From The Texas Tribune:
About this story: The Texas Tribune and Houston Chronicle spent months investigating how Texas cared for veterans and their spouses during the coronavirus pandemic at the nine state-run veterans homes. Reporters reviewed hundreds of pages of inspection reports and internal emails, and interviewed more than a dozen experts, resident advocates and families.
Mary Kay Dieterich was encouraged last year when Texas Land Commissioner George P. Bush promised to shake up the management of the El Paso nursing home where her father died of COVID-19.
She knew it wouldn’t bring Eugene Forti, a World War II veteran, back to life. But as the top elected official in charge of all nine of the state’s nursing homes catering to veterans in Texas, Bush certainly had the power to hold the private management company accountable for what Dieterich saw as a botched response to the pandemic.
Yet, despite telling the for-profit operator of the Ambrosio Guillen Texas State Veterans Home that he was “deeply concerned” about the care it was providing in El Paso, Bush’s promised shakeup, delivered to the local news outlet El Paso Matters, never came — even as COVID deaths soared at the facility.
More than a quarter of its infected residents died, nearly double the average 13% death rate across El Paso County’s 21 nursing homes.
And it’s not the only one.
Nursing homes, which care for people who are already medically vulnerable, were ravaged by the pandemic. But Texas’ state-run veterans homes were often the deadliest places to be.
The nine state homes had more than double the death rate among COVID-19-infected residents compared with other nursing homes in the state, according to a Texas Tribune-Houston Chronicle analysis of state data from the pandemic’s start until June 2021.
The Houston Chronicle and The Texas Tribune spent months investigating how Texas cared for veterans and their spouses at the height of the coronavirus pandemic at the nine state-run veterans homes in Amarillo, Big Spring, Bonham, El Paso, Floresville, Houston, McAllen, Temple and Tyler. After reviewing hundreds of pages of inspection reports and internal emails, and interviewing more than a dozen experts, resident advocates and families, the Chronicle and the Tribune found:
– Texas’ state-run veterans homes had more than double the death rate among COVID-19- infected residents compared with other nursing homes in the state.
– Seven of the homes had a fatality rate of 25% or more — far higher than the statewide average — 11% — among Texas nursing homes.
– Approximately 23% of the state veterans homes nationwide are overseen by outside management companies, but in Texas all nine of them are, and they account for a quarter of the privately run homes in the United States.
– Resident advocates say for-profit nursing homes tend to have lower staffing levels and perform worse than nonprofit and government-run facilities. Average staffing levels in Texas nursing homes are among the lowest nationwide. Five of Texas’ veterans homes fell beneath the state average.
– On July 8, one day after the Tribune and the Chronicle shared their analysis with the agency, Land Commissioner George P. Bush decided to end the relationship with the two for-profit operators of the homes and asked his staff to conduct a nationwide search to find replacements.
Three of the state’s nine veterans homes — including Ambrosio Guillen in El Paso — had the highest death rate among all nursing homes in their county. Seven had a fatality rate of 25% or more, far higher than the statewide average of 11% across Texas nursing homes.
All told, nearly 570 veterans home residents tested positive for COVID-19 in Texas and nearly a quarter of them, 134, died.
Veterans home residents are typically male and older than people in other nursing homes, and many have chronic conditions that can make them more susceptible to severe infection, Bush’s agency and experts said. The homes are often larger facilities, which studies have shown were at greater risk of outbreaks.
But Texas’ nine veterans homes are also among about 23% nationwide that are managed by private contractors rather than the state, which residents’ advocates and experts said could expose them to cost-cutting by for-profit companies.
After the Tribune-Chronicle findings were shared with Bush’s office two weeks ago, he vowed to take action to improve care — by not renewing the operators’ contracts and starting over from scratch.
Two for-profit companies manage Texas’ nine state homes under the auspices of the Veterans Land Board. The board, which oversees programs for veterans, is headed by Bush and housed within the General Land Office. A representative of Bush’s agency is on-site in each home and has sweeping access to attend meetings, hear complaints, “protect the interests of the board” and advocate for residents’ rights, according to the homes’ contracts.
