By Debbie Cenziper, Sidnee King, Shawn Mulcahy and Joel Jacobs, The Washington Post, May 17 2020
Nursing homes operated by Life Care Centers of America, one of the largest chains in the industry, violated federal standards meant to stop the spread of infections and communicable diseases even after outbreaks and deaths from covid-19 began to sweep its facilities from the Pacific Northwest to New England, inspection reports show.
Over the past six weeks, as the nationwide death toll among the elderly soared, government inspectors discovered breakdowns in infection control and prevention at at least 10 Life Care nursing homes that underwent covid-19 inspections overseen by the Centers for Medicare and Medicaid Services. That does not include deficiencies found at the Life Care Center of Kirkland in Washington state, which suffered the country’s first reported outbreak of the novel coronavirus in February.
At other Life Care nursing homes, inspectors have since then discovered staff members who did not wash their hands or enforce social distancing guidelines, according to the inspection reports. At one home in Denver on May 5, staffers left open the door of an isolation room, allowing a patient with covid-19 to slip into the hallway without a face mask and sit next to a room with two healthy residents. At another home in Colorado, a nursing assistant hovered 12 inches from the face of a coughing patient who was not wearing a mask.
In Kansas, inspectors found a nursing home’s infection control log failed to include two patients with fevers — one was sent to the hospital with a 103-degree fever and died.
Meet two families associated with the Life Care Center of Kirkland, Wash. As one family copes with their loss, the other visits their mother through a window. (Drea Cornejo, Alyse Young/The Washington Post)
In a home in Michigan, a nursing assistant rolled a blood pressure machine out of an isolation room and into a non-covid-19 room without sanitizing the equipment. At another Michigan home, inspectors found residents in a hallway who were not wearing masks and an aide who delivered meals without wearing gloves or a gown, even though the residents were at risk of respiratory infection.
“These deficient practices resulted in the high liklihood of spreading coronavirus and harmful pathogens among five residents . . . second floor residents that received direct care from staff, second floor residents that interacted with each other, residents that resided on the first floor that received food from the kitchen and nine residents that transferred to the hospital testing positive for covid-19,” the inspector wrote.
The Washington Post obtained a batch of inspection reports for 26 Life Care homes from CMS, the federal agency that regulates nursing homes, as well as the state of Michigan and Life Care, though the universe of total inspections may be larger. In 16 inspections, regulators found no deficiencies.
The Tennessee-based Life Care has said that no amount of preparation could have kept the virus at bay and that administrators worked early and often with health authorities to contain the spread of infection.
Since the outbreak in Kirkland, the privately owned company with more than 200 nursing homes has seen at least 2,000 cases and 250 deaths among residents and staff, according to a Post tally of state data and local media accounts. Five Life Care nursing homes have experienced outbreaks of 100 or more cases.
There is no comprehensive national data available to determine whether the rate of infections and deaths at Life Care facilities is higher than at other chains — or how often other chains have been cited for violations after the pandemic began. Nursing homes across the country have been hit particularly hard: About 1 in 4 have reported at least one case of the coronavirus, according to a Post analysis.
Around the country, even nursing homes with strong track records have publicly reported cases of covid-19, which is particularly lethal among the elderly.
“We have a virus that has attacked our vulnerable populations who have co-morbidities, and that has made this extremely difficult to manage,” said Tim Killian, public information liaison for Life Care Centers of America. “We need help. We need hands on the ground. We need money. We need equipment. We need doctors. And none of that is happening in a significant way anywhere in the country.”
Killian declined to comment on the specifics of the most recent inspections. Two of the reports obtained by The Post included Life Care’s responses to inspectors, with the homes noting that staff had received additional training and would be monitored for compliance.
“Choosing a handful of reports, especially during this time of great difficulty, has allowed the press to paint a picture of our company that does not accurately reflect our values or the hard work we do every day to take care of our residents and staff,” Killian said.
Life Care President Beecher Hunter said the homes submit plans of correction to the government.
“Life Care Centers of America and its affiliated facilities are not perfect; no organization is because it is made up of people, and people are imperfect human beings,” Hunter said in an email to The Post. “. . . Our healthcare heroes will from time to time unfortunately fall below our standards for resident care.”
To critics, the size of the outbreaks reflects profound flaws in the company’s management and the treatment of patients, which have been documented for years in lawsuits by families, former employees and federal prosecutors. Time and again, they described a company beset by staffing shortages and compromised care, deficiencies that critics say probably worsened as covid-19 infected hundreds of residents and caregivers.
