Cause of deadly nursing home clusters difficult to pinpoint

By Mary Clarkin

Roz Hutchinson believes her mother receives excellent care at Chisholm Place, a memory care home on Webb Road in Wichita. Seven deaths among residents from COVID-19 haven’t shaken that opinion.

“I believe that they have done everything that could or would or should have been done to protect the staff and to protect residents, and to communicate what they were doing,” said Hutchinson, whose mother, Betty Rowley, is 94. “I felt bad for them, because I know it’s not been easy and they’re very close to my mother and all the other residents.”

Chisholm Place is among three long-term care facilities in Sedgwick County that accounted for 85 percent of Sedgwick County’s COVID-19 deaths through mid-May. No one can say for sure why.

Clearwater Nursing and Rehabilitation Center had eight resident deaths and 61 confirmed cases — 47 residents, 14 staff — as of May 8. Chisholm Place, 1859 N. Webb Rd., had 34 cases among residents, including seven deaths, and 12 cases among staff as of May 12. Park West Plaza Retirement Community’s The Manor Nursing Home, 503 N. Maize Road. had nine cases­­ ­— seven residents, two staff­ — and one resident death as of May 4.

Sedgwick County announced May 15 there was a 17th death from one of these three long-term care COVID cluster sites. It did not disclose the location.

Some nursing facilities in Sedgwick County have had one positive case, but the virus did not spread and kept those facilities off the cluster list. Why did the virus spread in these other three?

“That is a good question, and one I don’t have an answer for. That’s a fair question, because we have a lot of nursing homes,” Sedgwick County Health Department Director Adrienne Byrne said.

Byrne also can’t say how the virus entered those three cluster sites.

The three have different for-profit owners, who also operate other facilities. They don’t fit in a mold, although each has had health inspection deficiencies. For example, Clearwater is a 69-licensed-bed nursing facility that accepts Medicare/Medicaid and sits on a side street in a town with a population of 2,533. It was identified as a cluster on April 17.

Chisholm Place is a 66-licensed-bed assisted living memory care facility that does not accept Medicare/Medicaid. It is located in an affluent urban area, with a plastic surgery center as a nearby neighbor. It was identified as a cluster on April 29.

Park West also isn’t shown as a Medicare/Medicaid facility, and it is licensed for 80 assisted living beds and 40 nursing beds on a west Wichita campus. It was identified as a cluster on May 4.

The three centers represent a fraction of that industry in Sedgwick County, where there are 5,086 licensed adult care home beds, according to the Kansas Department for Aging and Disability Services.

Inspection issues

Clearwater surfaced first as a cluster, even though it restricted visitors more than a week before the first coronavirus case was reported in Sedgwick County on March 20.

Because staff continue to “come and go,” said Byrne, the suspicion is that it must have been a staff member who brought the virus into the Clearwater facility. “But,” she said, “we don’t know.”

Tracking the source is difficult because of the 14-day incubation period for the virus and because a person exposed to the virus can be asymptomatic, Byrne said.

The top corporate executive for Clearwater Living LLC is Willie Novotny, who was self-quarantined in his Manhattan, Kan.-area home in early May, according to office staff. He did not respond to emails from The Active Age.

The Clearwater nursing facility received critical government reviews in 2019 and 2020.

In spring 2019 — before Novotny took control — the state announced it would impose denial of new Medicare/Medicaid admissions at Clearwater until it was in substantial compliance. Surveyors found in 2019 that the facility failed to plan interventions to prevent further falls for a resident. A bathroom call light was logged at over 100 minutes, one of numerous extended call light times blamed on a staff shortage. It was fined $54,493.

In January 2020, when Novotny’s company was operating Clearwater, staff and residents told a surveyor the center was not sufficiently staffed, according to reports on Medicare.gov

One CMA on Clearwater’s staff reported that the evening shift was often unable to complete baths or showers for residents and clean wheelchairs due to lack of staff. One resident failed to receive a bath or shower for a nine-day period in January.

Staff levels cratered on Jan. 14, 2020, described by staff to the surveyor as “mass chaos,” the report said.

When the surveyor asked a resident about that day, she became anxious and said, “Please help us. No one else seems to care,” according to the report.

Novotny’s wife, Michelle Novotny, is the chief nursing officer for Clearwater. Willie and Michelle Novotny are the two officers in their Cornerstone Employment Solutions Inc., a nursing staffing agency found on the Internet at Cornerstone Healthcare Solutions.

By April 18, a dozen Clearwater facility residents stricken by the coronavirus had been transported to the hospital and two had died. Willie Novotny wrote that day in a statement — still posted in May at the Clearwater facility’s entrance ­— that they had brought in staff reinforcements because some Clearwater staff “quit out of an abundance of caution, or fear,” and some had been sent home because they tested positive or showed symptoms of the virus.

Chisholm Place did not hire its staff through the Novotny’s Cornerstone agency, according to Laura Kislowski, vice president of sales and marketing for Anthem Memory Care, Lake Oswego, Oregon. Kislowski also said Chisholm Place did not know how the virus entered.

The most recent survey reports for Chisholm Place on the Kansas Department for Aging and Disability Services’ website date back to 2018. They list failures to ensure development of a written, negotiated service agreement for each resident and to ensure medications were administered to each resident in accordance with procedures.

Also, the reports show deficiencies in record-keeping for employees that included failure to request a criminal background check or to verify with the Kansas nurse aide registry that the individual did not have a negative record. Also, there was a lack of documentation of tuberculosis testing at the time of employment, the report stated.

A survey in 2019 cited infection control deficiencies at Park West, according to the Department for Aging and Disability Services’ data.

The property failed to ensure a sanitary environment by failing “to replace air filters on floor vents which were visibly soiled and failure to clean a ceiling vent in the beauty shop, which had dust debris on it and hanging down,” the report stated. Also, the inspection found a failure to properly store soiled resident clothing and to ensure laundry staff followed procedures. It also said the facility “failed to ensure staff served food in a sanitary and hygienic manner to prevent cross-contamination.”

Vigilance required

Wichita Presbyterian Manor employs about 175 people and serves roughly 225 residents on its campus at 4700 W. 13th St. It made the Department for Aging and Disability Services’ desired “zero deficiencies” list in 2019.

Executive director Courtney Wolfe said in early May they have had no coronavirus cases at Wichita Presbyterian Manor, but “quite frankly, any one of our communities could have a COVID case at any moment,” she said.

They are taking extreme caution and are not wavering “on any of that protocol whatsoever,” Wolfe said. That includes daily screening of employees, stringent limits on visitation and no new admissions since March 13. Wolfe said staffing remains steady.

“I think, though, that communities that had staffing challenges going into this are seeing a greater staffing challenge,” Wolfe said. “If you’re not already in health care, it’s unlikely you’ll get into it for fear that you might get COVID or bring it home to your family.”

As of May 15, there were 24 clusters in long-term care facilities across the state, accounting for 96 of the state’s overall 172 COVID deaths.

Hutchinson said she was “utterly shocked” when her mother tested positive for COVID-19. Her symptoms were limited to a low-grade fever, minor congestion and a few days of extreme fatigue.

“I’ve watched and they have followed the protocols for stemming the spread of infection,” she said. 

Staff helps residents stay connected with family through social media, Hutchinson said, and when Rowley turned 94 on May 2, they helped the family — looking through the window from the outside — celebrate it with her, she said.

This story was produced as part of the Wichita Journalism Collaborative, a partnership of seven news organizations. The effort is supported by the Solutions Journalism Network and funded by The Knight Foundation.

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