Kathy Pacheco’s photographs tell the story of her husband’s life in a Philadelphia nursing home.
In one photo, Joe Pacheco appears gaunt, with long hair and a bushy beard —nothing like the muscular, well-groomed man he was before entering the nursing home in late 2019, Kathy says. Other photos, some of them screen shots from FaceTime calls with her husband while the facility was locked down due to COVID-19, show dirt caked under his fingernails, food residue stuck to his shoulders, and his toenails a greenish color.
Perhaps most upsetting, she says, is the image from a video call of Joe, 68, sitting slumped over, his hospital-style gown falling off, leaving his torso bare. Seeing her husband in that state, “I wanted to cry,” says Kathy, 66, a retired police officer in Philadelphia.
The staffing level in the nursing home, Deer Meadows Rehabilitation Center, is “awful,” Kathy Pacheco says. The facility has a two-star, “below average” staffing rating from the Centers for Medicare and Medicaid Services, the federal agency that regulates nursing homes. When she recently raised questions about whether her husband is bathed twice a week as scheduled, she says, a staff member checked the records and couldn’t find any documentation of when he’d last had a shower. She noticed scabs on his back, she says, and later learned that he’d had scabies, an itchy skin condition caused by mites. And “he’s lost so much weight, we don’t know if he’s getting the food in his mouth,” she says. With pandemic visitation restrictions, her communication with her husband is often limited to a couple of 10-minute video calls per week, but “someone has to watch him” to make sure he eats, she says.
Deer Meadows executive Lisa Sofia said in a statement to MarketWatch that the facility can’t comment on any specific patient but “is dedicated to providing the best care for its residents and creating a safe environment. It does that by having trained and competent staff available to assist all residents.”
Despite receiving billions of dollars in federal aid during the COVID crisis, many nursing homes nationwide have done little to bolster the overstretched direct-care workforce that helps more than 1 million facility residents like Joe Pacheco bathe, dress and eat. Even as the nursing-home-resident population dwindled during the pandemic, staffing per resident has remained stagnant, studies show. The average nursing home’s daily direct-care staffing was about 3.6 hours per resident in the first quarter of this year, roughly the same as it was in the early days of the pandemic, according to the Long Term Care Community Coalition, a nonprofit advocacy group. The data indicate that many facility operators trimmed staff hours as patient numbers dropped, says Richard Mollot, the coalition’s executive director. Staffing cuts, he says, are “the sweet spot for the nursing-home industry to reduce costs and increase profits.”
The cost savings can come in the form of low wages and part-time positions for direct care workers. Nursing assistants in nursing homes earn a median $24,200 per year, 12% live in a household below the federal poverty line, and more than a third rely on public assistance, according to research and consulting group PHI.
“Locally, a lot of the factories are hiring with way higher wages,” says Jennifer Snow, a nursing assistant in Muskegon, Mich., who says she’s had to care for 35 residents on a single shift and often has to work 12 hours at a stretch. “I’ve definitely thought about quitting,” she says, “but I know it’s bad in every nursing home.”
That leaves nursing homes to face a virus resurgence with a burned-out and demoralized workforce, staff members, researchers and resident advocates say. In recent weeks, the rate of nursing-home-resident COVID cases hit its highest level since February, according to data from the Centers for Disease Control and Prevention, and the weekly number of resident COVID deaths is up more than 500% from late June. Several studies have concluded that facilities with higher nurse staffing levels are better able to contain the virus and generally have better resident outcomes.
Although understaffing in nursing homes long predates the pandemic, the long-term-care industry has recently used the staffing issue in a successful push for more government money and changes to the planned federal vaccine requirement for workers.
President Joe Biden’s August announcement that nursing homes must mandate staff vaccinations as a condition of participating in Medicare and Medicaid triggered industry objections that the move would cause nursing-home workers to decamp for other healthcare jobs. Last week, the administration expanded the requirement to all types of Medicare- and Medicaid-certified facilities and announced the release of another $25.5 billion in COVID relief for healthcare providers, including nursing homes.
To fix its staffing problems, the industry says it also needs more Medicaid funding and government support for tax credits for long-term-care workers, among other proposals. “We need state and federal policy makers to properly fund nursing homes, so they can become a more competitive employer,” Dr. David Gifford, chief medical officer for industry group American Health Care Association/National Center for Assisted Living, said in a statement to MarketWatch. Directing federal aid to staffing needs “has been a constant for providers during the pandemic,” he says, with many facilities hiring additional staff and offering bonus pay to caregivers.
Some researchers, meanwhile, say government funding of nursing homes needs more strings attached to ensure that facilities direct a substantial chunk of Medicare and Medicaid reimbursement toward staffing and other elements of direct patient care. Money that should be spent on patient care is often diverted into facility owners’ and investors’ pockets, researchers say, when facilities buy services from or pay rent to related parties. About 70% of U.S. nursing homes have for-profit ownership.
Congressional Democrats are pushing to address nursing-home staffing in their budget reconciliation package, including calling for a study of potential minimum staff-to-resident ratios. Such a study was done 20 years ago, establishing a recommended minimum of 4.1 hours of direct care staffing per resident day — a level most facilities still fail to meet. A minimum staffing threshold “should be implemented immediately,” says Toby Edelman, senior policy attorney at the nonprofit Center for Medicare Advocacy.
Bring your own nurse
Even with the pandemic severely restricting nursing-home visitation, some facilities are putting undue burdens on residents’ loved ones to compensate for gaps in staffing, family members and watchdog groups say.