In the past three years, dozens of Life Care homes received below-average staffing ratings or were flagged during inspections for not having enough nurses to properly care for patients, according to CMS.
At Life Care Center of Kirkland, which has had at least 100 reported cases, residents last year recounted waiting extended periods of time for help bathing and using the bathroom. One resident said she developed sores from sitting for too long on a soiled bedpan, the inspection report showed.
The Justice Department in recent years accused the company’s billionaire owner of leaving Life Care “severely undercapitalized” while engaging in a “systematic scheme to maximize its Medicare billing.” Prosecutors say Life Care subjected patients to excessive, unnecessary and “sometimes even harmful” rounds of rehabilitation therapy to draw Medicare dollars and chastised or punished those who complained the practice undermined the judgment of therapists at the expense of patients.
The company, without admitting liability and arguing the government did not prove its case, settled with the Justice Department in 2016 for $145 million — the largest settlement with a skilled nursing chain in the department’s history. Life Care also entered into a five-year corporate integrity agreement with the inspector general of the Department of Health and Human Services, which required an independent annual review of the company. Life Care was in its fourth year of the agreement when the coronavirus struck the United States.
Families, lawmakers and former and current employees say Life Care, after years in operation and amid intense scrutiny, should have done far more to protect patients and caregivers as the pandemic intensified.
After the early outbreak at the facility in Kirkland, inspectors found the facility failed to properly treat sick patients or alert authorities to widespread illness. The state banned the home from accepting new admissions until fixes were made, including training staff in managing infectious diseases.
“When you are a private, national corporation with skilled nursing centers all over the country, you’ve got what others don’t, which is economies of experience,” said Rep. Lori Trahan (D-Mass.), who called for more federal oversight after dozens of residents and staff members tested positive for or died of the coronavirus at the Life Care Center of Nashoba Valley outside of Boston. “Their facilities in Massachusetts and other states should have been way ahead, given what they learned in Washington.”
At the Nashoba Valley home, several staff members told The Post that critical information about the growing crisis was kept from employees and that a shortage of nurses and aides vexed the home long before the pandemic, including the weeks after the Kirkland outbreak.
“We kept waiting and waiting for them to do something, and they never did,” said Diane Crowley, who worked at the front desk at the nursing home, wiping her hands with a cloth soaked in bleach that she said she kept in a plastic bag in her pocket. She eventually quit. “I was literally surrounded by covid,” she said. “I just told my kids, ‘Please never put me in one of those places. These people live their whole lives — there are teachers, poets and everything else — and this is what they’re ending their lives with?’ ”
Killian said nursing home administrators and staff members followed federal guidelines and risked their own well-being to continue to care for residents throughout the crisis. He said personal protective gear was in short supply at nursing homes across the country and that staff members continued to come in even as their colleagues fell ill.
“These are good people who have been caught up in a difficult situation,”Killian said.
He added that an inspection at the Nashoba Valley facility on April 10 found no deficiencies in infection control or emergency preparedness.
“This environment of sort of conspiracy theories and negative news stories that has set a narrative and tone . . . we think is simply incorrect,” Killian said.
By early April, more than 60 people at the home had tested positive for the virus. Five had died.
Inconsistent infection control
The federal government has not yet released a death count in nursing homes nationwide, but state data has placed the number in the thousands. CMS in early March temporarily called off routine inspections of the 15,000 Medicare-certified nursing homes in the United States to focus most heavily on deficiencies in infection control.
Across the country, inspectorssurveyed nursing homes to determine whether front-line workers were unintentionally contributing to the spread of the coronavirus.More than 6,000 nursing homes have been assessed, with inspectors finding“sporadic noncompliance” involving hand-washing, the proper use of personal protective equipment and the separation of sick patients from healthy ones, according to Skilled Nursing News, a publication that covers the industry.
At multiple Life Care homes, inspectors documented lapses in infection control through observations, medical records and interviews with staff members and patients. Federal standards for nursing homes cover everything from food safety to residents’ rights.
On March 30, shortly after regulators announced they had found significant breakdowns at the Kirkland home, an inspector went to a Life Care nursing home in Pueblo, Colo. During the visit, several staff members did not wash their hands, wear masks or isolate residents. Doors were left open even when residents were supposed to be isolated inside their rooms, according to the inspection report.
A day later, in Greeley, Colo., an inspector found that residents in a television room were not asked to wash their hands before lunch. At another home in the Denver area, a nursing aide helping a resident with a soiled bedpan did not wash her hands when she was done.
