Report: Crestwood Behavioral Health
In 2009, Citizens Commission on Human Rights (CCHR) published its report, Universal Health Service: Profits over Patients, to expose this for-profit mental health chain’s scandalous history. It was initially motivated by reports of the deaths of three teens in Universal Health Services (UHS) psychiatric facilities—one of which was ruled a homicide. However, further research into UHS found incident after incident of crimes and human rights abuses: patient neglect, physical and sexual assault, more deaths, criminal convictions of facility staff, and more.
But it also uncovered something more: the existence of many other for-profit mental health hospital chains—perhaps not as large as UHS, but with the same kinds systemic abuses which are common to the for-profit mental health model.
One such chain is Sacramento, CA-based Crestwood Behavioral Health, which has 23 locations in northern and central California.
KEY POINTS:
· Several Crestwood facilities have been inspected multiple times by the California Department of Health and issued Statements of Deficiencies.
· One Crestwood facility was cited by the state relative to the death of a patient, and ordered to pay the highest possible fine.
· Crestwood facilities have been sued for personal injury, wrongful death, property damage, race discrimination/wrongful dismissal of staff, and other causes.
· One suit, which alleged that Crestwood staff failed to properly treat a diabetic patient, which left the patient in a permanent vegetative state, resulted in a $2 million settlement.
· A psychiatrist affiliated with one Crestwood facility was placed on probation by the California Medical Board for excessive prescribing and corrupt acts, among other things.
TIMELINE:
April 27, 2004: A lawsuit filed March 21, 2003 against Crestwood for deprivation of civil rights, wrongful death, and dependent adult abuse, was settled prior to trial. (Simpson v Contra Costa County, Crestwood Behavioral Health, et al. Case #3:03-cv-01223-THE, U.S. District Court Northern District of California.)
June 2004: A story in the Napa Valley Register reported that Crestwood Center in Angwin, CA “got a scolding by the Napa Valley Planning Commission” at a compliance review meeting in which neighbors of the facility “chronicled a variety of incidents…which…caused fear and concern.” One neighbor told the Commission “They are not doing the job they are being paid for,” referring to the facility’s lack of control in preventing patients was walking off, entering neighbors’ homes, using their hot tubs, etc. Crestwood’s representatives promised the Commission it would improve the situation.
February 2005: The Napa Valley Register reported on neighbors’ objections to Crestwood Center—patients leaving the facility and walking into residents’ homes, a faulty septic system, and other conditions which neighbors consider a nuisance. Such issues were addressed in a June 2004 meeting of the Napa County commissioners in which neighbors came out in force to complain. At a November 2004 meeting, it was thought that the problems had all been handled but this was only because neighbors were not aware that the meeting was taking place. They then called for another meeting to air their grievances.
April 13, 2006: The Medical Board of California issued an Accusation against psychiatrist John Engers III, who is affiliated with Crestwood’s Fremont, CA facility, which charged him with excessive prescribing, corrupt acts, recordkeeping failures, and incompetence, among other things.
The Board’s document states that Engers did the following:
· Enlisted a patient to pick up a prescription for amphetamines which he’d written in her name, but which he then had her deliver to him. He then diverted the drug to a different patient—allegedly the amphetamine-addicted child of a colleague. The patient who picked up the prescription later filed a complaint against Engers with the Board;
· Prescribed controlled substances and psychoactive drugs to a patient without documented medical rationale other than the demands of the patient, whom he recognized as a drug abuser and who later overdosed on narcotics that Engers prescribed;
· Prescribed Dexedrine to another patient without conducting any examinations;
· Prescribed Demerol injections to a patient to handle a pain situation in the hopes that it would then make psychotherapy possible but all it did was get the patient addicted to Demerol—something Engers recognized and acknowledged as his failure, but which he also failed to remedy.
· In July 2006, the Board placed his license on probation on for seven years. That same year, the Illinois Medical Board refused to renew his medical license.
