Rest home where 13 died from coronavirus passed all inspections

The Gordon Manor nursing home in Redwood City. Photo from the home's website.

Daily Post Staff Writer

State inspections as recently as January give no clue why 13 patients including former Stanford President Donald Kennedy would die from the coronavirus at the Gordon Manor assisted living home in Redwood City.

The only problems documented in the facility’s last four years of inspections was the wrong water temperature in two sinks, which was quickly corrected. But the inspection reports by the state Department of Social Services generally painted a picture of a well-run assisted living facility. The 49-room facility is just off of Woodside Road near Safeway.

Whatever caused the 13 deaths wasn’t apparent to the state inspectors.

The Post has tried repeatedly to interview Gordon Mano Director Alisa Mallari Tu over the past several weeks, but she didn’t return the newspaper’s messages.

But the Post interviewed two Stanford doctors who specialize in geriatric medicine to get their opinions about what might have happened at Gordon Manor. In addition to the 13 deaths, 25 other patients at Gordon Manor have fallen ill from the virus.

Dr. Mehrdad Ayati said it’s likely that an asymptomatic staff member unknowingly spread the virus to the home’s vulnerable population.

One issue in memory care facilities such as Gordon Manor is that patients don’t know, or don’t remember, to follow social distancing, or use hand sanitizer at every turn, Dr. Ayati said.

Dr. VJ Periyakoil, an associate professor at Stanford, said that there are three reasons why outbreaks such as the one that’s hit Gordon Manor have been so devastating:

• Most of the residents have a weakened immune system or have other underlying health problems.

• Proximity to others. Periyakoil noted that many of these residents can’t follow the six-foot social distancing rule when they need help showering or getting dressed.

• The people working in these homes are underpaid and overworked.

“I’m convinced that these are people doing as best they can, which is evidenced by the high ratings from the state,” Dr. Periyakoil said. “I think there were no bad actors here, but a bad screenplay.”

Expert says employees need breaks, sick pay

Dr. Periyakoil said the workers in the facilities need to be able to take 10 minutes out of their shift to meditate or relax in some way. Dr. Ayati said many of these workers are worried that if they get sick, they will get fired, so some employees will go to work even if they have symptoms or could have been exposed.

Workers at care facilities ought to still get paid if they go to get tested, Dr. Ayati said.

The doctors weren’t speaking about Gordon Manor specifically but the industry in general.

Both doctors said that there needs to be an increase in personal protective equipment, also known as PPE, in the care homes in order to reduce the spread of the virus, and the employees there need to know how to use them.

In San Mateo County, the Health Department has gone out to at least 244 of the over 360 care facilities in the county, including Gordon Manor, to conduct testing on both patients and employees. They are also teaching employees how to properly wear, and take off, the PPEs, as well as proper sanitation between seeing patients.

County’s assistance has stopped trouble

Dr. Ayati said the county’s team has been really helpful to care facilities, saying that in some cases if the county’s team hadn’t of come in, entire facilities could have been infected.

Gordon Manor is not the only care facility in the county where deaths and confirmed cases have occurred. There are 20 cases at Abigail Complete Care in Redwood City at 1230 Hopkins Ave., 14 at Atria in Daly City, and less than 11 cases at San Carlos Elms, Sterling Courts in San Mateo, Sunrise of Burlingame, and the Atria homes in Burlingame, according to the Department of Social Services.

The department does not break down the exact number of confirmed cases, or deaths unless it is over 11.

Other affected facilities

Eleven or fewer cases have been confirmed at Millbrae Skilled Nursing, Carlmont Gardens in Belmont, Seton in Daly City, Pacifica Nursing and Rehab and St. Francis Pavilion in Daly City.


  1. what is the most scariest thing , is to have on COVID 19 in the facility since one patient in a week time will be more than 20, no one care about the skilled nursing home, they are under many stress financially mainly, they don’t have Enough PPE, education and staff to care.
    I am expecting worse to come if we don’t support our facilities across the nation.

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