Infection control lapses, short staffing put senior care homes at risk

Camilla White visits her mother Lillian Barber, 90, from outside seeing her through the window while touching fingertips through the glass at Cottage Landing Assisted Living on Tuesday, April 28, 2020, in Carrollton. White didn’t discover there had been several deaths at the home from coronavirus and a significant outbreak until seeing the info on a state website and said that before the outbreak, “I would go inside and just lay my head in her lap, but I can’t do none of that anymore.” (Curtis Compton / ccompton@ajc.com)
Camilla White visits her mother Lillian Barber, 90, from outside seeing her through the window while touching fingertips through the glass at Cottage Landing Assisted Living on Tuesday, April 28, 2020, in Carrollton. White didn’t discover there had been several deaths at the home from coronavirus and a significant outbreak until seeing the info on a state website and said that before the outbreak, “I would go inside and just lay my head in her lap, but I can’t do none of that anymore.” (Curtis Compton / ccompton@ajc.com)

COVID-19 has ravaged even some highly rated Georgia long-term care facilities. But many of the Georgia homes with the worst outbreaks have a history of struggling to provide adequate care.

For weeks, the extent of the coronavirus takeover in many Georgia senior care facilities was hidden. Now, as entire facilities are starting to get tested, their operators and families are often alarmed — and sometimes terrified — by results that reveal dozens of infected residents where few had even shown symptoms.

Confirmed cases among residents of nursing homes, assisted living communities and large personal care homes have doubled in two weeks with 3,457 confirmed cases as of Friday. Coronavirus deaths at these facilities reached 511 across some 320 facilities with confirmed cases, according to the Department of Community Health. More than 1,650 staff have been infected.

The trend may not be reversed soon. As Gov. Brian Kemp last week cited favorable data to support reopening Georgia’s economy, he also acknowledged that the coronavirus crisis was still waging a deadly assault inside long-term care facilities.

“If it gets in that nursing home facility it is really tough on those people,” Kemp said in a briefing Monday. “It is brutal.”

» COMPLETE COVERAGE: Coronavirus in Georgia

Facilities say that they have made heroic efforts to contain outbreaks, but even though they care for the Georgians most likely to die from coronavirus if they become infected, they couldn't get the tests and personal protective equipment they needed early on. As a consequence, they couldn't tell which residents needed to be isolated and couldn't rely on masks, gowns and shields as a defense against the invisible enemy.

Many Georgia senior care homes, though, have struggled for years with poor care, and advocates for the elderly say the pandemic is exposing a system that too often leaves patients vulnerable. While many highly rated facilities have residents or staff members with confirmed cases of COVID-19, The Atlanta Journal-Constitution found that most of Georgia’s largest outbreaks in long-term care facilities have occurred in those that already had a history of problems.

PruittHealth-Palmyra in Albany, with 20 deaths, has lost more residents to coronavirus than any other Georgia long-term care facility. The nursing home, which operates in one of the state's hardest-hit regions, has had 120 residents and 47 staff test positive. The federal nursing home ratings system gives it 1-star — the lowest possible rating in its 5-star system.

A member of the Georgia Army National Guard infection control team from the 265th Chemical Battalion gently cleans the bed railings of a resident without waking him at Legacy Transitional Care & Rehabilitation in mid-April. As of Tuesday, the Atlanta nursing home had 104 residents who tested positive for the coronavirus, and three who had died, one of the worst outbreaks among Georgia senior care facilities. The facility also had 19 staff members who had tested positive. Curtis Compton ccompton@ajc.com
A member of the Georgia Army National Guard infection control team from the 265th Chemical Battalion gently cleans the bed railings of a resident without waking him at Legacy Transitional Care & Rehabilitation in mid-April. As of Tuesday, the Atlanta nursing home had 104 residents who tested positive for the coronavirus, and three who had died, one of the worst outbreaks among Georgia senior care facilities. The facility also had 19 staff members who had tested positive. Curtis Compton ccompton@ajc.com

The facility in Atlanta with the largest outbreak, Legacy Transitional Care and Rehabilitation, is rated 2 star, or below average. It has 104 residents who have tested positive, according to state reports.

