It was the beginning of the pandemic, and Michael Thompson was tired of commuting from his house in Twin Falls to his job at an assisted living facility in Burley, 40 minutes east. One day he saw a job opening on a Facebook page for Magic Valley caregivers that was closer to home.
“I thought, well, that sounds like a pretty decent job, you know?” Thompson said. “I mean, the pay was good.”
The job was at another assisted living facility, Twin Falls Manor. The building wasn’t open yet, but it was going to be soon. And it would serve only patients who had tested positive for COVID-19.
Thompson has worked as a caregiver in senior living centers for about 20 years, mostly in south central Idaho. The $15-per-hour wage Twin Falls Manor was advertising for a medical technician position was about two to three dollars above what he’d typically been offered before. Twin Falls Manor called this a “hero's wage.”
"We hoped that this would be a resource that could help be part of the solution."
Thompson applied and went in for his interview. The administrator met him in the common room at the front of the building. Thompson said it was nicely furnished, including a leather couch and a big screen TV.
“I mean, it was a pretty nice facility,” he said. The interview went well and Thompson was offered the job on the spot. “I was the first person they hired.”
The Pennant Group is an Eagle-based company that runs senior care facilities in several states. It purchased the Twin Falls Manor facility last February.
“We hoped that this would be a resource that could help be part of the solution,” said Pennant’s Chief Operating Officer John Gochnour.
At this point, the state needed an urgent solution to protect the elder care population. About half of Idaho’s coronavirus deaths were tied to long-term care buildings.
The company pitched the idea for a COVID-exclusive care center to the Idaho Department of Health and Welfare. Tamara Prisock, the administrator for the Division of Licensing and Certification at the health department, said the state liked Pennant’s idea and sped up the licensing process for the new facility so it could open a few weeks later.
“One of the really critical things that needs to happen in a long-term care facility,” Prisock said, “when there are residents that test positive for COVID-19 is those residents need to be separated.”
Idaho officials adopted this approach, in part, to try to avoid outbreaks. They’d transfer infected long-term care residents to special units, designed just for COVID-19 patients.
Within a few weeks, Twin Falls Manor opened its doors. Idaho would eventually have eight facilities that either just cared for COVID-positive patients, or had COVID-only wings.
It was a strategy other states from Connecticut to Florida to Michigan would adopt too.
But things at the Manor got off to a rocky start. That’s according to five employees we talked to who worked there in the beginning.
When Thompson showed up for his first day, he felt excited. He’d be helping the community stay safe from this infectious, mysterious virus, particularly seniors who he spent his career working with. Though when he walked past the common area for the first time, the sight surprised him.
“When you started walking down the hallways and looking at the rooms,” he said, “I mean, like broken furniture, broken glass, rooms full of garbage. I'm not talking like somebody's old clothes or something. I'm talking like food containers with food still in them and garbage.”
The administrator told Thompson, that was his first task: Clean it up.
“To say that there was trash in the facility I think is completely inaccurate,” Gochnour of the Pennant Group said. He said the company did expect caregivers to help tidy up, especially when there weren’t any residents, or just a few.
Another employee, Alisha Hersey, had a similar reaction as Thompson to the state of the facility when she started.
“I was surprised by it because it was a COVID center and I thought it was going to be a lot more put together than it was,” she said.
“I’m like, you guys just told me when I was hired that this place is set up to receive 80 patients,” Thompson said. “And it wasn't ready to receive even one.”
Gochnour said although the building was licensed to accept 80 COVID-19 patients, it never intended to do that, so some rooms weren’t set up for residents.
Hersey said she was expecting training for how to care for the COVID-19 patients, and how to properly wear the PPE they were given. Caregivers in assisted living facilities are required to get 16 hours of training. But she said that didn’t happen.
“And I literally just filled out paperwork and then they sent me to work,” Hersey said.
Again, Gochnour said this isn’t true.
