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Ernie Tosh, a lawyer in Texas who specializes in elder abuse, blames a lack of federal and state preparation before the virus arrived. When the virus surfaced in China in late 2019, CMS and

the states failed to prepare for a mass outbreak in America’s nursing homes, he says. “Instead of making sure facilities had adequate equipment and disaster plans, they did nothing,” Tosh

says. In the early days of the outbreak, nursing homes were caught flat-footed, without N95 masks and other needed equipment. A federal policy of prioritizing critical care hospitals left

states to procure their supplies. That set off bidding wars and often left nursing homes empty- handed. When the federal government did take action to help nursing homes, it often did so

with glaring incompetence. In spring, for example, the Federal Emergency Management Agency (FEMA) began sending badly needed masks, gowns and other personal protective equipment to more than

15,000 nursing homes. But many of the shipments, which were touted by Vice President Mike Pence as vital federal support for nursing homes, contained unusable gear, including expired or

faulty surgical masks and gowns without armholes. None of the shipments included what nursing homes needed most — the N95 masks that protect workers from inhaling the virus and spreading it

to residents. Ryan calls it the “Keystone Kops of a public health response.” Brendan Williams, president of the New Hampshire Health Care Association, wears an isolation gown with no sleeve

openings for hands, which was received in a shipment from the federal government in July. AP Photo/Charles Krupa In March, CMS made what many consider another huge mistake by suspending

routine state inspection of nursing homes and restricting long-term care ombudsmen, who are charged with advocating for residents, from making visits. The rules were meant to prevent

outsiders from bringing the virus in. But as a result, nursing homes operated without scrutiny. After the ruling, Melanie McNeil, the Georgia state long-term care ombudsman, had staff barred

from visiting facilities. She worries about what she will find when ombudsmen can return. “We really don’t have a good picture of what’s happening,” McNeil says. Critics also say the

overwhelming federal response to the crisis at nursing homes has been to throw money at the problem, without ensuring that taxpayer dollars go toward protecting residents. By September,

nursing homes had received over $21 billion in federal relief funds, according to CMS. But only $2.5 billion was specifically allotted to infection control; the rest came with almost no

strings. “It’s in my hall of shame that the federal government gave the nursing homes those dollars with no accountability,” Ryan says. A line of paper bags hold the individual masks of

nurses at a long-term care facility. Isadora Kosofsky AT FAULT THE NURSING HOME INDUSTRY * Many facilities were understaffed and underfunded prior to the pandemic * For-profit structure

appears to have reduced care quality at many homes Even the most ardent critics of the nursing home industry agree that it was dealt a nearly impossible hand, and in many cases, was left to

take the brunt of public anger over the large number of deaths at nursing facilities. But that doesn’t absolve the industry from the poor decision-making that made a bad situation much

worse, those experts say. In response to AARP calls for comment, American Health Care Association (AHCA) spokeswoman Cristina Crawford says the failure of public health services at all

levels to prioritize nursing homes for both testing and personal protective equipment left the industry unequipped to stop the spread of the virus. “It was difficult to get anyone to listen

for months, leaving devastating consequences for our residents and staff,” Crawford says. A nurse's face shield is left out to dry at Canyon Transitional Rehabilitation Center in

Albuquerque. Isadora Kosofsky The nursing home industry has been aggressive in shifting the blame and in trying to avoid the financial consequences of the deaths in its facilities. This

summer, Mark Parkinson, AHCA’s president, announced a $15 million media campaign to boost public opinion of nursing homes, which was badly bruised by the pandemic. The association is also

pushing for state and federal immunity from legal liability during the outbreak, which has been granted in more than 20 states. But data is beginning to show linkages between nursing home

quality and coronavirus cases. For example, researchers at both the University of California, San Francisco, and the University of Rochester Medical Center found that facilities that had

received lower quality ratings from regulators before the pandemic were more likely to suffer outbreaks. Seventy percent of nursing homes are for-profit operations, a factor that’s been

linked to the spread of COVID-19. An August report commissioned by Connecticut found that for-profit homes in the state had about 60 percent more COVID-19 cases and deaths per licensed bed

than nonprofit facilities.  Risks may be even worse at for-profits run by private-equity firms, which acquire nursing homes, cut costs and then sell at a profit. A study by Americans for

Financial Reform Education Fund found those nursing homes in New Jersey had a disproportionate share of COVID-19 deaths. Staffing levels also appear to be a key factor in the virus’ spread.

In August, a study in JAMA found that across eight states, facilities with higher levels of nursing staff had fewer COVID cases than those with fewer staff. And in July, a report published

by the National Bureau of Economic Research raised alarms about the common practice of care staff working in multiple facilities. Nursing homes with higher rates of shared staffing, the

researchers found, had higher rates of infection. Limiting care staff to a single nursing home, they concluded, could reduce COVID-19 infections in facilities by 44 percent. That’s no

surprise to Lori Porter, cofounder of the National Association of Health Care Assistants, which represents many nursing home care workers. With an average wage of around $13 an hour, care

workers often work at multiple nursing homes to make ends meet, Porter says. Many staffers don’t receive health insurance or paid sick leave, leading some to work even when they were

experiencing coronavirus-type symptoms. “What did you think was going to happen?” Porter says.          There is much responsibility to go around. But Richard Mollot, the executive director

of the Long Term Care Community Coalition, says he is appalled by the industry’s “take-no-prisoners” approach to deflect blame.  “After months of devastation for residents and their

families, I have yet to hear a single apology, a single provider say ‘We have learned, and next time we’ll do better,’ ” Mollot says. “The failure to fully acknowledge the losses and the

toll on residents and families is, in my opinion, unforgivable.” NEXT: NURSING HOMES’ FLAWED BUSINESS MODEL WORSENS COVID CRISIS