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Infection Lapses Rampant in Nursing Homes But Punishment Is Rare

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By Jordan Rau, Kaiser Health News

Basic steps to prevent infections — such as washing hands, isolating contagious patients and keeping ill nurses and aides from coming to work — are routinely ignored in the nation’s nursing homes, endangering residents and spreading hazardous germs.

A Kaiser Health News analysis of four years of federal inspection records shows 74 percent of nursing homes have been cited for lapses in infection control — more than for any other type of health violation. In California, health inspectors have cited all but 133 of the state’s 1,251 homes.

Although repeat citations are common, disciplinary action such as fines is rare: Nationwide, only one of 75 homes found deficient in those four years has received a high-level citation that can result in a financial penalty, the analysis found.

“The facilities are getting the message that they don’t have to do anything,” said Michael Connors of California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “They’re giving them low-level warnings year after year after year and the facilities have learned to ignore them.”

Infections, many avoidable, cause a quarter of the medical injuries Medicare beneficiaries experience in nursing homes, according to a federal report. They are among the most frequent reasons resideents are sent back to the hospital. By one government estimate, health care-associated infections may result in as many as 380,000 deaths each year.

The spread of methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant germs has become a major public health issue. While Medicare has begun penalizing hospitals for high rates of certain infections, there has been no similar crackdown on nursing homes.

As average hospital stays have shortened from 7.3 days in 1980 to 4.5 days in 2012, patients who a generation ago would have fully recuperated in hospitals now frequently conclude their recoveries in nursing homes. Weaker and thus more susceptible to infections, some need ventilators to help them breathe and have surgical wounds that are still healing, two conditions in which infections are more likely.

“You’ve got this influx of vulnerable patients but the staffing models are still geared more to the traditional long-stay resident,” said Dr. Nimalie Stone, the CDC’s medical epidemiologist for long-term care. “The kind of care is so much more complicated that facilities need to consider higher staffing.”

The Centers for Medicare & Medicaid Services (CMS), which oversees inspections, has recognized that many nursing homes need to do more to combat contagious bugs. CMS last year required long-term care facilities to put in place better systems to prevent infections, detect outbreaks early on and limit unnecessary use of antibiotics through a stewardship program.

But the agency does not believe it has skimped on penalties. CMS said in a statement that most infection-control violations have not justified fines because they did not put residents in certain danger.

For instance, if an inspector observed a nurse not washing his or her hands while caring for a resident, the agency said that would warrant a lower-level citation “unless there was an actual negative resident outcome, or there was likelihood of a serious resident outcome.”

In November, CMS waived penalties for 18 months against facilities that violate the new stewardship rule. The industry had said nursing homes needed more time to prepare. (The moratorium does not affect California’s antibiotic stewardship requirement, which took effect last January.)

Holly Harmon, the senior director of clinical services at the American Health Care Association, a nursing home trade group, said the industry has made strides in combating infections through better training and encouragement for staff members to look for gaps in infection control and to speak up about them.

The percentage of nursing home residents with urinary tract infections — the only type of infection all nursing homes must report to Medicare — has dropped by more than half since 2011.

“Infection prevention control is a priority,” Harmon said. “The path really is focused on continuous improvement.”

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Business

Oakland Children’s Hospital Workers and Patients Rally for Pediatric Medical Care

OAKLAND POST — “Children who go through a bone marrow transplant are immunocompromised, meaning that their immune system has been wiped out,” and having to take public transport to San Francisco exposes patients to the risk of getting a dangerous infection, said Paola Portillo, a social worker.

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Staff and family members of patients at UCSF Benioff Children's Hospital Oakland in Oakland, Calif., hold signs during a rally on Thursday, July 9, 2026. Rally participants protested the relocation of specialized care clinics to the hospital's San Francisco campus. Photo by Kayla Chan/Bay City News.

Staff, patients’ families, and supporters held a rally recently at UCSF Benioff Children’s Hospital in Oakland to protest the hospital’s decision to relocate specialized treatment clinics to San Francisco.