“There was a tremendous amount of training provided to all employees at Twin Falls Manor,” he said.
All five employees we spoke with who worked there in the first couple months it was open say they didn’t get this training.
For Hersey, the lack of preparation didn’t feel like a big deal at first. The first patient arrived on April 30 of last year and he was the only one there for a few weeks.
“The resident would just watch TV in a common area,” she said.
Soon after, though, the state began advertising the COVID center as a place for other long-term care facilities to send their infected residents, and more patients started arriving.
“Five, six people, okay, that's great,” Thompson said. “But then it was like all of a sudden this influx. Bam. We're at nine, 10 people a day.”
The employees we spoke with said there weren’t enough staff to care for the COVID-19 patients. One person worked the 12-hour day shift, one person worked the 12-hour night shift, and there was an on-call nurse.
The Pennant Group said it was extremely difficult for long-term care centers to hire staff during the pandemic, especially to work with COVID-19 patients. This was the case statewide. The Idaho Health Care Association launched a campaign in August, seeking more health care professionals to work in Idaho’s elder care facilities, which included a call-to-action video from Gov. Brad Little.
“The Idaho long-term care community is at a breaking point,” the organization wrote in a press-release. “Facilities need more employees but cannot find them.”
The challenge at Twin Falls Manor was exacerbated because the number of residents fluctuated depending on the level of community spread at a given time. That meant the facility had to quickly hire more people at times, which was tough, Gochnour said.
The lack of staff meant the caregivers needed to do more. Thompson and Hersey remember walking the hallways, searching for furniture and supplies to set up rooms for patients, as they were about to arrive.
“We need towels, we need sheets,” Thompson said. “We need all the stuff for bedding. We need soap.”
Hersey said she had to sew sheets to cover up holes.
“In the first months of the operation of the facility, it was a very new facility being operated in the midst of a global pandemic with a million different things happening,” Gochnour said.
According to the employees we spoke with, these issues lasted at least a few months. Thompson said the situation upset him so much, he felt he had to do something.
“That is the only facility I was ever compelled to call the state and the ombudsman on,” he said.
Two days before she’d quit in June, Hersey called the state, too. It was her complaint that brought a state inspector to Twin Falls Manor in July. The inspection would confirm a lot of what these employees shared. The building was messy, there wasn’t enough staff and in some cases, that resulted in poor medical care.
By the end of that month, all the employees we spoke with who were there in the beginning would no longer work at Twin Falls Manor.
"It was more in a consulting role than an approval role."
Tamara Prisock with the Division of Licensing and Certification at the health department said the eight COVID-19 care facilities helped other care centers that weren’t able to physically separate their residents who had tested positive for the coronavirus from everyone else.
She said they were especially helpful for the state’s roughly 280 assisted living facilities. Those facilities help less acute patients with daily care, like bathing, getting dressed, eating food and taking medications. But Prisock said they’re not always able to care for very sick patients.
“They can adequately care for their residents that have COVID-19, as long as those residents don't develop any severe medical issues as a result of the virus,” she said.
Skilled nursing facilities, also called nursing homes, have specialized staff in the building to provide around-the-clock monitoring.
Half of the COVID-specific care centers in the state were assisted living facilities like Twin Falls Manor. Some of the patients who ended up there had few symptoms, but several were on hospice and others had just been released from the hospital and were still very sick.
Hospitals used these facilities as a relief valve, Prisock said, when they experienced surges. Other states also leaned on special COVID centers to lessen pressures on hospital capacity and to avoid outbreaks in other long-term care facilities.
The Centers for Medicare and Medicaid Services even recommended the strategy – if it were done a certain way. The federal agency said states should choose facilities to operate as these COVID centers, and should make sure they had enough staff and PPE to care for patients who were sick with this virus, known to wreak havoc on seniors.
States like Connecticut made nursing homes meet higher standards to be “COVID Recovery Facilities.” The state opened up seven COVID long-term care facilities with 634 beds.