When an inspector showed up at a home in central Tennessee in April, the receptionist did not ask questions about the inspector’s health or about the health of a visitor who arrived afterward. The inspector looked at the visitor log and noted the receptionist had checked no screening questions, including whether the visitors had signs and symptoms of respiratory infection or had been in contact with anyone who had covid-19.
Concerns were also raised at a home outside of Detroit, where 10 people had died by the time an inspector visited in mid-April. Staff shared gowns, the inspector found, and one nursing assistant acknowledged not knowing which patients had covid-19 and required isolation. A week after the inspection, the relatives of a 77-year-old woman who died protested outside the home, with signs that read, “Our elderly deserve better” and “Liars. They are not ok.”
According to the report, the nursing hometold inspectors that training had been conducted.
“There are far more stories of success than will ever be published or recognized,” Hunter said. “We thank our dedicated associates for those successes.”
Lapses in patient care
Forrest Preston, the son of a Massachusetts pastor, settled in southeastern Tennessee in the 1950s to help his brother create booklets and public relations material for hospitals. Over time, he developed an interest in long-term care.
“He believed that if a person could build a beautiful building, highly functional for patient care, staffed with people administering professional skills in a spirit of love and compassion, a successful facility would result,” according to a Life Care publication from earlier this year.
Preston and his partners opened the first nursing home in 1970. From his Tennessee headquarters, the company would grow to more than 200 nursing homes, one of the largest networks in the country.
In 2015, the Chattanooga Times Free Press described the 45th anniversary of the first Life Care home, when Preston recounted the first night in operation: “I said these lights will never go off again until the second coming.”
Preston kept a low profile even as federal regulators began to question Life Care’s claims for Medicare reimbursement.
In 1999, the inspector general at HHS audited Medicare claims from Life Care’s homes in Tennessee and ordered $1.6 million returned, according to the report. Investigators found Life Care billed for “inappropriate services,” including eight occupational therapy appointments for an 84-year-old resident in a semi-comatose state.
The inspector general’s report contained no response from Life Care, and the company did not respond to questions about the audit.
In 2002, five whistleblowers with relatives at a Life Care facility in Georgia sued in federal court, saying that severe staffing shortages, inadequate training and an ineffective medical director at the home resulted in the deaths of several residents. The Justice Department intervened and filed a lawsuit on behalf of the whistleblowers and the government.
In 2005, Life Care agreed to pay $2.5 million to settle the case.
“In failing to provide sufficient care for these nursing facility residents, Life Care placed at risk the very residents who had been entrusted to its care,” Thurbert Baker, then Georgia’s attorney general, said at the time.
Killian declined to comment on the case.
“At this time, our entire focus is on the ongoing effort to fight the coronavirus,” he said. “We are working hard to support our residents and our staff.”
In court records, the company denied the allegations and said the nursing home’s conduct was lawful and appropriate.
In 2008, a registered nurse at a Life Care center in Tennessee sued, saying Life Care’s corporate managers pressured nurses and therapists to increase Medicare billing for physical and occupational therapy, even when patients were permanently in bed or a wheelchair.
“The therapists would essentially drag the resident down the hall and document the patient as having ambulated. The resident would gain a false sense of being able to walk and would fall when he tried to walk on his own,” according to a complaint filed in federal court.
A second employee also sued, this time a former occupational therapist at a Life Care center in Florida. Federal prosecutors once again intervened, suing Life Care as well as Preston, the company’s sole shareholder, on behalf of the two whistleblowers and the government.
Prosecutors alleged that “every level of the corporate hierarchy” at Life Care pressed staff to grow Medicare revenue. Some patients put in therapy were terminally ill, sick or medically unstable, according to the Justice Department’s lawsuit, filed in federal court in Tennessee.
In South Carolina, according to the complaint, a lethargic and frail 80-year-old woman was twice placed for 42 minutes in a standing frame — equipment to secure a patient in a standing position — even though she required assistance to control her head and open her eyes and her physical therapist had said she was unable to participate in treatment. She died five days later.
In Florida, prosecutors noted that a 92-year-old man dying of metastatic cancer that had spread to his brain and lungs was sent to rehabilitation therapy for at least two hours a day, including when he was spitting out blood. On the day he died, according to prosecutors, therapists recorded 35 minutes of physical therapy, with occupational therapy scheduled for later that afternoon.
In 2016, the company and Preston agreed to pay $145 million to resolve the cases and entered into a five-year corporate integrity agreement that required an annual, independent review of the organization.
Killian declined to comment on the lawsuits or the probe by the Justice Department. In court documents, Life Care disputed the allegations. The government, according to Life Care, “did not allege a single instance of physician orders for therapy services being false or inappropriate.”
