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Conestoga View has the most COVID-19 nursing home deaths in the state: what went wrong?

Conestoga View April 22, 2020

Conestoga View Nursing & Rehabilitation, 900 E. King St., Lancaster Township, is seen April 22, 2020. The facility has seen more COVID-19 deaths than any other nursing home in Pennsylvania.

The only thing separating Conestoga View roommates from each other — and from a deadly, infectious, airborne virus spread when someone coughs or sneezes — was a thin curtain.

A Mount Joy resident, whose sister-in-law lives in the nursing facility, said two people in her relative’s room had COVID-19 — one of them died April 15. It took two weeks for the room to get a deep cleaning, said Lynn Wallace McCleary.

McCleary’s sister-in-law wasn’t tested for coronavirus until two months later on June 17.

Unlike some of the county’s higher-rated nursing homes, like Masonic Villages at Elizabethtown and Willow Valley Communities, which have had no COVID-19 deaths, Conestoga View Nursing & Rehabilitation in Lancaster Township houses three or four residents in each room, and most residents depend on Medicaid to pay toward their housing.

“It’s like prison,” McCleary said in May. “It’s even worse some days because she can’t even get out of bed.”

Once the virus got inside Conestoga View, the 446-bed facility was hit hard. By May 23, there had been 74 deaths; one more was recorded by June 12, according to Lancaster County Coroner Dr. Stephen Diamantoni and the latest reporting from the state Department of Health.

More deaths have occurred at Conestoga View than any other facility in Lancaster County or across Pennsylvania.

As of Thursday, 289 of the county’s 338 dead were from nursing and personal care facilities, Diamantoni said.

The death count at the nursing home, whose roots stretch to its construction as an almshouse in 1799, has now surpassed Brighton Rehabilitation and Wellness Center in Beaver County, following an adjustment of their death numbers this week. The Pennsylvania National Guard began assisting Brighton in May.

The Beaver County facility previously reported 80 deaths, but now is reporting 73, according to a Department of Health update on Wednesday.

With the toll at 75, there are more deaths at Conestoga than there are beds on a single floor in the 446-bed, eight-floor facility.

But why have so many people died since the outbreak first hit the facility on April 4?

Crammed rooms with only a curtain separating people.

Lack of testing.

Lack of personal protective equipment.

Conflicting and confusing guidance from the state Department of Health, its consulting agency and the Centers for Disease Control and Prevention from the very beginning.

Conestoga View’s leadership says those factors combined into a deadly scenario for the nursing home. The facility points to the state Department of Health; the Health Department says it was Conestoga View’s duty to reach out if there was confusion.

Trying to prevent the spread of the virus and facing the death toll at one of the lowest-rated, poorest nursing facilities in Lancaster County has been grueling for the facility’s staff. LNP | LancasterOnline spoke with several current and former employees who said it’s been difficult to see so many residents they’ve cared for die from the virus.

“It is very sad, and it’s heartbreaking,” one employee, who requested anonymity for fear of retaliation, said. “They’re old. They didn’t ask to go through all this sickness. ... That’s heartbreaking because you get attached to some of these people because you’re there with them most of the time.”


‘Economically challenged’

As of Thursday, the federal government lists Conestoga View with an overall rating of 1 out of 5 stars on Medicare.gov. The star ratings take into account state health inspections, staffing levels and other quality measures. The last standard survey it shows was Aug. 8, 2019, and state records show several complaint and follow-up surveys since then.

In the past few years, Conestoga View has had inspections resulting in Department of Health findings ranging from the least to the most serious. Deficiencies are ranked from least to most serious, as follows: potential harm, minimal harm, actual harm and immediate jeopardy.

LNP | LancasterOnline records show the state Department of Health cited Conestoga View three times for serious problems from 2018 through 2019.

In 2018, the department found one immediate jeopardy deficiency. The report said a resident was taken to the emergency room and died on May 8 after a significant medication error involving blood thinning medication.

In August, the Department of Health performed standard and complaint inspections and reported two actual harm deficiencies. The report also showed eight minimal harm deficiencies. One of the actual harm deficiencies was later removed through the state’s dispute resolution process.

After an inspection in early February, the state Department of Health found that in one out of six cases reviewed, Conestoga View failed to ensure supervision was provided to prevent accidents. The review also found a patterned lack of infection control procedures at the facility. A little over a month later, the department found that the facility had corrected all deficiencies.

“One of the things we know is that containment of the spread is a big deal,” said Lisa McCracken, a Lancaster County-based director of senior living research and development at Ziegler, an investment bank based in Chicago.