“One example is they had to have higher staffing ratios than noncommitted recovery facilities,” said Patrician Rowan, a senior researcher at the firm Mathematica, which was hired by Connecticut last fall to evaluate the state’s response to COVID-19 in long-term care centers.
Michigan revamped its COVID-only care system in the fall after criticism, and eventually required these facilities to have an above-average rating on staffing levels from Medicare.
Idaho did not have an application process to select the most qualified care centers to be in charge of COVID-19 patients who were among the most vulnerable.
“The department doesn't have any authority to say whether or not a facility can operate as a COVID exclusive facility or not,” she said.
Skilled nursing facilities didn't need to do anything to turn their whole building into a COVID ward. If they wanted to isolate COVID-19 patients in a wing, they had to submit floor plans showing how they’d keep those patients separate.
For assisted living facilities, Prisock said, the state wanted to make sure they weren’t suffering staffing challenges or PPE shortages. But a public records request we filed showed the state didn’t have any consistent method to confirm that information.
For instance, some facilities had to answer questions in an email, while others did not. One facility reported it had “plenty” of PPE, while another facility was simply asked to describe the types of masks and protective equipment its staff would wear.
Twin Falls Manor did not have to answer questions about staffing, PPE or infection control – at least not in a formal way.
“I mean, it was basically the facility making, you know, assuring to us that they had sufficient staff,” Prisock said.
An inspection the state conducted in July found staff shortages at Twin Falls Manor.
“What we are authorized to hold that facility accountable to are the state licensing requirements,” Prisock said.
One skilled nursing COVID center also reported frequent shortages of N95 masks and clinical staff to Medicare. Prisock said the state worked with the facilities and FEMA to make sure they had the supplies they needed. She said it also brainstormed solutions with all long-term care centers when they were facing staffing shortages.
“It was more in a consulting role than an approval role, if that makes sense.”
The facilities did need the state’s approval in order to receive public funds, though.
Idaho’s coronavirus financial advisory committee dedicated $17.9 million CARES Act dollars toward COVID patients in long-term care centers. That included funds to help facilities set up COVID units, move patients between facilities and care for those patients.
In total, Twin Falls Manor received nearly $215,000 CARES Act dollars through January, according to data provided by the state controller’s office.
“It did not come close to covering the cost of operating Twin Falls Manor,” Gochnour said. “Almost all of the costs at that time were elevated.”
Other states paid much higher daily rates for COVID patients in long-term care centers than Idaho’s $54 per patient per day. Connecticut’s COVID facilities received $600 per day for each resident. In Michigan, it was $200 per day, and $5,000 total for the first month.
Gochnour said, even with the money from the state, Twin Falls Manor lost about $100 per patient per day.
"We could not take care of them appropriately."
A couple days before Alisha Hersey quit her job at Twin Falls Manor last June, she contacted the licensing division at the Idaho Department of Health and Welfare.
“I called and reported them to state,” she said.
A few weeks after Hersey’s call, in early July, the state did an inspection based on her complaints.
The surveyor said Twin Falls Manor was not maintained in a safe and orderly way and painted a similar picture of the new care facility as what some of the first employees described.
They said the COVID unit smelled like urine. Two toilets were dirty with what appeared to be feces. There was trash on the floor in the residents’ rooms. New oxygen breathing tubes were stored near a dirty adult diaper.
A licensed nurse wasn’t always available to come to Twin Falls Manor to care for the COVID patients if their condition suddenly changed, the surveyor said.
One day in mid-June a resident with COVID told their family they were having trouble breathing, the report described. The family said the patient seemed disoriented. They tried to get the facility nurse to help. But the nurse said she wouldn’t be able to come until that evening, six to eight hours later.
A few days after, a similar scenario unfolded with the same patient. But that day, they were brought to the hospital, where they’d stay for three weeks.
