While protests over police treatment of Blacks raged in Richmond in early June, Cheryl said she “felt like an invisible person” in management meetings at Morningside of Bellgrade, an assisted living facility in Chesterfield County that had been ravaged by a COVID-19 outbreak during the spring.
Cheryl, a Henrico County resident who does not want to be identified by her real name because she has begun a new job with another long-term care facility, is an African American registered nurse who had worked her way up the ranks in a long-term care hierarchy that is dominated by people of color on the bottom rungs and whites at the top.
She had already given her notice to leave Morningside, where her job was assistant director of nursing. She was acting as nursing director after her mentor, Lisa, contracted COVID-19 and went on medical leave in April. Lisa is also an African American RN who does not want to identified by her real name because of possible retaliation.
The nightly Black Lives Matter protests had pushed Cheryl to her emotional limit as a Black nurse caught between the front line of long-term care and the front office of a for-profit corporation that she said had refused urgent requests for help in a desperate battle to control the spread of COVID-19 through a vulnerable population.
“It started to feel like us against them,” Cheryl said. “It was just too much for me to bear.”
“You obviously have to deal with COVID,” she added. “You don’t have to sit here and deal with discrimination as well.”
Issues of race and class in the long-term care industry have come into stark focus during a public health emergency that has killed nearly 1,300 people in nursing homes, assisted living and other continuing care retirement communities in Virginia, while infecting almost 5,700 workers in a wide range of health care professions.
“We have essential workers in long-term care who feel disenfranchised by the system they’re working in,” said Ethlyn McQueen-Gibson, associate professor and director of the Center for Gerontology Excellence at Hampton University, one of Virginia’s historically Black colleges and universities, and a member of a long-term care task force Gov. Ralph Northam created to respond to the COVID-19 crisis.
“Just like you see folks at protests to push changes for police reforms, we’re going to have to take a similar approach for making changes in long-term care and home health,” said McQueen-Gibson, a registered nurse who also serves on the Virginia Board of Nursing. “We have another opportunity to protest in a different way to make these changes.”
Staff at Morningside had sought basic protections against the virus, such as face masks, hand sanitizer and thermometers at the beginning of the crisis before supplies became scarce. They requested hazard pay for beleaguered employees who had stayed on the job when half of the work force quit after the first positive case of COVID-19 in the facility, where 33 residents and 12 employees have been confirmed with the disease and nine residents have died.
Five Star Senior Living, a for-profit corporation that owns Morningside, even denied permission to stop using a time clock that could spread the virus by hands touching it, according to the former executive director of Morningside of Bellgrade, who said he had made multiple requests on behalf of staff that the company denied.
“It’s an extremely exploitative industry,” said the former executive director, Joseph, who is white and also asked not to be identified by his real name because he has started a new job at another long-term care facility.
Five Star responds
Five Star Senior Living, which owns Morningside and about 250 other long-term care facilities in the U.S., denied the allegations.
“In response to allegations raised by former employees, a Five Star team comprising members of both operations and human resources conducted a thorough internal investigation at Morningside of Bellgrade, including interviews with current team members,” a spokesman for the Boston-based company said in an email on Friday.
“Based on the results of the investigation and valuable feedback received during the process, we remain confident that our community team is appropriately trained in the proper use of personal protective equipment and that the community has the correct procedures in place and appropriate resources needed to continue protecting our residents and fellow team members from COVID-19,” the spokesman said.
“We are pleased to report that Morningside of Bellgrade currently has no active cases of COVID-19 within the community and, while weekly community testing remains ongoing, there have been no new symptomatic residents or team members since June 4.”
Dr. Alexander Samuel, director of the Chesterfield Health Department, confirmed Friday, “Their outbreak is no longer active in any area of the facility.”
Almost two-thirds of direct-care health workers in Virginia — personal care and home health aides, and nursing assistants — are Black or other ethnic minorities. In nursing homes alone, 56% of certified nursing assistants are African American and 14% are other ethnic or racial minorities, according to data from PHI National, a New York-based expert on the long-term care workforce.
“It’s very hierarchical,” said David Espinoza, policy director at PHI. “It’s very top down.”
The average wage for these workers in Virginia ranges from $9.47 per hour for personal care aides, who work in people’s homes, to $13.11 per hour for nursing assistants in long-term care facilities — jobs that can’t be performed remotely or without the risk of contracting a highly communicable disease.
“The pandemic has magnified the issue of inequity,” said Shawn Utsey, a tenured professor of psychology and interim chair of African American studies at Virginia Commonwealth University. “The pandemic has magnified the [racial] disproportionality of the workforce.”
