Clearwater nursing home death toll now at 11 as former nursing director details problems

By Mary Clarkin & The Active Age | June 9, 2020

Many residents of a Clearwater nursing home where 11 deaths from COVID-19 are now being reported were not given baths for more than five weeks, its former director of nursing says.

Christine Zeller, a registered nurse with a master’s degree in nursing, described the lack of bathing as part of a pattern of substandard care caused by employee turnover and a shortage of equipment and supplies at Clearwater Nursing & Rehabilitation. She made the allegations in written testimony to the Senate Judiciary Committee of the Kansas Legislature last week.

“Many of the residents had gone more than five weeks without being bathed, as the facility had a shortage of appropriate accommodations,” wrote Zeller, who started working Feb. 24 at Clearwater, about two months before the first resident tested positive for COVID-19.

Kate Flavin, a Sedgwick County spokeswoman, confirmed Tuesday that 11 residents of the home died from the virus. It had been reported previously that eight residents died. It wasn’t immediately clear why the number wasn’t updated earlier.

Altogether, 22 deaths in Sedgwick County have been attributed to COVID-19, with at least 19 occurring in Clearwater and two other long-term care homes. Across Kansas, clusters of cases at long-term care facilities have accounted for 126 of the state’s 236 deaths, according to the Kansas Department of Health and Environment.

Zeller’s testimony came as the Legislature was considering – and ultimately approving – giving nursing homes additional protection from lawsuits.

The Clearwater facility, certified for nearly 70 beds, had two side-by-side showers, allowing for at most two women or two men to be bathed at the same time, Zeller said.

A shortage of personal protective equipment caused staff members to share “isolation gowns” that were left in residents’ rooms, so that “everyone who entered the room shared the same gown,” Zeller wrote. The paper gowns were designed to be worn once and then disposed of, she said.

Before the first positive case was detected at Clearwater, staff did not consistently wear face masks – at management’s directives, Zeller said – and some PPE supplies were locked up and only accessible under the direction of the administrator, she said.

Zeller estimated that when she started, about 65 percent of staff were affiliated with various employment agencies. “It doesn’t offer any continuity of care,” she said, because the nursing home didn’t know which worker would be supplied by the agencies on any given day.

Zeller said there are “employees who are truly employees of that place that are still there because they love the residents and the people they’re caring for,” but added that overall staff morale was “zippo” when she arrived.

“They didn’t have any faith in the administration and the residents were the same way,” Zeller said.

She said one resident, speaking at a resident council meeting, said, “’How long will you be here? No one lasts in that position.’”


Owner: Home ‘in full compliance’

The Clearwater home is owned by Willie Novotny of Manhattan, who also operates Orchard Gardens in Wichita and several other nursing homes in Kansas. In an email to The Active Age, Willie Novotny said he was aware of the written testimony given by Zeller “as it is also being circulated around the state by Plaintiff Attorneys in preparation for their future.”

“Clearwater Nursing and Rehab was surveyed in May by The Kansas Department on Aging surveyors for compliance with infection control and COVID emergency plan. We were found to be in full compliance. In conducting this survey our records, procedures and response plan would have been reviewed and our staff would have been interviewed. There were no issues found. Ms. Zeller’s allegations are unsubstantiated.”

An inspection report shows residents complained about the infrequency of bathing in January. Clearwater had been given until March 29 to remedy several issues identified by the state, Zeller said. They included bathing, improper use of patient-lifting equipment and the facility’s grievance process, she said. Preparing for that March deadline was a priority, she said she was told.

However, the March follow-up inspection to see if previous violations had been corrected did not occur, according to Cara Sloan-Ramos, public information officer for the Department for Aging and Disability Services.

The federal government directed a streamlining of inspections as the nation dealt with the pandemic. Then, the Clearwater home asked permission to revise Clearwater’s plan of correction, which was granted.


Positive tests, deaths multiply

In April, a Clearwater nursing home resident taken to the hospital in respiratory distress was tested for COVID-19. The result was positive, and the hospital notified the nursing home on April 11, Zeller said.

By April 18, a dozen Clearwater residents had tested positive and two had died. Eventually, at least 51 residents and 17 staff members tested positive for COVID-19, including Zeller.

Zeller said that on the day of the first positive test, management and staff sanitized touchable surfaces, cleaned the room of the resident who’d tested positive, and quarantined all other residents in their rooms. After feeling weak, she went to her Hutchinson doctor and was tested for the virus. She had it. She remained isolated at home.

Cleared by her physician to return to work, Zeller went back to Clearwater on May 4. Willie Novotny told her in advance that staff had lost confidence in her and was angry with her for being out sick, Zeller wrote in her testimony. She also wrote that she found no one who said they were upset with her for being sick.

On May 12, Zeller was told by management and Novotny’s wife, Michelle Novotny, that her employment was terminated because she was not “‘a good fit,’” the testimony stated.

The termination “had nothing to do with her positive COVID-19 diagnosis,” Willie Novotny said in his email to The Active Age.

The Kansas Department for Aging and Disability Services provided a one-page report for the May 18 review of Clearwater that said a Targeted Infection Control Survey/COVID-19 Focused Survey found the facility to be in compliance with federally recommended practices to prepare for COVID-19.

Also, the allegations in five complaints “were not substantiated,” the report said, without describing the complaints in the report.

“No noncompliance was found. The facility is in compliance with all regulations surveyed,” the report concluded.


Nurse: ‘They deserve better’

The Clearwater nursing home is not required to have a bathtub or whirlpool bath, because it was initially licensed in 1969, before those accommodations became required in 1993. There are no federal or state set timeframes for staff to provide bathing to nursing facility residents, but residents must be provided hygiene consistent with their needs and choices. Sloan-Ramos noted that residents have a right to refuse a bath. The federal Centers for Medicare & Medicaid Services advised long-term care facility personnel to wear masks while at work starting April 2.

Zeller described herself as an advocate for nursing home residents who’s spent 24 years in her profession.

“I’m not doing this as a retribution thing at all,” Zeller said. “I’m doing it more just to make lawmakers aware of what kind of position they’re putting families in, as well as residents.”

“I’m thinking I’ll go out on my own and advocate,” she said. “I just feel that they deserve better.”

This article 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.