U.S. appeals court rules against nursing homes over COVID-19 lawsuits

By Tom Hals

(Reuters) – In a setback to nursing-home operators facing hundreds of COVID-19 negligence and wrongful-death lawsuits, a federal appeals court on Wednesday said cases against two New Jersey facilities should proceed in state courts.

The nursing homes had argued that the suits against them belonged in federal court, citing an emergency U.S. law known as the Public Readiness and Emergency Preparedness (PREP) Act, which shields those fighting the pandemic from lawsuits.

The 3rd U.S. Circuit Court of Appeals in Philadelphia affirmed a lower court ruling and rejected the nursing homes’ argument that the PREP Act was so far reaching that families’ state-law negligence claims were really federal claims that belonged in federal court.

The families “asserted only garden-variety state-law claims, so state court is where these cases belong,” the court said.

Neil Lapinski, a Gordon, Fournaris & Mammarella attorney who represented the families, said “the court has provided a clear roadmap for litigants” that was consistent with lower court rulings.

The cases were filed in state court in April 2020 by families of four residents who died of COVID-19. They sued two nursing homes operating as Andover Subacute & Rehabilitation I & II, alleging the facilities failed to take precautions to contain the spread of the virus.

The cases were among the first against nursing homes, where more than 100,000 people died during the pandemic. Like hundreds of similar wrongful death claims against care facilities, the cases stalled over which court should hear the lawsuit.

The operator said it was shielded by the PREP Act and the cases belonged in federal court. A lower federal court, however, said the case should be heard in state court, and the nursing home operator appealed.

The 2005 PREP Act is meant to jumpstart U.S. defenses against an outbreak like COVID-19 by shielding from lawsuits makers of critical products, from diagnostic tests to vaccines, as well as doctors and drug distributors. Nursing homes have said the law should shield them from liability because they were on the front line of the outbreak.

Wednesday’s ruling could help get cases moving, said Adam Pulver of Public Citizen Litigation Group, a consumer advocacy group that filed an amicus brief with the appeals court.

“By being the first appeals court to weigh in, the 3rd Circuit signaled to judges around the country that these appeals are unlikely to succeed and there is no reason to stop cases from moving forward while the nursing homes appeal,” he said.

The 3rd Circuit’s ruling said determining whether the PREP Act shields nursing homes from pandemic-related lawsuits should be determined by a state court, although other federal appeals courts are expected to address that question in the coming months.

Lann McIntyre, a Lewis Brisbois attorney who represented the nursing homes, declined to comment.

The appeal was heard by three Republican appointees – Michael Chagares, Jane Roth and David Porter, who was appointed by President Donald Trump and who wrote the opinion.

(Reporting by Tom Hals in Wilmington, Delaware; Editing by Noeleen Walder and Bill Berkrot)

Cuomo aide apologizes to lawmakers for withholding COVID-19 death toll in New York nursing homes

NEW YORK (Reuters) – A senior aide to New York Governor Andrew Cuomo apologized to state lawmakers this week for the governor’s office withholding requested data showing the death toll in nursing homes from COVID-19, according to transcripts of the conversation published by local media.

The aide, Melissa DeRosa, told Democratic lawmakers in a call on Wednesday that Cuomo’s office feared the death toll information would be “used against us” by federal prosecutors, according to the New York Post, which first reported the call.

“And basically we froze,” DeRosa said, the Post reported. The comments came about two weeks after New York Attorney General Letitia James published a report saying the true death toll of nursing home residents between March and August last year may be twice as high as the 6,400 officially reported.

Angered by what they perceive as a cover-up, Democratic and Republican lawmakers have said they are reconsidering their decision to grant Cuomo emergency powers last year to contend with the novel coronavirus pandemic.

“This is a betrayal of the public trust,” Andrew Gounardes, a Democratic state senator, wrote on Twitter. “There needs to be full accountability for what happened.”

Cuomo rebuffed efforts by state lawmakers last summer to force greater disclosure over the number of nursing home residents who died after contracting COVID-19.

Nursing home residents who were taken to hospitals were not counted in the state’s break-out of nursing home deaths, which lawmakers viewed as masking the true extent of the crisis.

Around the same time, the U.S. Department of Justice also began seeking data on deaths of nursing home residents.

In a statement on Friday, DeRosa said her office decided the federal request must be the priority before turning to the request by state lawmakers.

“As I said on a call with legislators, we could not fulfill their request as quickly as anyone would have liked,” her statement said.

Cuomo’s administration also unsuccessfully sought to withhold the data when it was requested through transparency laws by the Empire Center, a conservative think tank.

A judge ordered the disclosure of the numbers this month, and the state has released data showing that thousands more nursing home residents than was previously known died from COVID-19, even if their deaths occurred after being transferred to a hospital.

(Reporting by Jonathan Allen in New York; Editing by Dan Grebler)

At the urging of nursing homes, a law is amended and COVID court claims are slowed

By Tom Hals

(Reuters) – Garnice Robertson wants accountability for her mother’s death from COVID-19 caught while she was living at a Kansas nursing home that allegedly failed to prevent an outbreak of the disease. An unexpected legal hurdle stands in her way.

The nursing home argues it has complete legal immunity for lawsuits like Robertson’s stemming from COVID-19. It cites recent changes to a 2005 law by the former Trump administration that had been sought by the senior care industry.

The law known as the PREP Act was originally designed to encourage production of emergency vaccines during an epidemic by granting legal immunity to drug developers.

Riverbend Post-Acute Rehabilitation of Kansas City, Kansas, where Robertson’s mother allegedly became infected, is one of at least 36 nursing homes and senior living facilities that have cited the law as a defense.

Facilities across 14 states, where more than 650 residents died, have argued they should be immune from wrongful death cases – an early sign of how the PREP Act could be used by a range of businesses to fend off lawsuits resulting from the pandemic.

No judge has yet adopted the nursing homes’ view of the law, but those arguments, and disputes over which court should hear the case – federal or state – have led to months of delays, preventing Robertson’s lawyers from getting records and interviewing witnesses critical to her case, the lawyers said.

