‘Tinder boxes’: Secret data reveal how COVID-19 swept through Philadelphia nursing homes

The first confirmation that the coronavirus had infiltrated a Philadelphia nursing home came on March 20, an unseasonably warm Friday that hit 79 degrees. A test of a resident at the Renaissance Healthcare & Rehabilitation Center for COVID-19 came back positive.

In the weeks since, the coronavirus has torn through almost all of Philadelphia’s long-term care facilities, infecting at least 1,800 seniors, according to city records obtained exclusively by The Inquirer.

This first-ever picture of the havoc, how it spread, where and which homes were hit first and hardest is based on data the city inadvertently made available online that charted test results of residents at those homes from the start of the pandemic through April 23.

The consequences have been catastrophic: At least nine Philadelphia nursing homes had 50 or more cases by then. As of Saturday, 374 nursing home residents have died of the virus, accounting for more than half of Philadelphia’s COVID-19 deaths.

As the coronavirus took root in these facilities, the public and, all too often, family members of nursing home residents were left in the dark about where the outbreaks were occurring. Philadelphia public health officials, unlike those in other jurisdictions, so far have declined to disclose which senior facilities have experienced coronavirus outbreaks.

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Early in the pandemic, nursing homes — unlike hospitals, which benefited from intense efforts to equip them for the coming surge — were sitting underfunded, ill-equipped, and woefully unsupported. Yet their employees also worked the front lines, caring for society’s most vulnerable.

Even so, an analysis of the Philadelphia data shows that the worst 10 homes for rate of infections, based on number of beds, were all rated one star (“much below average”) to three stars (“average”) on the federal government’s five-star rating system.

Nursing home officials cautioned against drawing hard conclusions about specific operators during a pandemic with a novel, insidious disease.

Standard infection-control programs in nursing homes, even when well-executed, were as effective against COVID-19 as against a hurricane because the virus can spread easily among people showing no symptoms, a fact only recently understood, said Joshua Uy, a Penn Medicine geriatrician and medical director at Renaissance.

“With COVID, by the time you identify your first case, it has already spread,” Uy said. “It's going to spread in good nursing homes and bad nursing homes."

Renaissance, a 123-bed facility in Philadelphia’s Kingsessing neighborhood, got some bad news. Only three days after the state barred visitors at care facilities, one of its residents got test results back from the lab: positive for COVID-19. Renaissance had the unwanted distinction as Philadelphia’s first confirmed coronavirus case in a nursing home.

In three more days, it had 10 more. Once inside, the virus can spread exponentially.

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Nursing homes are “tinder boxes” for the disease, one expert said, because they house a vulnerable population living in close quarters and residents may have daily contact with six or more caregivers, who must go from room to room, as well as to and from the facilities.

Uy, at Renaissance, said being first was lucky in a way. “There was probably just a single exposure that led to our outbreak,” he said. All employees immediately started wearing masks and eye shields at all times, he said, helping to control the spread to one wing.

As the virus continued coursing through the city, reaching into more and more facilities, it claimed its first nursing home victim, a 73-year-old woman at Renaissance.

The Philadelphia Public Health Department knew stricter measures had to be taken. To try to slow the spread, it announced that all workers in nursing homes, even cleaning and food service staff, had to wear masks.

In hindsight, Public Health Commissioner Thomas Farley said he wished his agency had required all nursing home staff to wear masks earlier in the pandemic.

On this Thursday, U.S. officials reported more than 1,000 COVID-19 deaths in a single day and announced 6.6 million Americans sought unemployment benefits in a single week.

Chapel Manor, a nursing home in the Bustleton section of Northeast Philadelphia, also set a record: It reported 20 positive cases — the largest single-day tally to that point of any city nursing home.

But that count didn’t reflect a surge of cases at the 238-bed facility, owned by Genesis Healthcare, the large national chain based in Kennett Square. Rather, a large pack of delayed results came back from the lab that day, Richard Feifer, Genesis’ chief medical officer, said in a statement.

The company said Chapel Manor’s records showed 126 confirmed cases at a time when city records showed only 76, a significant undercount.