Protesters said the move is creating barriers for patients to access care and raised concerns over whether the hospital was appropriately using funds partially designated for pediatric services.

In response, hospital officials say they are concentrating resources for highly specialized procedures so patients can receive the highest quality of care.

One of the speakers at the rally, Paola Portillo, a social worker, said the hospital started transferring the clinics a year ago when UCSF Health integrated with the Children’s Hospital Oakland, located at 747 52nd St. in North Oakland.

According to Portillo, patients who need bone marrow treatments and interventional radiology are forced to travel to UCSF Benioff Children’s Hospital in San Francisco, which can be dangerous, she said.

“Children who go through a bone marrow transplant are immunocompromised, meaning that their immune system has been wiped out,” and having to take public transport to San Francisco exposes patients to the risk of getting a dangerous infection, she said.

UCSF spokesperson Kristen Bole says the move improves the hospital’s quality of care, giving bone marrow treatment (BMT) as an example.

“Inpatient BMT is a highly complex service where patient volume, specialized infrastructure, faculty coverage and 24/7 support are essential,” she said in a statement. “Concentrating non-gene therapy inpatient BMT care at Mission Bay allows us to provide the safest and most sustainable model for patients and families.”

Hospital officials also emphasized that moving care was not a one-way street. Beginning this month, patients admitted for rehabilitative treatment have been directed to the children’s hospital in Oakland, Bole said.

Speakers at the rally also claimed UCSF has not been transparent about how it has allocated funding from 2020’s Measure C, a measure that created a half-percent sales tax that partially funded pediatric health care at the children’s hospital.

“The community fought so hard for Measure C because every child deserves access to lifesaving, pediatric, high-quality care right here in Oakland,” said Agnes Cho, a policy advisor speaking on behalf of Alameda County Supervisor Nikki Fortunato Bas. “The funding should go towards strengthening care for children right here in Oakland.”

Protesters also said UCSF’s $3.3 billion endowment has been misused. Last October, the University Professional & Technical Employees union published a report on the University of California’s spending, which highlighted projects such as the $4.3 billion UCSF Helen Diller Medical Center at Parnassus Heights.

“What I have a problem with is saying the kids from the East Bay have to go to San Francisco to get care, so that UC can build a fancy hospital for its richest patients in San Francisco,” said union President Dan Russell.

The UCSF spokesperson said UCSF has been investing in its Oakland campus, explaining that upgrades that are expected to be completed in 2030 at a cost of $1.6 billion.

“Oakland is central to our pediatric health system, and we are making the largest investment in the campus’ history,” the spokeswoman said. “We do not make investments of this scale in a campus, workforce or community we plan to leave behind.”

This article includes coverage from Bay City News Service and media releases.

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Commentary

NPRC to Meet with California Attorney General’s Office on to Urge Guardianship Reform

OAKLAND POST — Black has been a professor of law and finance at Northwestern University and Northwestern Pritzker School of Law since 2010. Before joining Northwestern, he served on the faculties of Stanford University, Columbia University, and the University of Texas at Austin, earning international recognition as one of America’s foremost empirical legal scholars.

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Bernard ‘Bernie’ Black. Courtesy photo.

The National Probate Reform Coalition (NPRC) has announced that Bernard ‘Bernie’ Black, a nationally respected legal scholar, will meet with California Assistant Attorney General Eleanor Blume on July 27 to discuss the urgent need for guardianship, conservatorship, and probate reform.

The meeting marks another important step in NPRC’s effort to encourage California’s governor and attorney general to take a leadership role in addressing systemic abuse, financial exploitation, and the lack of meaningful oversight within probate and guardianship courts.

Black has been a professor of law and finance at Northwestern University and Northwestern Pritzker School of Law since 2010. Before joining Northwestern, he served on the faculties of Stanford University, Columbia University, and the University of Texas at Austin, earning international recognition as one of America’s foremost empirical legal scholars.

Despite his legal expertise, Black says neither his knowledge nor his professional reputation protected his family from what he describes as a deeply flawed guardianship system.

