When Anita Kelly asked whether the coronavirus had yet invaded her father’s nursing home in hard-hit Northwest Baltimore, the nurse’s reply worried her.
“Well, if you asked me yesterday, I would have said no,” but one case had just turned up, the woman said on the phone in early April.
Days later, a newspaper article gave Kelly a bigger shock. Her father’s home of four years, FutureCare Lochearn, had tested all the residents, revealing what was then one of the largest known coronavirus outbreaks in the country.
Now, it is just one of nearly three dozen Maryland nursing homes with coronavirus death tolls in the double digits.
The spread of the coronavirus in elder care centers has raised alarm for its speed and breadth, in many cases infecting a majority of residents before most begin coughing or showing a fever. But its spread has not been even.
The infection rate reported in Maryland nursing homes is one of the highest known in the nation, according to data compiled by The New York Times, shared with The Baltimore Sun in a reporting partnership. More than two-thirds of homes in the state are working to contain confirmed outbreaks. Among states The Times examined, only New Jersey, Massachusetts and Connecticut have reported a higher share of homes dealing with a coronavirus problem.
On top of that, racial disparities observed in the impact of the coronavirus nationwide appear vividly inside nursing homes in Maryland and across the country. Those with large black and Latino populations have been twice as likely to get hit by the coronavirus as those where white residents predominate, the analysis found.
The virus has struck more than eight in 10 Maryland nursing homes with a high proportion of black and Latino residents, compared with four out of 10 mostly white facilities.
Share of nursing homes with at least one coronavirus case
Only states that provided facility-level data and that have had outbreaks in at least 20% of nursing homes are shown.
Alexander Gaskins, Kelly’s father, was among at least 20 residents who died after contracting COVID-19 at FutureCare Lochearn, where virtually all residents, including Gaskins, are black. His daughter said she wonders if things might have been different if so many of the earliest victims were white.
“They wouldn’t stand for it,” Kelly said of federal leaders. “But it’s killing us at a higher rate and we don’t take it serious.”
The nation’s nursing homes, like many of its schools, churches and neighborhoods, are largely segregated. And those nursing homes that serve predominantly black and Latino residents tend to receive fewer stars on government ratings. Those facilities also tend to house more residents and to be located in urban areas, which are both risk factors in the pandemic.
Yet such differences still don’t explain why outbreaks are disproportionately occurring in the homes with more black or Latino residents.
The federal government’s five-star rating system, often used to judge the quality of a nursing home, was no predictor of whether a home was hit with COVID-19, the Times analysis found, while the race and ethnicity of the people living in the home was. Predominantly black and Latino nursing homes with high ratings were more likely to suffer coronavirus outbreaks than predominantly white nursing homes with low ratings, the data showed.
Terry Fulmer, president of The John A. Hartford Foundation, which is dedicated to improving care of older adults, said the trends are yet another sign of the disparities in health care and outcomes experienced by blacks and Latinos.
“They start off at a disadvantage, and it snowballs throughout their lives,” she said. “It doesn’t stop at the nursing home.”
Well beyond nursing facilities, the coronavirus has been infecting and killing people of color at disproportionately high rates in the United States, data from some states and big cities have shown. And officials in the nursing home industry say that the situations playing out inside homes largely reflect the circumstances unfolding outside their walls.
“The virus has disproportionately impacted minority groups,” said Dr. David Gifford, chief medical officer for the American Health Care Association, which represents the industry. “Typically, what occurs in the general population is mirrored in long-term care facilities.”
Nursing homes within cities that have been hot spots for the virus are more likely to see outbreaks, he said, especially in large facilities with lots of employees coming in and out.
It is less clear why nursing home residents in Maryland appear to face more risk of contracting the coronavirus than in other states.
Maryland health officials did not respond to requests for interviews for this article.
The Times’s analysis, which covers the 22 hardest-hit states for which data is available and the District of Columbia, represents a snapshot in time, and the picture could change as the crisis wears on. The analysis, based on data collected as of May 16, looked at coronavirus infections. It did not examine whether there was a disparity in coronavirus deaths for white residents and black or Latino residents in nursing homes because such data was not available.
Two of Maryland’s deadliest coronavirus outbreaks have occurred in nursing homes in rural parts of the state where most residents are white — at Pleasant View Nursing Home in Mount Airy, where 28 residents and one staff member died, and at Sagepoint Nursing and Rehabilitation Center in La Plata, where 34 residents and one staffer died.
Fulmer suggested Maryland’s nursing homes may appear to have more and larger outbreaks because of more thorough testing and reporting. She said the state was one of a handful employing the National Guard to collect samples from elder care facilities, for example. The results of more widespread testing that began in such communities could explain the different infection rates reported by different states.
Some states have not reported complete data about individual nursing homes, making comparison difficult even though it is clear nursing homes are accounting for many coronavirus deaths.
“I’m not convinced that some of the larger states have yet fully reported the COVID cases in nursing homes,” said Joe DeMattos, CEO of the Health Facility Association of Maryland, citing Florida and Ohio as examples.
