Why Was the Covid Death Toll So High at Some Veterans Homes?

How Charlotte Hall in Maryland, like other veterans facilities across the country, was devastated by the pandemic
(Illustration by Matt Williams)

It was almost Memorial Day, and retired Army Sgt. Bill Meck was thinking about the dead. It had been nearly a year since covid-19 had hollowed out Charlotte Hall Veterans Home — the state-run facility for veterans and their spouses where he lived. Before the pandemic, he could usually expect to honor a resident who had recently died. Taps would be played. An American flag would cover the body as it lay on a gurney. Employees and residents could line the hallway and sidewalk for a final salute. “With all of this, none of the guys have gotten that,” Bill said. The pandemic halted so much.

For most of 2020, Charlotte Hall was the site of the largest and deadliest coronavirus outbreak at a Maryland long-term-care facility. It remains the second-deadliest outbreak at a long-term-care facility in the state, and among the largest outbreaks in the country. So far, 66 residents and one staff member have died, and there have been 411 infections.

Among the dead were veterans of World War II, Korea and Vietnam. They were Army and Navy and Marines, fathers and husbands and brothers, recipients of the Purple Heart and the Bronze Star. Some had made a career of the military. Others had served for a few years. In their post-military life, their work varied: a machinist, a bus driver, a federal employee. Many of them had come to Charlotte Hall for the subsidized care it provided, a deep discount from private nursing homes whose costs their families could not afford.

Bill had lived at Charlotte Hall for about a decade, and in two other nursing homes before that. He knew the good and the bad of long-term care, that being close to death was part of it. But not like this. Near the height of the home’s outbreak, when its infection rate reached 50 percent and dozens of people had died in a matter of weeks, he asked to speak to a mental health professional. “I have been through a lot of s--- in my life, and that’s the first time I talked to a shrink,” he said. They met over Skype from the room where he was isolated.

Bill had not served during wartime, but the battle metaphors still came easy. “One of the other guys, he’s a combat vet. He said it’s like going out on patrol, getting ambushed, and you’re the only one that survived. And you spend the rest of your life asking why.”

Charlotte Hall was not alone in its struggles. Across the country, state veterans homes were among the most dangerous long-term-care facilities during the pandemic. More than 145 veterans died in two homes in New Jersey. One hundred and twenty-one at a New York home. Dozens more in Hawaii, Illinois and Oklahoma. Seventy-six veterans died in one Massachusetts facility, where two officials were later indicted on still-pending charges of criminal neglect.

The death toll raised urgent questions about what is owed to these veterans now and in the future. The country’s 160 state veterans homes are not run by the Department of Veterans Affairs, despite the fact that they are the largest institutional long-term-care provider for veterans. Instead, individual states own and manage them, and the department inspects them annually while paying more than $1 billion per year for their operation. The Maryland Department of Veterans Affairs oversees Charlotte Hall but outsources the facility’s management to a for-profit company, HMR Veterans Services. Last summer, the muddled oversight of state veterans homes — split as it is among federal, state and for-profit entities — prompted a congressional hearing, the title of which asked, “Who’s in charge?”

Bill felt the government had failed Charlotte Hall’s residents. He had spent part of the past year trying to get powerful people to pay attention to what happened there. A natural advocate, he had served for several years as president of the resident council. At 64, he was nearly two decades younger than many of the residents, and he was protective. “These are my guys,” he liked to say.

On Memorial Day this year, the veterans home held a ceremony to honor those who had died during the past year. It was smaller than normal, due to covid precautions. Staff members gathered to read aloud the names. But if anyone told Bill about the event or that it was broadcast on the home’s televisions, he hadn’t heard them. He missed it. In the video posted online afterward, the reading of the names of the dead had been cut out, for privacy reasons.

For Bill, none of this was good enough. He wanted a list of names of those who had died. He wanted a monument inscribed with them on the campus, a way to commemorate what happened. A larger memorial service. A ringing of bells. Something. “How the hell do I process all this?” he asked. He began to cry. “I didn’t get to say goodbye.” Perhaps most of all, what Bill wanted was an accounting of what had gone wrong at Charlotte Hall. After all, the residents had done a lot for their country. “If anyone deserved better,” he said, “these guys did.”

The first state veterans homes opened in the wake of the Civil War, when the ranks of disabled veterans soared. The homes were a manifestation of Abraham Lincoln’s pledge in his second inaugural address “to care for him who shall have borne the battle,” a quote that is enshrined on a plaque at VA headquarters in Washington.

