When Suzanne Robbins moved into Dignity Senior Living at Oceanside Hawaii last year, she reveled in the assisted living facility’s built-in community and its picturesque location on Oahu’s northeast coast.

“I wanted to be around other people and a large group setting like this,” she said. “I love the country.”

But after the state ordered an abrupt shutdown of the facility by Friday, Robbins found herself among dozens of residents scrambling to find another place to live.

“I was planning on staying,” she said. “I never wanted to go into foster care but I don’t think I have a choice now.”

Health officials said the closure was necessary to protect the health and safety of the residents after Adult Protective Services concluded there was caregiver neglect at the facility.

Inspection reports from the state Department of Health illuminate a history of neglect by facility staff, who according to records failed to administer medications on time or at all and did not provide sufficient wound care, dietary oversight and bathing routines.

The Office of Health Care Assurance initially said Dignity Senior Living must discharge or transfer all residents by Friday. However, the deadline was extended after the company appealed the decision to close the facility.

The facility may continue operating throughout the appeal process, which could take several weeks or even months, according to DOH spokeswoman Janice Okubo. A hearing has not yet been scheduled.

“The length of the hearing itself is dependent upon the case and evidence presented,” Okubo said by email. “Meanwhile, our Office of Health Care Assurance is committed to working with the facility in the best interest of the residents while ensuring they are living in a safe environment.”

The intricacies of the hearing process were of little comfort to residents interviewed by Civil Beat earlier this week, all of whom were under the impression they still had to leave by Friday.

Frantic Residents

Some said they were preparing to move in with relatives. Others felt paralyzed as their transfer process is in the hands of case management agencies.

Robbins, 68, uses a wheelchair and needs oxygen support. She’s also dealing with other health issues including cancer and heart problems.

“The fact that they’re not saying anything is very upsetting to all the people here,” she added. “There are some people moving out already and then there are others who are still so confused. They don’t have the mental facility to understand what’s going on.”

John McDermott, the state’s long-term care ombudsman at the Executive Office on Aging, visited the facility on Monday and spoke with residents for two hours.

“They are all in a panic,” he said. “Some have no family to help them. Several staff also live at the facility so here they are trying to focus on finding placements for the residents and only after that is done, trying to find a home for themselves by this Friday.”

Dignity Senior Living’s administrators did not respond to requests for comment.

Despite the positive experiences shared by some residents, some caretakers of former residents were relieved at the news of the closure.

The facility opened in 2016 and approximately 60 residents were living there at the time of the shutdown order.

Dignity Senior Living’s assisted living facility was by far one of the best bargains at about $3,000 a month, McDermott said.

“That’s cheaper than anybody else,” he said. “These folks are on very limited income, and quite a few are on Medicaid and have no income at all.”

History Of Complaints

Robin Kennedy cared for her friend and former co-worker Patrick Leonard, a longtime Honolulu marketing and advertising executive who had a stroke while watching a football game at her house in December 2019.

She put him in Oceanside for about three months but said poor care worsened his condition. He had diabetes and got an infection in his foot while staying there.

“The care that he got made him go downhill so fast,” she said. He died on Nov. 28 at age 64. Even though he died in a hospice home, Kennedy blames Oceanside.

“It started there and they were not taking care of him,” she said. She never filed a complaint and said his case is not the case that led to the adult protective services complaint. Instead, Kennedy plans to testify against the company at the upcoming hearing.

“It is a beautiful place, just not run correctly,” she said.

Robert Howe, who serves as former Dignity resident Kimberly Craig’s power of attorney, said Craig’s care at Dignity was negligent.

Craig, 58, has been paralyzed from the neck down since 2018.

“The place is horribly understaffed, particularly at night and there just weren’t enough people to go around,” Howe said.

Craig, who has transferred to The Queen’s Medical Center, was on a restricted diet after a stomach surgery. Dignity staff gave her peanut butter and jelly sandwiches, Howe said.

“Maybe once a month they’d shower her,” he said.

A urinary tract infection got so severe that she had to be taken to the emergency room last October.

“That was the only way we could get her out of there,” Howe said. “Once you’re admitted to the facility it’s hard to switch to another care home. COVID-19 hit and no one is going to look at taking another patient.”

Albert Chen, Dignity Senior Living’s CEO, did not respond to a Civil Beat inquiry about former residents’ allegations against staff.

The state Department of Human Services would not provide a copy of the Adult Protective Services investigation that triggered the facility shutdown, claiming confidentiality issues.

“The fact that they’re not saying anything is very upsetting to all the people here.” — Resident Suzanne Robbins

In addition to caregiver neglect, the license revocation stemmed from three complaint investigations that led the state to cite 149 facility deficiencies, “including deficiencies that placed residents at risk of harm without immediate corrective action,” according to the April 12 letter from the Office of Health Care Assurance to the facility.