Robertson, whose lawsuit was moved to federal court in Topeka, Kansas by Riverbend, said she was upset by the nursing home’s use of the law.

“If I’m feeling the way I feel, how do you think all these other people feel?” she said. “It’s just not right.”

Riverbend, which is affiliated with the publicly traded Ensign Group Inc, and its lawyers did not respond to a request for comment.


The Public Readiness and Emergency Preparedness (PREP) Act was originally meant to jumpstart U.S. defenses against a possible avian flu epidemic or bioterrorist attack.

It authorizes the Secretary of the Department of Health and Human Services (HHS), during a public health emergency, to shield from liability makers of “countermeasures” such as diagnostic tests, protective gear and vaccines like those developed by Pfizer Inc, Germany’s BioNTech and Moderna Inc.

The PREP Act does not apply in instances of serious injury or death caused by “willful misconduct”.

When the PREP Act shield applies, the injured person instead can seek compensation from a government fund, although most claims are denied.

Former HHS Secretary Alex Azar invoked the PREP Act in March in response to the coronavirus pandemic, and since then the agency has issued amendments and guidance as recently as Jan. 12 to broaden the reach of the law.

The agency guidance included criticism of rulings that went against defendants, including Riverbend.

“They have made the arguments for the defendants better than the existing defense lawyers,” said Jonathan Steele, Robertson’s lawyer, of the HHS guidance. “It’s unprecedented.”

Some changes were sought by the type of facility operators now defending against lawsuits.

In August, in response to a query from a lawyer at a lobbying firm, then-HHS general counsel Robert Charrow wrote that senior living facilities were covered by the PREP Act if they were using approved products to fight the pandemic.

HHS also said in recent months the PREP Act applied in situations where, while trying to comply with health regulations, an organization failed to take an action such as testing – which is an allegation in most of the nursing home lawsuits.

LeadingAge, a group that represents non-profit nursing homes and other service providers, sought the clarification in March, when masks and other protective gear were in short supply.

LeadingAge, one of several elder care groups that called for greater protection, declined to comment. The group does not represent Ensign.

HHS has said it wants to provide legal certainty to organizations that they will be immune from good-faith mistakes when trying to comply with health guidelines and ensure a unified national response against the spread of COVID-19.

HHS did not respond to a request for comment regarding the agency’s plans under a Biden administration.

Acting HHS Secretary Norris Cochran said in a letter to state governors on Friday that they could expect continued use of PREP Act declarations to support the fight against the pandemic.

More than 100,000 residents of U.S. nursing homes and senior living facilities have died from COVID-19. Some attorneys said that without some form of immunity, litigation over a novel airborne illness that could be spread by asymptomatic carriers could swamp the industry.


So far, seven federal judges have issued preliminary rulings, and all of them sided with the plaintiffs and ordered the cases returned to state court, Reuters found.

Six of the rulings were issued before HHS amended the PREP Act in December to declare that for consistent interpretation of the law the cases should be heard in federal court, which was reshaped by former President Donald Trump and is seen as more favorable to companies.

Only a few of the rulings touched on the question of PREP Act immunity, which nursing homes can still use as a defense in state court.

Just raising the PREP Act defense can complicate procedures in a way that could impact future cases, said Mike Duff, a professor at the University of Wyoming College of Law.

“Time is money and complexity is time and the more complexity in a case means the less likely the wrongful death claimants will find lawyers to represent them,” he said.

Nursing homes have used that HHS guidance to try to move cases from state court, adding delays.

For example, the family of Vincent Martin sued Hollywood Premier Healthcare Center of Los Angeles in state court a month after Martin died of COVID-19 in April.

The nursing home, where at least 11 residents died, cited the PREP Act to have the lawsuit moved to federal court.

The federal judge, however, sided with the family and sent it back to state court.

In January, armed with fresh guidance from HHS, Hollywood had the case moved back to federal court a second time, where it is pending.

U.S. District Court Judge Dale Fischer said Hollywood’s request to stay proceedings while it appealed the order sending the case back to state court raised “a serious possibility of such removals being used in a cynical, strategic way to stall cases and to extract concessions … from opposing plaintiffs.”

Hollywood and other facilities are not unreasonably delaying discovery, but are applying the law and HHS guidance which makes clear the cases belong in federal court, said Kim Cruz, a lawyer for Hollywood, in an email.


Robertson, whose case has been similarly removed to federal court, called Riverbend’s legal tactics unfair and she is waiting to gets answers about her mother’s care.

Her mother, Georgia Clardy, had been a resident since 2017 at Riverbend.

She was taken to a hospital in March for a broken femur and, during her absence, Robertson said coronavirus entered and spread within the Riverbend facility.

The lawsuit alleges Riverbend’s negligence included a lack of adequate staff, allowing infected employees to enter the facility and a failure to adopt social distancing.

Robertson said she would have brought her mother home from the hospital rather than returning her to Riverbend if the facility had told her there was an outbreak.

“Once I found out she was diagnosed with COVID nobody wanted to talk about it,” said Robertson. “That was very disturbing for me.”

The judge in Robertson’s case has set the next hearing for February.

(Reporting by Tom Hals in Wilmington, Delaware; Editing by Mike Collett-White and Noeleen Walder)

Spain opens 200 criminal probes into care home pandemic failings

MADRID (Reuters) – Spain’s public prosecutor is investigating more than 200 cases of potential criminal mishandling of the coronavirus pandemic at nursing homes, where the virus spread almost unchecked during the devastating first wave.

Nearly 43,000 care home residents died of COVID-19 or suspected infection during the March-May first wave of contagion, according to official data.

At the time, staff reported shortages of basic protective equipment and army units deployed on disinfection missions discovered unattended bodies at several facilities.

The prosecutor’s office said nearly half of its investigations related to homicide through a neglect of duty of care, while it was looking into 21 cases of deficiencies in medical treatment.

With Spain reporting record infection numbers on an almost daily basis, it warned that risks still remained across the care home network, despite improvements made in recent months.

“The increase in general contagion is still a risk for residential environments,” it said in a statement on Thursday, adding that it would continue to closely monitor the situation.

