James Jones weakened rapidly. Two days after testing positive for COVID-19, the 85-year-old retired mechanic died alone in Room 112 West in the Parkway Health and Rehabilitation Center.
Ironically, his daughter says, he was scheduled for only a brief stay there to regain his strength following a seizure.
But it was inside Parkway that Jones apparently caught the novel coronavirus as the disease ran like wildfire through the facility.
“I thought he was coming home. I had washed everything in his room. Cleaned it up real good,’’ said Jones’ daughter, Dinett King. “But he never made it home.”
Nursing homes are among the hardest hit by the coronavirus – nearly four in ten deaths in Shelby County occurred in those facilities.
Most of the local nursing homes with the largest number of COVID-19 infections had two things in common: they are for-profit operations, like Parkway, and they have below-average ratings for staffing, an analysis by the Institute for Public Service Reporting found.
As the coronavirus continues its spread – it’s killed 35 nursing home residents in Shelby County and more than 100 throughout Tennessee’s 700 long-term care facilities – critics believe troubles will only be compounded by profit-minded operators who receive taxpayer support through Medicare and Medicaid yet skimp on patient care.
“We’ve seen a number of out-of-state owners from New York and elsewhere come in and buy Tennessee facilities and not have any responsibility,’’ said Cameron Jehl, a Memphis attorney who specializes in suing nursing homes for abuse and neglect.
‘’The largest problem that we see in nursing homes is short staffing. Short staffing exists because that’s the largest expense and the easiest expense for the owners to control. And, so, if they reduce the staffing, then they have larger profits and then those profits are going out the door and to individuals in other states rather than being put back into the nursing home for the care of the residents.’’
Has low staffing at nursing homes contributed to the spread of the virus?
“That’s a possible hypothesis,” said Dr. Manoj Jain, the Memphis-Shelby COVID-19 Task Force’s infectious disease specialist who meets weekly with local nursing home leaders to encourage coronavirus prevention measures. The task force has had difficulties getting some nursing homes to test their workers, and it’s possible austere business practices are contributing to that and also to the thin staffs officials are observing in some facilities, Jain said.
“One would have to go nursing home by nursing home and see what is making them behave the way they’re doing,” he said. “I think it’s worth the inquiry.”
It’s a nuanced issue, complicated by nursing shortages and low pay that often make it difficult to fill vacancies. It’s also hard to measure: The Institute could not compare the actual COVID-19 infection rates among the county’s 27 licensed nursing homes because current population counts weren’t available.
Nursing homes have been underfunded and under-prioritized, said Rebecca Adelman, noting many providers rely heavily on Medicaid which pays about $175 a day — an amount that often falls well short of patient needs.
“If end-of-life becomes less valuable and the services become less valuable than any other point in life on the spectrum, then we’re failing as a system. And we’re failing those who have basically spent their lives building our country and our cities and our states,” said Adelman, an attorney who represents nursing home interests.
“What value do our state and federal governments put on the end-of-life care? And they’re sending you a message. They put, what, one hundred seventy five dollars a day on it? You know, like I said, we can’t even go out to dinner for, you know, I can’t take a family of four out to dinner and a movie for that.”
Yet critics say some nursing home owners are able to skimp on care thanks to recent tort reform that’s produced a series of laws in Tennessee making it harder to sue for abuse and neglect.
Shelby County Mayor Lee Harris said he believes the revisions to the law produced thin staffs that got even thinner when numbers of nursing home workers got sick with COVID-19. If the General Assembly reconvenes next month, Harris said he will push to reverse the measures, including a 2015 law that eliminated liability for many nursing home investors.
“In my opinion, that law had real effects on accountability, on staffing levels and the protections that are in place to protect residents and nursing homes,’’ he said.
Efforts to reach Parkway’s management and owners were unsuccessful. Administrator Natalie Berkley didn’t respond to three messages left at her office last week and this week. Neither did South Parkway Associates L.P. return messages. The suburban Atlanta firm is listed under “owner information’’ in Tennessee Department of Health records.
Yet it’s clear Tennessee’s nursing homes are hardly alone in their struggles. Nationwide, some 28,000 COVID fatalities have been linked to long-term care facilities – more than a third of the nation’s coronavirus deaths, according to a New York Times analysis.
