Editor's note: Scroll to the end of this story to read our response to N.H. Health and Human Services Commissioner Lori Shibinette's recent statements on NHPR’s reporting on COVID-19 and the state's long-term care facilities.
The last time Dianne Connelly hugged her mother, Anita Goodwin, was March 13. Had she known what the next few months would bring, she would have held on a little bit longer.
Since then, she’s only been able to visit Greenbriar, the Nashua nursing home where Goodwin has lived for the last eight years, a handful of times. There was a tearful birthday celebration, with balloons and hand-drawn birthday signs outside a thick glass window; then, in early May, an outdoor visit in the parking lot, with masks and 10 feet of space between them.
Less than two weeks after that visit, Connelly got the news she’d been dreading since COVID-19 arrived in New Hampshire: 10 residents were infected at Greenbriar. But she didn’t hear it directly from the nursing home; instead, she first heard it from a friend, who saw it on the local news.
While Greenbriar’s outbreak was at first relatively minor compared to the ones seen at other local long-term care facilities to that point, things escalated quickly. Within two weeks, resident cases quadrupled and some staffers started getting sick. Within a month, Greenbriar broke 100 cases — and all summer, its numbers kept climbing. As outbreaks came and went at other nursing homes, Greenbriar’s has been the longest and among the most severe to-date: More than 150 residents and staff infected, and 28 dead.
Along the way, Connelly realized she couldn’t rely on Greenbriar to keep her updated. One day in June, she again saw a local news story about a big new spike in cases at the facility. An hour later, the facility called to say her mom was among the residents who had tested positive.
At each turn, Connelly said she struggled to get clear and consistent updates about her mother’s condition. And unlike before the pandemic, she wasn’t able to see for herself how the facility was managing things on the inside. That was perhaps the hardest part — since she’d already reported the facility to state officials over and over again, for medication errors, a poorly managed infection, and more.
“The fact is that they already were struggling to operate,” Connelly said. “I think the state absolutely should have been in there right away, getting things ready, having a plan in place.”
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Were N.H. Nursing Homes 'As Prepared As They Could Be' For COVID-19?
Even some of the best-equipped long-term care facilities in New Hampshire were caught off-guard by COVID-19. Shortages in testing and adequate protective gear — and a workforce that was already paid little and stretched thin — made it hard for the whole industry to respond to the pandemic.
The virus has caused dozens of outbreaks at nursing homes and assisted living facilities across the state, claiming at least 345 lives in the last six months. Federal records indicate that nearly three-quarters of the state's nursing homes have dealt with at least one case of COVID-19, as of the start of August.
Health and Human Services Commissioner Lori Shibinette has maintained there’s little the state could have done differently to prevent those losses.
“I think that New Hampshire nursing homes were as prepared as they could be for COVID,” Shibinette said at a press conference earlier this summer. “And just like the rest of the nation, we were fighting an unknown virus and they employed all of the techniques that they know how to use to prevent the spread of an infectious disease.”
But Connelly isn’t alone in her assessment that Greenbriar was especially ill-prepared. State and federal regulators had been well aware of problems at this particular nursing home long before COVID-19 arrived in New Hampshire, as evidenced by hundreds of pages of inspection reports detailing deficiencies at the facility.
According to the Center for Medicare and Medicaid Services, Greenbriar was cited at least 55 times in the last four years, more than any other New Hampshire nursing home participating in those federal reimbursement programs. None of those citations were for problems that could have caused “immediate jeopardy to resident health or safety,” but they include such errors as failing to ensure staff are properly washing their hands when administering medicine to residents, or failing to wear proper protective clothing when dealing with a patient who is infected with a communicable disease — just the kind of precautions that have proven essential to fighting COVID-19.
And since last year, Greenbriar has been New Hampshire’s lone “Special Focus Facility,” a program for nursing homes deemed worthy of extra oversight.
Greenbriar is managed by Next Step Healthcare, a nursing and rehabilitation chain that operates in Massachusetts, Maine and New Hampshire. According to the company’s “COVID-19 Dashboard,” 22 of its 28 facilities have reported 30 or more cases.
Next Step Healthcare did not respond to multiple messages seeking comment on Greenbriar’s behalf. But Greenbriar wasn't the only facility that was struggling before COVID-19. An NHPR review of inspection records found that several other facilities with serious outbreaks were cited, sometimes repeatedly, for inadequate staffing, infection control and other problems relevant to their ability to handle this kind of crisis.