November 2008: A Sacramento Superior Court judge lashed out at psychiatrist Nathan Thuma, who is affiliated with Crestwood’s Angwin, CA facility, for having “clearly committed perjury….” Thuma had testified in court, recommending that a Napa State (psychiatric) Hospital patient who had murdered his own mother was fit to be released into the community and receive out-patient treatment. Thuma had examined the patient for less than 30 minutes before giving his testimony and thus, per the judge, “could not have had enough information” to make the recommendation.
Citizens Commission on Human Rights has received reports of psychiatric abuse from three of Thuma’s patients.
April 9, 2011: Just prior to jury selection, Crestwood’s facility in Vallejo, CA reached a nearly $2 million settlement to the family of a woman who is in a permanent vegetative state after falling into two diabetic comas while under the facility’s care. Martha Young, 62, was admitted to the facility in 2008, “in fairly decent shape [but] in need of care and with mental health issues and diabetes issues,” the family’s attorney said. However, within two months, she had deteriorated to the point that she wasn’t eating, drinking or taking medication. Young’s family asserted that “it is the facility’s responsibility to make sure those under its care do those basic things, even if they don’t want to.”
July 2015: The California Department of Public Health (CDPH) issued the most severe citation possible to Crestwood Behavioral Health and fined the company $100,000 for infractions that led to the death of a patient at Crestwood Manor (Fremont, CA) the previous year. The patient, who was known to have trouble swallowing and poor eating habits, died after choking while trying to eat a piece of meat. The CDPH found that Crestwood Manor “failed to provide a safe dining experience and failed to implement their care plan to consistently assist and assure safe eating occurred” relative to the victim.
September 23, 2016: The U.S. Department of Health and Human Services of the Centers for Medicare & Medicaid Services (HHS CMS) issued a Statement of Deficiencies on Crestwood Manor (Modesto, CA) following an inspection which found that the facility failed to notify a physician of a patient’s change of condition and failed to initiate a treatment plan to address it. This regards a patient who underwent a reduction in the range of motion of her legs and hips, requiring help to get from bed to bathroom, etc.
The inspection also found that Crestwood failed to store food under sanitary conditions, as evidenced by debris and an unidentified brown substance on the kitchen floor, underneath a movable cart, which kitchen staff did not regularly clean under, thus inviting pests into the kitchen and risking contamination.
May 2017: The Medical Board of California issued an Accusation against psychiatrist Nathan Thuma, who is affiliated with Crestwood’s Angwin, CA facility, charging him with unprofessional conduct, gross negligence, incompetence, prescribing without appropriate prior examination and medical indication, and excessive prescribing. The charges regard four patients to whom he prescribed numerous controlled substances at excessive or escalating doses, despite not having done appropriate prior exams or noted medical indications; failed to obtain patient’s informed consent; and prescribed narcotic painkillers and sedatives on a chronic basis. He also failed to properly monitor patients whom he recognized as addicts by continuing to prescribe controlled substances by request, to give early refills, etc. One of the patients continually relapsed into alcohol use over the nearly ten years that Thuma treated her yet Thuma never re-evaluated the effectiveness of his treatment (none) but rather continued to escalate the doses. That patient died of alcohol intoxication, along with Thuma-prescribed sedatives in her system. In November 2019, the Board placed Thuma on probation for four years with terms that included remedial education in prescribing and recordkeeping.
May 7, 2017: HHS CMS issued a Statement of Deficiencies on Crestwood Wellness & Recovery Center (Redding, CA) after inspectors found the following:
· A patient lost approximately 25 pounds in a four-month period. The patient’s care plan indicated that the weight loss was unplanned/unexpected due to poor food intake. In interview with the inspector, staff reported that the weight loss was planned but the care plan was not updated. However, the plan also did not indicate weight loss as a treatment goal.
· Crestwood failed to conduct blood test on one patient, as ordered by physician.