Pre-existing weaknesses, including governance, funding, working conditions, a lack of coordination with primary health care, and a lack of isolation spaces, are still widespread, the report said.

Prosecutors shelved other cases, most of the time after charges were rolled into other cases or passed to courts, rather than because investigators found no evidence of wrongdoing.

Spain has about 5,500 nursing homes, housing some 400,000 people, according to the European Ageing Network, which represents both individual carers and businesses.

The heads of both Spain’s main care home associations said they needed more information on the investigations before commenting. In the past, the associations have blamed the government for failing to provide adequate supplies and the health service for refusing to admit residents with a positive diagnosis to hospitals.

(Reporting by Nathan Allen, Belén Carreño, Emma Pinedoñ; Editing by Ingrid Melander and Andrew Cawthorne)

U.S. experts to review Biogen drug that could be first new Alzheimer’s treatment in decades

By Deena Beasley

(Reuters) – U.S. health experts this week will decide whether to recommend approval for Biogen Inc’s Alzheimer’s drug, which could become the first new treatment for the mind-wasting disease in decades even as serious questions persist over whether data show if it works.

In a field littered with unrelenting failure, Biogen believes in aducanumab it has the first drug that can treat an underlying cause, and therefore slow progression, of Alzheimer’s. But its path to approval has been anything but smooth or assured.

Biogen abruptly ended clinical trials of aducanumab last year after an early look at trial results showed it was not effective. Last October, the company shocked many Alzheimer’s experts by reversing course, saying that a new analysis showed aducanumab could help patients with early-stage disease preserve their ability to function independently for longer. In July, Biogen filed for approval from the Food and Drug Administration.

Now the agency faces tremendous pressure to approve a treatment option for millions of Americans suffering from Alzheimer’s and the millions more expected to face it in coming years.

Patient advocates say the need for a new Alzheimer’s treatment that could help people remain independent is heightened by the coronavirus pandemic, which has killed more than 229,000 people in the United States, including tens of thousands of seniors in nursing homes.

“The pandemic came and it changed everything,” said Russ Paulsen, chief operating officer at patient advocacy group UsAgainstAlzheimer’s. “We need something to keep people out of nursing homes.”

A committee of outside advisers to the FDA will discuss aducanumab on Nov. 6. The agency’s final decision is expected by March. European health regulators have also accepted the drug for review.

Charles Flagg, a 79-year-old retired minister from Jamestown, Rhode Island, had been enrolled for years in a trial of aducanumab before it was stopped. He started receiving the drug again in August as part of a follow-up study, according to his wife Cynthia Flagg.

“He’s not 100 percent himself, but overall I’m not dealing with someone that needs to be led around or be in a care home,” Flagg said.

Aducanumab, an antibody designed to remove amyloid plaques from the brain – a strategy tried with many failed Alzheimer’s drugs – would reap billions of dollars in sales if approved.

Biogen, along with partner Eisai Co Ltd <4523.T>, is one of the last large drugmakers pursuing treatments for a disease that afflicts nearly 6 million Americans and millions more worldwide. Biogen estimates about 1.5 million people with early Alzheimer’s in the United States could be candidates for the drug.


Late last year, Biogen said one of its two pivotal studies of aducanumab showed a statistically significant benefit at slowing cognitive and functional decline in patients with early Alzheimer’s. A second trial failed to achieve that goal, but did show a benefit for a subset of patients who were given a high dose for at least 10 months.

In March, it opened a follow-up long-term safety study to 2,400 people who had previously participated in trials of aducanumab, like Flagg.

Many Alzheimer’s researchers say Biogen should conduct a third large study to prove aducanumab works. They worry about its possible side-effects, such as brain-swelling, and the potential cost.

“Aducanumab’s efficacy as a treatment for the cognitive dysfunction in Alzheimer’s disease cannot be proven by clinical trials with divergent outcomes,” said Mayo Clinic neurologist Dr. David Knopman, who was recused from the expert panel because he helped conduct the trials.

Others believe the FDA could approve the drug without another trial.

Previous clinical studies had largely targeted patients in later stages of the disease, while many experts now believe attacking Alzheimer’s as early as possible may be the key to success. But there was a lack of clarity on how to assess a drug’s success when functional deficits are less pronounced.

In 2018, the FDA revised its standard of proof guidance for reviewing Alzheimer’s drugs by essentially combining what had been separate goals for cognition, or memory, and day-to-day function. The new guidance stressed the need for a drug to show “clinically meaningful” benefits, a term it has not clearly defined.

Alzheimer’s advocacy groups are pushing for a broad definition, saying it should include preserving the ability to perform daily activities such as shopping independently or remembering to turn off a stove.

“They have been trying to lower the bar and help any company to get a drug approved,” said Dr. Marwan Sabbagh, from the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas. “How much (improvement) do you need to be clinically meaningful? Naturally this is very subjective.”

The FDA did not immediately respond to a request for comment.

(Reporting by Deena Beasley; Editing by Caroline Humer and Bill Berkrot)

New York pushes ahead with more reopenings as COVID-19 cases rise in U.S. Midwest

By Maria Caspani and Barbara Goldberg

NEW YORK (Reuters) – Governor Andrew Cuomo on Thursday announced more reopenings in New York state as new coronavirus infections remained low in what was once the U.S. hot spot of the pandemic.

Next Wednesday, New York City malls will be allowed to reopen at 50% capacity and casinos statewide can reopen at 25% capacity, Cuomo said.

“Thanks to the hard work of New Yorkers, we are at a point in our fight against this virus where we can safely reopen malls in New York City as long as they adhere to strict health and safety protocols,” Cuomo said. “Masks, enhanced air ventilation systems, and social distancing will be mandatory.”

The governor also waded into the hotly debated issue of indoor dining in New York City, saying during a conference call with reporters that the final decision rested with the state.

New York City Council Speaker Corey Johnson came out on Wednesday in favor of allowing indoor dining in the city, which is home to a thriving restaurant industry that was battered by the pandemic.

“It’s time to allow indoor dining in New York City with reduced capacity and clear guidance to ensure social distancing and safety,” Johnson said in a statement.