Life Care also said the Justice Department did not link “alleged corporate practices and actual claims nor individuals involved with submitting false claims.”
A year after the settlement, 96-year-old Evelyn Bornstein died at Darcy Hall, a Life Care nursing home in Florida. Her son, Howard, said she spent three days in a room without air conditioning after Hurricane Irma hit Florida. Though a backup generator had restored cool air to the lobby of the building, he said he discovered that residents had been left in sweltering rooms.
Bornstein said he found his mother, a grandmother of four who grew up in the Bronx, unresponsive and curled up in a ball, her face red and mouth dry. He said he tried to put ice on her mouth and head and eventually left in shock. She died that evening.
After Bornstein sued the nursing home, an arbitration panel in Palm Beach County Circuit Court found that Evelyn Bornstein’s death was caused by negligence and awarded $150,000 in damages.
“I’ll live with this for the rest of my life,” Bornstein told The Post.
In court documents, Life Care said that no evidence showed the home’s conduct was “intentionally wrongful or showed conscious disregard or indifference to the life, safety or rights of the plaintiffs.”
‘It kept getting worse’
At the Life Care Center of Nashoba Valley, set amid the apple orchards of Littleton, Mass., former marketing director Lina Le said nurses and aides for months were working short, a term the caregivers used to describe low staffing levels.
By the third week of March, long after the virus had struck Life Care’s Kirkland home, Le said her colleagues were also short on masks, gowns and other protective equipment.
Le called the Nashoba Valley Chamber of Commerce and a local sewing studio and soon delivered 120 homemade masks to the staff.
Then she quit, leaving behind her job of two years.
“I was terrified for myself and my co-workers,” she said. “It kept getting worse and worse and worse.”
Several caregivers at the home told The Post they had no time to wash their hands, change soiled linens or help immobile patients get out of bed. One nursing aide said she found herself caring for 30 patients at once, helping them into bathrooms with filthy toilets or out of beds soaked in urine.
One afternoon in March, the local fire chief called state Sen. James Eldridge (D) and described two dozen ambulance runs to the facility in a single weekend.
“Something’s going on there, but no one at the Life Care Center will tell us,” Eldridge recalled the fire chief saying.
Eldridge reached out to the nursing home and to local and state health authorities, worried that residents, first responders and caregivers had been exposed. Much like in Kirkland, he said, Life Care provided little information.
“I literally live 15 minutes away from this nursing home,” he said. “It was just maddening to me that essentially state government didn’t have the authority to intervene. We were relying upon a nursing home that’s owned by a large corporation based in Tennessee that was being very unresponsive.”
On April 2, Rep. Trahan, sent a text message to a supervisor in the Massachusetts National Guard, which had been activated after a deadly coronavirus outbreak at a home for veterans. “We’re not getting cooperation or visibility from management,” she wrote about Life Care. “Is your team able to get there today?”
“Ma’am, let me speak with Department of Public Health representation now,” the supervisor responded.
The following day, the National Guard tested more than 80 residents at Life Care.
On April 10, inspectors surveyed the home and found no infection-control deficiencies. By then, dozens of people were infected and about 10 had died, including Maria Krier, a nurse who had quit her job at the end of March after developing a fever. She died on the day of the inspection.
Killian said the Nashoba Valley home worked to provide quality care under challenging circumstances and that administrators and company executives regularly reached out to lawmakers and state and local health authorities. He said local politicians and others created “acrimony” in the community by alleging that Life Care did not properly report the spread of infection.
Life Care President Hunter wrote to Trahan and other lawmakers on April 9.
“My promise is that our facility will be a model of cooperation and communication,” he said. “. . . This is a learning experience for all of us. We regard the protection, the care, and the love for our residents as a sacred trust. Their well-being is our highest priority. And we will make every effort to comply with all public health requirements.”
Since then, the virus has been reported at all 15 Life Care nursing homes in Massachusetts and at dozens more facilities in other states.
Executives from Life Care have made few public comments during the crisis. Hunter, however, has appeared on corporate videos emphasizing moral and spiritual lessons. Just before Easter, he spoke about the pandemic.
“These are difficult days to say the least,” he said. “Take heart. God has your back.”
This story has been updated to include a recently obtained inspection report of a Life Care nursing home in Michigan.
King, Mulcahy and Jacobs are graduate students in journalism at Northwestern University’s Medill Investigative Lab. Maria Sacchetti and Post researcher Alice Crites contributed to this report, along with Arnab Mondal at the Medill Investigative Lab.