Inspections conducted by health department officials in August, September, and December of last year and January of this year provided more details, including finding that some unqualified staff were administering medications, or the wrong dosages.

At least 18 patients did not receive all their prescribed medications according to record logs, and the state said issues inspectors had flagged a year prior were still not addressed.

Full copies of the inspection reports below were provided by the Department of Health. Many cases of neglect were recorded by DOH over the past year.

The inspection reports make no mention of COVID-19 related citations. Visitors were banned for much of the past year during the pandemic.

Among the other findings was a failure to transfer a suicidal patient to the adjacent Adult Residential Care Home unit for close monitoring after an attempted suicide.

A patient with bladder and bowel incontinence was not being helped frequently enough with changing clothes. That same patient’s physician flagged a stage-two ulcer in a patient, but inspectors found no evidence that Dignity addressed it.

A controlled substance medication log sheet was not properly maintained and signed by staff.

Staff also failed to provide proper wound care or assessments for residents who returned from the hospital after falling.

In general, numerous residents’ service plans, such as diet and bathing routines were not being followed.

Dignity Senior Living’s listing on the Business Registration Division, Department of Commerce & Consumer Affairs website shows it registered with the state business office in 2016, but is currently not in good standing.

Al Richardson, 82, who has lived at Dignity for six years, was wheeling himself around the parking lot on Monday to get fresh air. He said he’ll have to move in with his niece’s family in Kaneohe until he can find another place to stay.

Richardson said he grew unhappy with the care he received at Dignity.

When he first moved in, he enjoyed perks like the Hawaiian food a chef prepared. Now, he feels that the staff is inattentive and not well trained.

“The people that work here just come and go. Everyday you got a new nurse,” he said.

Lawrence Kawaguchi, 74, found out from a friend in the dining room that residents would have to move out. A Dignity resident of two and a half years, he said he hasn’t had any issues with the facility or staff.

Kawaguchi is blind in his right eye and uses a walker to get around. He said he wasn’t able to read the letter distributed by the facility indicating the April 30 move-out date.

“Nobody tells me nothing or what’s going on; I just know I have to find another facility,” he said. “It makes you worried because you don’t know where you’re going or what to do next. You know some of these people have dementia.”

Kawaguchi said he had two daughters who live on Oahu who could help him, but he’d rather stay. He has a girlfriend who also lives at Dignity. If he has to move, he’d be separated from her.

“I’m fine over here. The conditions are good,” he said. “The helpers are good and bad, of course every place has good and bad.”

Limited Alternatives

The clock is ticking to relocate residents, and options are sparse since many care homes won’t accept residents who use wheelchairs and don’t provide the level of care needed, McDermott said.

Still, most Dignity residents are still mobile. They just need to find a place to stay that can help them with certain things, like meals or baths. They would not qualify to be placed in nursing homes or even most community care foster family homes, which help patients who have the highest level of needs and are often bedridden, according to McDermott.

The financial situation also is complicated because about two-thirds of the residents are on Medicaid insurance, a health insurance program for people with low incomes and disabilities.

Dignity Senior Living is the only one of 15 assisted living facilities on Oahu that accepts Medicaid, according to McDermott.

Dignity also operates an adult residential care home for patients with Alzheimer’s disease and dementia, which is on the same campus but was not ordered to shut down.

Sarah Suzuki, owner and registered nurse at Blue Water Resources, a local case management and health care consulting agency that works with 24 Dignity residents, is trying to help them find a new home.

The health department provides a list of vacancies in Adult Residential Care Homes, but even though many facilities have availability, they don’t necessarily accept Medicaid.

Adult Residential Care Homes also are usually reserved for residents who need minimal assistance with bathing, changing, walking, eating, and getting out of bed.

Several other care home administrators have stepped up to offer space and help, including the Healthcare Association of Hawaii.

Darlene Nakayama at Palolo Chinese Home said her nonprofit is accepting one Medicaid resident transferring from Dignity. But she said it’s unfortunate that they have to move out of their homes.

Maribel Tan, the president of the Adult Foster Homecare Association of Hawaii, usually cares for three elderly clients in her home as part of Hawaii’s Community Care Foster Family Home program. She said the foster homes have vacancies and are discussing with Blue Water Resources case managers whether or not they’d be a good fit for some of the residents.

When asked if the governor’s moratorium on evictions during the pandemic would apply to the Dignity residents, the answer from health department officials was no.

“The situation at Dignity Senior Living is not an eviction or a landlord-tenant issue and therefore does not apply,” the DOH spokeswoman said.

Suzuki said she expects to be able to relocate five to eight residents by the end of this week — about a third of her clients at the facility — but said an extension of the move-out deadline would buy much-needed time.

“It’s just a struggle to try to secure placement for folks on such short notice,” she said. “It’s a sad thing. The majority of patients really like being there.”