Before moving to Kingston Healthcare Center a few years ago, Clyde Cooper worked as a diner chef. A stroke left him needing long-term care, but he seemed to be doing well at the nursing home in Bakersfield, California, his niece, Ucedrah Osby, told Jocelyn Wiener in CalMatters. Cooper loved “cigarettes, Pepsi, and the Lord.”

Then the COVID-19 pandemic struck, and nursing homes became ground zero for the coronavirus in California and nationwide. So far, more than 40% of COVID-19 fatalities were nursing home residents or workers. So when Osby saw news footage of ambulances leaving Kingston in May, she repeatedly called the facility to check on her uncle. After a week, a staff member finally informed her that Cooper had been transferred to a hospital.

Unbeknownst to Osby, her uncle was hospitalized for COVID-19 and on a ventilator. Because his condition was not improving, the family decided to take him off the ventilator. He died on May 13 at age 76.

According to the California Department of Public Health, 104 residents and 57 health care workers at Kingston have tested positive for COVID-19, and 19 residents have died.

Why have nursing homes been such hot spots in the pandemic, and were there warning signs? “There were very few geriatricians around the country that didn’t know what was about to happen,” Michael Wasserman, MD, president of the California Association of Long Term Care Medicine, told CHCF’s Steven Birenbaum in a recent interview. On March 10, Wasserman told a major broadcast network, “This is the greatest threat to nursing home residents that we have seen in many years, if not ever.”

Quality of Care — an Ongoing Problem

Nursing homes have long struggled with infection control. “According to a Service Employees International Union analysis of Medicare data, nearly 70% of California nursing homes did not have and were not implementing an infection control program on their latest inspection prior to the pandemic,” Wiener reported.

Poor quality ratings from the Centers for Medicare & Medicaid Services may signal which facilities should be watched closely during a public health crisis like COVID-19. Medicare ranks nursing homes on a five-star scale based on health inspections, staffing, and physical and clinical measures for residents.

CalMatters found the 73 nursing homes in California with more than 10 COVID-19 deaths, and Medicare rated about half of them “below average” or “much below average.”

Some researchers disagree about the relationship between quality ratings and COVID-19 cases. Charlene Harrington, RN, PhD, professor emerita of sociology and nursing at UCSF, looked at more than 1,000 nursing homes in California and found that the ones with the most quality problems before the pandemic were more likely to get the virus when the pandemic hit, Ina Jaffe reported for NPR. But when David Grabowski, PhD, a professor of health policy at Harvard Medical School, looked at nursing homes in 30 states, he found no correlation between quality ratings and COVID-19 infections.

Over the last decade, California nursing homes have averaged a higher number of deficiencies than nursing homes nationwide. In 2017, California nursing homes had, on average, nearly 13 deficiencies per facility, compared to 7 at facilities nationwide. However, California nursing homes performed about the same or better than the national average on several quality measures. (Learn more in CHCF’s Almanac report on long-term and end-of-life care in California.)

COVID-19 Undermines Transparency

In normal times, nursing home residents have regular contact with people who can advocate for their safety — family members, ombudsmen, and state and federal inspectors. However, with the pandemic necessitating physical distancing, visits and in-depth annual inspections have been halted. Transparency into resident health and safety has vanished.

“I can’t think of any other time like this, where all of the layers of oversight are missing,” Tony Chicotel, a staff attorney for the nonprofit California Advocates for Nursing Home Reform, told Wiener. “My guess is there’s lots of terrible neglect going on that is harming people to levels that are akin to the virus, but we just don’t know.”

Though the state is conducting infection control visits during the pandemic, these visits are less comprehensive than annual inspections and focus only on handwashing, personal protective equipment (PPE) supply, and isolation of infected residents. Chicotel’s organization recently released a report concluding that the state’s COVID-19 infection control surveys have not led to meaningful enforcement.

In addition to the oversight issues, geriatric experts are worried about the long-term effects of isolation on nursing home residents. “A number of my colleagues and myself are very concerned about the ageist approach that our government has taken to protecting nursing home and assisted living residents,” said Wasserman, whose organization has been hosting weekly webinars to provide COVID-19 guidance to long-term care facilities. “Their strategy has been to isolate nursing home residents — that’s the easy approach.”

Supply Shortages Aggravate Threat

Inadequate supplies of PPE have compounded nursing home infection control problems. As Jordan Rau reported for Kaiser Health News, the federal government has failed to deliver on its promise to “deploy every resource and power that we have” to protect older Americans.

The Federal Emergency Management Agency was supposed to deliver a 14-day supply of PPE to 15,000 nursing homes in May and June, and some nursing homes have yet to receive any, Rau reported.

“If you don’t have PPE, it’s game over,” Wasserman said. “That is number one. Number two is testing, because we know that asymptomatic staff can bring the virus into the facility.”

The ability to test staff and residents on demand could help nursing homes mitigate the spread of COVID-19 through the rapid isolation of those who test positive. The federal government’s recommendation is that nursing homes test all residents and health care personnel weekly. But four months into the pandemic, widespread shortages of coronavirus tests persist.

Falling Short on Testing

“To keep the virus out of a nursing home, you need to be able to test staff regularly, every time they come in for a shift,” Katie Smith Sloan, president and CEO of the nonprofit LeadingAge, told Olga Khazan in the Atlantic. “You need to get results within minutes, not days.”

Additionally, nursing homes are chronically short staffed, which can lead staff to cut corners when attention to protocol is paramount and they are underpaid: 15% of direct-care workers live below 100% of the federal poverty line, and nearly half live below 200% of poverty, according to PHI, a nonprofit that works to improve long-term services. These workers may need multiple jobs to make a living, which means greater risk of exposure to the coronavirus — or they may work through illness to continue getting paid.

With cases of COVID-19 climbing, nursing homes are hot spots because they combine numerous risk factors for transmission: congregate living, a mostly elderly population with underlying health conditions, and inadequate staffing, PPE, and infection control for an emergency.

It’s not too late to mitigate the harm. All levels of government can support nursing homes with increased testing, PPE supply, assistance with infection control and data reporting, and strict enforcement of health, safety, and security rules.

Stay tuned for CHCF’s next COVID-19 tracking poll, which surveys certified nurse assistants who work in skilled nursing facilities. It will be released on July 16. In the meantime, tweet at me with #EssentialCoverage or email me.

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

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