When Natalie Walters arrived at her father's nursing home, the parking lot was nearly empty and, inside, the elevator made no stops. On the 13th floor, the lights were off and the TVs silent. The last time she was allowed inside, nine months earlier, aides passed in the hall and a nurse waved from the records room.
Now, it felt like a ghost town.
One of the few staffers on duty broke the news: Walters was too late and her father was already dead of COVID-19. In the nursing home's newfound emptiness, the scream she unleashed echoed in the void.
"It was so still and quiet," says Walters, whose description of desolation at the home aligns with records showing its staffing level has fallen over the course of the pandemic. "How alone must he have been."
Nursing homes on brink as vaccine mandate may worsen staffing crisis
Even before COVID-19 bared the truth of a profit-driven industry with too few caring for society's most vulnerable, thin staffing was a hallmark of nursing homes around the country. Now, staffing is even thinner, with about one-third of U.S. nursing homes reporting lower levels of nurses and aides than before the pandemic began ravaging their facilities, an Associated Press analysis of federal data finds.
"It's already so low. To drop further is appalling," says Charlene Harrington, a professor at the University of California, San Francisco, whose research on nursing homes has frequently focused on staffing.
As COVID-19 engulfed homes, some workers fled over fears of exposure. Others were lured to easier work at similar or higher pay in restaurants and stores. And some were laid off by homes as occupancy fell.
Nursing aides are the backbone of homes' staffing. They are overwhelmingly female and disproportionately members of minority groups and, working jobs with high injury rates and low pay, the industry has long struggled to hire and retain them. Critics say if they simply boosted wages, the applicants would come.
Whatever the reason for skeletal staffs, the result is clear: Residents have fewer to answer their calls to keep them safe, clean and fed, while facilities have helped their bottom lines.
Some 32% of nursing homes reported staff-to-resident ratios in June that were lower than those in February 2020, AP's analysis shows. In homes posting lower ratios, the average resident had 21 fewer minutes of contact with staff each day, or about 11 hours a month, translating to scarcer help at mealtime, fewer showers and less repositioning to prevent painful bedsores. In the worst cases, when someone falls, chokes or is otherwise endangered, it means there are fewer people to discover the problem or hear their calls for help.
Tamika Dalton saw it first-hand with her 74-year-old mother, who moved to Blumenthal Nursing and Rehabilitation Center in Greensboro, North Carolina, in January 2019 as her multiple sclerosis worsened. At the time, the facility had a staffing level above the benchmark recommended by many experts.
But once COVID-19 kept visitors from going inside, Dalton peered through her mother's window, seeing fewer and fewer aides pass by and her mother sometimes sitting for hours in a soiled diaper. Her hair was often matted and her toenails grew long. A bedsore the size of a fist festered on her backside. Sometimes, unable to dial a phone herself and with no aides in sight, she would holler to a passing custodian for help.
"She would call out for help and no one would come," she said. "There was no one around."
As conditions continued to deteriorate, Theresa Dalton, a retired minister, contracted COVID-19 and died Feb. 12. By June, the facility's staffing was down 15% from the start of 2020, and 25% from the start of 2019.
"They did that for their own pockets," Tamika Dalton says of the lower staffing. "There's a lot of greed."
Requests for comment to Blumenthal and its operator, Choice Health Management Services, were not returned. In a letter to state regulators, an attorney for the facility said complaints were taken seriously and that some problems, like the bedsore, were exacerbated by the patient's failure to follow orders.
"The facility never fell below staffing expectations," the letter said.
The American Health Care Association, which lobbies for care facilities, said 99% of nursing homes and 96% of assisted living facilities said they had staffing shortages in a September survey. In a June survey, AHCA found 84% of nursing homes were losing revenue due to fewer patients coming from hospitals, and that nearly half of nursing homes and assisted living facilities had made cuts.
AHCA officials declined an interview request but, in a statement, called for additional federal funding, changes to Medicaid and government programs to bolster caregiver hiring and development.
"The labor shortage in long-term care is the worst it has been in decades. Many facilities are now in danger of closing because of workforce challenges," the organization said. "If we want to improve the workforce situation in nursing homes, we need policymakers to make a long-term investment."
