Using data from the Centers for Disease Control and Prevention, the analysis found that deaths over the four-week period ending Nov. 19 were more than four times higher than those recorded during a four-week period ending June 25.

About 1,000 residents died from the virus in the fall time frame, bringing the year-to-date total to roughly 9,000 residents, AARP reported. Since the start of the pandemic, more than 185,000 nursing home patients have died of COVID.

But vaccinations, at first widely embraced by residents and later mandated for healthcare workers, drove infection and deaths rates down dramatically starting in 2021.

The uptick in deaths last month, accompanied by a quadrupling of infections of both residents and staff compared to this summer, comes as vaccine coverage is way down compared to the last two winters.

But there is some reason for optimism. The AARP analysis reported about 25% of nursing home residents were considered up-to-date on COVID shots, though that figure was based on Nov. 19 reporting. As of Dec. 3, according to Centers for Medicare & Medicaid Services data, the resident up-to-date figure had climbed to 30.7%, with 7.2% of staff covered.

Resident deaths peaked at 338 the week ending Nov. 26, then fell back to about 260 per week for the first two weeks of December, according to a review of CDC data by McKnight’s Long-Term Care News on Thursday. That’s still on pace to record another 1,000 deaths by year’s end, however.

Providers have continued to encourage vaccination, but in many states they reported early challenges with accessing shots, paying for them and getting enough for all of their people. More broadly, aging services providers said they are facing the same challenges public health officials are: a lack of interest in yet another round of vaccines.

“Long-term care providers are making every effort to encourage residents and staff to get vaccinated, and we are confident we will continue to make progress in the face of cold and flu season,” David Gifford, MD, chief medical officer at the American Health Care Association/National Center for Assisted Living told McKnight’s in late November.

“While nursing home residents are more than three times as likely to be up to date on their COVID vaccinations compared to the general public, nursing homes do not operate in a vacuum,” he added. “Unfortunately, we face the same challenges that we’re seeing across the US population at large: vaccine misinformation, hesitancy and fatigue. We need a collective approach to boost vaccine access and uptake, and AHCA/NCAL will continue to seek support of public health officials and the broader health care community.”

In November 2021, AARP reported, almost 90% of residents were vaccinated and roughly 40% had received a booster shot. Staff vaccinations had also hit the 80% mark just ahead of the Supreme Court approving a federal mandate. That mandate was ended along with the expiration of the public health emergency earlier this year.

The study evaluated states on a scale of 100 based on a variety of factors, such as the number of nursing homes per 100,000 residents, occupancy rates, cost of residency and the percentage of nursing homes with no deficiencies. 

Iowa topped the list with a score of 70.67. Iowa was not a leading state in the individual categories, but was consistently in the top third of each category. Around 10% of Iowa homes had no deficiencies, which was well above the national average of 6%. 

Despite a top-five occupancy rate, California was the bottom-ranked state, with an 18.61 rating. This was partially because of its high cost. Private nursing home rooms in the state cost more than $12,000 per month, among the highest in the nation. The state also has the 2nd most deficiencies per facility on average.

Providing insight into nursing home care in the US is only growing more important as the population ages, said SonderCare CEO Kyle Sobko. 

“This data provides a clear insight into which states currently offer the best access to elderly care and outlines the factors contributing to this,” Sobko stated. 

Rural Southern and Great Plains states consistently received high scores in the study. The top 10, in order, were:

• Iowa
• Oklahoma
• Missouri
• Louisiana
• South Dakota
• Kansas
• Montana
• North Carolina
• Wisconsin
• Nebraska

Among more populous states, Texas, Pennsylvania, and Illinois ranked highest, at 11th, 15th and 16th, respectively. 

Sobko noted that there were some notable outliers in the SonderCare study.

“The most surprising finding from this study is that Alaska ranks overwhelmingly as the most expensive state for elderly care, both semi-private and private,” he said. “The cost of a room in a private nursing home in Alaska is $31,512 per month, this is more than $16,300 more than the second most expensive state, Connecticut.”

Those costs helped drag Alaska down to a ranking of 46th, rounding out a bottom five that also included the 2nd most expensive state, Connecticut, as well as West Virginia, Hawaii, and California. East coast states made up nine of the bottom 15.

The study included a model to demonstrate flu transmission in a nursing home. Researchers compared the number of symptomatic illnesses and hospitalizations under varying treatments to prevent the spread, including different levels of interventions along with how well residents and healthcare workers adhered.

Taking antiviral medication — namely oral Tamiflu (oseltamivir) — is recommended during flu outbreaks in nursing homes to prevent the virus from spreading and to curb severity in those who get it. The study was published Wednesday in Clinical Infectious Diseases.