Pennsylvania, for example, released data for the first time Tuesday on outbreaks by facility, so it was not included in the Times’ analysis. It showed that 68% of Pennsylvania residents killed by the coronavirus lived in nursing homes. In Maryland, by comparison, elder care facilities have accounted for 57% of deaths, as of Wednesday. The Times’ analysis, given limitations on available data, focused on outbreaks, but it has reported before that about a third of coronavirus deaths nationally are known to be in nursing homes and other long-term care facilities.
More national data could soon become available after the Centers for Disease Control and Prevention this month required nursing homes to begin providing weekly reports on confirmed and suspected COVID-19 cases and deaths, as well as information on protective equipment supplies, staffing shortages and ventilator capacity.
“There is no question the coronavirus has been devastating in nursing homes in Maryland and many other places,” said Dr. Joshua Sharfstein, a former state health secretary.
Sharfstein, now on the faculty at the Johns Hopkins University’s Bloomberg School of Public Health, said one reason Maryland nursing homes have faced such a challenge is because of how hard coronavirus has hit the state and region. Nearly 20% of coronavirus tests administered in Maryland have come back positive, a rate health experts say likely means that only the sickest patients are being tested.
“The East Coast has been hit pretty hard,” Sharfstein said.
At many Maryland nursing homes reached by The Baltimore Sun, administrators say they have taken every precaution recommended by federal and state health officials, and still have struggled to stop the spread of the virus.
Holly O’Shea, a spokeswoman for FutureCare, said the large numbers of infections revealed at the nursing home chain’s Lochearn facility where Gaskins lived reflected widespread testing that, until recently, few nursing homes had access to.
Maryland health officials have since begun testing as many as a few thousand nursing home residents a day, but before that, FutureCare sought out testing on its own at facilities including the Lochearn center, knowing it was in the middle of a Northwest Baltimore ZIP code that has been among the state’s hardest hit, O’Shea said.
At other facilities, staff say they have, at times, lacked the protective equipment they need to protect themselves and residents from the virus. Workers at Forest Haven Nursing and Rehabilitation Center in Catonsville, where most residents are black, said they were given rain ponchos and nylon hair bonnets in early April, after Maryland required all nursing homes provide staff with protective equipment.
They have since received proper supplies, including face shields, masks and gowns. But at least 97 people there, including 27 workers, have contracted the virus and eight residents died.
Ron Colbert, the facility’s administrator, said the home is restricting visitor access, screening anyone who enters for symptoms, and following federal guidelines for personal protective equipment and patient isolation. He did not respond to questions about the ponchos and hair bonnets.
Donna Johnson, who works as a cook at Forest Haven, said she was given only a mask for protection and came down with a 102-degree fever in April and tested positive for the virus. Still, she said she worries most about the impact of the disease on residents.
“It’s so unfair to them,” Johnson said. “They contracted this through no fault of their own,” she said.
As cases and deaths have mounted in Maryland nursing homes, the state has ramped up its efforts to help them. The state this month began training teams of nurses and nursing assistants to reinforce staff as the National Guard visits facilities to test all residents and staff, expecting that many workers also will test positive and be sidelined for weeks.
Nursing home industry leaders began asking for that help a month ago, and advocacy groups including AARP Maryland have expressed concern it isn’t arriving fast enough.
Earlier access to widespread testing might have made a difference in slowing the spread of outbreaks, said Morgan Katz, an assistant professor of infectious disease at the Johns Hopkins University. She has been working closely with many Maryland nursing homes to prevent COVID-19 infections and slow outbreaks once they arrive.
Because Maryland restricted visitation at nursing homes in early March, state health officials have said they believe staff members, many of them carrying the coronavirus without showing symptoms, have been responsible for introducing it into facilities. But a shortage of coronavirus tests nationally meant that nursing homes have been unable to effectively screen their workers, until Maryland started providing them with thousands of tests this month.
When some nursing homes were able to conduct widespread testing last month, Katz said that almost invariably, if a facility had one or two symptomatic residents, tests revealed dozens more cases. If a facility had five or more residents with coughs or fevers, it often meant the virus had already spread throughout its population.
“This is something we should have caught earlier,” she said.
New York Times journalists Robert Gebeloff, Danielle Ivory, Matt Richtel, Mitch Smith and Karen Yourish contributed to this article.
HOW THE NEW YORK TIMES COMPILED THE DATA
In examining racial disparity in coronavirus infections at nursing homes, The Times gathered data on infection reports from state and local health agencies and joined the information to databases of information about facilities, including the federal government’s Nursing Home Compare data and Brown University’s Long Term Care Focus data.
While the analysis could not fully explain why some homes have seen outbreaks and others have not reported any infections, it did identify variables that increased the likelihood of a facility reporting a problem, and found that the racial disparities persisted even after accounting for these variables.
There is no official published data on the race of nursing home patients by facility, so The Times obtained Medicare claims data and supplemented it with the Brown University data, which incorporates information from Medicaid and Medicare claims.
The analysis bypassed states which have published limited information, focusing on the District of Columbia and 22 states where at least 20 percent of facilities reported at least one coronavirus case.