While this information isn’t easily obtained by the public, all of this information and more was readily available to New Hampshire officials who were responsible for deciding how to allocate testing, training, staffing, protective gear or even extra levels of oversight across the state’s long-term care facilities. It’s unclear whether the state meaningfully factored in any of the documented deficiencies — at Greenbriar or at other facilities that have seen serious outbreaks — into their plan for protecting nursing home residents and staff against COVID-19.
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At Greenbriar, Inspection Records Reveal Years Of Infection Control Problems Before the Pandemic
Nursing home oversight is a shared responsibility between state and federal agencies. Most of New Hampshire’s nursing homes are inspected at least once a year; some, like Greenbriar, have to go through more frequent inspections because of past violations.
Those inspections are often conducted by New Hampshire’s “State Survey Agency” — a team with the Department of Health and Human Services that can handle inspections and other oversight activities on behalf of the federal government.
If everything comes up clean when a nursing home is inspected for federal standards, DHHS Chief Legal Officer Melissa St. Cyr said it’s usually “deemed” to be licensed under state rules and isn’t inspected again unless state officials need to investigate a complaint.
Since March, though, most New Hampshire nursing homes have been inspected only for their COVID-19 infection control protocols, after the federal government pulled back “non-emergency” oversight activities in the early days of the pandemic.
The reports from those inspections have been posted to the state’s licensing portal over the last few months. (That website can be challenging to navigate, so NHPR has uploaded the files to this searchable database.)
In all but a handful of cases, inspectors have determined that New Hampshire nursing homes — including Greenbriar — were “in compliance” with infection control standards and “implemented [federally] recommended practices to prepare for COVID-19.”
However, inspection files prior to COVID-19 show that Greenbriar was repeatedly cited for violating acceptable infection prevention and patient care standards.
For example, in 2016, inspectors reported that Greenbriar allowed visitors into the rooms of residents who were under extra infection control precautions without requiring those visitors to wear required protective gear. In the following years, they found more infection control problems. A glucose testing device was left on a nurse’s station, covered in a substance “consistent with blood.” A mouth suctioning machine was left, unemptied, on the nightstand next to a resident’s bed. Employees didn’t correctly use protective gear when dealing with potentially contagious patients. Residents reported that the place was so sparsely staffed that "the call lights took up to 2 hours to be answered." Residents also relayed uncertainty about whether the facility was taking their concerns seriously.
“The staff will listen and respond back, but not always timely,” one resident told inspectors during a 2018 visit. Another resident added, “but the next step is actions, and those seem to be rarely taken.”
Greenbriar’s last documented inspection before COVID-19 took place in October 2019. At that time, the facility was cited again for infection control and other issues, including failing to change an incontinent resident more than one to two times a day.
Based on the publicly available files, it does not appear that state or federal regulators issued any fines or penalties against Greenbriar for any of these violations. Within the Special Focus program, the federal government currently considers Greenbriar a facility that has “shown improvement."
Other Facilities Offered Warning Signs About Their Ability to Handle COVID-19, Too
Seven other facilities in New Hampshire have been flagged as candidates for the “Special Focus” program because of concerns over their history of violations. Four of them have had COVID-19 outbreaks, with varying degrees of severity.
One of those facilities, Derry Center for Rehabilitation and Healthcare, was cited for insufficient infection control procedures twice in the last six months: once in February, just weeks before the pandemic hit; and then again in May, in the middle of a COVID-19 outbreak that would claim 10 of its residents.
Inspectors who visited the Derry nursing home on February 14 of this year found that the nursing home failed to use proper protective gear to prevent the spread of communicable diseases, “did not have documentation to show that licensed nurses have demonstrated competencies” and failed to ensure a registered nurse was on duty at least eight hours a day.
When inspectors returned to conduct a COVID-19 focused infection control survey three months later, they found a staffer treating a COVID-positive patient without “a gown, gloves, or face shield” — despite the fact that, at the time, the facility “had an ample supply of PPE.” That staffer, according to inspection records, “was the nurse assigned to the COVID-19 designated unit on the 7:00 a.m. to 3:00 p.m. shift caring for 26 residents on 5 of the 7 days reviewed.” By that time, according to state reports, COVID-19 had infected 33 residents and staff at the facility.
