The Striking Racial Divide in How COVID-19 Has Hit Nursing Homes

The following article was originally published May 21, 2020, and republished through a collaboration with KPCC and LAist.

THIS ARTICLE IS A COLLABORATION, WITH REPORTING BY

Robert Gebeloff, Danielle Ivory, Matt Richtel, Mitch Smith and Karen Yourish of The New York Times; Scott Dance of The Baltimore Sun; Jackie Fortiér and Elly Yu of KPCC/LAist; and Molly Parker of The Southern Illinoisan.

In the suburbs of Baltimore, workers at one nursing home said they were given rain ponchos to protect from infection. Twenty-five employees at the facility, where most residents are African-American, tested positive for the coronavirus.

One of the many black residents of a nursing home in Belleville, Ill., died in April amid a coronavirus outbreak. But his niece complained that he was never tested for the virus.

In East Los Angeles, a staff member at a predominantly Latino nursing home where an outbreak emerged said she was given swimming goggles before professional gear could be obtained. She said she later tested positive for the virus.

The coronavirus pandemic has devastated the nation's nursing homes, sickening staff members, ravaging residents and contributing to at least 20 percent of the nation's COVID-19 death toll. The impact has been felt in cities and suburbs, in large facilities and small, in poorly rated homes and in those with stellar marks.

But COVID-19 has been particularly virulent toward African-Americans and Latinos: Nursing homes where those groups make up a significant portion of the residents — no matter their location, no matter their size, no matter their government rating — have been twice as likely to get hit by the coronavirus as those where the population is overwhelmingly white.

More than 60 percent of nursing homes where at least a quarter of the residents are black or Latino have reported at least one coronavirus case, a New York Times analysis shows. That is double the rate of homes where black and Latino people make up less than 5 percent of the population. And in nursing homes, a single case often leads to a handful of cases, and then a full-fledged outbreak.

The nation's nursing homes, like many of its schools, churches and neighborhoods, are largely segregated. And those that serve predominantly black and Latino residents tend to receive fewer stars on government ratings. Those facilities also tend to house more residents and to be located in urban areas, which are risk factors in the pandemic.

Yet the disparities in outbreaks among homes with more Latino and Black residents have also unfolded in confusing ways that experts say are difficult to explain.

The race and ethnicity of the people living in a nursing home was a predictor of whether it was hit with COVID-19. But the Times analysis found that the federal government's five-star rating system, often used to judge the quality of a nursing home, was not a predictor. Even predominantly black and Latino nursing homes with high ratings were more likely to be affected by the coronavirus than were predominantly white nursing homes with low ratings, the data showed.

To better understand the disparities in Maryland, California and Illinois, The Times teamed up with The Baltimore Sun, KPCC/LAist and The Southern Illinoisan to interview dozens of current and former nursing home workers, residents and their relatives.

Eric Russell, who moved his mother to a different nursing home in the Chicago area after she tested positive for the virus, said the prevalence of cases in homes with more black residents was alarming, and needed to be more widely understood and examined by the authorities.

"Nobody gave a damn about the black people dying at a higher clip," Mr. Russell said. At his mother's former nursing home, Villa at Windsor Park on Chicago's South Side, where most residents are black, at least 121 residents and employees have been infected and 24 people have died.

Company officials said in a statement that they had proactively sought testing for Villa at Windsor Park residents and tried to limit the spread of the virus.

The coronavirus has been infecting and killing people of color at disproportionately high rates in the United States, data has shown. And officials in the nursing home industry say that the situations playing out inside homes largely reflect the circumstances unfolding outside their walls.

"Typically, what occurs in the general population is mirrored in long-term care facilities," said Dr. David Gifford, chief medical officer for the American Health Care Association, which represents the industry. Nursing homes within communities that have been hot spots for the virus are more likely to see outbreaks, he said, especially in large facilities with lots of employees coming in and out.

