Did age of nursing homes intensify spread of virus?
Review finds that old systems, designs may have worsened crisis
Nearly two-thirds of the nursing homes in Connecticut are more than 50 years old, raising questions about whether facilities equipped with older HVAC systems, poor ventilation and problematic interior designs were ill-suited to contain the coronavirus as it spread through facilities like wildfire, a Courant review has found.
Almost 100 of the state’s 213 licensed nursing homes were built in the 1960s and 1970s to be more like “hospitals than homes,” with as many as four beds in a room, shared bathrooms and large cafeterias and common rooms. That sort of layout, experts say, can make them highly susceptible to a virus that spreads quickly and silently from person to person.
The death toll in the state’s nursing homes has been especially acute. Since March, 3,315 nursing home residents have died of COVID-19, accounting for roughly two-thirds of the state’s total death toll.
National studies have concluded the size of nursing home buildings, as well as the extent of community spread where they are located, are key factors in the virus’ spread through nursing homes. But to
“The reality is that most nursing homes in America were built a long time ago, and they absolutely weren’t designed to defend against viral illnesses, and they were not designed for a pandemic like what we have seen this year.” — Dr. Richard Feiffer, Genesis Health Care chief medical officer
date, there has been little detailed analysis on whether the age of the buildings handcuffed the ability of staffers to fight the virus once it entered the facilities.
The Courant analyzed the age of all 213 nursing homes currently licensed in the state, reviewed records of those that have recently renovated their facilities and death and infection statistics provided by the state. The review found:
Of the top 15 nursing homes in terms of total deaths, 10 of them were built before 1985, making them at least 35 years old. Seven were built before 1973. The facility with the most deaths — 60 at Riverside Health & Rehabilitation Center in East Hartford — was built in 1972.
·A total of 136 of the 213 licensed homes, more than 60%, were built before 1970. There are 20 facilities in Connecticut that are at least 100 years old.
The state has never done a comprehensive building analysis of its nursing homes, discovering only after the virus hit that many of them have the original HVAC systems and also offered little opportunity in terms of layout to separate infected residents — a key step in trying to stop the virus once it gets inside.
There are still nearly 25 nursing homes in the state licensed to have as many as four beds in rooms which are required by state regulations to only be 180-square feet, leaving the residents “sitting ducks” for a virus like COVID, according to a leading epidemiologist.
As costs to operate nursing homes have increased and federal and state funding remain stagnant, the state official who oversees nursing home renovations said providers have downgraded their maintenance staff and have put off doing potentially expensive upgrades to their facilities.
Over the past five years, there have been 12 nursing homes that were approved for renovations by the state. Of those 12, half have had no COVID deaths and only one has had more than 20 deaths.
“When you have a virus that severely impacts the elderly the physical environment that they are living in will definitely play a role on how that virus spreads and how many are infected,” Yale School of Public Health Epidemiologist Albert Ko said. The Courant shared its findings with Ko, who said he is interested in sharing them with state public health officials.
“COVID has brought deficiencies in older buildings to the forefront, surely the physical structure and how it is maintained impacts not only how you prevent an outbreak but how you stop it,” Ko said.
One of the facilities with a high number of deaths is Kimberly Hall North in Windsor, which was built in 1969 and has had 45 deaths. It is owned by Genesis Health Care, whose chief medical officer Dr. Richard Feiffer said he has “no doubt that nursing home design and the physical structure of some of the buildings has played a role in this pandemic.”
“The reality is that most nursing homes in America were built a long time ago, and they absolutely weren’t designed to defend against viral illnesses, and they were not designed for a pandemic like what we have seen this year,” Feiffer said.
“For us to protect against future pandemics we are going to have to seriously rethink building designs in nursing homes and if we are serious about protecting nursing homes we are going to have to make very, very large investments.”
The Courant tried to meet with DPH officials in charge of inspecting and licensing nursing homes and the head of the unit that oversees any renovations or changes that providers make to their buildings to share its analysis, but state officials canceled the interview and declined to comment.
Bare bones investment
Both Anthony Bruno, DPH’s head of facilities, and Barbara Cass, who oversees licensing and investigations into nursing homes, appeared before a Dec. 9 meeting of the infrastructure and capital improvement subcommittee of Gov. Ned Lamont’s nursing home working group to discuss the condition of the state’s nursing homes.
The group is expected to make recommendations to the legislature on everything from staffing levels to capital improvements.
Both Bruno and Cass told legislators during the subcommittee meeting “the footprints of Connecticut’s nursing homes are very old” and that many of them still have the HVAC systems and heating systems that were installed 50 or 60 years ago when they were built.
They also said too many of the buildings are “institutionalized,” designed to look more like hospitals than homes.
“The facilities are so old that nine times out of 10 (providers) don’t want to put the dollars into renovating them,” Bruno said.
“Many of the older nursing homes were built to look like hospitals from 30-40 years ago and people have been trying to use internal renovations to go to more of the home model.”
