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Above: Laurie Clark (left) plays checkers with brother Billy Stack while at Laguna Honda Hospital. Below: Stack has lived at the hospital for more than 40 years after a motorcycle crash.

Laurie Clark kneels for a photo next to her older brother William “Billy” Stack while at Laguna Honda Hospital in San Francisco on July 20. Stack has lived at the hospital for more than 40 years since suffering from a major motorcycle crash in his 20s. He, along with hundreds of other patients, may now need to leave his home after a federal agency decertified the hospital in April. The decertification came six months after state inspectors declared it to be “in state of substandard care” of its medically fragile and often low-income patients. As of July 20, four patients have died after being transferred out of the hospital, the Chronicle has learned.

Light streamed through the windows. Shelves held board games, a stereo and family photos. Old Christmas cards hung on the walls. All the little hospital room lacked was Billy Stack.

Laurie Clark, Stack’s younger sister, grew a little concerned. Her brother had agreed to meet us to discuss the potential closure of San Francisco’s Laguna Honda Hospital.

Aug. 17 will mark the 44th anniversary of Stack’s move-in date after a near-fatal motorcycle crash left him partially paralyzed and with traumatic brain injuries at age 21. Of the 610 patients living there, Stack, 65, has been there the longest.

Clark thought connecting me with her brother would illuminate the human toll of bureaucrats’ draconian decision-making and explain why Laguna Honda must remain funded and open.

Finally, a loud, delighted squeal filled the hallway outside.

“I hear him!” Clark exclaimed, dashing out.

Clark and Stack beamed at each other from opposite ends of the hallway. She walked quickly while he propelled his electric wheelchair forward, ever-so-slowly. Nurses make him keep it on its slowest setting following too many high-speed hallway jaunts.

“You’re a speed demon in that thing,” Clark teased, giving him a big hug before introducing us. Stack smiles easily, but struggles to speak. He lowered his yellow mask, moved his lips carefully and finally said, “Paper boy!”

Stack had worked as a Chronicle paper boy and gas station attendant growing up in the Sunset District and Daly City with his devout Irish Catholic family before crashing his motorcycle on April 17, 1978, in the Outer Richmond. He wasn’t wearing a helmet, Clark said, and flew through the air, slamming into a street light.

Doctors at San Francisco General Hospital warned the Stack family then that he might never wake up from his coma, but he did. After four months of acute care, he moved to Laguna Honda, where staff members have hoisted him in and out of bed, bathed him, assisted him with meals and helped him avoid bedsores every day since.

Billy Stack sits in a communal room as as a window washer works outside Laguna Honda Hospital. Stack and other patients may be transferred due to the hospital being decertified.

Clark said her brother was a moody young man, but the crash somehow made him more high-spirited. He laughs all the time — his trademark high-pitched squeal — and is known for his jokes and one-liners.

“I’ve nicknamed him the Mayor of Laguna Honda,” Clark said. “Everywhere we go, it’s, ‘How’s it going, Billy?’ or ‘My man, how you doing?’ His whole life since the accident has been nowhere but Laguna Honda. It’s the only home he’s known.”

But whether that will continue remains uncertain as federal bureaucrats — in this case at the Centers for Medicare and Medicaid Services (CMS) — prioritize codes and regulations above real people.

CMS decertified Laguna Honda in April, six months after state inspectors said it was “in a state of substandard care.” That means the agency will no longer subsidize the care of the hospital’s patients. The city’s Department of Public Health is working to regain certification by its Sept. 13 deadline while also proceeding with a closure plan.

Until late last week, that included transferring patients — 57 so far — to other nursing homes and even to homeless shelters. The Chronicle has confirmed that four of those patients died soon after their transfers, and there are indications the count may be higher.

Yet nobody seems to be taking responsibility for the devastation wrought on the hospital staff, its patients and their families.

Laguna Honda, which opened 156 years ago, is believed to be the country’s last big almshouse, a nonprofit nursing home run by the county to provide long-term medical care for the very poor, the very sick and the very disabled. Unlike most hospitals that aspire to move patients out as quickly as possible, Laguna Honda operates slowly and with great care.

It has a mock apartment where people undergoing rehabilitation after strokes, brain injuries and other trauma can relearn how to cook, do the dishes and use the toilet. Residents can use gyms, pools, an art studio, a library and a barbershop.

Out back, lush gardens and a fruit orchard sit among paths where people can practice using wheelchairs, walkers and canes. There’s even a surface made to resemble Muni tracks where people can practice crossing without stumbling. At a therapeutic farm, patients interact with chickens, goats and two pigs named Virginia and Hamlet.

Before the pandemic, legions of visitors entertained patients. The San Francisco Threshold Choir, for example, sang there for years. A member told me that one day, the choir visited the bed of a young homeless man who’d just died. A quilt covered his body. The choir sang “Amazing Grace” while a social worker held a phone up so his grandmother, far away, could hear her boy being ushered onward with love.

In other words, this is the place where San Francisco values — compassion, care and commitment to those with the least — continue in a fast-paced, high-tech city that’s largely seemed to discard them.

“They’re the people who fall through the safety nets of the safety nets,” said Dr. Victoria Sweet, who worked at Laguna Honda for decades and wrote the esteemed book about the hospital, “God’s Hotel.” “They have no other place to go. There’s no other way to take care of them but to do the kind of job that Laguna Honda has always done.”

Stack solves a crossword puzzle with his brother John (left) at Laguna Honda Hospital.

So why aren’t the federal and state governments committed to helping Laguna Honda improve and continue rather than threatening it with closure?