Windermere Health and Rehabilitation in Augusta, another 2-star home, also has one of the state’s largest outbreaks with 76 residents infected and six who have died of coronavirus so far.

Some assisted living communities and large personal care homes with troubled histories also have seen a large number of cases. The federal government doesn’t oversee or rate them, but an AJC investigation last fall of five years of inspection reports found that more than 20 percent of all these facilities had troubled inspection records.

» RELATED: State actions seen as too little, too late to spare senior care residents

» MORE: Death toll rises in Georgia's nursing homes, senior care centers

Among them was Cottage Landing. The Carrollton assisted living facility had an outbreak last month that left at least 22 residents infected and five dead as well as five staff members who tested positive. But residents’ families were kept in the dark about the extent of the outbreak, according to Camilla White, whose mom and uncle live at the home. White said she didn’t learn of the deaths and more than two dozen cases at the home until after an AJC reporter contacted her with the latest figures posted on the state website.

“It’s crazy,” White said of the facility withholding that information. “You don’t do that to people. These are our loved ones.”

After she confronted the home’s leadership, the facility director, Heather Crumbaugh, disclosed to families in a letter the outbreak figures that had been reported to the state. Her memo had no clear explanation as to why she had not provided the information to families earlier, other than to say “I was not at liberty to share the numbers at the time.”

Georgia Army National Guard infection control member Pfc. Cierra Williams assists Dr. Stephen Smith of Piedmont Healthcare as they collect swabs from Legacy Transitional Care & Rehabilitation residents recently to test for the novel coronavirus. Curtis Compton ccompton@ajc.com
Georgia Army National Guard infection control member Pfc. Cierra Williams assists Dr. Stephen Smith of Piedmont Healthcare as they collect swabs from Legacy Transitional Care & Rehabilitation residents recently to test for the novel coronavirus. Curtis Compton ccompton@ajc.com

Crumbaugh in an email to the AJC on Thursday did not directly address White’s concerns. She said the company had made efforts to communicate with families, but added: “We are committed to continuing to listen to the feedback and communications needs of our families and, to the best of our ability, to act accordingly.”

It wasn't the first time Cottage Landing had withheld damaging information. The facility had one of the most troubled safety records among assisted living facilities and large personal care homes in Georgia, the AJC investigation last year found. The home was among the private pay facilities flagged by the AJC for persistent violations over several years, including medication errors, breakdowns in training, and failure to report abuse to the state.

White was aware of problems at the home because she visited her mom several times a week, but she’s not been able to enter the facility since the coronavirus restrictions cut off visitors to hundreds of senior care homes in the state. That makes it all the more concerning the facility withheld the outbreak information from families, she said.

“If they couldn’t tell the truth to us about something this serious, there’s no telling what else is going on,” she said.

Families shut out

Federal regulators say that staffing is one of the most important elements of a home’s ability to provide quality care. As the pandemic spread in March, regulators also emphasized infection control as a key focus.

Both of those have been weak spots for many Georgia long-term care facilities.

Senior care providers everywhere have trouble finding enough workers, and being short-staffed before the virus hit seems to make long-term care facilities especially vulnerable now, the AJC found.

A banner hangs on the front porch of Windermere Health and Rehabilitation Center in Augusta. As of Thursday, the nursing home has had 76 residents with confirmed cases of COVID-19, where residents have had 75 positive cases of COVID-19 and six deaths. The home also has 33 staff members who have been infected. Curtis Compton ccompton@ajc.com
A banner hangs on the front porch of Windermere Health and Rehabilitation Center in Augusta. As of Thursday, the nursing home has had 76 residents with confirmed cases of COVID-19, where residents have had 75 positive cases of COVID-19 and six deaths. The home also has 33 staff members who have been infected. Curtis Compton ccompton@ajc.com

More than two-thirds of the Georgia nursing homes with coronavirus cases already rated well below average or below average for staffing, a measure that takes into account both nurses and other caregivers.

Infection control has been another persistent problem for years in long-term care facilities, especially nursing homes. Inspection records show Georgia homes have had problems with basic measures such as training staff on infection control measures, having caregivers wash their hands after caring for each patient and sanitize meters for blood sugar monitoring.

