Early in April, a nurse working at a massive Cicero nursing home was worried that lax infection control was putting residents in danger of catching the coronavirus.
According to an affidavit filed in Cook County Circuit Court, the nurse called the Illinois Department of Public Health — the state agency that regulates nursing homes — but nobody picked up the phone. Concerned Cicero officials said they called too, and got no response.
The state didn’t send inspectors to City View Multi-Care Center until nearly a month later. That was after Cicero filed a lawsuit against City View and the state, accusing regulators of “woefully lacking” oversight, and Circuit Court Judge Alison Conlon pushed regulators to check into conditions at the home. By then, more than half of residents had become infected, killing nine of them as well as one employee.
Two months into the pandemic, the case of City View highlights increasing complaints from the nursing home industry, consumer advocates and local officials over whether the state is doing all it can to limit deadly outbreaks in Illinois’ 1,200-plus long-term care facilities. The homes are tied to more than 1,500 coronavirus-related deaths of residents and workers — accounting for nearly half the deaths statewide.
Industry trade groups asked the Pritzker administration weeks ago to create a “comprehensive plan” the industry said was long overdue. The coalition of trade groups has pushed the state for more testing and transparency, assistance with protective gear and staffing, and a more centralized approach to managing the crisis.
“We need more help. We need more coordination from the Department of Public Health. There’s no question about that. And we’ve been begging for it from the beginning,” said Pat Comstock, who runs one of the groups, the Health Care Council of Illinois.
Others say deeper state oversight and intervention is especially important in an industry they say struggled to provide adequate care even before the pandemic.
“The state needs to step up and treat this as the emergency that it is, and it’s not,” said AARP Illinois State Director Bob Gallo.
State officials say they have long had a comprehensive plan in place to push facilities to follow care directives. They said they are helping a largely for-profit industry find staff and gear as much as possible but the state is also stretched thin fighting other aspects of the pandemic.
“We have a plan around state efforts, but the plan isn’t: run nursing homes in a pandemic,” said Deputy Gov. Sol Flores. “That’s where we need associations to step up.”
The Tribune interviewed more than a dozen advocates, researchers, families and industry representatives. They say they sympathize with the state’s challenges in fighting an unprecedented pandemic but argue it should be doing more.
Among the concerns:
Gear: The state has said that — despite nationwide shortages — it’s provided county officials with personal protective equipment to cover the needs of nursing homes, and even begun direct shipments to facilities. But workers and homes have said they lack consistent supplies.
Staff: The industry, fearing it will run critically low on workers, asked the state weeks ago to create a new work corps, even prepare to call in the National Guard. The state has loosened hiring regulations but said facilities are responsible for their own staffing.
Metrics: The state doesn’t ask each facility to report each day on staffing levels or gear supplies — something advocates are pushing for nationally. Illinois officials say they’re looking to improve the process. Illinois does require facilities to report COVID-19 cases to health officials, but the information that the state provides publicly about cases at homes can be tardy or inaccurate.
Inspections: The state can inspect facilities for infection-control violations, but the City View case shows that the bar to dispatch inspectors can be high. Mostly, regulators offer long-distance guidance, saying that approach best ensures rules are followed across the state. Advocates say it has further endangered residents, some of whom they say already were receiving substandard care.
State inspectors reported finding no major issues at City View after last week’s inspection. But the judge, Conlon, expressed doubt that state regulators would be quick to spot future violations there because “IDPH did not seem to be all over it.”
The advocates’ calls for more intervention are joined by relatives of nursing home residents, who complain they have been misled or left in the dark while infections spread.
Kate Gawlik, an Edward Hospital nurse, said her father’s Bolingbrook home, Meadowbrook Manor, struggled to care for him adequately before COVID-19. When the 83-year-old developed COVID-like symptoms, Gawlik said she asked to take her dad to the hospital where she works. Gawlik said workers told her that if she did, he might not have a bed at the home when he was released.
According to Gawlik, the workers told her he had tested negative and could be cared for at the facility. He died five days later.
“I know they cared for my dad,” she told the Tribune. “But their love and care for him could not keep him alive. How many others are going to die? How many other daughters have to feel like me and live with regret because no one is regulating what is happening in nursing homes?”
Meadowbrook Manor now leads the state in the number of residents and workers who died from COVID-19 — at least 26, as of Friday.
In a statement, Meadowbrook Manor did not address Gawlik’s account but blamed the high toll at the home on the virus’s ability to infect people without causing symptoms. Most residents and staff remain “safe and stable,” the statement said.
“As testing ramps up, no facility will be immune to the impact of COVID-19, or the loss of life that comes from it,” the statement said. “But at Meadowbrook, we take each loss to heart, regardless of whether it is our residents who passed here or, in most cases, after leaving here to only pass away at a nearby hospital.”
In daily TV briefings, including one Wednesday, Gov. J.B. Pritzker has said his administration is focused on the challenges of limiting COVID-19 in nursing homes while also saying that local health officials, not the state, are “the first line of communication and support” for the facilities.