Cuomo said he would like to see restaurants reopen for indoor dining in the city but that compliance and enforcement remained a major hurdle in doing so.

“We open restaurants, that’s going to complicate by the hundreds if not thousands the number of establishments that need to be monitored,” he said.

Indoor dining is allowed in New York state with the exception of New York City, where more than 300 restaurateurs recently filed a class-action lawsuit seeking $2 billion in damages, according to media reports.

On Wednesday, gyms in New York City opened for the first time in months. They must operate at 33% capacity, with floors rearranged so patrons can exercise more than 6 feet (1.8 m) apart.


New York has seen by far the most deaths from COVID-19 of any U.S. state, more than 32,000, but its rate of new infections has dropped to among the lowest in the country.

Nationally, new cases of coronavirus have fallen for six weeks in a row, but infections are surging in the Midwest. Iowa, North Dakota and South Dakota are reporting the highest percentage of positive test results in the country – over 20% in each state.

Iowa, with a population of more than 3.1 million people, saw over 8,300 new cases last week, up 116%. That compared with about 4,400 new cases in New York state, which has more than 19.4 million residents, according to a Reuters analysis.

Cases also rose 27% last week in Minnesota and 34% in Indiana.

The U.S. Centers for Disease Control and Prevention has told state officials to prepare to distribute a potential coronavirus vaccine as early as October, according to documents made public by the agency on Wednesday.

The vaccines would be given first to healthcare workers, national security personnel and nursing homes, the agency said in the documents.

(Reporting by Maria Caspani and Peter Szekely in New York and Barbara Goldberg in Maplewood, New Jersey; Additional reporting by Lisa Shumaker; Editing by Peter Cooney)

Life Care fired staffer who revealed nursing home nightmare to Reuters

By Chris Kirkham

(Reuters) – A nursing home owned by Life Care Centers of America Inc has fired one nurse and banned another from the premises after the two were quoted in a Reuters investigation detailing horrific conditions, a staff exodus and a botched management response to the facility’s deadly COVID-19 outbreak.

Life Care terminated one of the nurses, Colleen Lelievre, last week after managers at the Littleton, Massachusetts, home accused her of making clerical errors involving narcotics for residents. She said she had not been told of any issues until June 12, two days after publication of the Reuters report. Another nurse, Lisa Harmon, said a manager barred her from the building the same day, without explaining why.

“I don’t know how they think that they’re just blatantly doing this and getting away with it,” said Harmon, a supervisor.

The Reuters report included interviews with Lelievre and Harmon describing an overwhelmed and overworked staff. In one instance, so many workers had quit or called in sick that managers assigned a teenage nursing-assistant trainee to a shift caring for nearly 30 dementia patients, Harmon and a former worker said. Eighty- to ninety-hour weeks became the norm, the two nurses said. In a dementia unit, workers were unable to keep residents from wandering into hallways and other patients’ rooms, potentially spreading infection.

The two nurses also said management left staff in the dark about the outbreak and didn’t provide staff testing until mid-May. Thirty-four workers had tested positive by that month’s end, federal data shows. Twenty-five residents and one nurse died of COVID-19. (To read the Special Report, click here )

Amy Lamontagne, the facility’s executive director, denied that she fired Lelievre for talking to Reuters. Lamontagne said Harmon has not been terminated but that administrators wanted to meet with her to discuss concerns she raised in the article. Harmon said she hasn’t been paid since being barred from the facility.

An undated handout photo of nurse Lisa Harmon who was barred from entering her workplace at the Life Care Center of Nashoba Valley in Massachusetts, days after being quoted in a Reuters article detailing a staff exodus and a botched management response to the facility’s deadly coronavirus disease (COVID-19) outbreak. Lisa Harmon/Handout via REUTERS

Lamontagne said she terminated Lelievre for errors in “the administration and documentation of narcotics.” Lamontagne declined to detail that lapse and would not address why she hadn’t raised the problem with Lelievre until after the Reuters article ran. She said the facility started investigating Lelievre two days before the article ran.

“The timing of it is poor,” Lamontagne said.

A spokeswoman for the Massachusetts Attorney General, told by Reuters of Life Care’s actions against the nurses, said “we take allegations of workplace retaliation very seriously.”

Spokeswoman Chloe Gotsis added that the attorney general is already scrutinizing the facility’s management of the crisis: “We have an active and ongoing investigation into the Life Care Center of Nashoba Valley’s response to the COVID-19 outbreak.”

U.S. Rep. Lori Trahan, who represents the Littleton area, said the nursing home put its own interests above patient and staff safety.

“If the corporate leadership of Life Care Centers of America showed as much concern for residents and workers at their facility in Littleton as they do for their public image and self-preservation, lives could have been saved,” Trahan said. “Shameful behavior like whistleblower retaliation is often used to cover up wrongdoing.”

Life Care is among the largest U.S. nursing home operators, with more than 200 homes. Company President Beecher Hunter did not respond to requests for comment. Company spokesman Tim Killian declined to comment on the alleged retaliation and did not answer questions about whether corporate higher-ups directed or knew about the actions against the nurses.

Life Care also presided over one of the first and deadliest U.S. outbreaks of the coronavirus at its nursing home in Kirkland, Washington – with 45 deaths linked to the facility, according to local public health authorities. (For a story on the Kirkland outbreak, click here)

In its investigation, Reuters interviewed several other workers and former workers at the home, who also detailed mismanagement, staff shortages and lapses in care. But Lelievre and Harmon were two of three current employees who agreed to have their names published, and both nurses were quoted more extensively than the third worker.

The facility never restricted Lelievre’s access to drugs before she stopped working, Lelievre said. At the time of the alleged paperwork errors, Lelievre said, she had been working 16-hour days during the outbreak and in one case worked 24 hours because no one else could fill shifts.

Harmon, the nurse supervisor, said if paperwork mistakes during the outbreak are grounds for termination, then “every nurse in that building should be fired.”

Harmon herself contracted COVID-19 during the outbreak and used 10 days of accrued sick time because the company offered no additional paid days to workers who contracted the disease.