Hampered by limited test kits and personal protective equipment and the often-slow response by government to help, even the best-run facilities have been deeply challenged by the pandemic.
Some argue testing has been so limited there’s no way to know the true extent of the spread in nursing homes here.
“There are a lot of very good senior living facilities that did everything they could do, and the virus still gets in,’’ said Mike Craft, CEO of the Village at Germantown, a well-staffed nonprofit assisted living facility where five people have died in its skilled nursing unit.
Outbreak at Parkway
Dinett King last saw her father on March 19. The usually gregarious Jones had suffered a seizure, so King took to him to the Regional Medical Center.
“They kept him because he had a touch of pneumonia in his right lung,’’ she recalled.
Already, Memphis was under a coronavirus state of emergency. Because of it, King couldn’t visit her father at The Med or later when he was transferred to Parkway Health and Rehabilitation Center, a 120-bed facility at 200 South Parkway West where 35 residents and 12 employees eventually would test positive for COVID-19. Eight residents have died, according to the Shelby County Health Department.
“And one day I was called. And they said he was exposed to the virus at the rehab,’’ King said. Asked if they could test him, King consented. Two days later the results came back: Jones was positive. Two days after that – on April 21 – he died.
“I was crying so,’’ King recalled.
A Memphis Police Department report notes Jones’ positive COVID-19 test result on April 19. On the morning of his death, the report says, Jones was “responsive sitting upright in his chair.’’ About three hours later a caregiver returned and found Jones “laying in his bed unresponsive.’’
Jones suffered from kidney disease, pulmonary obstruction, hypertension and other woes that made him vulnerable to the coronavirus. But the question – was Parkway fully prepared for the coronavirus – haunts his daughter.
King says she had “no idea’’ of the center’s track record which includes some of the lowest nursing staffing hours in the state.
Staffing at Parkway is ranked with one of five stars – “much below average’’ – according to data maintained by the federal Centers for Medicare and Medicaid Services on the Medicare.gov website. Medicare assigns star ratings ranging from a low of one to a high of five based on the number of staffing hours for Registered Nurses, Licensed Practical Nurses, Licensed Vocational Nurses and nursing aides.
“Some nursing homes care for residents with greater care needs, like those who have just had an injury, surgery, or a serious illness,’’ Medicare.gov advises. Parkway fares well by other measures – three stars or average for quality of care and four stars or above average for health inspections.
“It’s been the center of a lot of controversy,” Adelman, the nursing home attorney, said of the star system, which she said doesn’t always reflect true quality of care.
Yet detailed federal data warehoused by the New York-based resident advocacy group Long Term Care Community Coalition (LTCCC) shows Parkway consistently ranked among the lowest in Tennessee over the past year when comparing average care hours per day that residents receive from Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants.
Parkway’s total in the third quarter of 2019, the latest available, was 1.9 hours a day per resident – dead last among 308 nursing homes in Tennessee. Top-ranked nursing homes like Allen Morgan Health and Rehabilitation Center of Memphis and Fort Sanders Transitional Care Unit of Knoxville averaged 5.5 and 6.3 hours respectively. (LTCCC added fourth quarter figures as this story neared publication. Parkway’s total was 2.5 hours per resident per day – third worst in the state.)
The national average was 3.4 hours for the third quarter. Tennessee Health Department rules require nursing homes to provide a minimum of two hours of direct care “to each resident every day.’’
The Coalition of Geriatric Nursing Organizations and the American Nurses Association recommend 4.1 hours of direct nursing care per resident per day with 30 percent of that coming from licensed nurses.
“That’s obviously very low. Wow!’’ LTCCC executive director Richard Mollot said of Parkway’s totals.
“Just a difference of minutes off of 4.1 hours is really the threshold for safety for residents. Even a tenth of an hour or a quarter of an hour makes a big difference. And then we see some of these facilities, let’s say 3.7 hours of direct care staff time that are really woefully unprepared to care for their residents on a good day, no matter with COVID-19, to think of someone having less than two. It’s honestly breathtaking.’’
Parkway averaged 2.5 hours in the second quarter of 2019, seventh worst in the state, and 2.5 hours in the first quarter, tenth worst.