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Not having enough test kits and a lag in getting back confirmed positives “while improved in Pennsylvania, continues to be a key issue for all nursing home operators in curtailing the spread of the virus,” he said. Of Chapel Manor’s 280 employees, 47 tested positive.

For the 18th day in a row, at least one city nursing home learned it was infected with a case. By now, nearly three of four homes had dealt with a confirmed case, some with dozens of infections.

The extent of the outbreak wasn’t clear to many family members who hadn’t been able to visit inside homes for three weeks. And unlike New York, New Jersey, or Maryland, Philadelphia and Pennsylvania do not publicly disclose the number of cases or deaths at individual nursing homes. When asked, the facilities usually don’t either.

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Jean Hackney had no idea there was a coronavirus outbreak at her mother-in-law’s nursing home until she got a call on April 8 telling her that her mother-in-law and two other residents of the Tucker House in North Philadelphia were being transported to Thomas Jefferson University Hospital.

Tucker House had the city’s highest rate of infections, 38 cases per 100 beds, based on health department data.

“When I found out about it, they called to say that she had the virus, and she was on the way out,” Hackney, 73, said.

By this date, Tucker House had more than 50 cases. Hackney said she had no problems with the facility before the pandemic, but was frustrated that it hadn’t alerted family members about the outbreak sooner or that government officials hadn’t disclosed where outbreaks were occurring.

“My whole problem is, if this is happening to these seniors in nursing homes, somebody should be made aware,” she said. “I think that they should tell the public not just the people dying in nursing homes.”

Hackney’s mother-in-law died three days after she got the call.

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On Passover, when families were forced to participate in their annual Seder feasts with extended family over Zoom or FaceTime because of isolation measures, the city recorded its highest single daily count, 88 people in nursing homes confirmed to have the virus. In fact, over the four days from Passover to Easter, the city saw its highest total for confirmed cases, compared with any similar stretch.

It wasn’t known at the time, but by Good Friday, the daily count had ticked lower, to 77, and would generally trend down for the next two weeks. The rapid moving spread through the city’s nursing homes had hit a peak, at least for this period of the pandemic and based on the limited testing. By then, at least 115 seniors had died from the disease in nursing homes. Commissioner Farley said cases overall may have peaked in the city, but was not confident the same could be said of nursing home infections.

“When I look at individual nursing homes, you see some cases coming and then maybe ending, but you don't know whether you might not get a subsequent cluster,” Farley said in an interview Wednesday.

The spread of the virus may have been slowing citywide, but that didn’t mean it was tamed inside individual homes. Staffers at the Immaculate Mary Center for Rehabilitation and Healthcare in Northeast Philadelphia learned of a torrent of cases on Easter weekend. In just four days, the number of residents confirmed positive had tripled, to 54.

Unknown is how many of those 54 remained in the facility, to be sequestered with others with the disease, and how many needed to go to the hospital for care. As was true for other homes, staffers had to improvise protective equipment then and in ensuing weeks because of shortages.

Staffers were using washable raincoats and donated Phillies ponchos as isolation gowns, said Paula Sanders, a lawyer for the owner. “This is how sad the world has become,” Sanders said. She also said the Immaculate Mary tally of 71 in the health department’s records was inaccurate: The former archdiocesan home had only 53 confirmed cases on April 11.

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Immaculate Mary still has six social workers and six unit managers who are calling families to keep them apprised of their loved one's condition, Sanders said.

Alicia McGovern said that was not her family's experience. Her grandmother, Loretta Schaffer, had been at Immaculate Mary for at least six years because of dementia, but nobody in the family knew how sick Schaffer was until she was taken on April 4 to Nazareth Hospital.

"Why was she left there to get that bad?" McGovern said through tears.

Doctors at Nazareth diagnosed her with pneumonia and COVID-19. Schaffer died 10 days later at 82.

It was the third Sunday in April when Shirley Adams finally got to see her sister, Brenda Frazier, on a video call at Maplewood Nursing Home & Rehabilitation Center in Germantown.

Adams had not seen her sister since visitors were banned in mid-March.

