In October 2019, months before the coronavirus pandemic hit, the Southeast Nursing and Rehabilitation Center in San Antonio received a citation for failure to “provide and implement an infection prevention and control program.” This was far from the first citation the facility had received. The report, which lists several problems at the facility, describes a staff member using a soiled towel to wipe clean a resident’s buttocks and then subsequently failing to wash their hands — and said residents were at risk of foodborne illness.
The nursing home, residents’ relatives said, did not take the necessary steps toward improving conditions. But in early November, the owner, nursing home magnate Eliezer Scheiner, attended a fundraiser in New York City and donated $750,000 to the top super PAC supporting Donald Trump’s reelection campaign, America First Action.
“I want to thank Eli Scheiner for doing such an incredible job,” Trump said at the event. The New York Times reported that the fundraiser brought in over $3 million for the super PAC from the nursing home industry, which has benefited tremendously from an ambitious deregulatory agenda under the Trump administration. The administration decimated an Obama-era rule that would have banned binding arbitration agreements that tilt the justice system toward the industry. The average fine from the Center for Medicaid and Medicare Services, or CMS, has gone down by 31 percent. And the administration proposed to water down a rule that would have enhanced infection control in nursing homes.
By late April, when the coronavirus was ripping through nursing homes nationwide, the San Antonio nursing home hadn’t made sufficient preparations for how to stop an infection in the facility. The Covid-19 outbreak at Southeast has killed 18 residents and one member of the staff, a nurse’s aide. Southeast houses about 85 residents, the overwhelming majority of whom are Black or Latino and are on Medicaid.
Residents of other nursing homes controlled by, operated by, invested in by, or are tenants of Scheiner, his business partner Teddy Lichtschein, or his company TL Management have borne the brunt of the Covid-19 pandemic. In all, facilities in Florida, Texas, Pennsylvania, and Washington, D.C., have seen over 135 coronavirus deaths. At the same time, TL Management hired lobbyists to assist them in getting federal funding, and Scheiner-affiliated nursing homes identified by The Intercept have received over $27 million in grants and loans since the Covid-19 crisis began, public records show — and many of them are among the worst-rated nursing homes in their states.
Delia Jaramillo lost her 93-year-old mother, Catalina Romero, who was a resident at the facility to the virus on April 5. Romero was born in Saspamco, Texas, and had worked her entire life to keep herself and her daughter afloat. “She worked in the fields, picking peanuts and tomatoes,” said Jaramillo. “When it wasn’t that season, she would work for 10 cents an hour as a housekeeper and as a cook. She had no education, but she forced education on me.” As Romero grew older, she developed dementia and Alzheimer’s, entering the nursing home in 2010.
Jaramillo had long felt that the facility didn’t adequately care for her mother. In the weeks before her death, Jaramillo said that she had to be at the nursing home six days a week, do her mother’s laundry, and give her medication. She couldn’t rely on the staff to ensure that it would happen.
Over the decade that Romero was at Southeast, she was assaulted, had many falls, and lived in subpar conditions. A San Antonio Police Department report from May 16, 2019, says that a nursing home employee observed an aide “Jerking on [Romero’s] right arm and being very rough with her while trying to change her clothes.”
Over the decade that Romero was at Southeast, she was assaulted, had many falls, and lived in subpar conditions.
“She broke both hips there at the facility,” said Jaramillo. “She broke one hand and had to go through surgery. When she had returned to the facility, she was attempting to get out of the bed and broke the other hip.” Jaramillo recalls having to clean fecal matter from her mother’s fingernails and dispose of adult diapers left on her mother’s bed because, she felt, the nursing home was too short-staffed. At one time Jaramillo found raw sewage in the home due to a broken sewer main.
Southeast is in the worst 1 percent of nursing homes in Texas for Covid-19 deaths. The nursing home had also been cited for infection control failures in March 2018 (the inspector saw three houseflies on a sleeping resident, and gnats and flies in the kitchen) and in October 2017 (a resident with exposed open wounds). The home was fined over $62,000 in March 2019 for failing to notice when a resident went 13 days without a bowel movement, resulting in the patient’s hospitalization.