State and federal regulators have repeatedly identified the problem in facility inspection reports, said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy in Washington, though penalties haven’t matched the serious threat to residents.

» RELATED: Coronavirus exposes gaps in infection controls in senior-care homes

» MORE: Gov. Kemp deploys National Guard to help nursing homes battle virus

Grace Healthcare in Tucker is among Georgia nursing homes that have had issues with both infection control and staffing.

The home has a 1-star overall rating for quality and a 2-star rating for staffing, and last year it was cited by inspectors for violations related to its infection-prevention program.

Grace Healthcare has had 29 residents test positive for coronavirus, with six deaths, state reports show.

Among the Grace residents to die of the disease was Bronson Edward Phillips, 82, his wife and daughter said.

Phillips had "Lewy body" dementia and had progressed to the point that his wife, Annette, also 82, could no longer physically take care of him at home. Her plan was to visit him every day, and she hoped that he would eventually qualify for care in their home.

Grace Healthcare of Tucker is among the Georgia nursing homes with significant outbreaks of COVID-19. As of April 28, 27 residents had confirmed cases and six had died. Eleven employees also tested positive for the virus. Curtis Compton ccompton@ajc.com
Grace Healthcare of Tucker is among the Georgia nursing homes with significant outbreaks of COVID-19. As of April 28, 27 residents had confirmed cases and six had died. Eleven employees also tested positive for the virus. Curtis Compton ccompton@ajc.com

But the facility went into a coronavirus lockdown in mid-March the day he went in, and visitors were no longer allowed, she said. After two weeks, she was able to get an Alexa video system to monitor and communicate with her husband and saw that his condition worsened. Phillips said she called the facility often, but had difficulty getting anyone to answer the phone and tell her how her husband was doing.

When she saw him 31 days later, it was in the hospital after a doctor told her he had the coronavirus and had died, Annette Phillips said. Since she hadn’t seen him since he got sick, the hospital allowed her to don full PPE and walk around his body to say goodbye. “I told him God was waiting for him” she said, and she prayed and cried in the hospital room.

Donna Phillips, Bronson’s daughter, said she works in a nursing home in Columbus and is convinced her dad’s care was mishandled.

Without family members being able to check on loved ones, she said, the state needs to step up its in-person checks. “Right now there is no oversight,” she said.

Dr. Stephen Smith of Piedmont Healthcare collects swabs from Legacy Transitional Care & Rehabilitation residents to test for the novel coronavirus, with assistance from Georgia Army National Guard infection control member Pfc. Cierra Williams (far right at the doorway) on April 19. Curtis Compton ccompton@ajc.com
Dr. Stephen Smith of Piedmont Healthcare collects swabs from Legacy Transitional Care & Rehabilitation residents to test for the novel coronavirus, with assistance from Georgia Army National Guard infection control member Pfc. Cierra Williams (far right at the doorway) on April 19. Curtis Compton ccompton@ajc.com

Brandon Todd, the administrator at the home, said he’s proud of his staff and their commitment to patients. The center took precautions and staff wore protective gear, such as gloves, masks and face shields, but the virus still spread. Once the home realized it had an outbreak, Todd said, the home was transparent with families and staff. And even when caregivers were out with the virus, others picked up the slack and they’ve continued to provide care. He said it was tough on staff to lose patients.

For now, he said, the virus is under control at the center after a retest of all residents last week showed five who were positive. The home is in daily contact with state regulators, who call to check on the facility’s outbreak status, offer assistance and provide oversight.

Todd said he doesn’t know what else they could have done to keep the virus at bay, but he understands at some point they will likely be judged on their performance.

“I think all nursing homes are going to be evaluated when this is over,” he said. “It’s unprecedented times. I don’t know what’s going to come out of it.”

Camilla White becomes emotional while visiting her uncle Eddie Marsh from outside his window at Cottage Landing assisted living in Carrollton on April 28. White didn’t know there had been a significiant outbreak of COVID-19 and several deaths at the home until seeing the information on a state website. White’s mother, Lillian Barber, also lives at the facility. Curtis Compton ccompton@ajc.com
Camilla White becomes emotional while visiting her uncle Eddie Marsh from outside his window at Cottage Landing assisted living in Carrollton on April 28. White didn’t know there had been a significiant outbreak of COVID-19 and several deaths at the home until seeing the information on a state website. White’s mother, Lillian Barber, also lives at the facility. Curtis Compton ccompton@ajc.com

‘Virtual’ inspections

The governor has said that testing is becoming more widely available to long-term care facilities, and he has deployed the Georgia National Guard to sanitize facilities around the state and to assist them with testing.