Following the death of his mother in 2012, Black’s sister, Joanne, who had lived with schizophrenia for more than 35 years, became the beneficiary of approximately two-thirds of their mother’s $4 million estate through a special needs trust established to provide for her lifetime care.

Seeking to preserve his mother’s estate plan and protect Joanne’s eligibility for public benefits, Black petitioned the Denver Probate Court for a temporary conservatorship and requested judicial approval for actions necessary to preserve assets. According to Black, the case initially appeared to proceed appropriately. Both the court-appointed counsel and a guardian ad litem supported his proposed conservatorship plan.

Black says the case later took a dramatically different turn.

According to Black, court-appointed professionals used family disagreements to seize control of the family trusts. What followed was 12 years of litigation and 96 probate court decisions, resulting in millions of dollars in professional fees.

Black says repeated settlement proposals intended to preserve assets for his sister’s benefit were rejected. He also strongly disputes adverse findings made by the probate court against him, his wife, and his son, arguing the court lacked jurisdiction over members of his family. Appeals were unsuccessful, reinforcing his concern that probate courts exercise extraordinary discretion with insufficient oversight.

Joanne Black passed away on Aug. 14, 2025. Black contends that millions of dollars that should have benefited his sister and preserved his family’s legacy have instead been consumed by litigation and administrative expenses. He continues to fight efforts to deplete the remaining family trusts.

“My sister has died, yet the Denver Probate Court and the guardianship professionals are still pursuing what is left of our family’s money,” Black said. “I’m talking millions of dollars.”

Black believes his family’s experience demonstrates that even experienced attorneys can become overwhelmed by a probate system that often lacks transparency and accountability.

Joining Black at the July 27 meeting will be Rick Black, founder of the Center for Estate Administration Reform (CEAR), who will present his organization’s proposed Victims’ Bill of Rights for individuals and families involved in probate and guardianship proceedings.

Together with the NPRC, they will urge the Attorney General’s Office to investigate fraud, financial exploitation, and predatory practices while aggressively enforcing existing laws that protect elders, disabled adults, and vulnerable families.

NPRC asserts California’s Attorney General, as the state’s chief law enforcement officer, has both the authority and responsibility to investigate fraud, public corruption, and financial exploitation occurring within probate courts.

The Coalition also hopes California will lead a national initiative by working with attorneys general across the country to develop coordinated enforcement strategies and meaningful reforms that restore integrity, transparency, and accountability to probate courts nationwide.

Bernard Black’s experience echoes hundreds of similar stories documented by probate reform advocates throughout the nation. His message to the Attorney General is both simple and sobering:

“If this can happen to one of America’s most respected law professors, it can happen to anyone.”

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Business

Mount Zion MBC, Church of Jesus Christ of Latter-day Saints Partner to Bring 29,000 Meals to Alameda County

OAKLAND POST — A semi-truckload of food arrived at MZMBC in Oakland on Tuesday, July 21. This was one of 250 trucks the LDS church is sending throughout the United States. By the end of the year 10 million pounds of food will be donated. Each truck carries approximately 40,000 pounds of shelf-stable pantry staples that can feed 1,400 families for one week.

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Pastor Michael Wallace of Mt. Zion Missionary Baptist Church (center) and David Kimball, president of the Oakland Stake of the LDS church listen to remarks before volunteers began their work. “We are grateful to partner with these organizations to help care for those in need in our community,” Kimball later told the assembled volunteers. Courtesy photo.

The interfaith community effort commemorates the 250th anniversary of the U.S.

More than 29,000 meals were received and distributed at the historic Mount Zion Missionary Baptist Church in West Oakland as part of an interfaith community effort to commemorate the 250th anniversary of the United States.

The Alameda County Community Food Bank (ACCFB), Mt. Zion Missionary Baptist Church (MZMBC), and the Church of Jesus Christ of Latter-day Saints (LDS) partnered to address food insecurity throughout Alameda County.