These are the questions nobody in San Francisco can answer, though many have been trying amid a lack of government transparency.

Incredibly, Laguna Honda is finding out about the post-transfer deaths only if family members notify staff there. The state has provided no official information about the deaths, despite approving the transfer plan in the first place.

On July 28, the state and federal government agreed to a temporary “pause” on discharges, though few details were given and the long-term outlook for the hospital remains the same.

“It’s a temporary reprieve, which is a good thing because it means that people are not going to die for a temporary period of time,” said Supervisor Myrna Melgar, who represents District Seven, which includes the hospital. “But the big issues are still unresolved.”

The reasons for the potential shutdown are serious, but aren’t worthy of turning hundreds of patients like Stack out. Not even close.

The hospital came under scrutiny in July 2021 after staff reported two patient overdoses from street drugs, neither of them fatal. In October, staff found contraband including cigarette lighters and drug paraphernalia in patients’ rooms and reported it to authorities. This spring, inspectors found more problems including issues with staff members’ hand hygiene.

Roland Pickens, the hospital’s CEO, said he has put in place new protocols to check patients and visitors for drugs and paraphernalia upon entering the hospital. But the latest mistakes — like a nurse spotted not taking off her gloves quickly enough after leaving a patient’s room — were human error common in any hospital, he said.

Michael Connors, an advocate with California Advocates for Nursing Home Reform, said closing nursing homes should be a last resort, and that there aren’t any problems at Laguna Honda that can’t be fixed.

He said he’s “very surprised” by CMS’ targeting of Laguna Honda, when many for-profit nursing homes have far worse records for patient care.

Until the recent pause in transfers, 32 Laguna Honda patients had been transferred to the Burlingame Skilled Nursing Facility, which a state Department of Public Health tracker shows is in the midst of a major COVID-19 outbreak and has struggled to contain the virus throughout the pandemic.

Laguna Honda, by contrast, did well containing the virus. The tracker shows the Burlingame facility had 34 COVID-related deaths, while Pickens said the far bigger Laguna Honda had six. A message left at the Burlingame facility was not returned, and additional calls went unanswered. A man listed online as its CEO didn’t return a call.

“I don’t think we really know what triggered all of this,” Connors said. “Laguna Honda never should have been decertified in the first place.”

He laid out a smart plan moving forward: CMS should extend federal funding while Laguna Honda seeks its recertification; rescind the hospital’s relocation plan; halt transfers permanently; and allow residents who’ve moved out already to move back.

The state and federal governments aren’t saying much. I emailed Dr. Tomás Aragón, director of the state’s Department of Public Health, to ask whether he’d withdraw the hospital’s relocation plan as requested by the Board of Supervisors in recent legislation.

A spokesperson for his department didn’t respond to that question, but wrote that the department “is providing technical assistance to the facility to improve its policies and procedures related to transfers.” That implies the transfers will resume.

Laurie Clark rests her hand her older brother William “Billy” Stack’s back while at Laguna Honda Hospital in San Francisco in July. Stack has lived at the hospital for more than 40 years since suffering from a major motorcycle crash in his 20s. He, along with hundreds of other patients, may now need to leave his home after a federal agency decertified the hospital in April. The decertification came six months after state inspectors declared it to be “in state of substandard care” of its medically fragile and often low-income patients. As of July 20, four patients have died after being transferred out of the hospital, the Chronicle has learned.

Asked whether Gov. Gavin Newsom would consider declaring a state of emergency regarding the hospital as pushed by the Board of Supervisors, his spokesperson sent the same statement from the health department — plus an old one from the health department.

At least they answered. Xavier Becerra, secretary of the U.S. Department of Health and Human Services, oversees CMS and could intervene. Requests to his department for comment weren’t acknowledged.

Jeff Cretan, a spokesperson for Mayor London Breed, said the mayor is frustrated that her staff has spent months on saving Laguna Honda due to a “confounding situation” that was avoidable if only the hospital had been given the time to fix errors.

“It diverts our focus away from all of the issues confronting our city,” he said.

Becerra did finally answer calls from Breed last week, when he agreed to the temporary pause in discharges, but could take far stronger action. Melgar, who was briefed on the call with the mayor, said the health secretary’s message was, “You have to follow the rules like everybody else.”

Really? Even if the rules mean the hospital will lose funding and hundreds of innocent patients will be turned out to worse facilities or shelters? I’d suggest Secretary Becerra tour Laguna Honda as soon as possible — and meet patients like Billy Stack.

Laurie Clark, Stack’s sister, has called Becerra’s office and that of every San Francisco politician in the state and national government she can think of. She rarely gets any acknowledgment.

“It almost seems cruel, the callousness,” she said. “It just doesn’t make any sense to do this instead of working very hard to fix it and make it better.”

She’s described the outlines of the problem to her brother.

“Yeah, I heard that,” Stack said. “I’m just putting up with it.”

Mostly, they keep their visits light. On a recent afternoon, that included several rounds of checkers.

“Have mercy on me, OK?” Clark asked her brother as they set up the game.

Her brother squealed and slid a red checker forward.

Heather Knight is a San Francisco Chronicle columnist. Email: hknight@sfchronicle.com Twitter: @hknightsf

Heather Knight is a columnist working out of City Hall and covering everything from politics to homelessness to family flight and the quirks of living in one of the most fascinating cities in the world. She believes in holding politicians accountable for their decisions or, often, lack thereof - and telling the stories of real people and their struggles.

She co-hosts the Chronicle's TotalSF podcast and co-founded its #TotalSF program to celebrate the wonder and whimsy of San Francisco.