‘A Tinder Box’: Nursing Homes Long Struggled to Contain Infections. Here’s What They Can Do Now

Advocates say homes must beef up staff and make other reforms. The nursing home industry rejects any connection with past problems and say they need billions to respond to COVID-19.

For the Isabella Geriatric Center at the northern end of Manhattan, the coronavirus has been a calamity, suspected of killing nearly 100 residents at the 705-bed nursing home.

The death toll forced it to store bodies in a refrigerated truck and prompted U.S. Rep. Adriano Espaillat to call for an investigation into whether nursing homes have withheld information from regulators and families. Its management says it could not get the tests it needed to save its residents. 

Like other nursing homes, Isabella Geriatric Center cares for an exceptionally frail population vulnerable to infection by the coronavirus. And like many other nursing homes, it had problems controlling infections before the new virus began sweeping across the country, according to federal inspections.

A New York City nursing home says nearly 100 of its residents have died from confirmed or suspected cases the novel coronavirus
Frank Franklin II/AP Photo

An NBC analysis of data currently available found that 54% of New York’s nursing homes that reported confirmed and suspected COVID-19 deaths had been cited for violations in recent years by the Centers for Medicare and Medicaid Services. Other states report similar percentages and higher -- even as death tolls, methods of reporting them and transparency among states are changing quickly in the midst of the pandemic.

Many nursing homes across the U.S. with coronavirus deaths have a history of infection-related citations

As shown below, the percentage of nursing homes with both coronavirus-related deaths and past infection control violations is as high as 87% in some states. The Centers for Medicare & Medicaid Services (CMS) issues infection control violations for things like staff working with unwashed hands or improperly cleaning equipment after use, such as glucometers.

Source: NBC analysis of data from the Centers for Medicare and Medicaid Services and state health departments. Note: The analysis looked at CMS-administered nursing homes that have reported at least one coronavirus-related death, either probable or laboratory confirmed. Only states that currently release the names of individual nursing home facilities with deaths were included. California and Delaware were omitted for masking the identity of various homes or death totals. Further, please note that states have different reporting standards. Some states, such as New York, do not include COVID-19 positive deaths that occurred outside of the facility, such as in a hospital, while others, such as Georgia, do.
Credit: Amy O’Kruk/NBC

“The nursing home industry was a tinder box,” said Mike Dark, an attorney with the nonprofit California Advocates for Nursing Home Reform. “This virus is the match that set it off.”

Dark is among the critics who say that the homes have long failed residents and have rarely been penalized for it. Even when they were cited for violations they faced few repercussions, their staffing levels remained low and their employees paid too little. The critics argue that government standards for care must be better enforced and even tougher ones should be enacted, among them minimum staffing and the requirements of at least one registered nurse in each home 24 hours a day. Efforts by the Trump administration to reduce the number of inspections should be resisted, they say. Nursing homes are well able to afford the improvements because of rising Medicaid rates and other changes, they say. The nursing home industry counters that violations were often unrelated to any actual harm to residents and were quickly corrected. It insists that the pandemic was unprecedented, leaving operators begging for help from the federal government. They now want billions of dollars in federal assistance and are pushing for immunity from lawsuits to owners and employees.

That the coronavirus could be especially deadly for nursing homes was apparent as early as February when the devastation at the Life Care Center of Kirkland, Washington, was becoming known. The home, an early epicenter that has been linked to 37 deaths, did not have an adequate infection control system in place among other deficiencies and now faces a fine of more than $600,000 and threatened termination from participation in the Medicare and Medicaid programs, federal and local officials say.

A worker wearing protective gear is seen through a window
AP Photo/Ted S. Warren, File

But by then homes had too little time to turn around lax procedures, Dark said. For decades before the pandemic, regulators had failed to treat infection control as a priority and to levy significant fines for lapses, giving nursing home operators few incentives to make improvements.

Advocates for reform say staff in the facilities have typically had to take on shifts at more than one place to support themselves. When the coronavirus began to spread, some through no fault of theirs brought it into the homes with them, Dark and others say.

Deadly clusters of COVID-19 have taken a toll at nursing homes and long-term care facilities across the country.

“The virus is using health care workers as a kind of Trojan horse to get in,” Dark said.

Older Americans have suffered disproportionately. In Connecticut, Massachusetts, New Jersey, Pennsylvania, Rhode Island and other states, more than half of the state's deaths have been nursing home residents, according to reports. In New York, nearly 5,000 people likely have died from COVID-19 at nursing homes, about 25%.

In the absence of a federal tally of deaths in homes nationwide, The Associated Press has been keeping its own, based on reports from state health departments and in the media. Its total: 23,065 out of 73,566 deaths across the country or just over 30%.

Infection control problems are common in the homes, according to reports from the Centers for Medicare and Medicaid. An analysis of its records since 2015 found that nearly 11,500 nursing homes among the country’s almost 15,500 homes had been cited for violations.