A semi-truckload of food arrived at MZMBC in Oakland on Tuesday, July 21. This was one of 250 trucks the LDS church is sending throughout the United States. By the end of the year 10 million pounds of food will be donated. Each truck carries approximately 40,000 pounds of shelf-stable pantry staples that can feed 1,400 families for one week.

Pastor Michael Wallace of Mt. Zion Missionary Baptist Church provides instruction as volunteers unpack pallets of food to be distributed. “We believe that having food is a basic human right and to address it is our Christian duty,” Wallace said. “That’s what makes this partnership so meaningful.” Courtesy photo.
Pastor Michael Wallace of Mt. Zion Missionary Baptist Church provides instruction as volunteers unpack pallets of food to be distributed. “We believe that having food is a basic human right and to address it is our Christian duty,” Wallace said. “That’s what makes this partnership so meaningful.” Courtesy photo.

The need for food is significant. According to the ACCFB, 1 in 4 members of the community they serve is experiencing or at risk of hunger.

“The challenges get much harder during the summer when children no longer have access to healthy meals at school,” says Regi Young, executive director of Alameda County Community Food Bank. “Our community and our food bank face similar challenges accessing some of the highest quality and high demand foods because they are typically also the most expensive.

Oakland Mayor Barbara Lee speaks at the JustServe event.
Oakland Mayor Barbara Lee speaks at the JustServe event.

“Fresh milk is among the top items on these lists, so we are extremely grateful for this donation to help more families stretch their budgets and get through these challenging summer months,” Young said.

Two days later, on July 23, another semi-truck, this one bearing fresh milk from the LDS church, arrived at the ACCFB.
Event organizers share a commitment to caring for those in need and fostering meaningful service connections within communities.

“After 250 years, there is still food insecurity in America, and this is an interfaith community effort to eradicate hunger in our communities and cities,” said Pastor Michael Wallace of Mount Zion. “We believe that having food is a basic human right and to address it is our Christian duty. That’s what makes this partnership so meaningful.”

“Members of the Church of Jesus Christ of Latter-day Saints believe in following the Savior’s commandments to love God and to love our neighbor,” says David Kimball, president of the Oakland Stake of the LDS church. “We are grateful to partner with these organizations to help care for those in need in our community.”

Word Assembly First Lady Denise Clark, left, joined Mt. Zion Missionary Baptist Church First Lady Velma Wallace at the food distribution site, where the first of the 250 truckloads of food LDS will provide to places across the country was distributed. Courtesy photo.
Word Assembly First Lady Denise Clark, left, joined Mt. Zion Missionary Baptist Church First Lady Velma Wallace at the food distribution site, where the first of the 250 truckloads of food LDS will provide to places across the country was distributed. Courtesy photo.

Welcoming the truck’s arrival at 10 a.m. at MZMBC were Kimball, Young, Wallace of MZMBC, and civil rights activist and Post News Group Publisher Paul Cobb. Oakland Mayor Barbara Lee was in attendance and addressed the hundreds of volunteers. Inspiring music was provided by members of the Oakland Interfaith Gospel Choir under the leadership of Terrance Kelly.

Teens from both churches were on hand to assist with loading food items for various local nonprofits and community groups to distribute to those in need. The teens also assembled 1,000 hygiene kits for the unhoused. Each kit will include a note of encouragement written by the children and youth of each church.
The churches and organizations that received food include:

  • Mt. Zion Missionary Baptist Church
  • ECAP (Emeryville Citizens Assistance Program)
  • Support Life Foundation/Islamic Cultural Center of Northern California (ICCNC)
  • Serenity House
  • CRECE (Central American Refugee Committee)
  • ION (Impact Oakland Now -Word Assembly, Center of Hope and Abyssinian Baptist Church)
  • True Faith Baptist Church (East Oakland)

“These two large shipments of food and milk, along with this interfaith, community event, exemplify the spirit of volunteerism and community service that this country was built on,” says Gregg Ankenman, assistant director of Community Service for the Oakland/San Francisco Communication Council of the LDS Church.

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