According to the CDC, all non-ill residents should start prophylaxis once an influenza outbreak is detected and continue on it for at least 14 days and until seven days after the last laboratory-confirmed influenza case is identified. Not every long-term care facility sticks to that guidance. 

When treatments were given in alignment with current guidance, they reduced total symptomatic illnesses and hospitalizations among residents by an average of 12% and 36%, respectively, compared to doing nothing at all.

The authors didn’t find that deviations from the guidance were any more effective. That is, partial adoption resulted in an increase in symptomatic illnesses and/or hospitalizations. On the flip side, longer or earlier adoption did not offer any additional improvements. 

The more residents and healthcare workers adhered to the CDC guidance, it worked to lower resident illnesses and hospitalizations. However, increasing adherence among healthcare workers had a minimal impact on residents getting sick, the authors found.

According to current CDC guidance, when two cases of laboratory-confirmed influenza are identified within 72 hours of each other in residents who live in the same unit, the healthcare workers should enact outbreak control measures as soon as possible.

Hathorne Hill, a 120-bed home in Danvers, MA, is offering a chance to win a KitchenAid stand mixer in return for 5-star reviews left on Google before the winner is selected on Jan. 2. 

The mixer is on display in the facility’s lobby and is advertised as having a $480 value.

A study of nursing home Yelp reviews found that a 1-star increase on the social review site led to 2.6% more new Medicare admissions than a 1-star increase in ratings from the Centers for Medicare & Medicaid Services did. 

While the practice of incentivizing reviews is not against the law, it has come under increased scrutiny from both private entities and regulatory bodies.  

In June, the Federal Trade Commission proposed regulations that would crack down on providing incentives that are contingent on leaving either positive or negative reviews. 

“Our proposed rule on fake reviews shows that we’re using all available means to attack deceptive advertising in the digital age,” explained Samuel Levine, director of the FTC Bureau of Consumer Protection. “The rule would trigger civil penalties for violators and should help level the playing field for honest companies.”

It is against Google policy to incentivize reviews. Google is known to remove reviews it believes violate its rules and will even suspend business profiles in more extreme cases.

The display at Hathorne Hill asks potential reviewers to “Please mention in your review that your Google review is incentivized.” A facility representative from parent company Genesis HealthCare told The Salem News that this clause was added after the company was informed that its review contest violated Google’s policies.

Paul Lanzikos, co-founder of Dignity Alliance Massachusetts told The Salem News that he questioned the legitimacy of the operator’s Google review strategy.

“If it’s not unethical, it definitely borders on being unethical,” he said.

Hathorne Hill currently has an overall 3-star CMS rating and lands just above the state’s average on the Massachusetts Health and Human Services nursing home rating website. Its Google star rating, however, is 4.6, based on 168 total reviews. Only 10 reviews left within the last two months are viewable. Four of those reviewers left a 5-star rating. 

Two other reviewers left a 1-star review and warned readers to not trust other reviews because of the prize being offered, with one equating it to a form of “bribery” — illustrating another potential form of blowback that can follow attempts to influence community reviews.

Representatives of Hathorne Hill did not respond to a McKnight’s request for comment.

Tighter regulation should be expected going forward, no matter how the proposed Centers for Medicare & Medicaid Services rule may ultimately be altered, according to Erin Shvetzoff, the CEO of Health Dimensions Group.

“We continue to see this administration really pushing higher regulation and higher penalties around skilled nursing facilities and this will be pushed to our states,” she said during a webinar forecasting trends that her firm produced.

Nursing homes must be proactive about addressing these problems going into 2024, asserted Paul Branin, HDG’s vice president of business development.

“[Solutions] should be implemented regardless of whether the final decision is made on the staffing mandate,” Branin said, before outlining his suggestions for SNFs. “Overall, a difficult operating environment for skilled nursing operators exists, but there are opportunities for success for operators committed to quality care and overall improvement.”

Experts spoke candidly on both the challenges and opportunities facing skilled nursing operators, laying out industry trends for the coming year.

An eye-opening 94% of nursing homes across the country do not currently meet at least one of the three staff-hours requirements in CMS’s proposed staffing minimum rule.

Meeting those requirements will mean 100,000 new full time employees country-wide and cost SNFs nearly $7 billion annually. This is especially burdensome when the workforce has already contracted by 210,000 since the COVID-19 pandemic — a block of the workforce that likely won’t be regained until 2027, according to John Capasso, executive advisor at HDG.

Oriented toward solutions

Branin gave three top tactics for addressing the changing employment landscape in 2024. Staff retention led out of the gate. 