Five Star Senior Living said it is committed to a diverse and inclusive workforce and does not tolerate unequal opportunity, discrimination or harassment in its facilities.
“The COVID-19 pandemic has had an outsized impact on the senior living industry, and we strive to maintain a safe and equitable workplace for all members of staff,” a company spokesman said.
The heightened concern about race in long-term care is more about the economic structure of the industry than allegations of overt discrimination or bias at any particular facility.
Long-term care is heavily dependent on Medicaid funding of skilled nursing facilities in Virginia and reliant on a low-paid workforce that traditionally has been overwhelmingly staffed by women, most of them people of color steeped in a culture of caregiving jobs, such as health care, social work and education.
“They find themselves in this situation as a result of race, class and culture,” said Utsey at VCU.
Amy Hewett, spokesperson for the Virginia Health Care Association and the Virginia Center for Assisted Living, said in a statement, “Our industry, like communities all across this country, recognizes that there is much work to do to address racial disparities in our society.”
“Our members seek to promote a culture of inclusion and diversity and believe everyone we serve and work with should be treated with kindness and respect,” said Hewett, whose organizations represent nearly 300 nursing homes and almost 100 assisted living facilities in Virginia. “We do not tolerate discrimination in any shape or form, period.”
The organizations had no data about how many people of color are in management roles in long-term care.
“I can only answer from my experience in multiple communities in Virginia — very rare to see people of color in management roles [and conversely to see Caucasians in direct care],” said Joseph, the former executive director at Morningside.
Issues of class, education and income also play their parts, but the inequities exposed by the crisis in long-term care have made race a central concern for direct-care workers and the residents they serve.
“You have minorities who are already susceptible, and they’re the ones on the front line,” said Jason, a biracial man who contracted COVID-19 while serving as director of the memory care program at Morningside. He asked not to be named because he has begun a new job at another long-term care facility.
Jason, who also attended management meetings at Morningside, said, “It’s strictly a bottom-line, numbers game.”
Lisa, the former nursing director, said, “Elderly people in nursing homes and African Americans, we’re going to suffer.”
Morningside of Bellgrade was trying to reverse a history of regulatory problems when Joseph, Lisa, Cheryl and Jason arrived at the assisted living facility in July 2019.
They had worked together at a troubled Henrico nursing home, Lexington Court, that was sold at the end of the year and renamed Canterbury Rehabilitation & Healthcare Center. Canterbury became the face of the coronavirus crisis in long-term care in the Richmond area this spring, when 51 of its residents died of COVID-19.
Before the new management team arrived last year, Morningside “had a significant non-compliance history” with state licensing standards for assisted living facilities, said Cletisha Lovelace, spokesperson for the Virginia Department of Social Services, which regulates the facility.
The new executive director and his team “implemented measures within the facility to meet compliance standards,” Lovelace said.
A year later, the four employees are all gone.
Joseph and Cheryl left in June. Lisa remains on unpaid medical leave as she recovers from the lingering respiratory effects of COVID-19 she contracted in April. Jason left the facility in early July after catching the virus and infecting his wife.
Five Star said the company moved quickly to replace administrative staff at Morningside. A new executive director started at the facility in late July, after the regional operations director served on an interim basis.
“Since the start of the pandemic, all key roles have been filled by qualified and experienced team members, and at no time were any community leadership positions without coverage,” a company spokesman said.
Martha Turner has a different perspective as the sister of a longtime resident of Morningside of Bellgrade.
“The facility was unprepared for the number of staff affected and how quickly it spread,” said Turner, a Chesterfield resident, in an email.
She questioned why federal emergency relief for health care providers wasn’t available to help Morningside.
“There was never enough staff and those there did not know the patients,” she said.
Morningside is an assisted living facility, not a skilled nursing facility. It does not receive funding under the Medicaid program, which the federal and state governments have used to funnel aid to nursing homes. In Virginia, Northam has channeled $20 million in federal aid to assisted living facilities.
Turner respected the previous leadership at the facility, but she said the corporate office was “not very supportive” during the COVID-19 outbreak that began at Morningside in mid-April.
“The front office and physical therapy departments were working hard with little support,” she said.
Three months before COVID-19 emerged inside Morningside of Bellgrade, Cheryl, then assistant director of nursing, ordered about 250 N-95 face masks to protect staff at the assisted living facility against the potential arrival of the coronavirus.
She said she acted after Dr. Jim Wright, the medical director at Canterbury, told her, “It’s not ‘if,’ it’s when’” the pandemic reaches long-term care facilities in Virginia.
Cheryl had the support of the facility’s executive director, but she said the regional nursing director at Five Star reprimanded her and told her to send the masks back. She didn’t return the masks.