A facility’s ability to separate residents into private rooms is often directly correlated to how many residents are able to pay out of pocket, McCracken said.

“We’re seeing a greater vulnerability amongst the economically challenged,” she said. “You don’t see private pay residents sharing a room.”

Carolyn Tenaglia, the northeast regional ombudsman, said long ago it was “extremely common” to have rooms with three to four residents per room, but over time that changed. Today, she estimated that 80% of rooms in Pennsylvania nursing homes have two residents. Private rooms and those with more than two residents are both relatively rare, she said. Ombudsmen work “to resolve complaints and issues on behalf of individuals residing in long-term care settings,” according to the Pennsylvania Department of Aging.

At last report from the state, Conestoga View was tied with Rose City Nursing and Rehab at Lancaster for relying most heavily on Medicaid, which pays less than Medicare and private insurance and was responsible for 88% of bed days in both facilities. By contrast, most of the highest-rated homes in the county were between 0 and 59%.

McCleary said Conestoga View was one of the only affordable places for her sister-in-law.


Conflicting guidance

The facility had made plans to create a COVID-19 unit even before the first case was confirmed, Executive Director Howard Hay said. But, he said, epidemiologists from the state Department of Health told Conestoga View officials they should consider everyone in a unit to be positive after a case is identified, and that moving residents would create a higher risk of infection than leaving a patient with roommates.

“This was contrary to CDC guidance,” Hay said in an email. “The DOH has changed its position about cohorting several times. ECRI, the DOH’s million-dollar infection-control consultant, told Conestoga View that it should not cohort residents, at times in direct conflict with then-current guidance from DOH and CDC.”

In early April, the state Department of Health contracted ECRI, a nonprofit health services research organization based in Philadelphia, to help with the department’s COVID-19 response — specifically in long-term care facilities.

In an email, department spokesman Nate Wardle denied that the home was given conflicting guidance.

cv.pressrelease.howardhay.6.9.20 by Gillian on Scribd

“If a facility was confused by our guidance, we suggest they ask for clarification,” he wrote. “It is the responsibility of a facility to understand their role in providing safe care to residents.”

Due to the number of cases at Conestoga View, the department informed the facility to follow recommendations from a health alert released April 3 about universal masking, Wardle said. The alert says that creating designated units for COVID-19 positive residents “may be an option in some facilities,” but needs to be done in a way that preserves the original unit.

About 10 days later, on April 14, the department released a health advisory on cohorting, or grouping, residents in skilled nursing facilities to clarify conflicting interpretations of their earlier recommendations and those of the CDC and the Centers for Medicare & Medicaid Services.

The advisory stated that if the first positive COVID-19 case is found and has not spread, moving the resident to an isolated unit is a feasible solution. However, once several people have already tested positive, moving them to a dedicated unit may have “minimal benefit.” The department also said that as more people are infected, “urgent room changes may negatively impact the health and well-being of the residents and should occur when benefits outweigh the risk.”

McCleary said she called to complain to the Pennsylvania Department of Health about her concerns regarding her sister-in-law’s care at the end of April. The department did an extended remote survey from April 6 to May 21, Hay said, with an on-site inspection in mid-May. He also noted 18 complaint surveys and “at no time did the DOH find or identify any deficient practices.”

Wardle said the department has conducted complaint investigations and, as is its usual practice, will post results publicly 41 days after the investigation is completed. The most recently shown as of Thursday was a March 20 survey that found all deficiencies noted in a Feb. 11 inspection had been corrected.


Probable cases, lack of testing

On the morning of April 21, at the height of the COVID outbreak in Lancaster County, Sheila Bair, of New Providence, called Conestoga View during her commute to check on her 90-year-old mother-in-law, Frances Bair, who she was told the night before had a fever and was put on oxygen.

Bair called at 6:40 a.m. and heard only positive news — her mother-in-law spent a restful night, the nurse said, and after a dose of morphine earlier in the morning, she was once again asleep.

About 30 minutes later, at 7:10 a.m., as Bair was starting her workday, she got a call from a physician at the nursing home. Her mother-in-law was dead.

The death certificate Bair later received, which was obtained by LNP | LancasterOnline, lists “probable COVID-19” as the cause of death.

Although Bair knew the virus was in the facility, she said she wasn’t aware that her relative might have been infected. Had she known, she would have asked for her to be tested, she said.

When Conestoga View turned to the Department of Health for testing materials, it received only 20 tests for the facility that had more than 400 residents, Hay said.