Ruperto Gutierrez Jr., whose father Ruperto Gutierrez Sr. also died at the facility in April from Covid-19, detailed similar concerns about the quality of the facility.
“[Southeast] didn’t really show interest in the residents,” said Gutierrez. “My dad was on a feeding tube and the bottle would run out. We would press a light for the aide and it would stay on for a half hour. He could go to the bathroom and it would take an hour before someone at the so-called nurses station would send somebody.”
“The place was not clean,” said Gutierrez, who also went to the nursing home at least five days a week. “The patient had some kind of surgery and they had to come in every day to clean his wound. They would change it and it had a bad smell and they would throw the waste into a bag and leave it on the floor in the room.”
Gutierrez said that he and his wife had never observed nursing home staff washing their hands prior to the pandemic.
According to documents filed with Berks County, Pennsylvania, in July 2018, Scheiner and Lichtschein “own 100% membership in ~100 skilled nursing facilities and hold membership interests in more than 40 entities that operate those facilities.” The document filed with Berks County says that they are concentrated in Texas, Florida, and Pennsylvania. The Intercept was able to independently identify 25 nursing homes nationwide through public records, including one nursing home in Pennsylvania and several in Florida and Texas. The Miami Herald was able to identify an additional 20 TL-connected facilities in an investigation published August 6. All but four of those identified by The Intercept have one- or two-star ratings for staffing from the federal government.
In comments to The Intercept, TL denied a role in operating the facilities, and clarified the way they invest in nursing homes. Scheiner owns the Texas nursing homes outright. Outside of Texas, TL typically owns the underlying real estate and leases to a tenant. The Miami Herald found that in Florida, the tenant will often not just lease the property but also the license for the facility as well. TL denied that it owned the Pennsylvania nursing home and operated the Washington, D.C., nursing homes identified by The Intercept, but previous reporting and documents have connected them, and they did not respond to a question about whether they owned the real estate.
Many of those nursing homes that were identified have poor records. Twenty-two residents have died at the Gulf Shore Care Center in Pinellas Park, Florida, putting the home in the worst 1 percent of nursing homes statewide for resident deaths. Eleven have died at Clarksville Nursing Center in Clarksville, Texas, while seven have died at Vista Hills Health Care Center in El Paso, Texas, putting the latter two in the worst 5 percent of nursing homes in Texas. Thirty-eight deaths have occurred at TL Management’s Spring Creek Rehabilitation and Nursing Center in Harrisburg, Pennsylvania, putting it in the bottom 2 percent of nursing homes in that state. The Sands at South Beach, in Miami, has 15 deaths, enough to put it in the bottom 2 percent of Florida’s nursing homes. The Deanwood nursing home in Washington, D.C., had 22 deaths, making it the second-worst nursing home in D.C. for Covid-19 deaths, and in the bottom 5 percent for nursing homes in D.C. and Maryland combined.
Many experts blame low staffing levels for coronavirus deaths in nursing homes nationwide. Charlene Harrington, a professor emerita of nursing at UC San Francisco, argues that registered nurse staffing in particular is critical in response to a pandemic. “If you don’t have RNs, you can’t focus on infection control,” said Harrington. “RNs are trained in infection control as opposed to CNAs [certified nursing assistants] and LPNs [licensed practical nurses]. The RNs are the ones who can assess the residents and create the infection control plans.”
Harrington has recently published research finding that poor staffing at nursing homes is correlated with higher Covid-19 cases, as have researchers from the University of Rochester Medical Center.
Residents at Southeast, which has a one-star rating on staffing, received an average of 13 minutes with an RN per day. The Texas average is 24 minutes, and the nationwide average is 41 minutes. CNA hours per resident was 1 hour and 49 minutes, as opposed to a Texas average of 2 hours and 2 minutes and a nationwide average of 2 hours and 18 minutes.