With infection control a paramount issue in a congregate care setting, Lisa and Cheryl also pushed, with Joseph’s support, for installation of hand sanitizer stations throughout the building. The company refused the request, they said. By the time they scoured local stores, the crisis had begun and “at that point, you couldn’t get hand sanitizer anywhere,” Cheryl said.
They said the same thing happened with thermometers, essential to monitoring temperatures to identify the spread of the virus.
“We had to purchase our thermometers at Walmart,” Lisa said.
Other personal protective equipment — gowns, gloves and foot coverings as well as face masks and shields — also became scarce as the crisis deepened and competition intensified for scarce supplies. Joseph said he was able to procure protective gear primarily through the Central Virginia Health Care Coalition and the Department of Social Services, not Morningside’s parent company, whose supplies he said had been inadequate.
The spokesman for Five Star said: “While certain health care equipment such as N-95 masks, thermometers and hand sanitizer were initially in scarce supply, our centralized strategic sourcing function and network of suppliers has ensured continuity of supplies and products for our communities.”
The COVID-19 outbreak at Morningside began on April 14, according to the Virginia Department of Health, which defines an outbreak as two cases of the disease confirmed by laboratory tests. The state tested everyone in the facility on May 4.
The outbreak tore the staff apart at Morningside. The former employees said about half of the direct-care staff quit almost immediately, as well as members of the dietary, housekeeping and maintenance staffs. Other employees refused to work with residents infected by the virus.
“I was cleaning bottoms,” said Lisa, the former nursing director. Joseph, the executive director, “was unclogging toilets.”
The former executive director said he told Five Star officials that the facility needed to take immediate steps to prevent the spread of COVID-19 through the facility. His recommendations included use of paper time sheets to avoid transmitting the virus at the time clock, disposable kitchenware for meals, and a new software tool to send alerts and updates to residents, their families and staff.
He wanted more personal protective equipment and outside help in cleaning and disinfecting the building.
Most of all, Joseph said he urged hazard pay for direct-care workers and warned that other long-term care facilities in the region had begun paying their employees hazard pay and offering recruitment bonuses for new workers.
He said he told the company that staff felt “uncared for, underappreciated and disposable.”
The former executive director said Five Star denied the requests.
“I feel like everybody pretty much abandoned us,” said Lisa, the former nursing director. “It was very, very stressful.”
Five Star hired outside agency staff who were paid at a much higher rate than long-term employees, the former employees said. The company’s regional nursing director never visited the stricken facility during the outbreak or gave any reason why, they said.
A Five Star spokesman said the company had provided shift bonuses and award pay to employees, in addition to free meals during shifts and assistance for emotional and mental health issues.
Former employees said the $150 bonuses were too little for the work they were doing and the risks they were taking.
“I brought the virus home to my family,” Lisa said.
She received 10 days of pay while recovering from the virus, but only after using all of her vacation and other paid leave. Now, she’s on unpaid family medical leave.
“I’m personally affected by this,” Lisa said. “I’m not receiving any help.”
‘The white world’
Cheryl never had worked on the management side of long-term care until she became assistant director of nursing at Morningside. She had been a registered nurse for two years, after eight as a licensed practical nurse and nine as a personal care aide.
“The biggest challenge as an RN on the administrative side was trying to fit into the white world,” she said.
She said it became harder during the COVID-19 crisis, and after the Black Lives Matter protests began, focusing attention not only on the death of George Floyd in police custody in Minneapolis but also on the systemic racism woven insidiously into the fabric of American life.
“You’re dealing with it at work. You’re dealing with it at home,” she said. “Black Lives Matter. Our lives matter, too, and we’re the ones on the front line.”
The solution has to begin with valuing the people doing the essential work, said Ethlyn McQueen-Gibson at Hampton University. “We wouldn’t have long-term care and assisted living without nursing assistants. There would be nothing.”
That means better pay and benefits for direct-care workers, through the Medicaid and Medicare systems, as well as private long-term care companies, said David Machledt, senior policy analyst at the National Health Law Program.
“As a nation, COVID is calling us to look at our priorities again,” said Machledt, who has written about racial disparities in long-term care. “We haven’t had the conversation about how do we fund our long-term care system and do it equitably.”
Dr. Jim Wright, medical director at Canterbury and two other facilities in the Richmond area, said the coronavirus crisis has opened an opportunity for essential structural changes in the long-term care industry.
“If COVID disappears, so will the urgency to make changes to long-term care,” Wright said. “We have a short window.”
The former Morningside employees say the solutions also must include a basic respect for the people doing the work and taking the risks.
“Listen to your staff,” Cheryl said. “Listen to their needs and support them.”