Emergency personnel wheel a resident out of Life Care Center of Kirkland, Thursday, March 5, headed for a hospital.
In early March, state inspectors entered a sprawling nursing home in the rural southeast corner of King County where concerns over thin staffing were mounting just as COVID-19 began to spread across the state.
One resident inside the Enumclaw Health and Rehabilitation Center said she hadn't been bathed for nearly three weeks after she first arrived, according to inspection records. Another described waiting roughly 15 minutes for help after her roommate fell on the floor, while others told of even longer waits for help, lasting 45 minutes or more.
"Sometimes there are so few people in the building," the resident told inspectors, "if there were an emergency, it would be a calamity."
Within weeks, coronavirus entered the nursing home, and workers scrambled to help ailing residents, as some got sick themselves. In all, the outbreak killed 26 people, according to the state.
As COVID-19 devastated nursing homes across the state, long-standing staffing woes created a perfect storm at many facilities at a time when workers were needed most. Even though inspectors had routinely found appalling instances of time-strapped staff and patient suffering over the years, Washington state hadn't raised its standard for adequate staffing.
A Seattle Times analysis found that inspectors cited 118, or more than half, of the state's skilled nursing facilities a total of 225 times for having insufficient or unqualified staff, according to federal data from 2018 through the start of the pandemic. The state rarely penalized nursing homes for these deficiencies, according to an analysis of thousands of pages of enforcement documents.
In dozens of interviews and a review of inspection reports, workers described poor wages and understaffing by facilities, while former residents and their relatives detailed how patients suffered as a consequence. Due to restrictions imposed since COVID-19 struck, spreading to some 160 of Washington's nursing homes and resulting in more than 625 deaths, regulators and families have been more in the dark about what's happened inside facilities.
"Staffing is the same across the board. You never really have enough or you feel like you never have enough," said Darla Williams, a nurse who has worked in Skagit County nursing homes for two decades.
The state is unlikely to raise its staffing standard while dealing with a massive budget shortfall due to the pandemic, even though COVID-19 exposed the persistent staffing problems. Studies vary on the link between COVID-19 outbreaks and nursing home staffing levels, but numerous analyses have found low staffing to be a predictor of whether facilities had outbreaks and how large they became. The research hasn't focused on Washington.
"What the government should have done is raise staffing requirements during the pandemic" when the workload increased, said Charlene Harrington, professor emeritus at the University of California San Francisco, who conducted one of the studies. "You wouldn't have had all the deaths if you had been able to maintain and improve the amount of staff and the quality of care during that time."
In Enumclaw, regulators noted complaints about staffing just before the outbreak, saying many workers were pulling double shifts.
"To have that many dead from COVID means they somehow weren't doing things right," said Abraham Ritter, whose mother has lived at the Enumclaw Health and Rehabilitation Center for more than a decade and survived the outbreak there. "And I happen to think it is more than just bad luck."
The Enumclaw nursing home has not responded to emails and voice mails requesting comment.
'The bare minimum'
When the state Department of Social and Health Services (DSHS) doesn't have staff in facilities for annual inspections or investigating complaints, it relies on quarterly payroll data to see when they may be understaffed. On average, the state requires nursing homes to spend at least 3 hours and 24 minutes a day directly caring for each resident.
Washington's staffing minimum is low enough that all but 20 facilities consistently cleared the threshold, despite inspectors routinely finding issues when visiting most facilities, according to a Seattle Times analysis of data from mid-2018 through 2019.
Just eight homes were ultimately fined after inspections in the period reviewed. The total was hefty -- about $450,000 -- and more than half of that was against one facility, Forest Ridge Health & Rehabilitation in Bremerton.
DSHS officials acknowledged the tool is imperfect at preventing or even detecting staffing shortfalls, but efforts to improve it have stalled because of the pandemic.
"I don't think we know exactly what the right staffing ratios are," said assistant secretary Bill Moss, who oversees long-term care. "The right place to be is whatever number gets us to a place where people get the care they need (and) staff are not overwhelmed."
Lawmakers set the state's staffing minimum in 2015 after extensive negotiations, said Patricia Hunter, who heads the state's ombudsman program for long-term care, which advocates for residents. Officials and the nurses' union called for regulation while nursing homes said they would need more funding.
"That's not the maximum," Hunter said. "That was like the bare minimum we could agree to."
Lawmakers pledged in 2015 to raise the staffing minimum to a higher federal recommendation -- at least 4 hours 6 minutes per patient per day to prevent harm. But they have yet to do so because it would require millions of dollars to boost reimbursement rates for Medicaid. Three-quarters of the state's nursing home population relies on the federal-state health plan for low-income residents.
If the state had adopted the higher federal recommendation, 153 out of some 200 nursing homes would have been below the threshold at least one quarter from mid-2018 through 2019, and could have faced penalties, according to state data, instead of the 20 that failed to meet the state's lower minimum.
It's "ludicrous" that states allow nursing homes to have staffing at the minimum level, which were set "below what any research shows it should have been," Harrington said.