· Crestwood failed to adequately assess and prevent accidents with regard to two patients—one of whom fell in the facility six times in an eight-month period. In another instance, she dropped the lighted part of her cigarette on her shirt. Facility failed to do a smoking assessment (to determine if it were safety, provide supervision, etc.) and failed to initiate any plan or modification to prevent falls. The other patient fell three times while smoking. In one instance, she sustained a hip fracture. In another, she sustained a laceration of the head requiring stitches. Facility likewise failed to conduct smoking assessment or institute plan to prevent falls.
June 15, 2017: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Stockton, CA) after finding that the facility failed to ensure a patient received adequate supervision to prevent accidents. An incident report showed that a patient physically assaulted three other patients in a 40-minute period. The offending patient was put on 15-minute checks after the first assault and continued on 15-minute checks after the second and was finally put on 1:1 supervision after the third. Facility administrator admitted to investigators that 1:1 should have been instituted after the second incident.
June 21, 2017: HHS CMS issued a Statement of Deficiencies on Crestwood Treatment Center (Fremont, CA) after an inspection found that Crestwood failed to “store, cook, and serve food in a safe and clean way” by having/using undated and unlabeled food items; food items stored on the floor; and storing of employee food items in the refrigerators meant for residents’ food storage—all of which had the potential to cause food-borne illness. [HHS CMS inspects health care facilities which treat Medicare patients to ensure that the facilities are in compliance with Medicare’s requirements to receive federal healthcare reimbursements. These requirements, called “Conditions of Participation,” cover numerous points, including patient safety, patient’s rights, building safety, and infection control, among other things.]
September 8, 2017: HHS CMS issued a Statement of Deficiencies on Crestwood’s Idylwood Care Center (Sunnyvale, CA) after inspection found that the facility failed to follow physician’s order to administer laxative to a patient or to notify the physician when the patient failed to have a bowel movement in six days, resulting in fecal impaction requiring the patient be sent to acute care to have the impaction manually removed.
October 5, 2017: HHS CMS issued a Statement of Deficiencies on Crestwood’s Idylwood Care Center (Sunnyvale, CA) after inspectors found the following:
· Crestwood failed to provide an ongoing program of activities for residents, which had the potential to leave residents “feeling bored and lacking a sense of purpose in maintaining their well-being.”
· Crestwood failed to implement interventions for falls with regard to two patients assessed as being at high risk for falls. The facility failed to properly supervise a third patient to prevent a fall. That patient was left alone in the bathroom and fell. Staff failed to fully assess the patient for injury after the fall.
· A high rate of medication error was noted by inspectors such as crushing vitamins and medications and administering them all at once, when physician’s orders call for them to be administered individually or simply administering the wrong drug to the patient.
November 9, 2017: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Modesto, CA) after an inspection found that nursing staff failed to properly monitor a patient who had fallen, resulting in a potential for unrecognized and unrelieved pain and a potential delay in treatment for the fall. Inspectors also found that the facility failed to train staff on what to do in an emergency, specifically finding that during an announced drill, seven of 11 staff members were unable to locate and demonstrate operation of gas, water, and electrical emergency shut-offs.
April 25, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood Wellness & Recovery Center (Redding, CA) upon finding that the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by kitchen staff failing to adhere to proper handwashing, proper thermometer usage, and proper food temperatures.
April 26, 2018: News reported that 32-year-old Marcus Tenes walked away from Crestwood’s psychiatric facility in Vallejo, CA and was found two weeks later, dead in the water off the nearby town of Crockett, having evidently committed suicide by jumping from a bridge. The article criticizes Crestwood’s psychiatrist, Michael Minzenberg, for failure to recognize Tenes’ dangerousness to himself.
May 18, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood’s Idylwood Care Center (Sunnyvale, CA) after an inspection found that the facility failed to report to the appropriate state agencies an elderly patient’s allegations of abuse. (Patient reported having been hit in the face on one occasion and in the stomach on another.) The facility also failed to provide adequate supervision to a patient who had instigated unprovoked assaults on three other patients.
May 23, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood Wellness & Recovery Center (Redding, CA) after an inspection found that the facility failed to provide sufficient staff to meet the behavioral and physical health needs of the residents and failed to maintain minimum safe staffing ratios on two night shifts. One patient reported to inspectors that there were only two nurses on duty at night for 95 patients. Staff told the inspector that four nurses was the minimum for that many patients.