“If you have a one-star rating, that’s really horrible,” said Harrington. “And that’s how [nursing homes] make all their money — keep RN staffing really low,” said Harrington, explaining that CMS grades are on a curve when rating nursing homes. “Cutting back on RNs is a bad idea but that’s standard practice for most of these chains. Since labor costs are their biggest line item, they try to cut corners on labor.”
At wages of $10 to $12 an hour, it can be extremely difficult for nursing homes to recruit quality staff. The industry claims that it cannot raise wages because federal reimbursement rates are too low, but Scheiner and his business partner have become wealthy enough in the nursing home business to assert that they have personal net worth “well in excess” of $37.5 million.
And Scheiner-affiliated facilities across the nation received forgivable loans via the CARES Act to maintain staff. Southeast, in Texas, received $675,000 in PPP loans on June 26. So did Clarkesville, also in Texas. The Pinellas Park nursing home in Florida received $1.5 million in PPP loans on April 28. Spring Creek in Pennsylvania received $3.5 million in PPP loans on May 2. Deanwood, in D.C., received $3.5 million in PPP loans on April 29.
Jaramillo witnessed the infection dangers outlined by state and federal inspectors when caring for her mother. “The CNAs didn’t wash their hands,” said Jaramillo. “The CNAs were definitely overworked. They worked more than 12-hour shifts at a time. There was a constant change of CNAs.”
Romero, despite being 93, was healthy. “I say that because her doctor’s assistant came to me in December 2019 and I said, ‘What am I looking at for a timespan for mom?’” said Jaramillo. She recalled the physician’s assistant told her, “‘Your mother is a healthy woman … when she dies it will be from a virus.’”
“They did not take good care of my mother.”
Jaramillo was informed that Covid-19 was in the facility on March 15, around the same time that the home became closed to visitors. On April 1, Jaramillo was informed that her mother was to be tested for Covid-19. On April 3, she was informed that her mother’s condition had deteriorated. On April 5, Romero passed away.
“She died from a virus because those people at that nursing home neglected to wash their hands,” said Jaramillo through tears. “They did not take good care of my mother.”
“Nursing homes get a lot of money,” said Harrington, the retired nursing professor. “I think they really like Trump, because since he’s been in office, he’s really made major efforts to deregulate nursing homes. Federal money is clearly for testing, staffing, and PPE, but deregulation means they don’t actually have to spend their money on that,” said Harrington.
Prior to Covid-19, infection control was a serious problem for nursing homes nationally. The Office of Disease Prevention and Health Promotion estimated in 2013 that as many as 380,000 nursing home residents died annually from infections. A 2012 study from the Journal of Elder Abuse and Neglect estimated that 24.3 percent of nursing home residents have experienced at least one instance of abuse by nursing home staff. Half of the nation’s 1.6 million nursing home residents will have at least one fall annually, with one in three falling more than once.
With the Affordable Care Act, the Obama administration in 2016 developed a suite of regulations related to nursing homes. Nursing homes had been a wild west of regulation until 1987, when the Nursing Home Reform Law was signed into law, which established a baseline set of regulations. The centerpieces of the new rules were ones that required at minimum a part-time infectious disease specialist to be employed at each nursing home facility and an additional rule that would bar binding arbitration in nursing home regulation. Nursing homes have used binding arbitration to restrict access by misconduct victims and their families to the civil justice system. Instead, binding arbitration is far more secretive with final awards never released and limited to no public access to proceedings. Nursing home plaintiff’s attorneys told The Intercept that punitive damages are more or less nonexistent with binding arbitration.
On September 16, 2019, the Trump administration relaxed the binding arbitration rule, once again allowing binding arbitration agreements. The fundraising bonanza from the industry came less than two months later.
The deregulation was an addition to a substantial reduction in already low fines for violations. The Trump administration switched away from fining facilities for each day they were out of compliance to issuing a single fine for most violations, as reported by Kaiser Health News in 2019.
As the pandemic was raging, the Trump administration announced a $4.9 billion distribution to nursing homes — but there would be no strings attached, like a tightening of minimum staffing requirements or a requirement to disgorge the money if violations were found.