Three of the homes are run by Texas VSI and accounted for 40% of the fatalities among sick veterans home residents.
The other contractor, Touchstone Communities, oversees the state’s other six veterans homes — including one in Floresville where state inspectors found residents were in “immediate jeopardy” and failures that constituted “actual harm,” according to regulatory records from May 2020.
After inspectors documented multiple violations, the Frank M. Tejeda Texas State Veterans Home was hit with state and federal fines totaling nearly $300,000 — the largest by far of the veterans homes in Texas, health authorities say. It had the most coronavirus cases and second-highest death toll of the five nursing homes in Wilson County, where Floresville is the county seat. (The home with the highest number of deaths had a dedicated COVID-19 ward that took in patients from other facilities and hospitals, its administrator said).
A second inspection in February of this year uncovered a new infection control violation at Frank Tejeda and resulted in another $30,000 in fines, federal records show.
Floresville Mayor Cecelia Gonzalez-Dippel blamed the Bush-led Veterans Land Board for failing to follow up on complaints and to ensure that residents received proper treatment.
“It makes me angry, you know. Yes, angry at COVID. But also angry at ‘how did this happen?’” Gonzalez-Dippel said in a January interview. “I can’t go and investigate [the veterans home] myself. I’m leaning on the Land [Board] to do everything they can to take care of all of the residents.”
On July 8, one day after the Tribune and the Chronicle shared its analysis with the agency, Bush — now running for Texas attorney general — decided to end his agency’s relationship with the for-profit operators of the homes and asked his staff to conduct a nationwide search to find replacements with “a proven track record at infection control procedures,” General Land Office spokesperson Rachel Jones said.
“The care our veterans receive is of utmost importance to the Veterans Land Board, and we take every charge levied by family members, residents, and public health authorities seriously,” Jones said.
Texas VSI and Touchstone referred questions to Bush’s agency.
The land board, citing incomplete federal data, said the homes operated by San Antonio-based Touchstone had a comparable death rate with other skilled nursing facilities nationwide. The Tribune-Chronicle analysis did not use the federal data from the Centers for Medicare & Medicaid Services because it does not include all COVID-19 cases and deaths before late May 2020 — and therefore doesn’t capture more than two dozen cases and 14 deaths at state veterans homes captured by state data.
Touchstone has managed every veterans home in the state at some point, Jones said.
Texas VSI is affiliated with South Carolina-based HMR Veterans Services, which manages at least nine veterans facilities across four states. In 2018, inspectors found an HMR-operated veterans home in South Carolina failed to thoroughly investigate claims of abuse and injuries and encouraged employees to be misleading in reports, according to The Greenville News.
The Land Board has previously tried to replace the operators without success, but as COVID-19 infection rates have dropped, the agency is “now able to review practices and procedures … and better prepare all homes for future pandemics,” Jones said.
In the meantime, inspectors have continued to find problems. A second Touchstone-operated facility, the Richard A. Anderson Texas State Veterans Home in Houston, was hit with another “immediate jeopardy” finding — a severe deficiency meaning at least one resident is at risk of harm or death — when an 81-year-old veteran was “found outside, unsupervised, crawling on the ground in his undergarments” in May of this year, according to federal records obtained by the Tribune-Chronicle.
After the Tribune-Chronicle sent Bush’s agency the federal records, Jones said the agency had already moved to terminate Touchstone’s contract to oversee the home, which opened at the end of 2019. Bush told agency staff to do so after the incident happened but before the “immediate jeopardy” finding was issued, she said.
The home received a $69,225 fine, according to federal health officials.
The disproportionate death toll in Texas’ veterans homes follows a national trend: According to a report in The Wall Street Journal, the facilities were among the hardest hit during the height of the coronavirus pandemic.
The heavily male and elderly population inside veterans’ homes may explain some of the discrepancy, since men are more likely to die from COVID-19 than women. But Texas’ nine homes account for about a quarter of the privately run state veterans facilities in the United States, and experts and residents’ advocates say for-profit nursing homes tend to have lower staffing levels and perform worse than nonprofit or government-run facilities.
