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The bleeding started suddenly and lasted 15 minutes, soaking through the sheets and pooling on the floor. Turning pale, Armando Reagan cried out to the nursing home staff.

“Help! Help! I do not want to die!”

By the time paramedics got Reagan to a Glendale emergency room, he was incoherent, with his heart beating rapidly and his breathing labored, documents show. Within an hour, he was dead.

The Los Angeles County coroner determined that Reagan, a 30-year-old paraplegic and former gang member, died that day in July 2010 from hemorrhagic shock due to chronic infections stemming from an old gunshot wound and “neglect by provider.”

The county Department of Public Health later found that the Montrose nursing home failed to closely monitor Reagan for the effects of blood thinners he was prescribed. An inspector told facility officials that they should expect the most severe citation possible: an AA penalty that can bring a fine of up to $100,000, according to the county’s long-term care ombudsman, Molly Davies, whose staff was involved in the case.

Yet the final citation, released in 2012, was reduced to a lower-level violation and Verdugo Valley Skilled Nursing and Wellness Centre was assessed just $20,000, documents show. No written explanation was given for the change.

A county auditors’ report in August found that supervisors in the public health department have regularly downgraded draft citations without documenting their justification or discussing their findings with inspectors.

But Reagan’s case and two others reviewed by Kaiser Health News appear to provide new details on how that practice played out when nursing homes were faulted in patient deaths.

The audit did not identify patients in the downgraded cases. Though it said some involved children as young as 3 years old, it is not clear who those children were.

However, two knowledgeable sources who were not authorized to speak on the record cited the deaths of two toddlers at a Sun Valley nursing home in 2012. In both cases, they said, inspectors’ recommendations for AA citations were lowered to level A’s.

Documents show the children died at Totally Kids Specialty Healthcare just seven months apart. Both had histories of trying to pull out their breathing tubes and eventually did so, the documents show. County public health inspectors found that the facility failed to have a plan to prevent the children from pulling out the tubes and to watch them closely, records show.

The A-level fine was $20,000 for the first child’s death, and because a similar violation occurred within the same year, the fine was tripled to $60,000 for the second death. (A-level citations are issued when a violation presents an imminent danger of death or serious harm to patients, while AA citations arise when a violation directly causes a patient death.)

Totally Kids believes that the allegations against the home are not correct and is contesting both citations, said Doug Padgett, CEO of Mountain View Child Care Inc., which runs Totally Kids.

“We know that we provided the best care possible to those patients,” Padgett said in an interview. “We believe we fully complied with the regulations.”

The Verdugo Valley facility, where Reagan died, also defended its care. A lawyer for the facility, Mark A. Johnson, said in a statement that it accepts “extremely compromised and challenging patients” that most facilities won’t take and is committed to providing them with the highest possible level of care.

The county Department of Public Health, responsible for overseeing nursing homes on behalf of the state and the federal government, described the A-level citations as appropriate in all three deaths described in this story.

“In some instances, violations found by our Health Facilities Inspection Division (HFID) surveyors require substantive review by both County and State physicians,” the department said in a statement. “After this review some citation levels may change based upon the medical consultations.”

Asked about its lack of documentation for downgrading inspectors’ recommended citations, officials noted that earlier this year, they began using a form developed with the state public health department to explain its approval or changes to such recommendations. The completed form is for internal use and not publicly available.

‘He was nothing’

A gang member with two drug-related criminal convictions, Reagan was wounded at 19 during a drive-by shooting outside a North Hills apartment complex.

He cycled in and out of nursing homes for years, arriving at Verdugo Valley in March 2010 with several pressure ulcers, kidney failure and a blood clot, documents show. He was briefly hospitalized in April for treatment of infections.

Three months later, in July, Reagan started bleeding from his groin. Nursing home staff applied pressure to the wound but didn’t lower his head as needed to help blood flow to his heart, according to an account by the ombudsman’s office.

In her citation, the inspector, Magnolia Frausto, wrote that staffers failed to follow the physician’s orders for lab tests to ensure blood thinners were given safely and that bleeding was not excessive. “Both the effect of the drugs on the resident’s ulcers and on the integrity of the blood vessels surrounding the ulcers were not monitored to detect early warning signs and symptoms for bleeding from the ulcers,” she wrote.

The public health department would not make Frausto available for comment and said in a statement that there was no documentation on “how, or if, any changes were communicated” to her.

But Rachel Tate, the regional manager of the county ombudsman’s office, was aware that the recommended citation had been downgraded because she was present when the inspector delivered her initial findings, said her boss, Davies.

Tate asked Yolanda Moore, a supervisor within the county public health department, for an explanation. “I am not at liberty to disclose this information,” Moore responded, according to an email reviewed by a reporter.

Davies officially appealed the citation. In a July 2013 letter, she wrote, “The facility made no attempt to ensure that a resident at risk for severe bleeding did not actually experience severe bleeding.”

Both county and state officials denied the appeal – in part by blaming the patient for poor cooperation in the past. The state public health department said in a November 2013 letter to Davies that Reagan had turned away treatment on several occasions, including refusing to take antibiotics and blood thinners and declining wound care.

“The resident’s refusal of treatments and care offered by the skilled nursing facility in question also makes him culpable for the risk of experiencing either imminent danger or serious harm to his health and safety,” wrote Debby Rogers, former deputy director of the state health department’s Center for Health Care Quality.

Reagan’s cousin, Marleen Aparicio, remains angry at the department and the nursing home for his death. “They just got a slap on the wrist,” she said of Verdugo Valley.

Despite Reagan’s troubled past, “he was somebody’s son, he was somebody’s nephew, he was somebody’s cousin,” she said.

To the nursing home and the health department, Aparicio said, “He was nothing.”

The downgrading of an AA citation can be more than a matter of money.

When a facility receives two AA citations within two years, officials are required by law to initiate the suspension or revocation of its license. Verdugo Valley had already received a AA citation after a developmentally disabled and mentally ill man, Charles Morrill, killed himself in 2009 by discharging a fire extinguisher in his mouth. Two weeks before his death, Morrill had attempted suicide in the same way.

According to that citation, the facility didn’t make a plan to protect Morrill once he returned from the psychiatric unit of an acute care hospital. The nursing home, owned in part by Brius LLC, one of the largest chains statewide, also was indicted on charges of abuse and neglect in 2011 because of the suicide. The California attorney general’s office agreed to drop the charges in 2012 in exchange for placing the facility under a three-year court injunction requiring ongoing monitoring.

“It should go without saying that the facility deeply regrets these tragic incidents, both of which occurred years ago and not long after the current owners acquired the facility,” Johnson, who also represents Brius, said in his statement. “It has been more than four years since the most recent of these incidents, and the facility has not had a citation for any serious incident since.”

Will Evans of The Center for Investigative Reporting contributed.

This article was produced by Kaiser Health News with support from .