Charlotte Hall Veterans Home opened in 1985 on the grounds of a former military academy in Southern Maryland. It’s Maryland’s only state veterans home and a community institution, a place where Scout troops drop off donations and the Veterans of Foreign Wars post sends money. A church group hosts a service on Sundays, and every year a car show fundraiser is set up in the parking lot. In obituaries, people in the surrounding towns often ask that memorial donations go to the vets home.

Bill Meck in 1976. (Courtesy of Bill Meck)

Bill’s journey to Charlotte Hall began in 1982, when he was a young Army sergeant stationed in Germany. He was driving off base when he swerved to miss a car that had slammed on its brakes. The last thing he remembers is hitting the windshield. No one else was seriously hurt in the crash, but he suffered a spinal cord injury. His C4 and C5 vertebrae were fractured, leaving him paralyzed from the chest down. He was 25 years old.

His younger sister, Patty Herrell, remembers waiting at the U.S. base where a transport plane brought him home. “It was shocking, just shocking,” Patty says. “There was a part of me that was like, no, this will get better.” Bill was placed in a Stryker frame; at the hospital, they would turn his whole body in the contraption, and sometimes he would be facing the ground. Patty would lie on the floor of his room, looking up, so they could talk face-to-face.

“We’re total opposites,” Patty says. “He was a brainiac. He was the scholastic guy. He could play any musical instrument you handed him.” Only 13 months older than her, Bill made honor roll and played in a band, while she was the rebel skipping school, giving her parents grief. She often thought about the irony that she was the one “on a fool’s errand all the time and he was such a good guy,” and then something like this happened.

Bill was honorably discharged, and he spent months in rehab at a VA hospital in Richmond, learning how to live as a quadriplegic. Later, he stayed in the area and got a job working for the city as a computer programmer. He married, but the marriage didn’t last. Patty wanted to move him back to Maryland, to be closer to family, and he agreed. They talked a lot about him coming to live with her, about remodeling her house for his wheelchair and hiring caregivers, but the costs were exorbitant, and Patty still had to work. He couldn’t be left alone. What if there was a fire, she thought, and he couldn’t get out?

He went to live in a nursing home, where he had access to round-the-clock care. Years later, he moved to Charlotte Hall because it was only six miles from Patty’s house. She could drop by anytime, bring him a plate of dinner, a steak or some crab meat in the summer. For 30 years, she had visited him every Friday. She and Bill met outside in the parking lot in early March 2020. It would be her last visit for a long time.

Meenakshi Brewster is the head of the health department in St. Mary’s County, where Charlotte Hall is located. She remembers being very impressed with the veterans home’s infection-control protocols. She met with the home’s leadership early in the pandemic. “They were on it,” she recalls. “They had a really solid team.”

The veterans home had vulnerabilities, though, and not just in terms of its at-risk elderly population. For one, it was a large facility, with at least 375 residents and 454 beds total, plus nearly 400 staff members. Brewster notes that by virtue of its size alone, it had a greater likelihood of a large outbreak. Its numbers also meant it had more than a few residents going to and from hospitals and doctors’ appointments for treatment. Many of its staff members also worked at multiple facilities to make ends meet. “It’s a small community, as nurses are in limited supply. Other staff are in limited supply,” Brewster says. “Staff take shifts at different facilities.” The more staff and residents moved about in the community and in and out of other facilities, the more likely it was that the virus would be transferred between locations.

On March 11, 2020, according to an internal memo, Charlotte Hall suspended visitation, except in end-of-life cases. But even as the home barred loved ones and nonessential visitors, residents in its assisted-living program — who live more independently than its nursing home residents — were allowed to come and go from the campus, creating another point of entry for the virus.

Two weeks after Charlotte Hall restricted visitation, on March 26, the facility had its first two residents who tested positive for the coronavirus. Both were from assisted living. On March 28, Brewster issued a short-term quarantine order for the assisted-living residents, discouraging them from traveling off campus. “We recognized that the mobility of the residents interfacing with their community was contributing to the spread of covid within that whole facility,” Brewster says, “including impacting the [nursing home side].” HMR then requested that its staff no longer work at multiple facilities; they had to choose one site.

By March 23, the state of Maryland was encouraging nursing homes to “cohort” covid patients and, if possible, to create a separate unit for them. Charlotte Hall had an empty unit, 1A, ready for residents with covid who needed skilled nursing care. The home, under the direction of the county health department, initially decided to keep the sick assisted-living residents isolated on their regular unit — a pattern that continued across the facility as the outbreak grew larger. In a statement, HMR said that unit 1A opened on April 8, when a covid-positive resident returned from the hospital. It also said temporary walls separated residents “when available space prohibited isolation on a dedicated covid unit.” This infection control strategy depended on sick residents remaining in their rooms, as the home mandated, but family members and nurses say it was nearly impossible to keep some residents from leaving their rooms and mingling.