That has been a help to long-term care administrators who have struggled to gain access to tests and protective gear as stretched staffs have performed heroically, said Tony Marshall, CEO of the Georgia Health Care Association, which represents nursing homes and assisted living facilities.

Marshall said it’s not yet clear why some homes have large outbreaks and others do not, but cautioned against drawing conclusions between star ratings and outbreaks at this point when there are still so many unknowns.

“Testing has improved dramatically in the last week, and yet there is still a significant population to be tested,” he said.

Testing is critical to managing the crisis, said Neil Pruitt, chairman and CEO of PruittHealth, which operates dozens of senior care facilities in Georgia.

"If they couldn't tell the truth to us about something this serious, there's no telling what else is going on." —Camilla White, whose mom and uncle live at an assisted living facility

The company has been aggressive with testing and has made a commitment to update that information daily on its website so families and the public know what's happening in its centers.

Some of them, like the Palmyra home, have had crushing outbreaks, and as testing becomes more available it’s going to reveal the virus “is more and more widespread,” Pruitt said.

The company is planning for the worst, potentially 18 months before the coronavirus is no longer a threat to nursing homes.

“We want to test everybody,” he said. “We want to know what we’re dealing with. We want to know exactly if it’s safe to admit patients, if it’s not (safe) to admit patients. While these numbers are heartbreaking to us, we now know what we’re dealing with.”

Advocates say that state oversight is another critical component to controlling the pandemic and ensuring that long-term care residents are receiving proper care.

Protecting the state’s most vulnerable residents is a top priority in the fight against COVID-19, said Kemp’s press secretary, Cody Hall.

The governor on Thursday extended his order through June 12 that bans visitors and non-essential staff from entering long-term care facilities, discourages group dining and activities, and encourages appropriate social distancing.

“State agencies are working around the clock to ensure these facilities are following the letter and spirit of all relevant regulations in accordance with CDC and Georgia DPH guidelines,” Hall said.

The Department of Community Health, which is responsible for licensing and inspecting senior care homes, is in contact daily with facilities to collect outbreak numbers and check on what’s happening to contain the virus.

It’s rare, though, for state inspectors to walk into a facility these days. DCH is doing most of its work through virtual “desk reviews.”

In March, when the federal government issued orders for states to focus only on infection control and serious harm allegations, it allowed for virtual checks in states without enough protective equipment. Since then DCH has done five on-site checks. But it has conducted 768 remote surveys to check on infection control and three for allegations of possible harm. DCH said it had cited six facilities for infection control violations since March 1.

One of the facilities, Nurse Care of Buckhead, which has an overall 1-star rating, was cited April 7 for not following social distancing guidelines and for hand-washing violations involving a laundry aide. The home has 12 infected residents and one death, state data show. The home declined to comment.

Some advocates say that residents can’t truly be protected during the pandemic without in-home checks by regulators. “Any state agency that takes its role of protecting residents seriously would be getting some PPE to do this,” said Richard Mollot, executive director of the Long-Term Care Community Coalition.

Melanie McNeil, Georgia’s long-term care ombudsman, worries about what is not getting reported and reviewed without any of the regular outside eyes watching facilities. Her office advocates for residents and a big part of its job is to be inside facilities talking to people and understanding the conditions.

McNeil said her staff is starting to discuss how their work might change once facilities do open back up, but no one knows when that will be.

“I feel we’re missing a lot of stuff,” she said. “It’s like trying to do your job with both hands tied behind your back.”

Edelman, the Medicare advocacy attorney, said the combination of families and inspectors not going into facilities and some rules being waived for an industry with a history of trying to weaken enforcement is deeply concerning.

“It’s terrifying how many people are dying from this and how many people will die from this,” Edelman said. “We don’t seem to be getting the equipment, supplies and the staff who know how to provide care properly and how to do infection control really carefully.”