The facility also was forced to buy its face shields from a company in Pittsburgh and local hardware stores, even buying cow-birthing gloves to give staff an extra layer of protection when its gown stockpile was depleted, he said.

“Conestoga View mourns the loss of its residents and grieves with their families and friends,” Hay said. “The virus’ spread, however, was unavoidable under the circumstances and attributable to many factors over which the facility had little, if any control.”

Advocates, facility administrators and lawmakers have been sounding alarms on the limited testing at long-term care facilities statewide since the early days of the pandemic.

In a joint hearing between the Senate Aging and Youth and Health and Human Services committees at the beginning of May, nursing home representatives and legislators criticized the department’s slow and shifting response to the needs of long-term care facilities.

“They have been begging for the PPE, support and testing, and quite frankly, they have taken a backseat to hospitals,” McCracken, who spoke at the hearing, said later in a phone call. “We knew from the outbreak of this, we knew the vulnerability of our seniors and older adults, but despite that, they haven’t been getting the same supplies (as hospitals).”

The health alert from the state on April 3 tells providers that unless they are instructed otherwise, to “not provide routine laboratory testing of asymptomatic staff or residents for COVID-19.” In May, the department announced universal testing of long term care facility staff and residents, but testing was elective for facilities. In early June, an order from the state mandated that all staff and residents of skilled nursing facilities must be tested at least once by July 24.

And the outbreak isn’t over.

The number of deaths at Conestoga View is “extremely high,” but across the state, the data is shocking, said Karen Buck, executive director of Senior Law Center based in Philadelphia.

“I believe that there is much that we don’t know, that’s still under the cloak of secrecy — there’s just so little access right now,” Buck said. “I think that we are going to have some shocking stories come out after the crisis is over.”


‘It wasn’t the best, and it wasn’t the worst’

McCleary and Bair both said they had been concerned about the quality of care at Conestoga View prior to COVID-19.

But with limited financial resources, Conestoga View “wasn’t the best and it wasn’t the worst,” Bair said.

Bair, who worked at a local nursing home for 25 years, said she suspects her mother-in-law was not monitored appropriately throughout the night.

“I called at 6:40 (a.m.). My brother-in-law called at 6:44, and they told him the same thing. At 6:50, she was gone,” Bair said. “[F]rom the reports we got about her being OK on oxygen all night ... to being gone like that, it just seemed impossible.”

Her family wants to report the facility and pursue legal action, but her mother-in-law had a “do not resuscitate” order. Bair doesn’t think a complaint would go far.

If Bair and her family do pursue legal action, they wouldn’t be the first. In the past 10 years, Conestoga View or its parent company have been sued in 9 separate actions in either state or federal court, including employment claims and professional liability cases.

However, the facility is not unique in the number of times it has been sued. Over the same time span, ManorCare Health Services-Lancaster and Lancashire Hall have been sued more than Conestoga View in county court.

Lawyers representing Conestoga View in civil and debt collection lawsuits declined to comment and referred comments to the company’s leadership, Complete Healthcare Resources Inc. in Dresher, Montgomery County, which has been operating Conestoga View for more than three decades.

Complete Healthcare did not respond to multiple requests for information, including emailed questions, voicemails and an in-person visit to its office in Montgomery County.

However, Hay, the executive director of the company’s Conestoga View location, defended the facility’s practices during the pandemic.

“To suggest that Conestoga View did something wrong is to divert attention from the larger underlying societal problems and the nation’s questionable commitment to its frail and elderly citizens. Unfortunately, the COVID-19 pandemic has exposed the inequities in the country’s health care system at the expense of many,” Hay said in an email.

He also said the state Department of Health conducted a survey in May that examined the facility’s infection control and prevention, handling of 19 COVID-19 related cases and 18 complaint surveys and “at no time did the DOH find or identify any deficient practices.”

“Conestoga View continues with the mission the facility had when it was county-owned, namely, being the safety net facility for many in Lancaster County,” Hay continued. “Many of its residents are older, and more compromised than in other facilities. It is well known that the elderly, and those with multiple comorbidities are at higher risk for contracting and dying from COVID-19. That had been borne out at Conestoga View.”

Buck, of the Senior Law Center, said facilities that are “in crisis” with known infection control problems or staffing issues are the ones that the state Department of Health should be assisting with funds, resources and supplies

“People are dying every day. This pandemic is not over, and the crisis in long-term care facilities is not over,” she said.

Staff writer Heather Stauffer contributed to this report.