Short of the Legislature or Congress raising requirements, nursing homes have little incentive to improve, said Bianca Frogner, director of the University of Washington's Center for Health Workforce Studies.
"They are a business and need to figure out how to maximize their revenues for their expenses. I don't think that's unreasonable," Frogner said. "I think it's a question for society about whether this is fair or not, and whether we want them to face that choice."
It's an issue in other states as well. Only Alaska's average staffing levels met the federal recommendation to prevent harm, according to an analysis from the New York-based Long Term Care Community Coalition of data from the end of 2019.
And as states struggle to reach the higher federal standard, some experts say it isn't enough.
'My biggest fear'
On Christmas Eve, a mother told inspectors she feared staffing issues at Everett Center would lead to her son's death.
Only one nursing assistant had worked the night before in a unit with 28 patients with breathing tubes and ventilators, after another assistant said she wouldn't make her shift. The assistant told inspectors he couldn't have cared for all the residents without extra help from therapists and a nurse, who said it was an "extremely busy shift."
In a statement, Everett Center said it had "acceptable staffing support" that night.
On paper, Everett Center appears to do well. The facility, operated by Genesis HealthCare, one of the largest nursing home providers in the country, consistently exceeded the higher federal recommended minimum for direct care in recent years.
But when inspectors visited, they repeatedly heard similar concerns about the facility. The state cited Everett Center four times for staffing-related violations since 2018 -- the third-highest number in the state for that period. But the state did not consider any of the staffing problems as rising to the level of causing harm, and chose not to issue a fine for repeated issues, according to DSHS.
The Centers for Medicare and Medicaid Services (CMS) issued significant fines against Everett Center in years past, but not for findings of insufficient staffing, according to the agency.
The state has its own power to penalize homes for insufficient or inadequate staffing, but rarely uses it. DSHS has only issued $11,500 for staffing deficiencies it's found since 2018, while seldom taking the more punitive step of preventing nursing homes from accepting new residents.
Instead of immediately issuing fines, DSHS has tried to work with facilities to address issues, an agency spokesperson said.
During visits to Everett Center, Tyffani Murillo said she noticed signs of an overwhelmed staff.
Murillo said her family once timed how long it took for staff to respond to her great-grandmother's call light: 47 minutes. The 103-year-old also suffered from bed sores and often didn't receive help with food, Murillo said. She died last year of respiratory failure, and malnutrition was also listed as a cause of death, according to state death data.
Despite the issues she observed, Murillo wasn't too worried about her grandmother, Darlene Mach, who chose to move to Everett Center to be close to Murillo's great-grandmother.
Mach's family described her as self-sufficient, even with the oxygen tank she relied on since the start of the year, and a friend who saw the 83-year-old in March said she still seemed "20 years younger."
So when the facility said she stopped breathing and died a few weeks later, it was a shock.
"My biggest fear is that she pushed the call light button because she couldn't breathe. And because it takes so long for them to come into the room, she had issues and stopped breathing," Murillo said.
Everett Center declined to respond to questions about the deaths, citing patient privacy, but said in an emailed statement that staff were trained after the inspection around the start of the year. The administrator touted the facility's high direct care hours in a statement, adding that Genesis has "deep workforce resources" to help its centers with staffing.
Low wages, high turnover
Washington state has received national praise for its long-term care policies, including a payroll tax passed last year that will pay up to $36,500 in long-term care services for residents who worked in the state and require assistance with daily living.
But Washington's nursing homes have still faced staffing challenges seen across the industry.
Nursing assistants in Washington, the backbone of nursing staff who tend to residents' daily routine care needs, make an average of $33,800 per year, according to federal statistics, and often lack sick leave and have poor health care coverage. Researchers and workers say it's tempting for assistants to work for higher wages at a hospital or for similar wages in industries like food service.
"That's backbreaking work at $16 an hour," said Williams, the Skagit County nurse.
It's also not uncommon for workers to hold multiple jobs, which initially contributed to the spread of the virus. A federal study in the spring found that staff from Life Care Center of Kirkland, the early epicenter of the pandemic, spread the virus to other facilities.
The conditions contribute to "fairly constant" turnover among nursing assistants, Frogner said. It hasn't been well-tracked, but some policy groups estimate annual turnover rates for direct care workers nationwide is often around 60%.
At Marysville Care Center in December, a nursing assistant tried to put a resident into bed on her own, even though it required two people, according to a state inspection report. It was a situation inspectors also saw at other facilities: She said the only other assistant working was busy, and the resident didn't want to wait.
The resident suffered a leg fracture, and the assistant was fired. She later told inspectors she had worked over 100 hours the last pay period.
"It never seemed like we had enough staff or time to do our jobs right, and I cared about those residents," she told inspectors. "There was lots of turnover with people quitting."
Nursing home operators often argue they have trouble attracting and retaining staff, saying that low Medicaid reimbursements leave them short. If the state raised the staffing minimum, they say they'd be even more behind.
In Washington, Medicaid rates were recently raised to an average of about $265 per patient per day, higher than the national average of roughly $206 per day.