Another facility considered worthy of extra oversight, RidgewoodCenter in Bedford, reported a second outbreak one month after its first outbreak subsided.
Editor's note: An earlier version of this story listed incorrect information about the number of "Special Focus" candidates in New Hampshire and an incorrect case count for Derry Center for Rehabilitation and Healthcare as of May 13. It has been updated with the correct information.
State Officials Say N.H.'s Oversight System Is Working
The issues documented in the inspection files for Greenbriar and other facilities paint a more complex portrait of nursing home quality in New Hampshire than what’s generally offered by state officials.
“If you look at nursing homes and you compare in New Hampshire survey results to those in other parts of the country, you'll see that New Hampshire has historically done much, much better,” Shibinette said when asked about the state’s oversight of nursing homes at a press conference earlier this summer.
According to data analyzed by ProPublica, New Hampshire does report fewer nursing home deficiencies, fines and infection control violations than most other states. But the investigative news outlet has also uncovered “big disparities” in how different states approach nursing home sanctions and enforcement, meaning that the same kind of violation could result in a vastly different punishment depending on how aggressive or lenient a state is in its enforcement posture.
Melissa St. Cyr, Chief Legal Officer for the state health department overseeing licensing and regulation, said the state does factor in whether there’s a pattern of recurring incidents, or problems implementing past plans of correction, when deciding what disciplinary measures to take against nursing homes. If a facility is still operating despite past violations, she said, “they have done what they need to do, to correct those violations.”
St. Cyr said the state’s decision to take more significant disciplinary measures would depend on the individual track record and circumstances at a given facility.
“Certainly we don't want them to jeopardize the health and safety of the patients that are there,” she said.
But in general, St. Cyr said the state tries to avoid taking steps to shut a facility down or limit its ability to take in new patients.
“We do our best to work with the nursing homes to support the nursing homes, to allow them to continue to operate because they're so needed in this state,” said St. Cyr, who in the past served as the administrator for Pleasant Valley Nursing Home in Derry. “We want them to be able to provide the care.”
St. Cyr and other officials involved in New Hampshire’s pandemic response have said they did the best they could to protect the state’s long-term care community against COVID-19 given the information and resources available. But they didn’t make any significant changes based on, for example, a facility’s “Special Focus” status or past infection control violations.
“I would say that the state took precautions on all facilities, and although Special Focus Facilities may have had non-compliance issues, it doesn't necessarily mean that those non-compliance issues were related to their infection control practices,” St. Cyr said.
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Aside from Ventilation Review, N.H. Hasn't Signaled Plans to Study What Went Wrong
As New Hampshire enters its sixth month of the pandemic, state officials are taking steps to better understand what exacerbated the outbreaks at long-term care facilities. But aside from studying the ventilation systems in facilities that experienced outbreaks, they have not signaled any plans to examine why certain nursing homes were hit harder than others.
A few weeks before announcing plans for that ventilation study, Gov. Chris Sununu vetoed a Democratic-backed proposal that would have authorized a more sweeping audit. That bill called for “an independent review of the COVID-19 situation in long-term care and nursing homes in New Hampshire” to help the state better understand what “funding, safety and public health upgrades, standards and rules” would protect long-term care facilities against future waves of the virus.
“Although this bill is well intended, it is redundant,” the governor wrote in his veto message.
Outside New Hampshire, experts studying the pandemic’s toll on nursing homes across the country have not yet reached a consensus on the connection between a facility’s past track record and its ability to contain COVID-19.
In June, one group of researchers said they didn’t find a connection between the quality of a nursing home and the seriousness of its outbreak.
“It has much less to do with a particular building and much more to do with how prevalent the virus is in the community, because the staff of the nursing home live in the community and they're the ones who bring it in,” said one of the researchers behind that analysis, Brown University School of Public Health Professor Vincent Mor.
Rather than taking a harder line on nursing homes for infection control or other violations, Mor said policymakers should focus on expanding testing and reducing the spread of COVID-19 among the public at large. While he said New Hampshire officials could have theoretically been more proactive about making sure their most problematic facilities were better prepared, he said that’s not really a posture taken by most state health agencies.