Small nursing homes, which are disproportionately occupied by white residents, tend to have fewer outbreaks than larger facilities, and urban nursing homes have more outbreaks than suburban or rural ones.

But the Times analysis found that a racial disparity remained even after accounting for a variety of factors, including the size of a nursing home, the infection rate in the surrounding county, the population density of the neighborhood and how many residents had Medicaid or Medicare.

Large homes with few black and Latino residents were less likely to have outbreaks than large ones with more black and Latino residents. A home in an urban area was less likely to get hit by the virus if it had a small black and Latino population.

The Times analysis, which covers the 22 hardest-hit states for which data is available and the District of Columbia, represents a snapshot in time, and the picture could change as the crisis wears on. Based on data collected as of May 16, the analysis could not determine whether there was a disparity in rates of illness or death for white residents and people of color within nursing homes because data was not available.

About 1.3 million people live in the nation's nursing homes, according to federal data. About 80 percent of those residents are identified as white by nursing home administrators.

Long before the pandemic, there was disparity in homes. Those with more black and Latino residents tended to score worse than mostly white homes on quality metrics used by regulators. And they were more likely to have been punished for serious rule violations.

"I had roommates who pushed the call button because they needed help to go to the bathroom," said Armand Harris, who said he was discharged in February from Gateway Care and Rehabilitation Center in Hayward, Calif., after receiving care for cancer and kidney disease. "After about a half-hour or 45 minutes, they would just go on themselves."

Officials from Gateway, which has had a diverse group of residents who are black, Latino, white and Asian, did not respond to specific criticisms from former residents, workers and relatives that the home had serious problems with hygiene and attentiveness to residents before the coronavirus crisis. In a statement, they said workers were doing all they could to keep residents safe and healthy. They said there had been "significant mischaracterizations and misrepresentations" about their handling of the crisis, but gave no specifics.

The situation there only grew worse, the interviews suggested, once the pandemic hit. At least 100 residents and employees were infected, and 17 died, including some of Mr. Harris's friends. "I got out in the nick of time," said Mr. Harris, who is of mixed racial background. The Alameda County district attorney's office said it was investigating deaths at Gateway and the safety and well-being of its residents.

Nationally, at least 106,000 people have been sickened by the virus in more than 4,000 skilled nursing facilities, which do not include stand-alone assisted living centers, retirement communities and other long-term care facilities. Almost 19,000 people have died, and that is quite likely a significant undercount. All sorts of nursing homes, including those with mostly white residents, have been affected.

In Maryland, 80 percent of nursing homes with high black and Latino populations have been hit by the coronavirus, double the rate for homes with hardly any such residents.

At the FutureCareLochearn nursing home, in Baltimore, 158 residents and 75 employees tested positive for the virus over a few weeks, and 20 have died. Holly O'Shea, a spokeswoman for FutureCare, said the large number of infections reflected the widespread testing that the company sought out.

Anita Kelly, whose father fell ill at FutureCare, said she was angry that testing had not come sooner, and said she wondered whether the fact that her father and most other FutureCare residents were black had played a role. Her father, Alexander F. Gaskins, a former interior decorator who tested positive for the virus, died on April 19.

"They wouldn't stand for it," Ms. Kelly said of how officials might react if the pandemic was disproportionately affecting white Americans. "But it's killing us at a higher rate and we don't take it serious."

In some facilities that had coronavirus outbreaks, concerns about how residents were being cared for came well before the virus. Bria of Belleville, in southern Illinois, has been tied to at least 22 cases and two deaths. It is one of more than 300nursing homes in the state where the virus has been detected. Bria, where many residents are black, has a one-star overall rating, the lowest available, from the federal government.

Juanita Willis helped look after her uncle Ralph Wellmaker, who had lived at the home since last summer. Ms. Willis said she had raised concerns about sanitation and staffing at the home, and she described the care there as "just horrible."