The Washington Health Care Association, which represents nursing homes, estimates facilities are still short about $20 per patient per day on average, not including costs from COVID-19.
"Facilities have been on tough shoestring budgets for a long time because of the reimbursement rate," said Robin Dale, president of the association. "And then you add COVID on top of that ... of course it makes it more difficult."
Rep. Eileen Cody (D-Seattle), a recently-retired nurse who chairs the state House's health care committee, said she believes facilities are no longer "that far behind" with recent adjustments to funding.
Nursing homes in the state also received a boost in Medicaid reimbursement rates because of the pandemic -- although the state lowered the additional $29 per patient per day to $5 once Medicaid rates were raised this summer -- and a combined total of around $90 million in federal relief payments.
A cycle of citations
Last year, Marysville Care Center was directed to cut staffing. The order came from Life Care Centers of America, which operates about 200 facilities nationally and at least a dozen in the state that have been struck by COVID-19, including its Kirkland facility.
The facility was over budget but was still expected to provide care for residents, corporate executives later told inspectors.
Marysville continued to surpass the state's minimum and was near the federal recommendation for direct care before the inspection. But the standard offers only a snapshot. It doesn't show what staffing's like on specific shifts or wings.
In the months following the staffing cuts at Marysville, the state began to hear complaints about one particular unit, called Havenwood, which is primarily for residents with cognitive impairments.
When inspectors visited the Havenwood unit earlier this year, they found 18 residents suffering from skin deterioration, with open wounds, foul odors and "inflamed and angry looking" skin. The residents, who were completely reliant on staff, received a fraction of the showers they should have, inspectors found.
One resident -- who was incontinent, unable to communicate and at risk for skin issues -- was not bathed at all in 30 days.
The findings were cited as neglect, which inspectors linked to staffing. The lack of showers was isolated to the Havenwood unit, which staff said didn't receive the amount of resources as others in the facility. One nursing assistant added: "Havenwood residents can't complain."
Staff told inspectors the unit had lost an aide who bathed residents in the cuts months prior, which the nursing director said caused the facility to struggle. Corporate executives denied knowing of the bathing issues, according to state inspection reports.
The facility said it would add a shower aide to the unit, and the state found it back in compliance soon after. CMS fined the facility $10,000 for the deficiencies.
But it wasn't the first time inspectors observed troubling signs at Marysville Care Center. The facility received the most citations for staffing deficiencies in the state from 2018 through the start of the pandemic, having been cited six times.
In August 2018, residents said they dealt with long wait times, and inspectors observed similar issues the following February. One resident said she would be left on the toilet for so long that she and her neighbor would bang on the wall to ask each other to find help. In November, residents and staff complained of long responses to call lights and showers on one particular unit.
After each finding, the state found the facility back in compliance without issuing fines, only to find similar issues soon after.
In a statement, Life Care said it provides the same service to all residents and takes action when learning of issues. The company said citations can be "subjective."
After the outbreak
Because of the coronavirus outbreaks, much less is known about what's happened inside facilities this year.
Regulators suspended all surveys not focused on infection control and ombudsman staff have just begun to re-enter facilities.
Hunter, the state ombuds, said her office received several complaints in the past few months that residents waited days longer than they should have for staff to change their wound dressings.
"That could be a sign of not enough nursing staff," Hunter said, noting that infections can occur when wounds fester beneath bandaging. "To me, these are egregious concerns."
Adding to the incomplete picture, CMS did not require facilities to report direct care hours for the first quarter of this year.
But in response to a survey conducted by the state labor board and UW's Center for Health Workforce Studies, nursing home administrators described workforce shortages with employees falling ill, being at high risk for COVID-19 and unable to work or choosing to work only at another facility.
Since CMS began asking nursing homes to submit coronavirus-related data in May, at least 100 of the state's approximately 200 facilities reported not having enough nursing staff at least once.
In Enumclaw, staff struggled to stop the virus' spread after inspectors say three workers fell ill, one of numerous nursing homes where officials reported employees were the first to get sick.
The virus entered the home in the early weeks of COVID-19's sprawl across the U.S., when much less was known about the virus. Inspectors' reports during the nursing home's outbreak described missteps.
Initially, residents were not isolated if a roommate tested positive for coronavirus, which likely allowed for further spread, according to the reports.
Within several days, nearly 50 residents and staff members tested positive for the virus as it continued to spread.
Six months later, data shows the facility has not returned to normal. Out of 92 beds, only about 36 were filled, according to recent CMS survey data.
Ritter, whose mother receives care for multiple sclerosis and dementia, says the slips in her hygiene and routine care over the years leave him concerned. He witnessed too many alarming instances over the years including when he paid regular visits to brush her teeth.
This month, he was finally able to see her again for the first time since the outbreak.
Despite his concerns, he has not moved his mother out, in part, because he feels his options are limited in Enumclaw, the small town where she raised him. He would also face the challenge in ensuring the care at the next nursing home isn't worse. Given the landscape, that worries him.
"Sometimes the devil you do know is better than the devil you don't know," he said.
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