In 2006, Gary Davis' stepfather Harold was at a San Jose nursing home when his blood sugar fell dangerously low. The staff made note of it; Harold pleaded for help. After six hours, he died.
The state cited and fined the home for failing to provide prompt medical and emergency treatment, leading to his eventual death.
"For them to do what they did, you know, they were untrained and that happens a lot, I guess," Davis said.
According to a California Watch investigation, a number of nursing homes do not meet state standards for staffing, despite a 2004 state law that was designed to keep cases likes Harold's from happening.
The law has given an additional $880 million to California nursing homes since 2004. That taxpayer money was supposed to be used to hire more caregivers and boost wages.
"This law was built on a lot of incentives; they were all rewards for nursing homes to do the right thing," California Watch reporter Christina Jewett said.
Jewett poured over documents provided by the state to see if nursing homes were meeting the law's requirements.
"About 260 homes actually either cut staffing or cut wages or they still lagged behind a state-mandated staffing minimum," Jewett said.
But at the same time, Jewett found most of those same nursing homes were making big money.
"The profit margin for the homes that cut staff was about 60 percent larger than the profit margin for the rest of the homes," she said.
The California Watch investigation also showed there have actually been more complaints against nursing homes after the law went into effect. In 2004, before the law, nursing homes registered 4,499 complaints. In 2008, 5,549 complaints were filed. State regulators also documented nearly 1,000 deficiencies for inadequate care in 2008, up 65 since 2005.
The state Department of Health Care Services doles out the tax money to nursing homes. State health officials say they have found more deficiencies because they hired more inspectors, but that does not explain the 23 percent rise in complaints filed by patients, advocates and their families.
The nursing home industry disputes the California Watch findings.
"Our data shows that there are in fact some people that are not in compliance, and they should be in compliance, but it's about 6 percent," California Association of Health Facilities spokesperson Deborah Pacyna said.
Pacyna says the vast majority of nursing homes are doing the right thing.
"Our goal is to see that every skilled nursing facility is in compliance," she said. "If you turn that around, 94 percent of all the facilities are in compliance, and if you go to any classroom in California that's a grade of 'A.'"
Pacyna dismisses the notion that California nursing homes as a whole are not meeting state standards.
"Right now, skilled nursing facilities in California staff at above the national average; the staffing standard is 3.2 nursing hours per patient day, the national average is 3.3, California is at 3.6," she said.
She says the reason average pay has gotten lower is because nursing homes are hiring more staff and those new workers start at entry level wages.
Advocates for nursing home patients say the California Watch investigation shows there needs to be more oversight.
Pat McGinnis is with California Advocates for Nursing Home Reform. Her organization opposed the 2004 law.
"We opposed it because we knew there wasn't going to be any accountability," McGinnis said.
She says even one nursing home not in compliance is a serious problem.
"The fact is, is that Christina had to put this all together, the department should have that," McGinnis said. "The department doesn't have the data on this, they don't know how many facilities haven't met the 3.2, haven't spent their money on staff, haven't increased the wages on staff, I mean, come on."
Gary Davis and his mother do not have much confidence in the state either; they hoped the state's $100,000 fine for Harold's death would send a message to other homes.
The $100,000 fine did not stick; it was ultimately reduced to just $5,000.
Written and produced by Ken Miguel