Ms. Willis, a nurse at a St. Louis medical center, is still unsure whether her uncle had the virus. She last visited him in early March, shortly before visitors were told to stay away. In mid-April, she received a call from a hospital social worker asking about funeral arrangements for her uncle, learning for the first time that he had died two days earlier. His death certificate listed cardiac arrest as a cause of death, but records indicate he was not tested for the virus, according to the local coroner's office.

"It is very upsetting," Ms. Willis said. "I think once they got the first case, they should have tested everyone in the facility."

In a statement, Bria officials defended the quality of care at the Belleville facility, noted the difficulty in securing coronavirus tests and said Mr. Wellmaker lived in a part of the center separated from people known to have had the virus.

"Bria of Belleville took early and aggressive steps to protect the health and safety of its residents and staff," the facility's administrator, Stephanie Birch, said in a statement.

Along with residents of nursing homes, thousands of nurses and aides have been sickened by the virus in an industry where African-Americans make up an outsize share of the work force.

Dozens of nursing home workers interviewed across the country described short-staffed, disorganized facilities that sometimes lacked adequate protective gear amid the pandemic. Workers fell ill, alongside their patients.

In Baltimore County, at the Forest Haven Nursing and Rehabilitation Center, where many residents are black, workers said they were given rain ponchos and nylon hair bonnets in early April, after Maryland required all nursing homes to provide the staff with protective equipment.

They have since received proper supplies, including face shields, masks and gowns. But at least 97 people, including 27 workers, have contracted the virus and eight residents have died.

Ron Colbert, the facility's administrator, said the home was restricting visitor access, screening anyone who entered for symptoms, and following federal guidelines for personal protective equipment and patient isolation. Asked in an email about the ponchos and hair bonnets, Mr. Colbert did not respond.

Donna Johnson, a cook at Forest Haven who says she was given a mask for protection, said she came down with a 102-degree fever in April and tested positive for the virus. She said she worried that the virus made its way in because some staff members were working in multiple facilities.

She said her strongest concern was for the residents.

"It's so unfair to them," Ms. Johnson said. "They contracted this through no fault of their own."

In East Los Angeles, at the Buena Ventura Post Acute Care Center, a five-star facility where many residents are Latino, Alma Lara-Garcia, a certified nursing assistant, said workers were not given masks until April, well into the outbreak in the United States.

Ms. Lara-Garcia said administrators told her that they were going to order medical-grade eye protection, but that suppliers were out. Instead, she said, she was given orange plastic swimming goggles. The goggles did not fit under her glasses, so she did not wear them.

Not long after, she said, she started to feel sick. She said she was told to come into work anyway. Days later, she said, she was sent home when she complained of a sore throat and uncontrollable coughing, and she eventually tested positive for the virus at a county-run testing site.

Tiana Thompson, Buena Ventura's administrator, said that the facility had worked to secure protective gear for workers and that Ms. Lara-Garcia had not been asked to work while sick.

"At no time has Buena Ventura Post Acute Care Center asked any employee who reported experiencing Covid-related symptoms to report to work," Ms. Thompson said in an email.

At least 83 residents and employees have contracted the virus, and at least a dozen of them have died.

Sheelagh McNeill contributed research.

HOW THE NUMBERS WERE CALCULATED

In examining racial disparity in coronavirus infections at nursing homes, The New York Times gathered data on infection reports from state and local health agencies and joined the information to databases of information about facilities, including the federal government's Nursing Home Compare data and Brown University's Long Term Care Focus data.

While the analysis could not fully explain why some homes have seen outbreaks and others have not reported any infections, it did identify variables that increased the likelihood of a home reporting a problem, and found that the racial disparities persisted even after accounting for these variables.

There is no official published data on the race of nursing home patients by home. The Times obtained Medicare claims data and supplemented it with the Brown University data, which incorporates information from Medicaid and Medicare claims.

The analysis bypassed states that have published limited information, focusing on the District of Columbia and 22 states where at least 20 percent of facilities reported at least one coronavirus case.