Lamontagne said Harmon never addressed staffing issues with management before speaking to Reuters, “even though that’s her supervisory role to bring it up through a chain of command.”

Harmon said she raised concerns about staffing shortages many times with Lamontagne and other administrators, often telling them the home had no nursing assistants on certain shifts.

“The whole time, I have been begging for help,” Harmon said. “How much more do you need to know that the staffing is horrible?”

(Reporting by Chris Kirkham; Editing by Brian Thevenot)

Special Report: Pandemic exposes systemic staffing problems at U.S. nursing homes

By Chris Kirkham and Benjamin Lesser

(Reuters) – One night in April, as coronavirus swept through the Hammonton Center for Rehabilitation and Healthcare, Robyn Esaw, a double amputee, signaled for help with her bedpan. She said she hit the bedside button that turns on a red hallway light. None of the few remaining staff showed up – and one of them turned the light off. Esaw only got help, eventually, by wheeling herself to the nursing station and yelling.

On another night in another room of the New Jersey home, Barbara Grimes noticed her roommate sitting in a puddle of urine, which seeped into a wound on her tailbone. No one checked on the roommate for three hours. The woman, Grimes said, had given up on calling for help.

That same month, Hammonton staffers moved David Paul and another man into a room last occupied by two residents infected with the coronavirus, one of whom later died of COVID-19. The floors were still dirty, the bathroom littered with trash, Paul said. Paul and the other man, he said, soon tested positive themselves, and his roommate died. In all, the Hammonton outbreak resulted in 238 infections and 39 deaths, state data shows.

“You cannot live here and really believe that these people care about you,” said Esaw, 70, who has lived in the home for nine years and knows Grimes and Paul well.

Nursing homes worldwide, filled with elderly residents who are particularly vulnerable to COVID-19, have suffered a harrowing toll in the pandemic.

A woman watches as emergency medical technicians (EMTs) unload a patient into an ambulance outside of the Hammonton Center for Rehabilitation and Healthcare one of numerous nursing homes to have staffing shortages during the national outbreak of the coronavirus disease (COVID-19) in Hammonton, New Jersey, U.S., May 19, 2020. REUTERS/Lucas Jackson

In the United States, longstanding problems with staffing shortages and chronic turnover have left nursing homes especially exposed. An estimated 40% of the country’s more than 100,000 COVID-19 deaths are connected to long-term care facilities such as nursing homes or assisted-living centers, according to a Kaiser Family Foundation tally.

About a quarter of nursing homes responding to a recent federal survey reported shortages of direct-care staff during at least one of the last two weeks in May, according to a Reuters analysis of survey data from the Centers for Medicare and Medicaid Services.

A separate Reuters analysis of federal nursing home data shows that, before the virus hit, about four in 10 homes nationwide would not have met the minimum staffing regulations in California, which has among the highest standards in a nation where some states have few or no requirements for nursing staff levels. About 70% of U.S. nursing homes would fail to meet a stricter staffing standard advocated by some experts, the analysis showed.

The coronavirus pandemic has laid bare and deepened these historical staffing problems, according to interviews with nearly two dozen nursing home workers and residents nationwide. Nursing home staffers are quitting in large numbers, these workers said, because of illness fears and what they described as a slipshod emergency response by management.

As outbreaks hit homes nationwide, administrators often sought to downplay the danger, 17 workers at eight homes run by eight different companies told Reuters. Managers hid the severity of outbreaks, the workers said, in part because they were desperate to retain staff who were scared and disillusioned with poor working conditions and pay as low as $11 per hour. Some managers pressured sick or infected workers to show up, said five workers at four facilities.

At Hammonton Center, overworked nursing assistants have regularly had to bathe, clean and feed as many as 30 residents by themselves, far more than usual. Staffing on two occasions was so thin that nursing assistants found residents who had been dead for several hours in rooms no one had time to check, two Hammonton employees said.

Centers Health Care, which runs the facility, declined to comment on most accounts of residents and workers cited in this report. It denied any lapse of care at the home. The company disputed the contention that residents were not discovered for hours after they died.

Reports of overwhelmed staff extend far beyond Hammonton. At Life Care Center of Nashoba Valley in Littleton, Massachusetts, so many staff had quit or called in sick that managers left a teenage nursing-assistant trainee on a shift caring for nearly 30 dementia patients, said a current worker and a former worker. Partway through the shift, one more nursing assistant was assigned to help her in response to staff complaints, the workers said.

The vast majority of more than 40 nurses and nursing assistants at the Life Care home have quit since April, six current and former workers told Reuters. Twenty-six people died, according to federal data, including a nursing assistant. The outbreak caused 87 confirmed infections, the data show.

The rapid staff exodus left residents without the most basic care, the workers said. “These are people who all need to be changed. They’re incontinent. A lot of them need help eating,” said Lisa Harmon, a nurse who supervises weekend shifts. “There’s only so much one person can do.”

Tim Killian, a spokesman for the home’s owner, Life Care Centers of America Inc – one of the nation’s largest operators – acknowledged that a large portion of the Massachusetts home’s staff quit under “extremely challenging” conditions. He said facility leaders could not recall a teenager being assigned to care for dementia patients alone.

Echoing other industry advocates, Killian said nursing homes have generally reacted well to an unprecedented challenge, despite little government help. The U.S. government has taken heavy criticism for being slow to react to nationwide shortages of protective gear and testing kits.

“It’s just ridiculous to think that nursing homes, absent direct and substantial government support, could manage a global pandemic,” Killian said.


Staffing had long been a problem at the Massachusetts Life Care home, with nursing assistants often caring for too many residents, workers said. The shortages became a crisis in the outbreak, they said, as management failed to provide protective gear or to communicate how the virus was spreading.

In March, veteran nursing assistant Patti Galvan noticed residents getting fevers and coughing. She brought her own mask, but a manager told her not to wear it, saying it wouldn’t prevent infection. Other workers said management told them to remove masks they brought from home because they would cause other workers to ask for protective equipment the facility could not provide.

Killian acknowledged protective-gear shortages, which created “tension” between management and workers, but said administrators were powerless to solve nationwide supply problems.