Medicaid, whose benefits are reserved for the poor, is the largest payer of long-term care in the U.S. Older adults' shorter nursing home stays – a monthlong rehabilitation after a hip replacement, for example – are typically covered by Medicare, which often pays providers a rate several times higher than Medicaid. For that reason, short-term Medicare patients are nursing homes' golden geese.
But the pandemic shrank new Medicare admissions just as outlays for things like protective gear soared.
With profits imperiled, some homes went on a search to cut costs.
All told, across all job types, nursing home employment, which had grown steadily in the decade prior to the pandemic, has plunged by more than 380,000 jobs in the past year and a half, according to Bureau of Labor Statistics data. Staffing ratios would almost certainly be worse if not for lower occupancy due to more than 135,000 COVID-19 fatalities in nursing homes and higher-than-normal deaths of other causes.
Many families of those who have died in nursing homes since COVID-19's start are convinced their loved ones' deaths were precipitated or hastened by poor staffing. Linking an individual death to staffing is difficult, but studies have repeatedly linked higher nursing home staffing with better outcomes.
Harrington has little doubt that low staffing, combined with poor testing practices and lack of protective equipment, played a role in COVID-19's proliferation.
"This is why the infections spread," she said. "If the nursing homes had beefed up their staffing, done the testing twice a week and had adequate PPE ... they would have saved thousands of lives."
For those who remain in nursing homes, the impacts of lower staffing are dovetailing with the pandemic's toll.
Dave Bartok, a 74-year-old retired steelworker with vascular dementia, has lost weight since COVID-19's start and has often been so weak he could barely hold his head up. His family blames much of that on isolation.
But they see other problems as products of lower staffing: Unchanged diapers. Ants crawling on the mattress. Being left in bed instead of taken on a walk.
Bartok's son-in-law, Eric Paulikonis, said staff would drop off food for his father-in-law but left without helping him eat, leaving him unable to open milk cartons and attempting to eat cellophane-wrapped sandwiches through the plastic. The staff ratio at the facility, The Laurels of Huber Heights, just outside Dayton, Ohio, fell 8 percent from the pandemic's start through June, according to its filings.
"They just don't have enough time in the day to do what a patient needs to be done," Paulikonis says.
In a statement, The Laurels of Huber Heights acknowledged "a staffing situation that looks much different than when Mr. Bartok was initially admitted to the facility in 2019." The facility is committed to hiring and retention, the statement said, "but it is an uphill battle to overcome preconceived notions about the industry" and because it is "unable to match" the wages of competitors.
Federal law requires nursing homes to have sufficient staff to meet residents' needs, but nearly all interpretation of what that means is left to states. Some states have no set staffing thresholds. Others have one so low advocates see it as meaningless. Even when laws exist, enforcement is often toothless.
A landmark 2001 study funded by the Centers for Medicare and Medicaid Services, which oversees nursing homes, recommended, on average, more than 4 hours of nursing care per resident daily.
Most U.S. facilities don't meet that threshold.
When Kristin Pullins rejoined the staff at Montrose Health Center in Montrose, Iowa, last August, she was immediately struck by how different staffing was from when she worked there a year earlier, when the home had a different owner. Instead of two licensed nurses on a given shift, now there was just one.
"We just weren't able to answer their call lights quick enough," says Pullins. "As soon as I could get in and get out, I had to go, because I had so much to do."
With fewer on hand, Pullins said bedsores, wounds and falls increased. When one resident had stroke-like symptoms as her shift ended, Pullins said a supervisor said he'd have to wait an hour until the night nurse arrived. Staff was spread so thin that Pullins had to keep working when she had COVID-19.
When Pullins brought up poor staffing with managers she said she was listened to, but nothing changed. She says the home's administrator told her if she left, "You'll come crying back."
By the time Pullins quit in February, staffing at Montrose was 9% lower than a year earlier.
In a statement, Montrose's administrator, Mallory Orton, said the home "provides appropriate levels of staffing" and that it "disputes the allegations made by Ms. Pullins," but could not comment further.
Facilities' staffing ratios don't always tell the full story of how few may be working at any given time because they are based on averages across shifts, including those that are most thinly staffed.