This animation shows what the coronavirus can do to the lungs and how it compares to pneumonia.

"People talk about the COVID virus as though it were an astroid that has struck the Earth," Dark said. "It’s an infection. Infections are a common thing that you have to deal with in the nursing home." 

Poor infection control set the stage for the crisis that homes are in now, he said

Missing from the NBC analysis are states that are refusing to release information about deaths in its nursing homes, Texas the largest among them. Only about dozen states are both disclosing how many deaths have occurred in nursing homes and identifying the individual homes.

In those states, 52% to 87% of CMS-administered nursing homes with COVID-19 deaths had violated infection control protocols, according to past inspections.

Richard Mollot, the executive director of the LongTerm Care Community Coalition in New York City, said that those infection-control violations should have been a red flag at the end of February, but were not.

“Facilities have never felt the need to improve their infection control, they've never felt the need to have sufficient staffing because they're never held accountable for it,” he said.

The pre-coronavirus infection-control violations, though spelled out in reports, frequently were not rated seriously enough to push the homes’ operators to make changes, Mollot said. Even before the pandemic, one to three million serious infections occurred every year in longterm care facilities, and as many as 380,000 people died, according to the federal Centers for Disease Control and Prevention.

“If you look at the CDC data, clearly residents are endangered by inadequate infection control and prevention,” Mollot said. 

More than 4 million Americans live in nursing homes or skilled nursing facilities, and another 1 million are in assisted living facilities, according to the CDC. Nearly 70 percent of nursing homes are operated under for-profit ownership, the CDC reports.

The nursing homes and other adult care facilities dispute a direct connection between past violations and the current coronavirus outbreak. They blame this particular virus and the threat it poses to their residents, older people with many health conditions, rather than any shortcomings in the facilities. 

“Prior infection control citations and being prepared for this virus are not directly related,” the American Health Care Association and National Center for Assisted Living said in a statement. “Many of these citations were unrelated to an actual infection or resident harm. They also were all corrected quickly. “

Long-term care providers are facing an unprecedented situation and have been pleading for testing, personal protective equipment or PPE and staff, the statement said.

“Just like hospitals, we have called for help. In our case, nobody has listened,” it said.   

Without access to more testing, nursing homes are at a severe disadvantage in identifying residents and staff who have COVID-19 but who do not have symptoms. Without more PPE, staff are at a serious disadvantage in protecting themselves while they try to care for residents, the statement said. 

“Plain and simple, whether it’s federal, state or local health agencies, long term care needs to be a priority for supplies and help,” it said. “We need adequate testing and PPE. We need help with finding more staff. And we need it now. It’s time that America rally around our long term care residents just as they have with hospitals.”  

The industry is now asking for $10 billion in help from the CARES Act. In a letter to the administrator of the Federal Emergency Management Agency, Peter Gaynor, and to Health and Human Services Secretary Alex Azar on May 6, the American Health Care Association and National Center for Assisted Living asked for priority testing for all residents and caregivers in nursing homes and assisted living centers, for expedited shipments of personal protective equipment and the $10 billion in emergency relief funding to pay for staff, testing and the equipment.

“Right now, the epicenter for COVID-19 is in our nursing homes and assisted living communities,” the letter read. “Our ask to HHS is to create a specific fund for long term care, just as the agency has done for hospitals.”

Shady Oakes, a small assisted living residence in Bristol, Connecticut, has had no cases of COVID-19 after 17 caregivers and the owner moved onto the property on March 22. The plan was to buy time so that the residence could get the tests and equipment it needed to keep everyone safe, said the owner, Tyson Belanger. He has been paying aides and nurses incentives to stay —  $15,000 a month for aides and $20,000 to nurses — but he had to draw loans on his savings of about half a million dollars and has been approved for $343,243 from the Payroll Protection Program. Without assistance, he cannot afford to hold the bubble, as he calls it, much longer.

He argues that government funds should be made available to help nursing homes and assisted living residences to pay their staff to live onsite while disease is raging. Without adequate testing, homes were powerless against people who were asymptomatic, he said.

“The homes that have been exposed to COVID over these last few weeks, it’s been an unfair challenge to them because they haven’t had enough testing, they haven’t had enough available testing to take care of their residents and to take care of their caregivers,” he said. “It’s not fair to them because they can’t fight what they can’t see and they can’t detect.”

New York state had reported only 13 deaths at the Isabella Geriatric Center until April 30, when the New York City cable television station NY1 broke the news that the death toll was actually 98. Since then, the New York State Attorney General Letitia James has announced that her office will investigate complaints about the center and other homes.

Adrienne Blackett, a 68-year-old retired postal worker, died on April 6 at the Isabella Geriatric Center in New York City from COVID-19.
Courtesy Melody Jenkins

Adrienne Blackett died at the Isabella Geriatric Center on April 6. Over the phone days before her death, her daughter Melody Jenkins heard Blackett gasping for air, Jenkins told NBC.