It’s a key part of infection control to move sick residents into a separate wing, according to Charlene Harrington, a nursing-home expert and professor emerita at the University of California at San Francisco’s nursing school. “That’s common sense.” A delay can be “the kiss of death,” she says. “Once you have one patient, it can just spread.”

Thousands of pages of emails from state officials and HMR employees — obtained through a public records request — detail how the virus moved through the facility. At first, they were buoyed by the low case counts. Maryland Secretary of Veterans Affairs George W. Owings III bragged in an email about the “outstanding” work of the staff, writing, “The numbers speak for themselves.” By April 20, Charlotte Hall had at least six confirmed covid cases among residents — five of them in assisted living. Two and a half weeks later, it had 49 resident cases and three covid deaths.

“They were swamped,” says Col. Eric Allely, the Maryland Army National Guard state surgeon. “They didn’t have enough people to do everything they wanted to do as quickly as they would have liked to have done it.”

A Maryland Department of Veterans Affairs spokesperson declined interview requests on behalf of Owings and Sharon Murphy, who was the home’s director until she retired this year. Russell Keogler, the home’s administrator until last year and an HMR employee, also declined an interview, but he contributed to written statements provided by HMR.

Like in most facilities early in the pandemic, personal protective equipment (PPE) was in short supply, though Brewster says the veterans home never ran out. Gowns were particularly scarce. Ad hoc supply chains sprung up. Volunteers delivered face shields to the facility. HMR contracted a hockey-jersey manufacturer to make reusable gowns.

Coronavirus testing was also limited. It took days to get results. “Sometimes it was longer than a week,” Brewster says. On April 29, a month into the outbreak, Gov. Larry Hogan announced that Maryland nursing homes should test both the symptomatic and the asymptomatic. In May, a National Guard team arrived to assist with testing and moving positive patients into covid units. “They were swamped,” says Col. Eric Allely, the Maryland Army National Guard state surgeon. “They didn’t have enough people to do everything they wanted to do as quickly as they would have liked to have done it.”

After that round of universal testing, the home reported that 92 residents and 43 staff members had tested positive, and nine people had died of covid. Charlotte Hall was well managed with good procedures in place, Allely says, but “they were overwhelmed by the speed with which the disease moved through the community.”

Caring for residents with dementia became a particular challenge. “You can’t really train them to wash their hands or use hand sanitizer,” says Heyward Hilliard, HMR’s executive vice president of operations. It is doubly hard to have them mask or social distance. Dementia patients are prone to wandering, which is why they often reside in locked units specializing in memory care to keep them safe and limit their mobility. The website of the Centers for Disease Control and Prevention has stipulated that long-term-care facilities should weigh the pros and cons of keeping dementia residents with covid in their locked units, instead of moving them to covid units that aren’t set up for memory care. A loved one emailed Keogler on May 5 with a “plea to quarantine positive residents” who were still living on one of Charlotte Hall’s locked memory-care units, where there were then seven cases: “To hear from you tonight that it is difficult and that there are no current plans to quarantine … the positive cases on 1C from the twenty-five or so other residents is not only disappointing but quite frankly, negligent.” Keogler replied that they were very firm in following infection-control protocols set by multiple agencies.

Alex Kavounis’s father, Al, lived on a dementia unit. The 92-year-old was confined to his room after the outbreak. According to Kavounis, the World War II vet, a rule-follower to the end, would yell out his door if he could see fellow residents wandering in the hallway, telling them to stay in their rooms. On May 13, he died of covid.

Outside the home, loved ones waited for information. They could call a hotline and hear the number of cases that day. “The person who was doing the updates had just the kindest voice,” one family member says. The numbers kept going up. For some, it was hard to reach nurses on the units by phone.

On May 23, Cedric Davis got a phone call from his sister that his 95-year-old father, James H. Davis, was nearing the end after a covid diagnosis. Born in segregated South Carolina before moving to New York, his father had served during the Korean War. What little he told his three children about the war included that “it was coldest place he’d ever been.” Later, he became an Army recruiter in the D.C. area, and he retired after 24 years in the service.

Cedric thought he could see his father in person if death was imminent. When he drove to Charlotte Hall from his home in D.C., he says, a staff member told him it was a false alarm, and he was turned away — only to receive a call within an hour that his father had died. (In a statement, HMR told me that staff mixed up two residents with the same name.) Cedric returned to the entrance in a rage. His sister, Sandy Davis, was afraid he would break the doors down with a nearby hand-sanitizer stand. Security guards never let him get into the lobby. Cedric Davis says, “The next time I saw my father was in the funeral home.”