The renovations that are being done are mostly cosmetic to make the building look better rather than operate better, Bruno said.
“Most are the renovations are common space renovations, lobbies, entrances, therapy rooms that are more for marketing purposes,” Bruno said. “We don’t see renovations to residents rooms because the room sizes are already minimal and facilities don’t want to take the chance of losing beds. There’s not much room to do anything in those rooms other than cosmetic changes like painting or changing the wallpaper.”
“Renovations aren’t the ones that we should be seeing. And I think it’s shameful to the residents and the community out there,” Bruno said. “We’re not seeing any renovations with regards to HVAC systems. What’s there is what’s there and they are just maintaining it basically bare bones.”
Bruno said officials from various facilities have been contacting him weekly since the pandemic hit, asking for ideas on how to try to reconfigure their HVAC systems once they have COVID in the building. He said most of the older buildings don’t have individual HVAC units for certain areas of the building and they are trying to limit using their HVAC systems when the virus hits.
“Some went above and beyond with the pandemic to try and make their HVAC systems a little better for filtration,” Bruno said. “But it is a large ticket item that people aren’t putting money into but instead are basically maintaining what they have, no matter how old it is.”
But many providers said it has been the state that has been shortsighted when to comes to nursing homes — eliminating a capital improvement program years ago and consistently underfunding them.
“The state got to the point where they decided to stop investing in these buildings and we were no longer getting reimbursed for capital improvements and without that incentive some places didn’t do any work,” said David Hunter, director of the Mary Wade House in New Haven.
The original Mary Wade house was built in 1890, but in 1989 a new building was constructed. It serves as the long-term care facility now. The older building houses residential care residents and has had some COVID cases, Hunter said.
The older building doesn’t have air conditioning and in the spring, when COVID hit, fans were installed on the roof of the building to try to help air circulation. UV lighting was installed and a microbial spray was used in all of the shared bathrooms.
“Nursing homes aren’t built to hospital grade level. We don’t have that equipment,” Hunter said.
Pandora’s Box
Last month, Paul Liistro found himself dealing with a COVID-19 outbreak in one of the two nursing homes he owns — Vernon Manor. The 53-year-old, two-story building has an elevator to the second floor. It is divided into four separate units, including a dementia unit.
Liistro said a housekeeper was asymptomatically positive and appeared to infect a resident in the dementia unit, located on the first floor. Before long, almost everybody in that unit tested positive.
But then Liistro noticed some
thing else.
The only other residents in the building to test positive were located directly above the dementia unit and Liistro wondered if it had something to do with the configuration of the building.
“Does having an elevator in your building make a difference in how the virus spreads? Is that how it got to the second floor?” Liistro asked. “Does having shared bathrooms have an impact? Did it go through the HVAC system?”
Big ticket items such as removing elevators or installing new HVAC systems come with other risks in older buildings. Some of the buildings are so old, it’s unknown what’s behind the walls.
“When you start opening up walls and moving duct work or opening up ceilings, then you start dealing with other issues you had no idea what’s behind there and in some cases that would be opening Pandora’s Box,” OPM Deputy Secretary Kosta Diamantis said.
“Based on the age of some of these buildings the last thing they’d want to do is touch their HVAC systems, and for that reason they are merely maintaining what they have.”
Bruno acknowledged it would be opening up a Pandora’s Box in some of the older buildings but “I am seeing buildings where the HVAC system is as old as the building — 40, 50 years old in some cases and they are having a hard time maintaining them.”
“It should be a priority moving forward on how we can get these HVAC systems either up to current codes and standards, better maintained or even install new ones,” Bruno said. “It’s going to be tough for a lot of facilities that are old but it is definitely a focus of what is not really in compliance out there right now.”
Communal showers, shared rooms
Neither the state nor the nursing home owners have ever done an overall assessment of the physical plant needs of the 213 buildings. Nursing home officials are hoping the DPH will start with that step, according to Mag Morelli, president of LeadingAge Connecticut, the trade group representing non-profit nursing homes.
“How many people need new roofs, new windows, how’s their heating and cooling systems? Really the basic bones of these buildings need to be assessed,” Morelli said, at a recent infrastructure committee meeting.
“We need to see what that investment needs to be in the sector from that perspective and then we can discuss the secondary issues of infection control on the interior, like do we need to reconfigure rooms, have more open spaces or in-house dialysis units.”
DPH officials also have acknowledged that they need to review regulations regarding room sizes, number of beds per room and maintenance staff levels.
“The current regulations don’t allow for a great size of rooms to accommodate residents’ needs,” Bruno said. “They are really small and that is something that we have been looking at over the course of many years on how to make those facilities less institutionalized and have more of a home-like environment and room size is a major factor.”
Ko said the smaller rooms are an epidemiologist’s nightmare.