“They could have identified Special Focus Facilities, identified facilities with low staffing or other things, and looked at those places and then made sure that those places had enough PPE on hand and then forced them to order it,” Mor suggested. “They could have been much, much more proactive. I don't know about the legal basis for doing all that stuff, that's not my world. But that would have required the state agency to adopt a very different strategy.”
Elsewhere, UCSF School of Nursing Professor Emeritus Charlene Harrington, who has studied nursing home oversight for decades, said state and federal officials dropped the ball by not putting more focus on facilities known to have problems with staffing and infection control.
Harrington said New Hampshire’s plan to focus its review of COVID-19 long-term care outbreaks on ventilation is “ridiculous.” Instead, she said they should look at how the virus spread through resident and staff contact, how residents are housed and whether too many residents are crowded into individual facilities.
“We need real reform. Nursing home residents are less than one percent of the population. There's no reason they should have died like this,” Harrington said. “It's poor nursing home quality that we've allowed to go on for years, and it's poor policy and oversight and regulation. There's no question about that.”
As Crisis Wears On, One Family's Left Feeling 'Helpless'
When Shibinette and other state leaders directing New Hampshire’s response to COVID-19 are asked to address the damage wrought in long-term care facilities, they’re careful to frame the conversation around certain pieces of data. It’s misleading, they argue, to focus only on the share of New Hampshire’s COVID-19 deaths linked to long-term care facilities: more than 80 percent, one of the highest in the nation.
“A percentage is a ratio,” Gov. Chris Sununu said when that statistic came up at a press conference in early June. “So what it really is, is a sign that we’re doing a very good job of keeping the mortality rate outside those facilities extremely low.”
Instead, Sununu and Shibinette have urged the public to focus on other metrics: New Hampshire’s relatively low number of total deaths due to COVID-19, for example, or the low percentage of nursing home residents who have died, when measured against all available beds. Given New Hampshire's proximity to places like Massachusetts, Connecticut and Rhode Island, which have all experienced serious outbreaks of their own, Shibinette said the state has "been able to manage the situation very, very well in our long-term care facilities."
Throughout the last few months, Shibinette has expressed confidence in New Hampshire’s handling of COVID-19 in nursing homes, pointing to a dedicated team launched within the public health division to focus solely on institutional outbreaks, and state’s oversight system more broadly.
Asked specifically about any steps taken to help Greenbriar, given its past record of noncompliance, the commissioner attributed the severity of its outbreak in part to the size of the facility. But she also stood by the state’s approach to holding facilities like Greenbriar accountable.
“We’re following the same system that’s been in place since probably the 1980s when it comes to plans of correction,” Shibinette said. “If they’re not correcting the action, you would see more steps from the state and federal partners, if they’re not correcting the deficiencies we find.”
That pattern of accountability is less apparent to Dianne Connelly, who said there have been many times in the last eight years when she’s wished she could remove her mother from Greenbriar because she worried about her safety. But it’s not that simple.
Before her mother moved to Greenbriar, Connelly took care of her at home for several years, but that wasn’t sustainable for either of them. Her siblings live out of state, making Connelly her mother's primary family caregiver. She's struggled to find an open bed at another facility close enough to be able to continue checking in on her mother regularly. On top of that, elder care is expensive — and Connelly says she doesn’t have the resources to easily move her mother back to her home or to another facility.
“It’s hard to be so unhappy with a facility because of so many failures and just feeling like your loved one that hasn't been cared for the way she deserves,” Connelly said. “Unfortunately, there's nowhere in my home that I can do it myself.”
Connelly says her family recently filed yet another complaint with the state over Greenbriar’s lack of communication, and the state responded to say they reprimanded Greenbriar for not being more transparent. As of press time, there’s no public record of that reprimand on the state’s licensing and inspection website.
And while Connelly’s mother has recovered from COVID-19, her daughter says she’s still suffering in other ways: She’s lost a lot of weight in the last month, her cognitive abilities have taken a sharp slide and she begs, tearfully, on phone calls to be able to see her family.
She was put on hospice care July 11, but since then Connelly has only been allowed to visit her once — and only after repeatedly petitioning Greenbriar. Despite the broad restrictions on visitation, state and federal officials have told facilities throughout the pandemic that they can still allow visits in “compassionate care situations," even during an active outbreak.