“What are you doing to keep your staff in place?” he asked. “Are you surveying them? Are you asking for their input? Are you implementing the recommended changes?”

He also highlighted pursuing new technology as a way of streamlining workflows. Shvetzoff endorsed the recommendation.

“[New technology] can help with monitoring profiles, changes in vitals, helping quickly respond to clinical needs, and assisting with staffing needs,” she said. “What tasks can we replace with technology to allow our people that we’re able to hire to take care of the amount and the acuity of people coming our way?”

Finally, Branin recommended outsourcing or centralizing administrative tasks as much as possible to continue freeing up time for care workers to focus on residents. 

“Revenue cycle management is one area that can be completed fairly easily offsite, which allows your community to spend more quality time taking care of their residents,” he explained.

Experts agreed that, overall, the key ways to weather current market challenges will involve holistically looking inward and finding innovative ways to maximize efficiency rather than hastily expanding outward in search of new profits. 

“When considering growth … thinking in a holistic approach is most important,” Branin stated. “Growth will bring new revenue, but what are the risks associated with this growth — reputational, regulatory or financial?”

An article published Dec. 7 in Infection Control Today highlights the concept of having a chief infection prevention officer (CIPO). This executive role supports operational roles through the lens of preventing infection. The concept is gaining popularity in hospitals and other healthcare organizations and could influence the long-term care segment. 

This executive position oversees and enacts infection prevention and control activities for an entire organization. The person has to collaborate with administrative, board members, quality management, clinical microbiology, clinical engineering, nursing, materials management and environmental services personnel. The CIPO essentially supervises other infection preventionists, whether they’re at the same location or multiple facilities, the article noted. The CIPO also has to be able to represent the concerns and practices of infection control personnel and initiatives to executive level officers.

“Hospital epidemiologists play a vital role in orchestrating the efforts to prevent the emergence and transmission of infection within a hospital,” Shira Doron, MD, the chief infection control officer at Tufts Medicine, and a hospital epidemiologist, said in the article. “[CIPOs] … serve in that same role at a health system level, coordinating those efforts across multiple entities and various health care settings. As a hospital epidemiologist and CIPO, I have years of formal and on-the-job training that is highly specialized at the intersection of epidemiology, infectious diseases, public health, and clinical research methods.”

“As hospitals and other healthcare entities consolidate into larger health systems, having someone responsible for infection control oversight at the system level is critical,” Doron said.

The financial problems threatening Linn Health and Rehabilitation in East Providence are emblematic of challenges faced across Rhode Island and the country, long-term care leaders in the state say.

Linn Health — founded in 1971 and home to 70 residents cared for by more than 150 staff — is now operating on a month-to-month basis, according to Rick Gamache, CEO of Aldersbridge Communities, the nonprofit organization that runs it. This is largely due to a significant gap between the costs of care and staffing, and Medicaid reimbursements from the state, he said. 

Linn Health’s residents have tried to pitch in, even running a bake sale that raised around $2,000. That is not nearly enough to cover operating costs, however. 

“During COVID, all costs skyrocketed, especially staffing, for which every penny going to staff is deserved and more, but state Medicaid programs have not kept pace,” Gamache told McKnight’s Long-Term Care News. “Our costs have increased by nearly 35% with Medicaid reimbursement increasing about 15% including the increase we received in October. We still lose over $100 per day per resident, and 80% of our residents are on Medicaid.”

Linn Health is far from alone, according to Jim Nyberg, executive director at LeadingAge Rhode Island.

“The precipitous decline in [nursing homes’] financial situation is unprecedented,” Nyberg told McKnight’s. “The gap between average Medicaid reimbursement and the average cost of care has spiked to over $60 per day in 2022, the last year for which we have cost data, and has presumably grown larger.”

Nyberg also noted that six Rhode Island nursing homes have closed and three more have entered receivership since 2022, which accounts for 12% of the long-term care industry in the state.

Battling funding struggles

Both Nyberg and Gamache are advocating for the state to provide some manner of “bridge funding” to Linn Health and other facilities in the state to alleviate financial struggles in the short term.

“We have been advocating with our governor’s office, the Medicaid program, and other stakeholders on potential remedies to try and provide a funding infusion into the industry,” said Nyberg.

Gamache spoke about how the financial emergency facing his nursing home is just one example of stories that are playing out across the US.

“All nursing homes are dealing with the same circumstances to some degree, and it’s not just here in Rhode Island. This is a nationwide problem that impacts independent not-for-profits, rural nursing homes, and those that are owned by individuals and families the hardest. Hundreds have closed with many more to come,” Gamache said. 