Out-of-state owners
Critics contend government regulators often don’t have a firm handle on who owns or ultimately controls a given nursing home, an issue that’s recently concerned attorneys exploring abuse claims at Parkway.
A 2015 wrongful death lawsuit filed against the nursing home in Shelby County Circuit Court lists ten separate partnerships, limited liability corporations and investment funds as plaintiffs, alleging the various entities were “mere conduits’’ and “mere tools’’ of an ultimate controlling real estate fund called WCP Real Estate Fund I, L.P.
Records show the four-acre nursing home property was purchased for $15.9 million in 2012 by another real estate fund with addresses in Santa Ana, California, and Roswell, Georgia.
The now-settled suit alleged Parkway “cut its labor force in an effort to maximize profits,’’ failing to provide a sufficient number of certified nursing assistants, non-licensed staff and adequate resources leading to the death in 2015 of Gwendolyn J. Bush, 75, a retired Memphis City Schools educator. Bush suffered an infected bed sore, “deep tissue’’ wounds, urinary tract infections, deep vein thromboses and a head injury from a fall, the suit alleged.
The nursing home denied the allegations. The suit was settled last year to undisclosed terms as it was headed toward trial.
Jehl, the Memphis attorney who filed the suit, said he’s noticed a pattern among some for-profit operators.
“The nursing home itself will operate in the red. And then the management company would be owned by the same group and it’ll charge a management fee and then there’ll be another parent company that’s on top of that,’’ he said. “And so the money will just go up the chain and out the door. And the owners that are taking all the money out don’t have any liability.’’
That pattern is repeated all over the country, said Mollot, the resident advocate.
But it isn’t just a lack of accountability, said City Councilman Dr. Jeff Warren, a physician who serves as medical director at Allen Morgan Health and Rehabilitation Center. Though Allen Morgan doesn’t accept Medicaid or Medicare, some centers that do can’t afford to pay enough to keep qualified healthcare workers, resulting in high turnover, he said.
“You can’t find people to do that work. It is hard. It doesn’t pay much. It is hard to keep these places staffed,’’ Warren said. “You can’t get people to work in them. OK? So, it’s not like they’re not hiring people.’’
Regardless of the reasons, records show four of the five facilities that have struggled most with the coronavirus to date have also struggled with staffing.
In addition to Parkway, the following nursing homes had 25 or more positive COVID-19 cases as Tuesday, May 19, according to the Shelby County Health Department:
- The Highlands of Memphis Health and Rehabilitation Center, a for-profit center: 66 residents and 25 employees or a total of 91 have tested positive. There have been five deaths. Medicare.gov ranks the facility’s nursing staffing as two of five stars or “below average.’’
- Quince Nursing and Rehabilitation Center, a for-profit center: 26 residents and four employees or a total of 30 have tested positive. There have been seven deaths. Medicare.gov ranks the facility’s nursing staffing as one of five stars or “much below average.’’
- The King’s Daughters and Sons home, a nonprofit center: 19 residents and seven employees or at total of 26 have tested positive. There have been six deaths. Medicare.gov ranks the facility’s nursing staffing as three of five stars or “average.’’
- Christian Care Center of Memphis, a for-profit center: 17 residents and eight employees or a total of 25 have tested positive. There have been no deaths. Medicare.gov ranks the facility’s nursing staffing as two of five stars or “below average.’’
Still, lack of accountability is a recurring issue.
There is no greater example of that in Memphis than Skyline Healthcare of New Jersey, which operated three nursing homes here as recently as three years ago.
One was the 155-bed Mid-South Health and Rehabilitation Center, closed by regulators in 2018 following a series of abuses that included allowing four unattended, cognitively impaired residents to wander from the facility. The facility also failed to protect eight residents “from potential cross contamination of blood borne pathogens from glucose monitoring,’’ according to a state order.
Another was Ashton Place Health and Rehabilitation Center, closed in 2017 following a slew of horrors including maggots found in a resident’s wounds.
“That means that those beds are not available for nursing home residents anymore,’’ said attorney Carey Acerra, Gehl’s law partner. “And it was all due to Skyline’s mismanagement.’’