“If you get an older facility with multiple people in the same room and the virus is introduced to that room then they all will get it,” Ko said. “Once you have an outbreak
in an older building do you have the ability to cohort people? The physical structure may just not allow that to happen.”
DPH officials estimate there are less than 25 facilities in the state still housing as many as three or four in a room.
“It is still very common that nursing homes have three or four to a bedroom as well as shared bathrooms,” said Bill White, owner of Beechwood Acute Care in New London.
“When the pandemic hit it presented all kinds of challenges for older buildings. You already have buildings where things are breaking and now you are trying to stop a virus we’ve never seen before,” White said. “It was like the little Dutch Boy putting his finger in the dike. People were dealing with their HVAC systems and how to clean their buildings while figuring out how to move residents around to keep them safe.”
Michael Smith, the CEO of Live Well in Southington, said having multiple people in a room or shared bathrooms should no longer be acceptable.
“When you sit about 6 to 8 feet away from somebody ... throughout the night, you are going to infect them and we need to figure out a way to change that pattern.” Smith said.
Live Well was built in 1992, the same year four other nursing homes were built across the state.
“Sadly there were about five other nursing homes built at exactly the same time as ours and the design of those buildings still replicated designs that were probably in place about 15 to 30 years before that so they have the gang showers at the end of the hallway and shared rooms,” Smith said.
Live Well has full bathrooms for the resident rooms but they are still shared by residents in two rooms so while “we were very progressive 30 years ago it is certainly outdated now.”
Live Well, operated by a non-profit organization, is the only facility that opened in 1992 that hasn’t had any deaths and until last week had no infections either. Two facilities that also opened in 1992 — Autumn Lake in Norwalk and Evergreen Woods in North Branford — have both had 28 deaths each.
Smith said they are now looking at building six bed units all with private bathrooms.
Future of nursing homes
There has only been one nursing home built in Connecticut since 2010 and there are four that are less than 20 years old. The newest one is the Jewish Service Center in Bridgeport — a $100 million, 294-bed facility, which opened in 2016.
The building’s design is very different from older homes. Every room is private with 21 separate pods and 14 residents per pod. They all have what DPH officials refer to as “country kitchens,” meaning each pod has one kitchen staffed by the nursing home where residents can eat anytime they want. There is no centralized large cafeteria style room. Each private room has its own full bathroom as well as access to a balcony.
“Our whole premise is the small house or household model,” director Andrew Banoff said. “We want it to feel like a house, not a nursing home.”
The legislature passed a special act in order to allow the nursing home to be built. Cass said it was the best special act the legislators
have ever passed and she called the Jewish Service Center the “nursing home of the future.”
But even that facility hasn’t escaped COVID, as 29 residents have died since March, DPH records show.
“We certainly have had COVID here but we have been able to control it somewhat because our residents are so spaced out and we can isolate them quicker when we know they are sick,” Banoff said.
But not everyone can raise $100 million to build a new nursing home. The pandemic has only sharpened the financial crunch many facilities are facing even after getting millions of dollars from the federal government and the state through June.
Two nursing homes closed recently and many are struggling, according to Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities.
“Occupancy was 88 percent pre-pandemic and now it’s about 74 percent as of October,” Barrett said. “The implications of the occupancy disruption creates an enormous loss of income at a time when more resources were needed to address the pandemic. We feel our resources are going to run out before we start getting people back into the beds.”
One area that has suffered is maintenance, according to Bruno. He remembers when each building had multiple maintenance staff, but now many companies have one person maintaining multiple buildings.
“Maintaining the building is a big aspect and in some cases where buildings are falling apart it is because the facilities have limited amount of maintenance staff taking care of them,” Bruno said. “Financial difficulties impact their capacity to maintain the buildings. Maintenance is a big issue. They are very limited.”
Legislators on the infrastructure committee have been talking about “stop gap” or short-term plans such as having facilities pool their resources to hire contractors who can work on multiple buildings. But State Sen. Paul Formica said there are problems with that approach, as not all buildings are alike.
“Its not like we have cookie cutter buildings throughout the state . We have 213 buildings and 213 separate designs and layouts,” Formica said.
Over the past five years, there have been 12 nursing homes that have gotten state approval to do renovations. Of those 12, half have had no COVID deaths yet and one has had three. Only one facility, the Lutheran Home in Southbury, has had more than 20 deaths, with 21.
Morelli said hard questions need to be asked, such as is it worth renovating some of these older buildings — or starting from scratch.
“We are dealing with an aging infrastructure so does it make sense to renovate an old nursing home or build a brand new one?” Morelli said. “How do we create the right number of beds and have functioning and modernized buildings that will serve the community for years to come?”
Ko said the state needs to take some action before the nursing homes are faced with a different virus.
“Many of the nursing homes built in the 1960s and 1970s were built like hospitals without the necessary equipment to fight a virus like COVID,” Ko said. “This is an opportunity to modernize our nursing homes and bring them out of the 20th century and into the 21st century.”