“It has been extremely difficult — emotionally, of course — but also just in the lack of communication, knowing what was going on with her, especially as she began to decline and could not really speak for herself,” Connelly says. “It's been the most helpless feeling, to feel like she feels like she's been abandoned.”
In one such moment of desperation earlier this summer, Connelly sat down and typed out a long note to Sununu and Shibinette. She wanted them to understand how painful it’s been to be cut off from her mom and to feel like her complaints about Greenbriar haven’t prompted any real change. More than anything, she wanted to remind state leaders that there were real people on the other side of the policy documents and data points they kept talking about.
“To you she may just be a statistic,” Connelly wrote, “but to my family she is a loving mother, grandmother, and sister, who has battled the debilitating effects of a stroke with grace and determination despite being trapped in a facility that she despised and that failed her.”
Editor’s note: At a press conference Tuesday afternoon, Health and Human Services Commissioner Lori Shibinette said this recent NHPR report on New Hampshire’s response to coronavirus outbreaks at state nursing homes omitted facts and was flawed by bringing a “predetermined narrative” to the story. We believe many of the commissioner’s claims mischaracterize our reporting and merit a fuller response.
Shibinette described NHPR’s report as being selective and biased in its use of facts regarding facilities’ inspection records and the severity of their COVID-19 outbreaks: “The attempts to correlate prior survey deficiencies to COVID outcomes only makes sense when you report part of the data,” she said. “So what wasn't reported is that several nursing homes that were deficiency free in 2019 also had significant COVID outbreaks.”
In fact, NHPR’s reporting underscored this exact point in several ways. For example, the story’s second section begins with this paragraph: “Even some of the best-equipped long-term care facilities in New Hampshire were caught off-guard by COVID-19. Shortages in testing and adequate protective gear — and a workforce that was already paid little and stretched thin — made it hard for the whole industry to respond to the pandemic.”
In addition, the story includes three separate graphics, using the state’s own data as well as federal data, about nursing homes with all levels of deficiencies and all levels of outbreaks. The story made clear, here and elsewhere, that it’s not possible to draw a direct correlation between a facility’s past performance and the severity of its outbreak. As the story says: “Outside New Hampshire, experts studying the pandemic’s toll on nursing homes across the country have not yet reached a consensus on the connection between a facility’s past track record and its ability to contain COVID-19.”
Shibinette noted that NHPR interviewed Melissa St. Cyr, the chief legal officer at the Department of Health and Human Services who has also managed the department’s licensing and certification bureau, and said the story failed to fully include St. Cyr’s perspective: “[St. Cyr] talked at length about all of the things that we did with the facilities in New Hampshire," Shibinette said. "And a lot of that was omitted because I think there was a predetermined narrative to that story.”
In fact, NHPR’s report included a summary of the relevant information that St. Cyr provided during an interview that was focused primarily on the state’s oversight practices for long-term care facilities. NHPR also sought, on multiple occasions, additional information from the department about the state’s testing schedule at long-term care facilities and PPE distribution at large, among other things, and did not receive responses to those inquiries.
Shibinette appeared to take issue with the story’s reporting on Greenbriar, the Nashua nursing home that has been the site of one of New Hampshire’s most severe COVID-19 outbreaks: “It certainly highlighted everything in Greenbriar's past,” she said. “It certainly did put the spotlight on Greenbriar and their prior survey history and try to make that correlation that we should have known that Greenbriar would have an issue because of their past deficiencies.”
NHPR focused on Greenbriar in this story because state and federal regulators have named it New Hampshire’s only “Special Focus Facility,” a designation for nursing homes that warrant extra attention because of past deficiencies. In a story about nursing home oversight, we determined that information is relevant. We also chose to highlight the experiences of one family at that facility to illustrate the human impact that the pandemic has had on the state’s nursing homes.
Finally, Shibinette suggested several times that NHPR’s overall reporting on the impact of COVID-19 on the state’s nursing homes has been slanted and has consistently sought to “place blame.”
“I think what I've seen in this article, in many of your reports, is trying to place blame,” she said. “And I don't think there's room for blame here.”
We will let our body of reporting on COVID-19 speak for itself. We will simply note that a news organization’s duty is to hold public officials accountable in times of crisis and to analyze how those crises were handled, to allow the public to better understand whether reform is needed to prevent similar losses in the future. We believe the story, and accompanying data and graphics, do so fairly, comprehensively and accurately.