COVID cluster at The Highlands
For a time, Skyline also owned The Highlands of Memphis Health and Rehabilitation Center, which now is enduring one of the largest COVID-19 clusters in Shelby County.
According to Tennessee Department of Health spokesman Bill Christian, ownership of the facility changed hands last year when Harborview Highlands LLC assumed control. Records on the TDH website list the facility’s “owner information’’ to a second limited liability corporation, TN MEM OP LLC.
Meantime, property records show a third entity, TN Memphis Holdings LLC, bought the 180-bed facility at 3549 Norriswood Avenue near the University of Memphis for $11 million in February 2019.
Each of the three companies lists a singular address in Cedarhurst, New York – the offices of Harborview Health Systems Inc., which operates a national chain of nursing homes. Calls to a phone number listed to the office went unanswered.
But local representative Sandra Daniels said the company is doing its best to battle the coronavirus.
“We have a great company,’’ she said. “And they’ve given us everything we need to do the job that we’re doing.’’
When asked what company owns the nursing home, Daniels said, “Our facility name is The Highlands of Memphis by Harborview’’ but she declined to name the parent company.
“The actual name of the company is a different name and I’m not going to go into that,’’ she said.
A COVID-19 cluster was first identified at the Highlands on April 6 and for weeks now it has been the largest nursing home cluster in the county. At one point last week the home had 102 positive cases – 78 residents and 24 employees who have had to be quarantined, according to the Shelby County Health Department. Five residents have died.
Official reports at times paint a troubling portrait.
A police report on May 2 describes how a 79-year-old man “diagnosed with Covid-19, Diabetes, Hypertension’’ and obstructive pulmonary disease appeared to literally drop dead. The man “collapsed in the hallway after having a conversation with another resident in the building,’’ the report says.
The facility’s COVID thinned-out staff appears to have complicated an already delicate situation.
Medicare.gov gives The Highlands two of five stars – “below average’’ – for nurse staffing level.
County Health Department Director Alisa Haushalter said her team has talked with The Highlands about possibly transferring residents to other facilities or bringing in additional workers perhaps through a staffing agency.
“I understand they did reach out to try to find some locations for individuals that may need (to be) hospitalized, but also have reached out extensively to try to bring staffing on board,’’ Haushalter said at a news briefing last week. “I would also say that we all have to keep in mind across the United States, it’s not Shelby County specific, we have a significant nursing shortage.’’
Haushalter added that the nursing home “is doing everything they can to rise to the occasion and address that particular issue around staffing.’’
Highlands representative Daniels said part of the problem involves “staff that don’t come to work to take care of their residents.’’ But a bigger concern involves testing of COVID-19.
“Our facility is in the situation it’s in because we’re doing testing and other facilities are not. And if everybody tests in their buildings they would see their asymptomatic people can be positive just like we’re finding out,’’ Daniels said, underscoring her point with a written statement that in part read:
“While it may appear that our facility has reported higher than average cases it is not a function of our infection control policies, it is because we are testing everyone and not just symptomatic residents.’’
Testing struggles
Daniels’ point is well taken among colleagues in the business – many long-term care facilities have struggled for weeks to do even very limited testing. Even those with greater resources to arrange testing and obtain PPE have had difficulties keeping the coronavirus out.
“That’s very disheartening,’’ said the Village at Germantown’s Craft. His well-funded facility tested scores of workers on April 30. He expected to spend as much as $23,000 for a second round of testing that took place May 14 and 15 for more than 300 employees.
Gov. Bill Lee mandated late last month that the state’s 700 nursing homes, assisted living facilities and long-term care facilities test all workers and residents by the end of May. Craft said the state will reimburse for one round of testing. But the problem for many facilities has been scraping together resources to do it.
“I don’t know if they’ve got that amount of money,’’ said councilman Warren. Allen Morgan, where he works, tested its workers on April 23. But Warren said other nursing homes may lack the money.
Jain, the infectious disease specialist, said despite the task force’s urging several nursing homes haven’t been testing for “multifactoral’’ reasons including cost and poor leadership.
“There are a number of very progressive, very good nursing homes who are doing stellar jobs,” he said. Yet others have failed to test even after the task force recommended steering workers to free testing sites that often are operating at 50 percent capacity or less.