His administration says it has taken aggressive steps to help, including holding frequent webinars on proper infection control, sending “strike teams” to some places and, more recently, dispatching nurses to ramp up testing. That’s along with directing dozens of pallets of gear to local officials to distribute across the state.
“It is a very challenging environment. We said that even before we had our first case. And it’s proving to be very true,” IDPH Director Dr. Ngozi Ezike said Monday. “But we’re staying on it and trying to see what we can do to dampen the spikes that we’re seeing.”
Those statements have done little to temper the growing unease expressed by families and their advocates. They fear facilities have become black boxes, with residents locked in, loved ones locked out, and too few people keeping watch.
“I think there needs to be some sort of fundamental, simple check where people actually go into nursing homes — government officials, whoever’s free — and just sort of eyeball what’s going on,” said longtime attorney Steven Levin, who specializes in suing facilities over allegations of abuse and neglect.
Shortages of equipment
The Pritzker administration said for weeks that the state has distributed enough personal protective equipment throughout Illinois to supply long-term care facilities.
Pritzker noted April 21 that each local health department “is provided with all the PPE they ask for from the state” to supply long-term care facilities, and on Monday he said facilities receive a “plethora” of PPE “to make sure that they’re able to keep themselves safe.”
But workers and the industry have described shortages.
One Meadowbrook Manor worker complained to her family that her gear was so lacking she made masks at home and bought her own goggles. She later contracted COVID-19 and died. The facility said it followed state and federal guidelines.
In an April 23 letter to the state, three trade groups — Health Care Council of Illinois, Illinois Health Care Association and LeadingAge Illinois — complained they had “sounded the alarm about our limited PPE inventory for weeks.”
The resupply process can be hit or miss, the groups said, depending on which part of the state is involved and what’s needed. Sometimes facilities ask for gowns but get gloves. One southern Illinois facility reported receiving garbage bags instead of gowns.
The groups asked the state to take over distribution of supplies “using consistent protocol” — similar to the way hospitals get gear from the state.
Pritzker said Wednesday that the state stockpile “always provides a backup” for long-term care facilities and “is not the primary supplier for private businesses.”
The industry said it is still buying its own gear, even at inflated prices.
In response to the concerns, Pritzker said, the state undertook a “somewhat unprecedented effort” April 30 to begin direct deliveries to more than 1,200 long-term care facilities. The health department has delivered PPE to more than 1,000 homes so far, enough to cover 200 beds each, a spokeswoman said. Facilities with more than 200 beds will get two shipments, she said.
Facilities also can send masks to be decontaminated and reused up to 20 times, for free, at a facility in northern Illinois.
The industry said supplies of PPE have improved in recent weeks but still not to a consistent level. “Our challenges with PPE are far from over,” Comstock said.
Federal legislation, pushed by Democrats, would require facilities that receive federal money to report on supplies — including projected shortages — as well as staffing levels to state health departments every 24 hours. That bill is still pending.
In Illinois, the state sent a one-time survey to facilities in late March that asked how many days of supplies they had for each type of PPE. Officials with IDPH said the agency also makes calls each day to facilities and asks about issues including gear and staffing but does not track it electronically.
Ezike said Wednesday that the state has discussed creating a digital system to process other notifications it receives. She said it could include tracking nursing home staffing and supplies. But, as of now, such a system doesn’t exist.
Chronic understaffing
Workers and the industry agree that — even before the pandemic — staffing was stretched and turnover high in an industry where much of the hands-on work has been done by people often making less than $15 an hour.
There has long been debate why; homes say they can’t afford to pay more because Medicaid pays them too little, while advocates say many homes are run by chains or families seeking to maximize profits.
Regardless, the industry and advocates agree that, when the pandemic hit, things got worse.
The industry asked the state last month to help recruit replacement staff, creating a “centralized pool of workers available for deployment as needed.” And, for places that may experience “significant staff losses,” the industry asked the state to prepare to send in the National Guard.
The state responded by loosening hiring regulations, something the industry also sought. Flores said the state also compiled lists of staffing agencies that facilities can contact and showed them how to tap the Illinois Helps volunteer network.
But ultimately, IDPH said, it can’t become a staffing agency for private, for-profit nursing homes.
“It is their job to be staffing their facilities. It’s their job to manage them,” Ezike said Wednesday.
Experts and advocates have noted that proper staffing is particularly important during a pandemic. Workers need to know how to don gloves, masks and gowns the right way, how to wash hands completely and frequently, and how to sterilize equipment shared among patients — tasks often poorly carried out before the pandemic.
“I think there are many very good people working in the long-term care industry who care deeply about residents and their well-being,” said Syracuse University law professor Nina Kohn, who’s studied elder rights. “That said, it was an open secret that nursing homes were infection tinderboxes.”
A 2018 investigation by Tribune and Kaiser Health News found that sepsis, a deadly bacterial infection, had proliferated in Illinois’ understaffed nursing homes. The AARP that year ranked Illinois among the worst states for understaffing and inappropriate use of psychotropic drugs to sedate residents.