“I’ve had candid conversations with several others here and we’re all barely hanging on, operating month-to-month.”

Linn Health’s attempts to address the crisis have included everything from the bake sale, to advocacy with the state, to a media campaign to raise awareness. Still, Gamache says the facility is planning ahead for how to meet the needs of staff and residents if the facility is forced to shut down.

“We have two task forces working seven days a week to identify every way possible to prevent or at least minimize discharges and staff layoffs,” Gamache said. “We are looking at other ways we can utilize our building to care for the residents we love and provide jobs for the staff we painstakingly recruited and retained. It’s going to take a miracle, but sometimes miracles happen. I’m hoping the stars line up for this one correctly.”

The results can give people and their loved ones evidence-backed data if it comes time to make that decision. The study was published on Dec. 4 in JAMA Internal Medicine.

The team evaluated data from two groups spanning 1998 to 2019. It covered 3,327 people over the age of 65 who likely had dementia. Of them the mean age was 82.4 years old, and 70% were female.

The team defined the need for nursing home-level care as depending on others for three or more activities of daily living (ADL), having two or more ADL dependencies and wandering, or needing help to eat. Predictors for needing care included age, baseline ADL status, instrumental ADL dependencies, and an individual’s driving status. One model included body mass index and history of falls; another added how well people could recall a date, their sex, and if they experienced incontinence. 

At the end of the follow-up period (that varied depending on the group of data used), 63.3% of the people needed nursing home-level care. 

When the researchers tested the models to see how well they predicted who would need the level of care provided in a nursing home, the team found they worked well to tell which people needed the care. 

“These models may be used to enhance conversations with patients and families about future planning by giving estimates of when an individual with dementia may need high-level care, whether provided in a nursing home or at home. Predicting need for nursing home-level of care rather than nursing home admission provides a standardized metric applicable across cultural and socioeconomic backgrounds,” the authors wrote.

Federal officials have announced they will terminate Medicare payments to Viviant Healthcare of Bristol, TN, on Sunday (Dec. 10). That comes on the heels of two Vivant facilities in South Carolina being moved to the Ensign Group, following a state-initiated receivership this summer.

In all, six Viviant facilities are majority-owned by the Goldner Family Trust and Samuel Goldner, according to a federal database. They’re part of a larger nursing home portfolio held by the trust. Nursinghomedatabase.com reports that the trust has at least a 5% ownership stake in 14 facilities in six states.

But many of those facilities appear to be hanging on by a thread financially. 

Private equity critics see the apparent collapse of Goldner’s holdings as a harbinger for other facilities that find themselves in the hands of such owners, and by association, the nursing home sector in general.

A bank that helped finance operations at two other Viviant sites in Tennessee asked a federal court on Nov. 21 to appoint a receiver for both, calling the Goldner trust and its partners “insolvent on both a cash flow and a balance sheet basis, inasmuch as they are unable to pay their debts.” The related parties owe nearly $15.5 million in payments and interest alone, court records show.

Local media also has outlined a systemic failure to pay vendors and equip other Viviant facilities with supplies needed by staff and residents, a practice that Centers for Medicare & Medicaid Services documents indicate went up the chain to owners.

The accusations echo ongoing concerns about the role of private equity owners in the skilled nursing space. They’ve been a repeat target for the Biden administration, whether in proposing its first-ever staffing mandate for nursing homes or increasing transparency requirements to paint a clearer picture of skilled nursing owners and their partners.

The latest transparency rule finalized in November establishes definitions of private equity and real estate investment trusts for reporting purposes. It included a research brief by the Health and Human Services Office of Behavioral Health, Disability and Aging Policy. Researchers found that private equity ownership in nursing homes had fallen to about 5% of all US facilities by 2022, down from 8% in 2018.

But as large-scale PE investors move out of the space, some observers predict smaller players may move into the void.

“I don’t think PE firms are nearly as interested in nursing as they were 10 years ago or 15 years,” said Eileen O’Grady, research and campaign director for healthcare at the Private Equity Stakeholder Project. “But I also think the type of PE firm that’s investing in nursing homes has shifted and will continue to shift.

“In the past, bigger name PE firms that had lots more money and did lots more things were the ones investing in nursing homes. But over the last few years, it’s shifted to these boutique private equity firms or family investment offices that I see as the bottom feeders of the PE world. They’re buying into an industry that other PE firms have decided is no longer going to make the kinds of returns that they’re aiming for.”

But those firms are no less focused on squeezing out generous returns on their investments; those efforts could just divert more cash away from frontline care and into related parties quickly, O’Grady warned. 