June 2018: A story in the Press-Democrat (Santa Rosa, CA) reported on the arrest of 37-year-old Sam Massette, on charges of sex trafficking, including having placed a minor into prostitution. The story stated that Massette had obtained a BA degree in psychology and had interned at Crestwood’s Angwin facility “one day a week under constant supervision” in 2015.
Massette was convicted on October 12, 2018 human trafficking for the purposes of prostitution and two counts of pimping women in prostitution and was sentenced to 20 years in prison.
June 21, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Stockton, CA) after finding that the facility failed to ensure food was prepared and served under sanitary conditions as evidenced by accumulated debris (“brown-black, three-dimensional residue”) on all vents above the food prep area and the front cage piece of a fan which was blowing directly onto the food prep area.
July 18, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood’s Idylwood Care Center (Sunnyvale, CA) after an inspection which found that the facility failed to provide 1-on-1 supervision of a patient, as called for in the patient’s care plan, which enabled the patient to become involved in aggressive incidents with other patients.
October 5, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood’s Idylwood Care Center (Sunnyvale, CA) after inspectors witnessed facility staff not treating residents with dignity by staff failing on numerous occasions to knock on the door before entering the patient’s room.
October 23, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood’s Idylwood Care Center (Sunnyvale, CA) after inspectors found that facility staff failed to thoroughly investigate and take corrective action on a patient’s report that she was mistreated by a facility employee. The patient stated that a male nurse’s assistant came to her room while she was sleeping, abruptly pulled her blanket and addressed her as “hey.” Crestwood’s own investigation indicated that they did not interview or suspend anyone in the matter, though it was noted that there was only one male nurse’s assistant on duty at the time of the incident. Crestwood’s own policy on Elder and Dependent Adult Abuse/Suspicion of a Crime required that all incidents be thoroughly investigated in an attempt to determine what occurred and to make changes, as needed, to prevent reoccurrence. It also indicated to immediately suspend any employee accused of abuse, pending completion of the investigation.
October 24, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Stockton, CA) after finding that the facility failed to update and revise a patient’s care to include the initiation of new interventions following several falls.
November 18, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Fremont, CA) after an inspection found that the facility failed to “procure food from sources approved or considered satisfactory and to store, prepare, distribute and serve food in accordance with professional standards.” Inspectors found numerous examples of stored foods which were past their indicated expiration date, and vegetables which were obviously past their expiration and which did not bear a “use-by” date, which had the potential to cause food-borne illness.
December 14, 2018: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Modesto, CA) after inspectors found the following:
· The facility failed to make publically accessible to patients the results of the facility’s state recertification, abbreviated inspections and the state Department of Health hotline phone number, thus denying patients and public the right to be aware of this data.
· Nursing staff did not use appropriate patient identifiers on cups for liquid medication, which could potentially result in patients receiving the wrong medication. (Nurses were noted to only write a single initial for the patient rather than their entire name.)
· Crestwood failed to ensure that the medication error rate was five percent or less. Inspectors found that nursing staff administered expired vitamins, medications past the physician-prescribed administration period, failed to properly administer medication, and other errors.
· Nursing staff failed to appropriately secure medications; administered medication which did not bear an expiration date; and stored vitamins in same place as expired drugs.
· Crestwood failed to ensure that physician-ordered diets were followed for two of three patients reviewed, to whom salt packets were included with meals, despite the patients being prescribed no-salt-added diets.
· Crestwood failed to ensure that food was stored, prepared, distributed, and served according to professional standards, including food handlers failing to wash their hands, spoiled food in the refrigerator, and dirty equipment.
· Crestwood failed to maintain an infection control program, involving seven of seven patients observed, whom facility staff failed to have wash or sanitized their hands prior to eating lunch and/or breakfast.
· Crestwood failed to maintain their equipment in operating condition, as regards a condition of ice build-up in the freezer, which had the potential to compromise food quality for patients.