“Studies for decades have documented that not-for-profit and public facilities have more staff, they spend more money on staff, they spend more money on supplies, on food, things like that, and they generally have better care,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a national nonprofit.
Texas’ nursing homes overall have some of the lowest nursing hours per resident nationwide, behind all but three U.S. states, and five of Texas’ nine veterans homes fall beneath even the state average, according to federal data. At the end of 2020, six of Texas’ veterans homes were reporting that residents received less time with a nurse each day than the average across nursing homes nationwide.
The numbers are “cause for serious concern,” said Richard Mollot, head of the Long Term Care Community Coalition, an advocacy group based in New York.
It’s particularly disheartening to see government officials fail to ensure proper care for a population that gave so much to keep Americans safe, he said.
Veterans homes are “set up to care for people who have sacrificed — or dedicated at least a part of their lives to protecting our country,” he said. “We’ve kind of stepped back, as a country, from protecting them just when they needed it most.”
“Who’s In Charge?”
COVID-19 outbreaks in veterans homes nationwide have highlighted what critics describe as a porous regulatory structure, where oversight is fragmented among states and federal agencies — as evidenced by the title of a July 2020 congressional hearing: “Who’s in charge?”
The U.S. Department of Veterans Affairs gives states funding to help operate each home and inspects each facility annually. But the nonpartisan U.S. Government Accountability Office criticized those inspections as lax and said the VA did not post information about the quality of the homes on its website. VA officials have now done so and emphasize the homes are “owned, operated and managed” by the states.
More than half of the veterans homes, including all those in Texas, are subject to extra scrutiny from federal health authorities because they receive Medicaid or Medicare payments.
The Centers for Medicare & Medicaid Services is the primary regulator for nursing homes in the U.S., but most of the health agency’s inspections were paused during the pandemic. The surveys that did occur were focused on infection control or responding to serious complaints, leaving a gap in oversight, said Charlene Harrington, a professor emeritus of social behavioral sciences in the University of California, San Francisco’s nursing school and an expert on nursing homes.
Following federal guidance, nursing homes halted visitation to forestall the spread of the virus. The state ombudsman’s office, an independent advocate for nursing home residents’ rights, also stopped making in-person visits because of the pandemic.
“I think that nursing homes knew they didn’t have the oversight and they could pretty much do what they wanted,” Harrington said. “So they took advantage of it. And as a result, I think there were a lot of unnecessary infections and deaths.”
A Centers for Medicare & Medicaid Services spokesperson noted that federal authorities increased penalties for noncompliance with infection control, issued regulatory waivers to help nursing homes obtain staff quickly, and provided funding for facilities to buy tablets and other communication devices to help residents better communicate during the pandemic.
But Melissa Jackson, president of the National Association of State Veterans Homes and administrator of Vermont’s state-run veterans home, said critics unfairly villainized the homes during a pandemic that the entire country was unprepared for. Administrators scrambled to find protective equipment that was initially in short supply and had to hire contract staff to help when their employees had to quarantine.
The first positive case at her state’s veterans home was the “worst day” of her career, she said. She at times felt helpless or went home and cried.
“I still haven’t done that sigh of relief. You go into long-term care — in any setting but specifically in the setting when you’re caring for America’s heroes — and you do everything you can to keep them safe,” she said. “Then you have this outside virus and all of the system failures that came down.”
Half a dozen experts interviewed by the Tribune-Chronicle said the pandemic laid bare long-standing issues in long-term care including chronic understaffing and high employee turnover.
Nursing homes often have more than one resident in each room, which can make it difficult to separate residents to stem the virus’s spread. Many of their employees are front-line workers who receive low wages, sometimes lack paid sick leave and work in multiple facilities — providing hands-on care in close quarters.
“You couple that with a virus that can be asymptomatically spread and that’s airborne, and that’s going to pose a risk pretty much no matter what nursing homes do,” said R. Tamara Konetzka, a health economist at the University of Chicago, who co-authored several studies about nursing homes during the pandemic.