Marla Carter’s mother-in-law has lived in a Owensboro, Ky., nursing home since 2018. When the facility, now known as Chautauqua Health and Rehabilitation, changed hands earlier this year, Carter was asked to sign a new admissions agreement that contained some striking language, she says. The resident and “sponsor” — in this case, a family member — “agree to arrange for and provide supplemental private duty nursing to help reduce the risk of injury or to improve overall care if the Resident or Sponsor believes the Resident’s condition so requires,” the agreement said. Furthermore, the agreement said, the resident and sponsor agree to hold harmless the facility for any injury that “could have been avoided had supplemental private duty nursing been provided by the Resident or Sponsor.”
Under federal law, “the nursing facility has the legal obligation to provide all the care the resident needs,” says Eric Carlson, directing attorney at nonprofit legal advocacy organization Justice in Aging. “It’s improper for the facility to use an admissions agreement like this in an effort to get out from under the legal obligations” of the federal law, he says.
Carter says she would move her mother-in-law to another facility rather than sign the agreement. The wording “seems to indicate that I can’t expect them to properly care for my mother-in-law,” she says. Although she checks in with her mother-in-law by phone and video, she says, “her mental capacity has changed so much during the pandemic, she wouldn’t be able to tell me if there was anything wrong.”
The facility’s new owner, according to Kentucky licensing records, is Owensboro KY Opco LLC, a company that state business filings show was set up earlier this year by Simcha Hyman, CEO of Englewood Cliffs, N.J.–based Portopiccolo Group. Portopiccolo has rapidly expanded its nursing-home portfolio during the pandemic and is a defendant in a class-action lawsuit filed in May in U.S. District Court for the Middle District of North Carolina, alleging “severe systematic understaffing” at a Portopiccolo-affiliated facility in the state.
“Our local care teams work extremely hard to provide residents with the highest-quality, individualized support — and love — they need,” a spokesperson for Portopiccolo’s ClearView Healthcare Management said. “We are proud of them and their work and any accusation otherwise is simply false.” Portopiccolo has asked the North Carolina court to dismiss the lawsuit, calling the understaffing claim “meritless.”
What was supposed to be a quick fix for nursing homes’ COVID-era staffing problems has dialed up risks for residents as well as pressure on the more experienced workers who remain on the job, staff members and watchdog groups say. At the start of the pandemic, federal regulators waived the 75-hour minimum training requirement that typically applies to nurse aides in nursing homes, and many states allowed workers who had completed an eight-hour online course to work as temporary nurse aides. Eighteen months later, many of these workers with minimal training remain in nursing homes.
One nursing assistant in northwestern Pennsylvania says she was so alarmed by some of her coworkers’ lack of training that she quit her nursing-home job earlier this year. Temporary nurse aides were left to look after whole halls full of residents by themselves, and residents were left in bed all day and not bathed on schedule, says the aide, who asked that her name not be published. “The ones suffering are the residents,” she says. “It’s just not fair.”
More professional development, combined with more reasonable workloads, would go a long way toward stabilizing a workforce of nursing assistants that has already shown extraordinary dedication to residents, says Lori Porter, CEO of the National Association of Health Care Assistants. “Some of them are living in their cars and haven’t missed a day of work,” she says, but “you can’t treat people like they don’t matter and expect them to have loyalty to you.”
While many facilities belonging to large corporate chains may be positioned to ride out staffing shortages with staffing-agency workers and other stopgaps, some independent and nonprofit facilities say they have no choice but to shut down units or close completely. Island Nursing Home and Care Center, a nonprofit facility in Deer Isle, Me., announced in late August that it would close this fall. “Facilities like ours can no longer find qualified staff,” the nursing home said in a Facebook post. “We have spent months exhausting every staffing resource at our disposal and beginning this fall, we will no longer be able to meet our minimum staffing requirements.” The facility, which didn’t respond to a request for comment, said in its announcement that it would spend the coming months finding appropriate placement for each resident.
At the Washington Veterans Home in Port Orchard, Wash., home to about 200 residents, there were recently about 40 vacant direct care positions, according to an Aug. 26 letter the facility sent to residents and families, and a summer COVID outbreak affected dozens of residents and staff members. As of early September, only 54% of staff were vaccinated.
Kris Boudreau, 48, a U.S. Navy veteran who has lived at the facility for several years, has multiple sclerosis and relies on the staff to help him get in and out of bed, transfer to his wheelchair and complete countless small tasks. But lately, he says, a decline in the facility’s staffing, combined with the virus outbreak, has made the challenges of his daily life even tougher. With just a handful of staff members to care for dozens of vets in his unit, “I’ve sat here for more than 20 minutes sometimes waiting for someone to put me on the toilet,” he says. His favorite outings — to Imagine Dragons or Lorde concerts, or just down the hill for wings and a beer — have been largely out of reach during the pandemic. More than 18 months into the crisis, he and the other veterans at the facility “shouldn’t be going through this,” Boudreau says. “It’s like prison.”
The facility is actively recruiting and using staffing agencies to fill in gaps, says Heidi Audette, a spokesperson for the Washington State Department of Veterans Affairs. “We always attempt to answer call lights as quickly as possible,” she says, “but, if staff are caring for other residents, it can cause a delay in responding.”
Back in Philadelphia, Kathy and Joe Pacheco will mark their 50th wedding anniversary this weekend. But Kathy is worried that COVID restrictions could prevent her from celebrating the milestone in person with her husband. “This is not what we planned on,” she says of Joe’s life in the nursing home. “He always told me we were going to dance on that day.”