At Bay Breeze Health and Rehabilitation Center in Venice, Florida, staffing ratios posted in June showed the home was better staffed than before COVID-19. But Amy Runkle, a veteran nurse's aide there, says on her shifts, she is typically responsible for 16 to 18 residents, higher than before the pandemic's start.
"Can anybody in their right mind tell me how that's even possible? There's no way you can do all the things that these residents need never mind deserve," she says. "They're needing a lot of care and you can't give it to them because you have so many to take care of. You have to work there every day knowing you can't do the best you can because you don't have the staff."
Neither Bay Breeze nor its parent company, Consulate Health Care, responded to requests for comment.
Negative perceptions of nursing homes – necessary institutions for those with complicated medical and psychological cases – have led a majority of the U.S. public to insist they'd never end up in one and has fueled the growth of other types of facilities, including assisted living. Operators of those types of homes have tried to cut a starkly different image, from chandelier-bedecked lobbies to dining rooms with house wine lists, even as they are often plagued by some of the very same problems as nursing homes.
Assisted living homes are out of reach for the country's poorest and often don't offer the services needed by the sickest, and are largely outside of federal oversight and more laxly regulated by states.
Though the federal government does not gather staffing data from assisted living facilities, families of residents around the country are noting fewer staff on-site as the pandemic has worn on.
As Suzette Heathcote monitored feeds from two video cameras her family mounted in her father's room at a Michigan assisted living facility, she saw him left for an hour and a half on the toilet and longer in a chair or bed, waiting for help. His catheter bag was left unchanged and overflowing. He'd go 14 hours without someone filling his water. A large wound was left untreated and a gaping bedsore cratered.
"When they shut down, all of a sudden there wasn't that family there and they lost all that free help. He was always waiting for it and he was begging for it," says Heathcote, who believes the lack of care hastened her 81-year-old father's death in January as he struggled with the effects of Parkinson's disease. "They had nobody to do the job that we were paying them to do."
Despite all the horror stories of long-term care, it seemed 77-year-old Jack Walters was better positioned for his final years than most Americans.
He and his wife had been prodigious savers, allowing the family to spend around $17,000 each month for his care as his vascular dementia worsened. And though most U.S. nursing homes are for-profit companies, Walters found a place at a non-profit home, Loretto Health and Rehabilitation in Syracuse, New York.
But Loretto is marked by many of the same problems as elsewhere.
It struggles to hire and maintain front-line workers to a staff that is emblematic of the haves and have-nots. Nursing aide jobs have been advertised as paying $17.85 hourly, while Loretto's CEO was making over $508,000 in 2018, according to the most recent available IRS filing for the organization.
And its staffing ratio – 3.9 hours per resident daily at the start of the pandemic – fell about 6 percent to below 3.7 hours by the time Walters died. It dropped even more in the months after.
Walters says, looking back, the evidence of low staffing was scattered in her father's final months.
A retired pharmacist who never left a hair out of place or a nail untrimmed suddenly looked to his daughter like "The Big Lebowski," appearing unshaven and shaggy on FaceTime calls, having weeks pass without a shower, and wearing the same shirt for days at a time in photos snapped by aides.
A man who always had a voracious appetite and tore through peanut butter cups with Walters the last time she saw him was now looking drawn as his weight dropped and suffered bouts of dehydration.
Walters doesn't know if poor staffing led to her father's COVID-19 infection, or what other missteps might be revealed when her family ultimately goes through her father's medical file. She wonders, if staff couldn't even get around to bathing her father, what else might they have missed?
In a statement, Loretto's chief marketing officer, Julie Sheedy, said the facility couldn't comment on Walters' specific experience, but said "while our employment numbers may have changed up and down over the years, our staffing levels have been consistently higher than the statewide staffing averages."
It was just before Christmas when Walters and her mother arrived at Loretto after an urgent call, only to learn they were too late. Walters stood at her father's feet and wailed. Her mother collapsed atop him.
When the funeral director came to take the body away, Walters' mother kissed her hand and pressed it on the back of the hearse. "I love you, Jack," she said.
The sun was bright and the air was bitter and no one else was in sight.