Studies have found that the prevalence of the virus in the surrounding communityand the size of the nursing home largely determined how hard facilities were hit: Larger facilities in COVID-19 hot spots were more likely to have infections. Having more staff helped to blunt an outbreak once the virus entered a nursing home, according to one study.
Like “Pulling Teeth”
Inspection records from the state’s health commission paint a chaotic picture of life inside several of the state veterans homes as the pandemic took hold.
In the spring of 2020, state inspectors found potentially life-threatening deficiencies at the Frank Tejeda home in Floresville, reporting that the facility — then home to some 140 residents — hadn’t put in place recommendations from the U.S. Centers for Disease Control and Prevention to prepare for COVID-19, and failed to prevent transmission of the virus to more than a dozen residents and nine staff members.
Residents with no symptoms were not separated from those who tested positive. Employees cared for both infected and well residents, sometimes while not wearing proper personal protective equipment. Some of the residents’ care plans didn’t say they were infected or should be isolated.
“I can’t believe they have both positive and negative [residents] on the same hall way,” one licensed vocational nurse told the state inspectors, according to the report. “We are trying to be careful not to cross contaminate, but it’s going to [happen]. Especially with staff coming in and out of the resident rooms.”
The director of nursing told the inspectors that residents weren’t separated because employees were waiting for coronavirus test results to come back and figured those not yet sick “were already contaminated.” Another employee said it was difficult to separate residents because there was not enough staff working overnight to care for both the sick and healthy groups.
Touchstone is disputing the state report in administrative proceedings, and Bush’s office said the contractor is asking federal authorities to remove deficiencies they documented in a published report — including alleged failures in infection control and PPE use. The Texas Health and Human Services Commission said it could not discuss the related state case due to the “active litigation.”
Workers at the home also said they had to reuse masks and were told they did not need goggles or face shields.
One nurse would take her mask home, spray it with disinfectant and let it air dry. Another employee said she was given a loose-fitting N-95 and wore it while working in each unit, including the one housing infected residents, the inspection report said. Others wore just surgical masks while caring for patients with the coronavirus rather than the recommended N-95.
The findings anger but don’t surprise Jeanette Christensen, whose 64-year-old husband has been housed at the Floresville home since 2019. She said getting information from Touchstone during the pandemic was like “pulling teeth.”
In one email she sent to Touchstone and the land office in January, she said a message the operator sent notifying families about new cases came across as a “slap in the face” because it included only a link that led to a webpage with no information about the Frank Tejeda home.
“This is NOT transparency in any possible way, shape, or form. In fact, if I may be so bold as to speak truth, it has a tendency to feel more deceiving than clarifying,” she wrote to the company.
Before the coronavirus, she said, Touchstone had a “revolving door” of workers at the home and failed to help her husband with daily tasks — like regularly brushing his teeth — and did not consistently change a patch that helps control symptoms of his dementia.
“The corporation is always about the bottom line,” she said.
Beyond the Frank Tejeda facility, at least six other Texas veterans homes were cited for health or regulatory failures since the pandemic began, including deficiencies unrelated to the pandemic like poor continence care and unpalatable foods (“pureed sausage — gravy grainy and salty,” according to a March 2021 state inspection of the Lamun-Lusk-Sanchez Texas State Veterans Home). Four, including Frank Tejeda, received fines for the lapses; another faces a potential fine.
Jones, the General Land Office spokesperson, said the land board was not made aware of the problems at the Frank Tejeda home until after state inspectors issued their warning to the company, and was not told about any protective equipment shortages by Touchstone. She faulted Touchstone for the “failure” of not ensuring staff wore available protective equipment and said the agency helped obtain COVID-19 test kits for each home.
Jones noted the contractors are in charge of staffing, but she did not respond to questions about why the land board’s on-site representative did not alert the agency to problems at Frank Tejeda and other homes.
“It Makes Me Furious”
Local officials and distraught loved ones say Bush’s land board and the veterans home operators left them blind to the risks posed by COVID-19 and with little information about what was happening inside the homes as the pandemic took hold.