Staffers started getting sick and staying home, but managers “weren’t taking it seriously,” said Galvan.

“They were just hiding it from us,” said Galvan, who left more than two months ago after getting flu-like symptoms and has no plans to return. “If they were honest with us, and were more caring and more responsible, they wouldn’t have lost us all.”

Galvan had worked at the facility for three decades.

Amy Lamontagne, the facility’s executive director, said management never withheld information. “There was no secret-keeping,” she said.

Killian said management couldn’t inform staff about coronavirus infections until it had confirmed test results or, when testing wasn’t available, a formal diagnosis from a nearby hospital.

Colleen Lelievre, a nurse who still works at the facility, said testing wasn’t needed to recognize the unusual number of residents with COVID-19 symptoms in March. But management, she said, never leveled with the staff about why so many residents were being hospitalized.

As more workers quit or called in sick, those who remained regularly worked 80- to 90-hour weeks, said Harmon, the weekend nursing supervisor. Physical- and occupational-therapy assistants filled in for nursing assistants.

The depleted staff couldn’t bathe and feed every resident, workers said. In a dementia unit, workers were unable to keep residents from wandering into hallways and other patients’ rooms, potentially spreading infection. Staff had no time to sit with dying residents, said Harmon, who sometimes left her phone with them so they could call relatives in their final hours.

Despite these conditions, the facility reported no staff shortages in response to the government’s nursing-home survey. Killian said the facility had no shortages in late May because the number of residents had declined to the point where the home was “fully staffed” with many fewer workers. Lamontagne said the 120-bed facility now has 65 residents.

Overall, 192 of Life Care’s more than 200 nursing homes responded to the federal survey, and about 29% of those reported staff shortages, according to the Reuters analysis.

Harmon and Lelievre said the Massachusetts home still has far fewer staff than it needs. The facility has very few nursing assistants, Lelievre said on Saturday, making it nearly impossible for staff to safely move some residents out of their beds, which often requires two people.

Lamontagne, the executive director, had a different take: “We’re doing fine with our staffing,” she said.

Several workers questioned why the facility wasn’t more prepared, since its owner had, weeks before, managed the site of one of the first major U.S. outbreaks, at the Life Care facility in Kirkland, Washington – with 45 deaths linked to the home, according to local public health authorities.

“They didn’t have any plan,” said John De Mesa, a nursing assistant who said he contracted the virus in March.

Killian said the gap between the Washington and Massachusetts outbreaks gave the company little time to act on lessons learned.

In late March and early April – as many Life Care residents were hospitalized – the Massachusetts National Guard came to the home to administer tests. Administrators brought in corporate staff and workers from a nearby Life Care facility to give the appearance of a fully staffed home around the time of the Guard visit, Harmon and Lelievre said. Most of the added staff left within a week, they said.

Killian dismissed the contention that the extra staff were deployed for appearances, saying all staffing decisions aim to improve care.

The home told workers they could not get tested along with residents, staffers said. The state at the time, in early April, was restricting testing in nursing homes to residents only.

After workers complained about the lack of testing, management sent a text message to the staff on April 5.

“We encourage you to direct any questions or concerns about your health to your personal physician,” read the message, which was reviewed by Reuters.

Some workers sought out their own testing. Life Care did not test workers until mid-May, Harmon and Lelievre said. Staff had to bill their insurers for the tests, they said. Those with no insurance had to pay upfront and seek reimbursement from Life Care.

Thirty-four workers at the facility had tested positive by the end of May, according to federal data. Those who became ill with COVID-19 were not paid for their time away, Harmon and Lelievre said. Killian said sick workers could use accrued paid time off.


Insufficient staffing and frequent turnover have caused quality-of-care problems at nursing homes for decades, studies and government inquiries have shown.

Most nursing-home revenue comes from Medicaid and Medicare, the federal health programs for the poor and elderly. The fixed payments, some researchers say, incentivize companies operating on thin margins to cut staffing to the bone. Industry lobbyists have long sought higher reimbursements, which they argue haven’t kept pace with costs.

The American Health Care Association, an industry trade group, testified before Congress twice last year and requested help in attracting workers. Since the pandemic hit, the group has asked state officials for help recruiting nurses from less-impacted regions, as New York City hospitals did. “Just like hospitals, we called for help,” the group said in a statement.

“In our case, nobody listened for months.”

The federal government conducted its nursing home survey last month to seek data on staff and equipment shortages during the pandemic. At least 3,200 nursing homes – 23% of the 13,600 facilities that submitted data – reported staffing shortages in late May, according to the Reuters analysis. About 2,000 facilities did not respond to the survey.

U.S. regulators set few standards for nursing-home staffing, requiring only the presence of a registered nurse for one eight-hour shift and a licensed nurse, with a lower-level credential, in the building at all times.

At least two-thirds of states, including California, set minimum-staffing standards for nursing care, though the requirements vary widely and often contain loopholes. Some, including Indiana and Virginia, have no minimum standards for direct-care nursing staff.

California requires its 1,200 nursing homes to provide 3.5 hours of daily direct care, part of a 2017 law setting some of the highest standards nationally. If applied nationwide, about 37% of nursing homes would fail to meet that requirement, according to the Reuters analysis, which examined federal data on staffing during the last quarter of 2019 for nearly 15,000 nursing homes.

About a third of California homes don’t meet the state’s own staffing standards because regulators last year granted them exemptions from requirements for overall staffing or for certain positions. The state said it granted some waivers because of workforce shortages.

Annual turnover of nursing staff at homes in California – among the few states that track that data – has increased from 44% in 2014 to 53% in 2018.

Some researchers believe California’s requirements don’t go far enough. Charlene Harrington – a nursing professor emerita at University of California, San Francisco, who has studied nursing-home staffing shortages – advocates for 4.1 hours of per-patient direct care. She cites a 2001 federal study that concluded quality of care can decline below that level. At least 70% of nursing homes nationwide would fail to meet that higher bar, the Reuters analysis shows.

Some scholars and industry advocates blame staffing problems on systemic weaknesses in U.S. nursing-home funding.