"She sounded horrible, she could barely breathe, she could barely talk," Jenkins said. "When she heard my sister's voice, she got so excited and she kept telling my sister -- every time she would gasp for air, she would just say, 'Come, come get me.'"

Jenkins said that she and her sisters were refused a visit with their mother, who had dementia, though Jenkins pleaded with a social worker. She said it took her 30 minutes to convince someone to bring a phone into her mother's room.

They had been unable to see their mother, whom they had visited every day, since March 11, when she appeared well. Jenkins said she called repeatedly to ask about a video chat, but did not get an answer until about a week later. By then her mother was depressed and crying and Jenkins said she tried to reassure her that she would return as soon as she could.

She talked to her mother one more time before, on April 1, they were told, "She's very sick and she's not going to make it," Jenkins said.

Her sister was told that her mother's roommate had died and that a new roommate was now in her room, but the nursing home said it was not testing for COVID-19, though her mother then had symptoms, Jenkins said.

Even before the pandemic, the family was not happy with Blackett's care, but could not find another home for her, Jenkins said. In 2017, her mother had a viral infection that required her to be hospitalized but only after another daughter insisted, Jenkins said. Over the years, her mother had bed sores and a large unexplained bruise on her arm. One time, she found her halfway out of her wheelchair, crying, she said.

Another resident, Toribio Antonio Garcia, was at Isabella Geriatric Center for nine days, recovering from a tracheotomy, when he died. The 62-year-old struggled to breathe and wrote notes to his family pleading for help, his relatives told NY1.

“They did not inform us that COVID-19 was at the facility,” Xiomara Garcia-King, Garcia’s daughter said. 

A man whose father is still at the Isabella Geriatric Center and who does not want to use his name worries that he and his mother will never see his father again. They have had no access to him since mid-March. He said that the home undercounted the number of cases it had.

“It’s just downright criminal,” he told NBC. 

In a statement, the Isabella Geriatric Center said that like all other nursing homes in New York City, it had limited access to widespread and consistent in-house testing to quickly diagnose residents and staff.

“Sadly, while we have always had daily health screenings of staff, this hampered our ability to identify those who were infected and asymptomatic, despite our efforts to swiftly separate anyone who presented symptoms,” it said. 

The nursing home is now getting more access to testing, it said.

It insists that it accurately reported confirmed and presumed COVID-19 cases, including deaths, that it follows New York State Department of Health infection control, that it hired staff from outside agencies when it experienced shortages and that it was able to purchase personal protective equipment that its staff needed.

“Like every other health organization in March, we were concerned about having enough PPE for our employees, which is why we repeatedly appealed to—and worked with—city, state and federal officials, private resources and vendors to secure and purchase as much as PPE as possible,” it said.

It maintains that families have been able to say goodbye to dying relatives in person.

And finally it said it was not embarrassed that it had the foresight to order a refrigerated truck. Funeral homes across New York City have been overwhelmed and unable to pick up bodies for days, it said.

“Our commitment to caring for our residents with compassion, dignity and respect continues after the person has passed,” it said.

Over the weekend, New York Gov. Andrew Cuomo announced new rules for nursing homes to try to curb the spread of the coronavirus. Hospitals cannot release patients to homes in New York unless they test negative for the virus, Cuomo said Sunday. Earlier, the state's health department required nursing homes to accept recovering patients. Staff must now be tested twice a week, and Cuomo guaranteed that tests would be available. Homes that fail to meet the new standards by May 15 risk losing their licenses.

The federal government will begin requiring nursing homes to report COVID-19 information to the CDC and to residents and their families. Facilities must submit their first set of data on May 17.

In New Jersey last month, 17 bodies were found in bags in a small room at an overwhelmed nursing home in Andover, the Andover Subacute and Rehabilitation Center II. At least 94 residents and one member of the staff have died from the coronavirus. 

An inspection by the Centers for Medical and Medicaid Services found infection control and other failures that led to a fine of more than $220,000. Paperwork was missing for residents with elevated temperatures, some who died. 

Former workers who did not want to be identified told NBC New York that conditions were terrible before the pandemic. 

"There would be urine and fecal matter on the floor, in the hallway, in the bedroom, like it was just gross,” one former employee said.

“I have seen bedbugs in patient beds and, you know, we have reported this a couple of times and nothing is being done about it. Nothing. They don't care about the patients,"  "And then with the virus happening...things just got 10 times worse because there's nobody there to help these residents, because of the staff being so scared of working there."

Earlier inspections gave the home a much below average rating.

The co-owner, Chaim Scheinbaum, told NBC News in an email in April that the health and safety of residents and staff was the top priority.

“Ownership and administration is working around the clock to ensure we are able to resolve the pandemic in the facility,” he said.

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