January 28, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Stockton, CA) after inspectors found that the facility failed to ensure a patient was free from unnecessary medications by failing to reevaluate the patient every 14 days while the patient was under a PRN (“as needed”) order for an antipsychotic drug. This failure increased the risk of excessive drugging.
February 8, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Stockton, CA) after an inspection found that the facility failed to conduct a thorough investigation of alleged abuse of a patient who was found to have numerous bruises and who alleged that another patient kicked her while she was asleep. The patient’s record indicates that the allegation was unfounded, however, inspectors found no evidence that an investigation was actually done.
April 4, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Stockton, CA) after inspectors found that the facility failed to ensure a care plan for fall prevention was revised to include treatment team recommendations, for a patient who is described as having fallen approximately ten times in a one-year period.
June 13, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Treatment Center (Fremont, CA) after an inspection found that the facility failed to “provide appropriate treatment and care according to orders, resident's preferences and goals.” Staff failed to provide timely treatment of a patient’s infected eye condition, failed to have patient assessed for it in a timely manner; and failed to report findings to the patient’s doctor or conservator.
The facility also failed “procure food from sources approved or considered satisfactory and to store, prepare, distribute and serve food in accordance with professional standards.” Inspectors found food items which were past their expiration dates and found foods stored in an unsafe manner, as well as two kitchen staff whose hair was not fully covered by their hair nets, all of which had the potential to cause food-borne illness.
September 16, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Fremont, CA) after an inspection found that the facility failed to “protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.” Inspectors found that a staff member had assaulted an elderly patient, resulting in bruising and swelling on the face and neck and a bloody nose. The staff member was arrested though no further information was found regarding their prosecution.
October 24, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Fremont, CA) after an inspection found the following:
· Crestwood failed to keep residents' personal and medical records private and confidential. A nurse, who was treating pressure ulcers on patient’s rear end, left the privacy curtain open as she went in and out, exposing patient’s buttocks to passersby.
· Crestwood failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and were stored in locked compartments. Inspectors found a particular medicine refrigerated which was required to be stored at a temperature between 59 and 77 degrees, and also two medications, each with different uses, stored together, causing the potential for cross-contamination of both.
- Crestwood also failed to procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Inspectors found that several food items were stored beyond their use-by dates and that kitchen staff handled food before washing their hands.
December 1, 2019: The Los Angeles Times’ investigative report on deaths and abuses in California psychiatric facilities showed that a patient who had been admitted to Crestwood’s psychiatric facility in Bakersfield, CA died after being transported to a nearby hospital. State investigators found Crestwood partially responsible.
December 1, 2019: The Los Angeles Times’ investigative report of deaths and abuses in California psychiatric facilities indicated two patient deaths had occurred at Crestwood’s Santa Barbara Crisis Residential facility since 2009.
December 19, 2019: HHS CMS issued a Statement of Deficiencies on Crestwood Manor (Modesto, CA) after inspectors found that the facility failed to obtain patients and/or their responsible parties (conservators, etc.) informed consent regarding medication risks and benefits, dosages and frequency. This involved three of seven patients reviewed.
January 13, 2020: Citizens Commission on Human Rights received reported stating that a 60-year-old male had been struck in the face on two occasions while admitted to Crestwood’s facility in San Jose, CA resulting in two black eyes both times.
April 12, 2020: HHS CMS issued a Statement of Deficiencies on Crestwood Wellness & Recovery Center (Redding, CA) after inspectors found that the facility failed to ensure that a patient was protected from physical abuse. Staff found a patient smoking marijuana in his room. Staff confiscated the marijuana and began searching the room. The patient struck two staff members. When another patient inquired as to why staff were searching the first patient’s room, he struck the inquiring patient and kicked her when she was on the ground.
May 12, 2020: ABC News reported that staff and patients of Crestwood San Diego MHRC tested positive for COVID-19. The outbreak was reported to have started with one part-time employee who reported having been diagnosed positive. “Ambulances transported several people to local hospitals,” the article states.
Source documents list available upon request.