Her sister, a retired seamstress, went to Maplewood after a stroke and needed full-time care. In the week after Easter, whenever Adams had called Maplewood about her sister they brushed her off, she said, claiming Frazier was eating lunch or dinner, or sleeping, and was unavailable.

She was appalled.

“She’s not groomed. She has a beard,” Adams said. “It broke my heart. She was just laying there, you know, to die, because they weren’t going to do anything.”

By then, Maplewood, which has 180 beds, had 34 cases.

The family demanded that Frazier be sent to the hospital. She was admitted to Einstein Medical Center Philadelphia, found to be positive for COVID-19, her daughter, Davetta Frazier, said.

On Saturday, Frazier made the excruciating decision to take her mother off the ventilator.

“Everything was failing on her, and they said she wasn’t getting better.”

The company that manages the facility, Bedrock Care, based in Pomona, N.Y., also operates four other nursing homes in Philadelphia — Care Pavilion, Cliveden, Tucker House, and York — plus Parkhouse in Montgomery County, according to its website. It did not respond to messages.

By this fourth Thursday of April, 34 days after the city’s first confirmed nursing home case of COVID-19, the virus had infected at least 1,202 of the more than 6,500 elderly Philadelphians in the city’s 47 long-term care homes. Only five of the 47 nursing homes reported no positive cases by that point. But while the peak in city nursing home cases may have passed, the suffering continued: Twenty residents died between that date and the next day.

The city data gave no information on how many tests the facilities were doing. If few tests were being conducted, it would result in low numbers of confirmed cases.

Some facilities, like Renaissance, have been able to squelch outbreaks in a matter of weeks, while others continue to battle the virus, the data show.

On March 23, Cliveden Nursing and Rehabilitation Center in Mount Airy became the second facility in the city with a confirmed COVID-19 case but four weeks later was still reporting new cases.

With 85 cases, the St. John Neumann Center for Rehabilitation & Healthcare in Northeast Philadelphia had seen the highest number of its residents test positive for the virus as of April 23, and the second-highest rate, the data show. St. John Neumann objected to the notion of ranking the facilities by the number of cases, arguing that some facilities test more rigorously than others.

Chapel Manor in Bustleton, the York nursing home in East Oak Lane, and Immaculate Mary were also at the top for cases.

None of these four are rated above average on federal measures that take into consideration staffing levels, the mix of services required, and other measures of care.

For some, it isn’t surprising to see lower-performing facilities at the top of the list.

“It is luck, but it is also the way a facility is run,” said Anthony Manzo, CEO of Protestant Home in Philadelphia, a 126-bed facility that had seen only 14 cases as of Friday. “There’s no room for profit in this business, but it is big business, and some of the ones that run the big chains of nursing homes make a lot of money.”

However, Farley, the health commissioner, said his staff has seen no correlation between how well facilities follow expert recommendations on infection control and how many COVID-19 cases they report.

With a vaccine a year or more away, it is time to begin a “fundamental rethinking of how these facilities operate,” he said. “Right now, the facilities have a staff that don’t get paid very much, and they operate on pretty thin budgets, and so it may be that you’re not going to get the kind of meticulous attention to infection control that you need.”

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On April 23, Philadelphia’s Department of Public Health inadvertently exposed more than 35,000 coronavirus test results, including those of “congregate” facilities, on its website where it routinely updated public data sets about coronavirus cases, deaths, and other information. Those results did not include any names or personally identifiable information of tested individuals, and were closed off hours later. The records did name the facility, the date of each test, and whether the result was negative or positive. In interviews with Inquirer reporters over the last several days, the department’s chief epidemiologist and commissioner explained the data, including its limitations. They also provided other data for context. Before publication, The Inquirer also shared with them its own analyses of these unique records for feedback. The city noted that the data were not final and may have discrepancies. To that end, in some instances nursing home operators told reporters the city data didn’t match their own records of positive test results at their facilities. For example, a Chapel Manor official said its records showed 126 confirmed cases at a time when city records showed only 76, a significant undercount. At Immaculate Mary, an official said the health department’s total of 71 was inaccurate: The former archdiocesan home had only 53 confirmed cases on April 24.