In the spring, as residents died, Scheiner and TL cozied up further to an administration that would decide whether or not to mete out accountability to an industry that accounted for at least 40 percent of coronavirus deaths.
In early May, Scheiner donated the legal maximum to Trump’s reelection campaign. He also donated $50,000 to the Trump Victory Fund, as reported by the Miami Herald. (The Trump campaign responded to a request for comment about Scheiner from The Intercept by linking to a Daily Caller article about a Biden family member benefiting from the PPP program.)
Scheiner and TL Management’s connections to Trump don’t stop with the sizable Scheiner donations. Stat News revealed in July that TL Management had hired Emily Hargan, the wife of Deputy Secretary of Health and Human Services Eric Hargan, as a lobbyist on June 1. Hargan’s lobbying disclosure shows her lobbying the U.S. Department of Health and Human Services, the U.S. Department of Labor, and the White House. The disclosure says that she is focusing on “1. Federal civil liability protection in regards to coronavirus for skilled nursing homes. 2. Work to ensure priority access to PPE, rapid testing, and stronger guidance to states on new regulations. 3. Next steps for Phase 4 funding for skilled nursing facilities.” (On July 17, records show that Hargan terminated her relationship as a lobbyist, but she told The Intercept that she was still employed as a consultant by the nursing home firm. She told The Intercept that her husband had recused himself from matters related to Scheiner and TL, but as deputy secretary, Eric Hargan supervises the entire Department of Health and Human Services.)
Hargan wasn’t the only lobbyist hired by TL Management; records show TL lobbyists working to expand civil liability protections for nursing homes. They hired Ballard Partners, who Politico said in 2018 “is closer to the president than perhaps any other lobbyist in town.” Ballard was Trump’s lobbyist in Tallahassee for years and is a top fundraiser for the president. Ballard’s disclosure shows them lobbying CMS and HHS on “Long term care issues and regulatory reform.” TL Management also hired Nicholas Muzin of Stonington Global; Muzin is a former chief of staff to Sen. Ted Cruz, R-Texas. Muzin’s disclosure shows him lobbying the Department of Health and Human Services and the U.S. Senate, with the goal of “Obtaining federal and state assistance for nursing homes dealing with COVID-19.” All of the hires came after April 1, as the pandemic was spreading.
Lobbyists could also be working to ensure that the Centers for Medicare and Medicaid Services does not punish nursing homes for their coronavirus deaths by cutting off their revenue stream. An August report from researchers at the Kaiser Family Foundation pointed out that “deficiencies that result in immediate jeopardy, a facility is subject to the appointment of temporary management to oversee operations while deficiencies are corrected or termination from the Medicare and/or Medicaid programs with the safe and orderly transition of residents to another facility or community setting.” CMS termination can be fatal to nursing homes, as Medicaid is the primary insurance for 62 percent of nursing home residents, with Medicare covering an additional 12 percent.
TL Management has likely been able to evade scrutiny so far in part due to the rise of complex ownership structures in the nursing home industry, that is, separating the ownership, operations, and real estate into separate entities and avoiding any documentary coagulation with other facilities under common ownership or operation.
“The bottom line is it’s a lot more difficult than it should be to see who is involved in a particular facility’s care.”
“These complex ownership structures have become more common over the past decade plus,” said David Stevenson, a professor of health policy at Vanderbilt University School of Medicine. “The bottom line is it’s a lot more difficult than it should be to see who is involved in a particular facility’s care.”
Stevenson pointed out that the desire by the industry to avoid liability has in part driven the move to complex ownership structures. “If there are claims against a particular facility as part of a larger ownership group, one strategy is to limit the liability to that particular facility than the whole group, and that’s what it boils down to,” said Stevenson.
Jaramillo has filed a wrongful death lawsuit against Southeast for her mother’s death, as has Gutierrez for his father’s death. “I don’t want Mama’s life to be taken in vain,” said Jaramillo. “There has to be changes made. These nursing homes cannot mistreat those who don’t have a voice.”
This reporting was supported by NursingHomeCrisis.org, a project of Social Security Works.