“We could not take care of them appropriately,” said Michael Thompson, the first caregiver hired by Twin Falls Manor. “The morning I left, we went from nine residents to 13 residents. And we were going to be taking care of 13 residents by ourselves every shift because there was only one staff member per shift.”
Gochnour said it’s not accurate that there’d be one staff member caring for 13 patients. But he said he wasn’t familiar enough to know what a normal staffing ratio looked like.
The state survey confirmed the staffing challenges, too. It said that meant the caregivers couldn’t ensure the health, safety, comfort and supervision of the residents.
There were some things Hersey reported that the inspector wasn’t able to confirm. The claims the inspector said were unsubstantiated included the staff didn’t receive training on using PPE, residents didn’t receive a proper diet, and there was a lack of basic supplies. But these were all points the former staff members we spoke with said were true.
The employees said there were other problems that weren’t in the complaint, like how Twin Falls Manor would accept patients who needed more care than the staff could give. There were multiple situations, they said, where a patient needed two people to move them – a two-person assist – but there was only one staff member on a shift.
“So you had to wait however long until your next shift came to relieve you for both of you to pick him up,” Hersey said.
Gochnour said two-person assists need to be established by a doctor.
“It may be the opinion of the caregiving staff that an individual is a two-person assist,” he said. “I can't speak to any particular situation and whether it was ever established that a patient was a two-person assist, because I'm not aware of that, where there wouldn't have been two people scheduled on the floor.”
The employees did the right thing by calling for backup, though, Gochnour said.
Yet these situations – where employees tried their hardest, but still felt they couldn’t provide the care the residents needed and deserved – put them over the edge.
“I got to the point where I had gotten so stressed out that I would vomit constantly,” Thompson said.
“I don't tell people that I worked there,” Hersey said. “Honestly, I hate thinking about it, and I hate thinking about what happened to the residents there, and I hate that I was even a part of it for the two months that I was there. It makes me sick thinking about it. So I try not to.”
Gochnour said, after the survey, the company changed things. By then Hersey and Thompson, and many of the other employees at Twin Falls Manor who were there in the beginning, had quit.
“I think there was some real points of feedback in the survey that really drove an intense plan of correction,” Gochnour said.
For one, they hired another on-call nurse.
Employees we spoke with who started at Twin Falls Manor later on described a different care center.
“I would honestly say that Twin Fall Manor saved more lives than had they not opened,” said Thomas Turner who started in November.
He said staffing levels improved, even as they started getting more patients. November turned out to be the busiest month for the care facility; the census rose along with the local disease prevalence and a hospital surge.
Turner also said the residents in the COVID facility were able to socialize more with each other because they were all sick.
But challenges didn’t disappear after the July inspection.
In August, a resident at Twin Falls Manor escaped through a window. He had dementia and was COVID-positive. After an extensive search throughout the city, Twin Falls police found him three hours later at a nearby hotel two miles away, according to a police report.
Before the building opened, a fire and safety inspector with the Idaho Department of Health and Welfare did an in-person inspection.
He said in his write up, that if Twin Falls Manor wanted to accept memory care patients, they’d have to do more work. The windows on one side of the building were not secure. Gochnour said the Manor made the necessary changes. The inspector also said the company addressed that issue.
Twin Falls Manor closed last month. COVID cases were down, and patients stopped coming from other facilities. The Pennant Group said it cared for about 130 residents total during the months it was open.
Idaho didn’t track how the COVID-exclusive care centers were working, so it’s unclear how successful this strategy was – how it helped other facilities put a halt to outbreaks and how it acted as a relief valve for hospitals experiencing surges.
“We didn't spend a lot of time developing, you know, outcome metrics for the COVID-exclusive facilities,” Prisock said.
Six of the state’s COVID-exclusive facilities are still open, according to the most recent information available. But as more staff and residents get immunized against COVID-19, the need for them will wane too.
Find reporter Rachel Cohen on Twitter @racheld_cohen
Copyright 2021 Boise State Public Radio