Floresville’s mayor, Gonzalez-Dippel, said the situation there has been “very, very concerning since day one, since the first reported case and the first reported death.” She said she was “not impressed” with the land board after it provided her with incorrect information — that residents would receive coronavirus tests in a set time frame, which didn’t happen — in the pandemic’s early days.
Gonzalez-Dippel said Touchstone Communities never returned her calls.
She learned of new cases at the home through information the Veterans Land Board released to San Antonio media outlets. Family members of residents said they “didn’t know how their loved one was doing” or whether they had tested positive for the virus, Gonzalez-Dippel said.
In the spring of 2020, Gonzalez-Dippel alerted state health officials to possible problems in the home after hearing there wasn’t enough protective equipment and that it was being improperly stored. She said no one told her that the inspection in May 2020 found that residents were in “immediate jeopardy” — and resulted in fines totaling $281,500.
“It makes me furious,” Gonzalez-Dippel said after being told last month of the violations and the fines. “These people deserve so much more than what they got.”
Jones said the agency stayed in regular contact with Gonzalez-Dippel throughout the pandemic.
At Ambrosio Guillen in El Paso, Mary Kay Dieterich said she and her brother Guy Forti could get almost no information about their ailing father despite promises from management that they would be kept in the loop.
“I’d have to really give them a poor, poor grade for communication. And especially during such a stressful time,” Dieterich said. “We were getting no information.”
Forti was admitted to a nearby medical center last May with chest pains, a fever and a dry cough. He tested positive for the coronavirus and was moved to a COVID-19 wing on the seventh floor of the hospital, where his attending physician called Forti’s son and daughter and promised to give daily updates.
Before that, they’d received two text messages — similar to Amber Alerts — saying the facility was locking down to prevent spreading the new coronavirus and that visitors were no longer allowed, even at the windows.
An employee at the veterans home also had declined to tell Forti’s son how many cases the facility had.
“Those numbers were protected by law and could not be revealed,” Dieterich said her brother Guy was told by phone around the time his father tested positive.
Yet the for-profit contractor was providing regular updates to the General Land Office, many of them obtained this summer by the Tribune and the Chronicle. In one email, sent just weeks after the promised leadership shake-up that never came, a Texas VSI representative told Bush’s office that 14 new residents and nine staff members had been diagnosed with COVID-19.
“El Paso test results were horrifying but this was no Halloween trick,” the employee wrote. “4 residents are hospitalized. … Current numbers are 44 positive residents and 19 positive staff members.”
In later calls with Texas VSI officials, Dieterich said she was told the contractor didn’t have the staff or funding to have employees wait to receive negative test results before starting to work.
Jones called the email update by the VSI representative “disrespectful and unprofessional in every sense” and said the state could release medical information only to a resident’s “responsible party” — in Forti’s case, his son Guy. She also said the homes together sent thousands of mass messages during the pandemic.
Dwight Henry, a 77-year-old resident of the El Paso home, was hospitalized with COVID-19 for 14 days, four in the intensive care unit, around the time his friend Forti was also in the hospital, he said.
He learned of Forti’s death while he was there. Two other residents who lived across the hall from him also died, he said.
“We lost a lot of them,” he said.
Dieterich said her father had improved in the hospital after receiving a convalescent plasma treatment. But he took a sudden turn for the worse three days after he was returned to the veterans home.
He stopped eating and drinking. He wasn’t responding verbally. The next day, he was dead.
Dieterich said in a June 2020 email that her dad was “a war hero, a husband of 68 years to a woman he adored, and a dad that worked his fingers to the bone supporting his family.”
She believes her dad’s death was “100% preventable” and said she was “extremely disappointed” that Bush did not follow through on his promise to shake up the leadership of the Texas VSI team that oversees the El Paso facility.
“He was demanding these leadership changes and nothing happened. Nothing,” Dieterich said. “George P. Bush certainly needs to be held accountable.”
Texas Tribune Deputy Data Visuals Editor Chris Essig contributed to this story.