Larger, Low-Income Nursing Homes At Higher Risk As COVID-19 Surges in California, Experts Say

Sammy Caiola

When Sharon Kimball got to the Arden Post Acute Rehab Center in March, her first thought was that it was a whole lot larger than she’d anticipated.

“It’s a big place,” she said. “There’s all these halls … five hundred halls.”

The 75-year-old was transferred to the Sacramento facility in March to recover from pneumonia after a hospital stay. 

The Arden home cares for people in recovery from a fall, a stroke or a surgery. The state health department qualifies it as a skilled nursing facility, and according to their data the home has had 83 positive COVID-19 cases among residents since the start of the pandemic. 

As of Nov. 12, Kimball is one of them.

“I have no idea who gave it to me or anything,” she said. “I just found out I was positive, and I was put in a room.”

There were 11 total COVID-19 cases among facility residents as of Dec. 4, according to the state database.

Skilled nursing facilities have been a major source of spread since the pandemic began. Nursing home residents make up 0.5% of California’s population, but 26% of COVID-19 deaths, according to a report out this month from the University of California, San Francisco, IBM Watson Health and the California Health Care Foundation.

The analysis found the death toll in these facilities is rising. In May, a quarter of the 800 nursing homes studied had one or more residents with COVID-19, and 16% had at least one resident death. By August, 66% of facilities had a COVID-19 case, and 37% had at least one resident who had died of COVID-19, according to the report. 

Kristof Stremikis, director of market analysis at the California Health Care Foundation, says the most up-to-date data shows more than half of nursing homes have seen a resident death related to COVID-19, and the problem is likely to get worse during the current surge.

“It’s just really, really prevalent and it’s very lethal in that setting … It requires attention,” Stremikis said.

Many Beds, Few Workers

The report found there are several risk factors that make COVID-19 more likely to spread in a skilled nursing facility, including the size of the home, its staffing levels and the racial and economic makeup of its residents.

Nursing homes with at least 99 beds had case rates at least 55% higher than those with 68 or fewer beds, and the death rates were also higher for larger homes. Arden Post Acute Rehab, where Kimball got sick, had 177 beds as of August, according to the study.

Arden Post Acute Rehab did not answer requests for comment on Friday.

DeAnn Walters is Director of Clinical Affairs and Quality Improvement for the California Association of Health Facilities, which represents nursing homes and other congregate care settings. 

“Between May and August as the community continued to deal with COVID …it came into the doors of many more facilities,” she said. “It’s not unexpected that we would see the number of facilities affected by the virus grow because the virus is spread across our whole state.”

The report found that nursing homes not meeting the state’s recommended staffing levels had about twice the case rates of homes with those above the threshold, and nursing homes with adequate registered nurses on staff had 50% fewer COVID-19 cases than those with fewer nursing hours per resident per day.

Walters says staffing has been a long standing problem, and the industry hasn’t yet found a solution.

“Unfortunately as the pandemic goes on, we’re continuing to find that bringing people into health care is very intimidating,” she said. “Showing up to an environment every day where you’re exposed to a deadly virus can really take a toll. People are really tired.”

The report authors recommend nursing homes reduce the number of residents in their larger facilities, increase the use of private rooms and seek to reduce staff turnover by increasing Medi-Cal reimbursements for services or making other payment adjustments. 

Residents Of Color Most At Risk

The report found that the COVID-19 case rate was disproportionately higher in nursing homes with a higher percentage of Black or Latinx residents.Their August data showed nursing homes where more than 26% of residents are Latinx had a 50% higher case rate than those where less than 6% of residents were Latinx.

“Unfortunately it’s not surprising,” said Stremikis, of the California Health Care Foundation. “We have seen in other settings across the health care system that this pandemic is having a disproportionate impact on certain populations in California.”

Who owns a nursing home is also a factor in whether or not an outbreak will occur and how deadly it will be, according to the report. Their data found for-profit nursing homes had COVID-19 case rates five to six times higher than nonprofit and government-run nursing homes, which held true both for independent nursing homes and those that are part of a chain.

Researchers are recommending the California Department of Public Health to ensure facilities test staff weekly for COVID-19, and require training, at least annually, on infection control and culturally sensitive care. They’re also urging the state to prioritize residents and staff in the highest-risk facilities when it comes to vaccine distribution.

An Information Gap

Kimball has recovered from her mild COVID-19 symptoms but as of Friday was still being kept in a special ward with other residents who tested positive.

She says she likes the staff at her home, but that they haven’t filled her in on the status of the COVID-19 outbreak as much as she’d hoped they would.

“I think they really pulled us through,” she said. “But the main thing for me was that the information could have been a little bit better. We could have had a little more information about what was going on in general, how many more people were getting it.”

She says she has not been re-tested since testing positive, and is not sure how long she’ll be kept in isolation with other COVID-positive residents.

Walters, with the California Association of Health Facilities, says protocol is to test staff at nursing homes frequently, since they’d be the most likely to bring the virus into a facility, and to only test patients when someone is symptomatic.

She says if patients test positive, protocol is to move them to a “red zone”, where they’re kept with other COVID-19-positive patients until they’re 14 days past when their symptoms started and not running a fever without the use of fever-reducing medication.

“They’re cohorted together in order to stop the spread,” Walters said. ”Typically upon that first positive there’s not additional testing because the CDC recommends a time-based strategy and not a test-based strategy.”

She says those guidelines are public, and facilities do their best to notify families about their loved ones’ status in the case of an outbreak, but that it can be a challenge to keep in touch when grappling with an outbreak.

Still, some elder care advocates say the lack of transparency from these facilities has been frustrating for families. 

“The disaster that is happening in nursing homes is not surprising at all,” said Patricia McGinnis, executive director of California Advocates for Nursing Home Reform, earlier this year. “Nobody’s there to watch. It’s been absolutely traumatic both for the residents and the family members of those residents. They can’t talk to anybody.”

Mary Kimball, Sharon’s daughter, said she’s not sure what’s next for her mom or how to find out when her go-home date might be.

“We were a little worried about her getting COVID, and then she does get COVID, and then nobody calls us,” she said. “It’s all a big, shadowy deal.”

Some nursing homes have made efforts to increase communication between residents and loved ones using technology —especially given the risk of mental deterioration due to loneliness — but advocates say more effort is still needed as the pandemic wears on.

CapRadio gets support from the California Health Care Foundation.

Sammy Caiola

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