Both reports spurred a 2019 law that offered more money to the industry, tightened rules on sedative use and required the state health department to better enforce staffing minimums set in 2010 that the Tribune found had regularly been flouted. Fines from that law don’t take effect until 2021.
Limited inspections
The state does have one tool to cut through any confusion about whether a home is keeping residents safe: sending inspectors.
The Department of Public Health works with the federal Centers for Medicare & Medicaid Services to regulate nursing homes. In March, a federal directive told states to focus more of their inspection resources on infection control, as a way to limit the virus’s spread. CMS also began conducting “targeted” infection-control inspections at facilities deemed high risk.
As of April, CMS had visited 19 Illinois facilities, cited 15 for breaking the rules and determined two had violations so egregious they put residents in “immediate jeopardy” of harm.
Those facilities were Aperion Care in Chicago Heights, which regulators said had continued to let residents congregate together too closely, and Central Nursing Home in Chicago’s Belmont Central neighborhood, which did that as well as failing to isolate sick patients, the inspection found.
Pritzker has also talked tough about the state punishing the worst offenders.
“We will not hesitate to hold any bad actors at the management level accountable,” he told reporters at an April 20 briefing. “We expect owners and managers responsible for (residents’) care to take every action at their disposal to keep them safe.”
An IDPH spokeswoman said the agency had resumed unannounced inspections of facilities to look at infection control but did not immediately have further details.
State officials also have said they’re focusing more on guidance than on inspections. The information is sometimes provided in person but often by phone or internet, using state employees as well as academics and volunteers.
Industry leaders have welcomed this approach, saying they are working in good faith to face an unprecedented pandemic, one where directives change as knowledge of the disease evolves.
But advocates say surprise inspections are the best way to catch mistakes and keep facilities honest, particularly in Illinois, where many facilities scored poorly on federal quality ratings before the pandemic.
“The ‘good cop’ approach doesn’t work when, historically, we’ve had so many bad players,” Gallo said.
CMS records show that one of the facilities rated poorly — with just one star out of five — is City View in Cicero, which also happens to be the state’s largest nursing home.
Calls for help
According to an affidavit filed in court, the nurse at City View reported to Cicero health officials that not only were residents allowed to mingle, they stood shoulder to shoulder while waiting in line for medicine or to smoke. Sick patients tested for COVID-19 also weren’t isolated while waiting days for results, she said.
The nurse said her boss had told workers to delay sending patients to the hospital, according to the affidavit. That included a woman with a 102.9-degree fever who was moved from one floor to another — infecting both floors — before she was taken to the hospital and died from the virus, the nurse said.
At the time of her April 14 call, Cicero officials had already chastised the facility for violating infection-control rules, they said in court documents. Cicero firefighters who responded to emergency calls there in late March had noticed staffers not wearing protective gear, sick residents not wearing masks and other residents allowed to mingle in the cafeteria, the officials said.
City View has disputed the allegations in court documents. The facility said it has followed evolving health directives to stop the virus’s spread but has been hampered by nationwide shortages of protective gear and testing. The virus “has challenged even the most careful and meticulous nursing homes,” it noted.
By the time the nurse contacted Cicero officials, at least one complaint had already been filed with the state, by the niece of a resident who contracted the virus and later died.
Susan Campos told the Tribune she passed along a tip she’d heard from an employee that social distancing rules were routinely flouted. She received a letter back acknowledging the complaint was received, but then said she heard nothing more.
State lawyers said in court that the agency had no record of receiving calls from either the nurse or Cicero officials.
Instead of inspecting City View, the state said, it began daily check-ins with the facility’s top staff to advise them on how best to follow health directives. That didn’t impress the judge hearing Cicero’s lawsuit last week.
“Conversations are different than an inspection … and conversations do not reveal the true conditions at a facility,” Conlon said.
Within 24 hours of that hearing, the state sent inspectors to spend a morning at City View. They reported back no significant issues, state lawyers said in court, and the state said it had no plans to recheck the facility.
Citing “alarming” numbers of people infected, Conlon granted a request from Cicero officials to make their own surprise visits to the facility, allowing up to two such inspections through June 5. If they saw problems City View wouldn’t correct, Cicero officials could contact the state.
State lawyers noted in court that even if Cicero asked for another inspection, the state would decide on its own if, and when, to come back.
jmahr@chicagotribune.com
![By ADRIANA GOMEZ LICON and DARLENE SUPERVILLE (Associated Press) WASHINGTON (AP) — Vice President Kamala Harris on Monday said the first rule to set minimum staffing levels at federally funded nursing homes and require that a certain portion of the taxpayer dollars they receive go toward wages for care workers is a long-overdue “milestone” that […]](https://www.chicagotribune.com/wp-content/uploads/2024/04/Election_2024-Harris_89203.jpg?w=525 "By ADRIANA GOMEZ LICON and DARLENE SUPERVILLE (Associated Press) WASHINGTON (AP) — Vice President Kamala Harris on Monday said the first rule to set minimum staffing levels at federally funded nursing homes and require that a certain portion of the taxpayer dollars they receive go toward wages for care workers is a long-overdue “milestone” that […]")