“If (workers) test positive then they have to be put in isolation,” Jain said, indicating some nursing homes may fear they can’t afford to lose workers to quarantine.
Adelman said the government could be doing more to help.
“Despite all evidence showing the outsized impact that COVID-19 is having on long term care residents, the industry (has) not received priority when it comes to supplies, testing and resources. Long term care is doing the best it can with what is available,’’ the attorney wrote in an article for the American Health Care Association. She cites several AHCA proposals to aid trouble nursing homes including waivers to allow medical professionals to work across state lines, fast-tracking training for nurses aides and deploying the National Guard as was done in Georgia.
Shelby County incurred its first COVID cluster in a long-term care home in late March with an outbreak at Carriage Court, an assisted living facility in East Memphis. But as clusters grew in long-term care facilities (there are currently 20) officials struggled to provide help:
- April 23: Health director Haushalter said the growing number of nursing home outbreaks “is very disconcerting to us. We don’t believe at the current time that we have all of those outbreaks under management or under control.’’ She said the health department was looking to partner with facilities to get workers tested and assure they have PPE and appropriate screening protocols in place.
- April 24: County Epidemiology Chief David Sweat said officials were in discussions with providers to test health care workers “regardless of their symptomology.’’
- April 28: Haushalter said some nursing homes are testing new residents, calling it “an organizational decision that we would support.’’ Some facilities with “sufficient resources’’ also were testing employees after some workers had caught COVID. “We support and provide technical assistance,’’ she said, “but at the current time, don’t have a specific recommendation.’’
- May 15: Haushalter said once a cluster is identified in a nursing home the health department assesses its infection control practices, staffing and ability to cohort or isolate infected patients from others.
“We can work with the facility to assist them in getting tested. Some can do their own testing. Others have needed assistance either from us or the state to do testing,’’ she said.
Haushalter said the close-quarters nature of the facilities makes them “very much like jail settings’’ with a “high risk for transmission.’’
“We anticipate this will continue to be a struggle for us locally for some weeks to come, if not longer,’’ she said.
Tort reform
County Mayor Harris said the struggles with COVID-19 are leading him to lobby the Tennessee General Assembly to tweak the state’s nursing home laws.
“Right now, nursing homes are not required to have any insurance, which is another kind of anomalous item in Tennessee state law,’’ Harris, a former state senator, said in an April 24 press briefing.
“You have to have insurance obviously to operate a car and insurance to do any number of things. But operating a nursing home is actually a pretty high-risk activity, as we can see right now. And so maybe we should have a conversation on requiring insurance at nursing homes, because that may be also another way to offer another layer of protection for the residents of nursing homes.’’
Harris said he would also like to reverse a 2011 law change that required expert medical witnesses to bring nursing home suits.
“I believe juries should be able to decide most non-medical/basic negligence questions at nursing homes in Tennessee without the injured party having to get an expert that will cost $50,000,’’ he wrote in a text message last week.
Another critical law change involved a 2015 bill sponsored by state Sen. Brian Kelsey, R-Germantown, that made it harder to sue so-called “passive investors’’ or individuals who have ownership interests in nursing homes or other healthcare operations but don’t “directly participate in the day-to-day operations.’’
Kelsey did not respond to phone messages left last week at his Nashville senate office and Collierville law office. Adelman said the law was “a very well thought-out compromise’’ to promote investment in Tennessee, but Harris sees it differently.
“That law, in my view and I only speak for myself, has led to some of the understaffing at nursing homes and the absence of protections at nursing homes,’’ Harris said. “So, I think owners of nursing homes, like owners of any business, should be held liable under certain circumstances as that everyone has to be accountable.’’
Some fear the push for legal immunity will only grow. Time magazine reported last week that as many as 18 states have granted long-term care facilities some degree of immunity related to the pandemic, through laws or executive orders.
“The industry is very, very powerful,’’ Mollot said.
“The voices protecting people who are in nursing homes or their families are not as well funded. And, there are far fewer of us, frankly. We don’t donate to re-election campaigns. We don’t go to those five thousand dollar golf outings or dinners. That’s just not the thing that we do.’’
This story first appeared at dailymemphian.com under an exclusive use agreement with The Institute. Photos reprinted with permission of The Daily Memphian.