“No one wants to pay the taxes for them, even though they’re all of our grannies, or mothers,” said Vincent Mor, a professor at Brown University’s school of public health, who has studied nursing home quality and staffing.

Some experts blame nursing home owners, mostly for-profit companies, for skimping on staff to make more money. Harrington, the UCSF nursing professor, called industry complaints about government funding “nonsense,” arguing that major companies would leave the business if it were unprofitable.


When outbreaks hit, some nursing home managers pressured sick workers to show up unless they had a positive coronavirus test, or to return to work before the recommended self-quarantine period, five workers at four facilities said.

Nursing assistant Gabby Niziolek, 20, said she started feeling sick in late March during a shift at Plaza Healthcare and Rehabilitation Center in Elizabeth, New Jersey. Some co-workers had started feeling ill, she said, and she noticed residents losing their appetite and turning a pallid color.

When she asked to leave, her manager told her to finish her shift, Niziolek said. The next day, after she got tested, she said she was told to return to work while awaiting results. When the results came back positive, Niziolek’s boss asked if she was showing symptoms. She said she was, and stayed home.

“If you’re positive and you don’t have symptoms, they still want you to work,” Niziolek said.

Plaza Healthcare and Rehabilitation Center did not respond to requests for comment.

Residents and staff at New Jersey’s Hammonton Center were kept in the dark for weeks about the extent of the facility’s outbreak, said three residents and six staffers.

As illness spread in late March, managers told workers that the sudden jump in residents with fevers, appetite loss and shortness of breath stemmed from cases of “aspiration pneumonia,” a condition that usually isn’t caused by an infectious disease. Weeks later, managers said that residents who had been hospitalized tested positive for the coronavirus.

Workers weren’t informed at the start of shifts that they would be working on hallways filled with residents believed to be infected, staffers said.

Home operator Centers Health Care said it couldn’t be sure that symptomatic residents had the virus until testing became more widely available in April.

A nursing assistant who was among the first to test positive for the virus said she reported the diagnosis to her supervisor and told several co-workers, as her doctor had advised. Five days later, when she was at home sick, a manager called to chastise her for telling co-workers, she said.

Centers Health Care said in a statement that its staff are “working tirelessly around the clock.” The company said staffing shortages are an industry-wide issue, but that it has ensured it meets state minimum staffing requirements during the pandemic by redeploying staff as needed within its network of facilities. The company declined to detail its staffing levels.

Hammonton nurses and aides said that about half of the facility’s direct-care staff have left, and that the facility replaced some with workers from temporary staffing agencies.

Hammonton Center reported some staff shortages to the government, as did about half of the 38 Centers Health Care homes that responded to the survey, according to the Reuters analysis of the data.

Grimes, who has lived at Hammonton for six years, said she started noticing that her roommate had a “horrible cough” that kept getting worse. She told nurses about the condition, and her roommate was hospitalized in April. The woman later died, but Grimes said staff never told her the cause.

Grimes said she got moved to a separate wing for those who had not contracted the virus – but staff never explained, she said, whether her roommate had tested positive. Last month, after getting a second test, Grimes learned she was positive, though she said she only had a slight fever.

“We don’t know when somebody gets sick; we have to sniff it out like a bloodhound,” she said. “You can only guess what happened when that person is getting carried out on a gurney.”

(Reporting by Chris Kirkham and Benjamin Lesser; Editing by Janet Roberts and Brian Thevenot)

A daughter learns in voicemails that coronavirus has killed her mother

By Tim Reid

(Reuters) – Debbie de los Angeles woke up on March 3 to two voicemails from nurses at the Seattle-area care home that housed her 85-year-old mother, Twilla Morin.

In the first one, left at 4:15 a.m., a nurse asked a troubling question – whether the “do not resuscitate” instructions for her mother’s end-of-life care were still in force.

“We anticipate that she, too, has coronavirus, and she’s running a fever of 104,” the woman on the recording said. “We do not anticipate her fighting, so we just want to make sure that your goal of care would be just to keep her here and comfortable.”

The nursing home in Kirkland, Washington was dealing with the beginnings of an outbreak that has since been linked to more than 30 deaths. De los Angeles had not yet fully grasped the grave threat; she comforted herself with the thought that her mother had made it through flu outbreaks at the center before.

Then she took in the next voicemail, left three hours after the first by a different nurse.

“Hi Debbie, my name is Chelsey … I need to talk to you about your Mom if you could give us a call. Her condition is declining, so if you can call us soon as possible that would be great. Thanks. Bye.”

De los Angeles called the home immediately. Her mom was comfortable, she was told. She did not change the “do not resuscitate” instruction. She wanted to visit, but held off: She is 65, and her husband Bob is 67; both have underlying medical conditions that pose serious risks if they contract coronavirus. She thought they had more time to find the best way to comfort her mother in what might be her final hours.

At 3 a.m. the next morning, Wednesday, March 4, de los Angeles woke up and reached for her phone. Life Care Center had called – leaving another voice message just a few minutes earlier, at 2:39 a.m.

“I know it’s early in the morning but Twilla did pass away at 2:10 because of the unique situation,” the nurse said. “The remains will be picked up from the coroner’s office. They’ve got your contact.”

The “unique situation” has of course become tragically common worldwide, as thousands of families have been separated from their loved ones in the last days before they died in isolation, often after deteriorating quickly. The three voicemails – eerily routine and matter-of-fact – would be de los Angeles’ final connection to her mother. She had gone from knowing relatively little about the threat of COVID-19 to becoming a bereaved daughter in the span of one day.

The hurried voicemails with such sensitive information were one sign of the chaos inside the facility at the time, as nurses worked feverishly to contain the outbreak while residents died from a virus that was just hitting the United States. One of the nurses who called de los Angeles, Chelsey Earnest, had been director of nursing at another Life Care facility and volunteered to come to Kirkland to care for patients through the outbreak. She never expected the disease would cause dozens of deaths and the mass infection of patients and staff.

Earnest worked the night shift, when patients with the disease seemed to struggle the most, and many, like Morin, succumbed to the disease. Infected patients developed a redness in and around their eyes. The center’s phones rang constantly as worried families called for updates. About a third of the center’s 180 staff members started showing symptoms of the disease; the rest started a triage operation.