Each negative PE story increases scrutiny of private owners in general, who argue they have been unfairly lumped in with a few unscrupulous investors.

“I’ve been publicly supportive of this,” Rick Matros, president and CEO of Sabra Health Care REIT, told McKnight’s after the latest rule was finalized last month. “There are groups that have opaque ownership structures so you don’t know who owns what. REITs have never taken steps to disguise/hide ownership.”

The American Health Care Association has called PE rhetoric and rules a distraction, repeatedly noting the low prevalence of private equity in the sector since Biden blasted Wall Street’s involvement in nursing homes during his 2022 State of the Union address.

Too little, too late?

O’Grady says some of the CMS efforts, while laudable, are coming too late. PE firms today are finding more traction in other healthcare sectors where they’re less regulated, be it home care or durable medical equipment.

But the practices replicated by PE firms over the last decade — such as real estate sales followed by lease backs, management fees, and the establishment of related parties to do business under the same corporate umbrella — are now widely practiced by all kinds of private owners. 

“The table was set for private equity to come in and exploit a lot of loopholes that [CMS] is slowly trying to patch, but when you have all this money flowing through the system and little to no accountability from CMS and how it’s spent, this is the type of behavior you get,” said Sam Brooks, ​​director of public policy for The National Consumer Voice for Quality Long Term Care, a consumer-oriented group that has been a major critic of investors in skilled nursing. 

Brooks believes the HHS estimate and others that put PE ownership in the single digits are too low, simply because the current reporting doesn’t go high enough to reveal all layers of corporate structure. He says he often sees such buyers or lenders associated with PE firms at work in remote areas, but their borrowers aren’t necessarily reflected in publicly available records.

He supports new rules that might help reveal more PE ownership, as well as activity patterns of big, well-known players such as the New Jersey-based Portopiccolo Group. That firm is associated with at least 135 facilities, according to new ownership data from CMS. 

Quality concerns

The involvement of Portopiccolo and other PE firms has become a natural curiosity for consumers as a growing body of research associates PE-backed facilities with lower quality and other negative metrics.

“Critics of PE acquisitions note that these firms typically have little experience in the provision of care and seek short-term profits over patient health interests,” the November HHS brief noted.

“Additional concerns include the potential for PE firms to prioritize short-stay, post-acute care patients over long-term residents, a group for whom federal reimbursements are significantly higher compared to state Medicaid reimbursements for nursing home care, researchers added. “These concerns are consistent with research [that] found increased short-term mortality, higher antipsychotic use, reduced patient mobility, lowered nurse hours per resident day, and increased costs for post-acute patients following PE acquisition.”

PE facilities had the lowest inspection,staffing and overall star ratings among six ownership types compared by HHS. 

Goldner facilities had an average rating of 1.77 stars and 1,019 deficiencies for a total of $2,4 million in fines, according to nursinghomedatabase.com. Among the much larger Portopiccolo portfolio, a Consumer Voice analysis of CMS data found 15% of facilities have abuse icons; they average an overall star rating of 1.9; and have a quality measure rating of 2.6.

McKnights’ attempts to reach Goldner executives through their nursing homes or through a website for Goldner Capital Management were unsuccessful. Portopiccolo also did not respond to a request for comment.

Staffing pressures may slow interest

After purchases, PE facilities saw a 12% drop in their RN staffing compared to other for-profit facilities, according to HHS.

That’s a major way most PE firms, regardless of sector, increase their revenues, said O’Grady. She’s witnessed fast and steep cuts to staffing in hospitality and retail sectors when PE swept in there, often followed by bankruptcy filings or rapid-fire sales when the businesses can no longer stand up to the pressures. 

Because most PE firms are limited partnership or limited liability companies, their losses are typically capped at whatever they’ve put into the business. 

O’Grady’s not been surprised to see the same model repeat itself in long-term care settings. 

She doesn’t see any of the CMS transparency rules to date keeping the PE firms still in nursing homes in check.

“I think that all of the sort of regulatory and political attention to nursing homes now is the result of behaviors PE firms were doing a while ago,” O’Grady said. “The regulatory and legislative response is just now catching up, and it’s sort of too late.”

Instead, market trends and staffing pressures could be the real difference-makers, argues Brooks.

“There’s a couple ways that I think you can drive out private equity: One is something similar to transparency, and that’s creating a direct care spending ratio where 80 or 90 cents out of every dollar goes to care,” he said. “But also we see a staffing standard as another way to do it. It’s an inadvertent direct space spending ratio. You need to spend enough money to get to this number. … That’s a very similar thing in some ways to a profit cap.”