  215082 (Mike Siegel / The Seattle Times)
Nursing homes in Washington state struggled with adequate staffing for years. Then coronavirus struck.

Executive Director David Duvall said in a statement that administrators are addressing the issues to prevent them from reoccurring. Duvall, who was hired just months ago, said new leadership has more oversight from those at the corporate level.

The report on Marysville echoes findings of a Seattle Times investigation in September, which found the state’s low standards for staffing levels left residents in many Washington long-term care facilities vulnerable to suffering in the years leading up to the pandemic.

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The new findings against Marysville also do not represent the first time inspectors cited the facility operated by Life Care Centers of America, one of the nation’s largest nursing home chains, for staffing struggles, as The Seattle Times reported

Marysville Care Center was cited just before the pandemic for insufficient staffing and for neglect, as its most vulnerable residents in one particular unit went without showers, The Times reported.

When inspectors visited in November, responding to 21 complaints to DSHS from residents and their families, they found the neglect had spread to the whole building of 72 residents.

A third of the residents hadn’t received a shower in a month, while another third received just one.

One resident suffered from “a rotten odor” and pressure injury resulting in an open wound about 3 inches wide and 2 inches deep. Her calves and feet “had very dry, thick, crusty skin,” making part of her bed look as if it was covered in “a slight layer of snow.”

A director of nursing who resigned in August said she told corporate leaders that the building faced a “staffing crisis” and needed to stop admissions. Yet new residents continued to be admitted, and she was told to cut shower aides.

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Life Care chalked the resignation up to a personality conflict. But inspectors found that the facility had gone through at least six directors of nursing in 2020, half of whom lasted only a month, and at least six administrators since 2019. Turnover rates for nursing assistants and registered nurses were about 100% last year. When inspectors visited, two resident care managers had just quit, leaving one for the whole building.

“It’s hard not to neglect residents when you don’t have enough staff,” one staff member told inspectors.

On a particularly bad night, two nursing assistants worked a 12-hour shift caring for 29 residents. Both said it was an impossible task. Most of the residents required two-person lifts. Call lights were left blinking for an hour and a half.

Inspectors also found that in nearly two dozen cases reviewed, the facility failed to follow its policies on preventing and investigating abuse and neglect. Neither the then-administrator nor the then-director of nursing, who had been there two weeks, knew the policies.

The state found that corporate and facility leaders failed to address neglect, understaffing and lack of supervision at all levels. By not halting admissions, the facility was “further rationing out already inadequate care” and subjected new residents to “unacceptable” conditions. 

The facility was in a precarious position when it had an outbreak in November.

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It ran out of gowns the first day that the building was put on “code yellow,” requiring full PPE in all resident rooms, and some staff weren’t aware of the requirement. 

When inspectors visited the unit for residents with COVID-19, dirty linen barrels overflowed in the hallways and garbage cans in residents’ rooms overflowed with soiled PPE and trash. The two nursing assistants caring for 19 residents were also expected to handle housekeeping and showers. The assistants told inspectors they often didn’t have time to clean.

The state Department of Health expressed concern that the facility was understaffed during the outbreak and that there was not an active director of nursing or infection-prevention specialist. The facility also failed to provide updates on new cases.

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Toward the end of November, Yldefonzo Arganda told her sister how upset she was — that she believed someone had come to work sick and that others were beginning to cough during shifts.

The facility kept coronavirus tests on site, had a strict screening process for workers that required temperature checks and did not allow them to work if they showed virus symptoms, said Nancy Butner, vice president of Life Care’s northwest division. But the virus still entered the facility.

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Butner added that the company has made numerous efforts to recruit and hire more staff.

Yldefonzo Arganda, who started at Marysville in 2019, began to worry about her health and safety after long being the type to tell others she was OK. She had taken so many coronavirus precautions in 2020, and made it to the final months of a devastating year for nursing homes without getting sick.

She had always been the one in the family to push others to be extra careful about the virus, her sister said. Always fun-loving, she had chosen a favorite song — “Mambo No. 5” — that they could sing or think of while washing their hands for a full 20 seconds. She put masks inside Ziploc bags for loved ones to keep in their cars.

“None of us can really comprehend what happened,” said her sister, who said Lourdes, a widow since 2016, was survived by siblings and nieces and nephews. “It’s just really hard every single day.”

Lourdes visited an emergency room in Everett on Nov. 30 for her COVID-19 symptoms. That day, doctors sent her home because her temperature was going down. But she still had trouble breathing and returned at 5 a.m. the next day.

She never left the hospital again, learning while there from state health officials that other co-workers had been infected, too.

Lourdes made her last call to her sister on Dec. 5, a Saturday, saying doctors were putting her on a ventilator. She still believed she would recover, she said on the phone. “Don’t worry about me, don’t cry,” her sister recalls her saying.

Her sister wept as she recalled the memory.