“There were no protocols,” said Life Care spokesman Tim Killian, as nurses found themselves thrust into a situation more dire than any faced by an elderly care facility “in the history of this country.”

The center’s nurses, he said, would not normally leave such sensitive information about dying relatives in voicemails, but they had little time to do anything else – and did not want anyone to hear about a loved one’s condition in the news before the center could inform them. Outside the home, journalists and family members gathered for the latest scraps of information on the home’s fight against the virus. Many relatives, barred from going inside for safety reasons, stood outside the windows of their loved ones’ rooms, looking at them through the glass as they conversed over the phone.

Leaving the emergency voicemails, Killian said, made “the best of a difficult situation.”

From the outside, the messages appear abrupt and impersonal, but may well have been the best or only way to properly notify families in such a crisis, said Ruth Faden, professor of biomedical ethics at John Hopkins University’s Berman Institute of Bioethics. While medical professionals should normally aim to impart such urgent information in person, the circumstances – an overwhelmed staff, dealing with dozens of dying patients – likely made that impossible, she said.

“The way to find out is difficult, always,” Faden said. “What people remember is how much the nurse cared about the person.”

When de Los Angeles heard of her mother’s death in one of those voicemails, she immediately called one of the nurses back, looking for any bits of information about her mother’s final hours. The nurse sounded upset.

“She told me my Mom was one of her favorite people there; she was going to miss seeing my Mom going up and down the hallway in her wheelchair,” de los Angeles said.

They had given her mother morphine and Ativan to keep her calm and comfortable, the nurse told her.

“My Mom was asleep, and then she just went to sleep permanently,” de los Angeles said.

De los Angeles, an only child, aches over not having spoken to her mother before she died. Morin had been a bookkeeper for several companies. De los Angeles fondly remembers doing household chores with her mother on Saturday mornings, then going to the local mall or to Woolworth’s for lunch.

The separation continued even after her mother’s death. De los Angeles telephoned the crematorium where her mother had been taken, as Morin had arranged years earlier, to ask if she could view the body.

“Absolutely not,” the woman told her, out of concern de los Angeles could be infected.

Morin had been tested for coronavirus shortly after she died, on March 4. The results confirmed her coronavirus infection a week later. Soon afterwards, she was cremated.

“We picked up her ashes on Saturday,” she said. “I never saw or spoke to mom. It’s put off the closure.”

It’s also put off the funeral. De los Angeles had planned the ceremony for April 4 – the birthday of her father, who died ten years ago. Her ashes would be placed next to his. But the service will have to wait because Washington’s governor, Jay Inslee, has banned gatherings of 10 people or more.

In the meantime, de los Angeles has worked to make sure her mother’s death certificate records her as a causality of the pandemic. The doctor who signed it did not have confirmed test results showing a COVID-19 infection at the time of her death, de los Angeles said, and listed the cause as “a viral illness, coronary artery disease and a respiratory disorder.” But the doctor has since moved to include coronavirus as a cause, at de los Angeles’ request.

As she waits for the funeral, de los Angeles has put the urn holding her mother’s ashes behind some flowers on the mantle in her living room. She says she can’t bear to look at it.

(Reporting by Tim Reid; Editing by Brian Thevenot)

As Dorian nears, one in five Florida nursing homes lacks a generator: state agency

FILE PHOTO: Two days after Hurricane Irma, William James, 83, sits without power, food or water, in his room at Cypress Run, an assisted living facility, in Immokalee, Florida, U.S., September 12, 2017. REUTERS/Bryan Woolston/File Photo

By Scott Malone

(Reuters) – Only one in five Florida nursing homes plans to rely on deliveries of temporary generators to keep their air conditioners running if Hurricane Dorian knocks out power, a state agency said on Friday, short of the standard set by a law passed after a dozen people died in a sweltering nursing home after 2017’s Hurricane Irma.

State officials are also racing to check some 120 nursing homes and assisted living facilities where they are unsure if generators or contingency plans are in place, Governor Ron DeSantis told a news conference.

The state’s residents, meanwhile, scrambled to board up their windows and stock up on food ahead of the storm, which is forecast to grow into a potentially deadly major hurricane before it roars ashore early on Tuesday.

The generator question is a matter of urgency in Florida, an aging state where some 190,000 people live in nursing homes and assisted-living facilities. DeSantis’ predecessor, Rick Scott, signed the March 2018 law requiring all nursing homes to be able to keep their temperatures at or below 81 degrees Fahrenheit (27°C) for at least 72 hours after losing power.

The law followed pervasive problems in the wake of 2017’s Hurricane Irma, which knocked out electricity to a wide swath of the state. Police in Hollywood, Florida, earlier this week charged four nursing home employees with causing the deaths of 12 patients in the sweltering heat of a post-hurricane power outage.

“There are going to be site checks, there are going to be phone calls to make sure that they have a plan to deal with folks that are in their care,” DeSantis said.

State data shows that just 41.8% of Florida’s 687 nursing homes have permanent generators in place, with 36.4% having temporary generators on site. Some 21.4%, or 147 nursing homes with beds for 17,754 people, have arrangements in place to have temporary generators delivered if they lose power, while three with the capacity to house a total 338 people, would evacuate if they lose power.

The picture is brighter among the state’s 3,061 assisted-living facilities, which can house 106,086 people. Fully 94.3% of those sites have permanent generators in place, according to Florida’s Agency for Health Care Administration.

State legislative records, however, show that hundreds of nursing homes have received waivers allowing them to operate with temporary generators, even though the 2018 law intended for all sites to have permanent generators in place by the start of last year’s hurricane season.

The agency, which oversees nursing home and assisted-living facilities in the state, said it was working to ensure that all those sites complied with the law.

“Our Agency remains committed to making sure long term care facilities can support safe conditions during loss of power,” AHCA Secretary Mary Mayhew said in a statement on Friday. “Agency staff are also conducting outreach activities for facilities without current generator information.”

(Reporting by Scott Malone in Boston; Editing by Dan Grebler)