For weeks, Bill’s unit had been spared from the virus. The building’s main dining room was closed, but Bill says his unit, 3C, had its own dining area, where the staff still served residents communal meals. He chose to stay in his room. (HMR says residents were supposed to eat in their rooms, and, when possible, those who needed assistance with eating were to receive help in their rooms.) Many rooms at Charlotte Hall were shared, and between most rooms was a shared bathroom. Bill said he spoke to a supervisor about residents who weren’t social distancing. “Well, we can’t make them stay in their room” was the reply. Bill told me, “I mean, I get it, there were guys here that were really hard to keep in their room. Okay, but you know, letting them wander in and out of everybody else’s room was not helping anything.” According to his notes, the first covid case showed up on his unit on May 14.

Employees were also falling ill in large numbers. A staff member died of covid. At one point, the home’s assistant administrator had a symptomatic case of covid and was trying to telework, according to an account in Provider, a trade magazine. Keogler, the home’s then-administrator, told Provider that he slept on an air mattress in his office and that 24-hour shifts for him were common.

Without adequate staffing, it becomes more difficult to practice good infection control. Hilliard of HMR says, “You lose some of your tools and controls because you’re not just battling the virus with those you’re taking care of, you’re battling it with those who are doing the caring.” On May 24, a volunteer who had a loved one at Charlotte Hall emailed the state secretary of health to complain about the staffing shortages. “Nurses and aides are working the covid wings and crossing over to the healthy units to fill in the shortages,” she wrote. “One night shift over Memorial Day weekend had only one nurse, one aide for 40 residents. This is unacceptable.”

In May, nearly two months into the outbreak, Charlotte Hall and the state alerted the regional Veterans Health Administration that help was needed. Murphy emailed that “staffing is at a critical low.” By late May, the home had recorded 15 deaths and 162 total cases, including 48 among the staff. While VA is clear that it doesn’t run the state veterans homes, it can provide extra health care and resources in times of crisis.

“If they did such a good job, how come so many of my buddies are dead?” asks Charlotte Hall resident Bill Meck.

The federal agency deployed 38 volunteer nurses within five days from D.C., Maryland and West Virginia. They arrived at a local hotel with go-bags of PPE and extra supplies for the facility. VA personnel also provided training to the Charlotte Hall staff in infection control, patient safety and PPE use, according to a Veterans Health Administration report. VA nurses staffed most of the night shift at Charlotte Hall and later helped on the day shift. They helped create three additional covid units to house the growing number of positive residents, according to the same VHA report. “The last three days have been incredibly challenging,” Keogler wrote to senior staff just before midnight on May 25.

Sabrina Morningstar, a registered nurse from a West Virginia VA facility, deployed to Charlotte Hall for three weeks, arriving on May 25. What she remembers most about her first day is how thankful the staff were for their help — and how large the outbreak was. “They had been working very hard on very slim staffing numbers,” she says. Morningstar, an assistant nurse manager, says they prioritized assigning staff to either covid units or non-covid units for shifts. That first week was especially hard. The death toll was “very high,” and she focused on supporting the Charlotte Hall staff. “We are human,” she told me. “If you need to cry, cry.”

On unit 3C, Bill heard his roommate coughing. Not long after the VA reinforcements arrived, his roommate tested positive and was moved to a covid unit downstairs. Within two days, Bill also had a positive test and was moved to another covid wing. VA’s arrival couldn’t stop what was already in motion: Their mission coincided with the deadliest weeks of the outbreak.

One of those losses was Cy “Tike” Butler, an 81-year-old Navy veteran with Alzheimer’s. In late May, his family got a call that someone he shared a bathroom with had covid, and then a few days later, he had it. He was eventually sent to the hospital, where his daughter Sandi Junge held the phone so her high-risk mother could talk to him before he died. “They just had the love story,” she told me later. Married 55 years and still holding hands. Her mother had polycystic kidney disease and died nine months later. “If you can die from a broken heart,” says Junge, “I think she did.”

At one point, more than half the residents were testing positive. By mid-June, more VA staff had been deployed to the home from across the country. Dementia care continued to be a challenge. Brandi McAtee, a VA licensed practical nurse from Missouri, worked on a dementia unit at the home and says that at one time 31 of her 33 patients had covid. She says they tried to implement hand hygiene, keep the residents out of one another’s food and redirect wandering residents to their rooms. “I would say that is probably why they had so many that were positive,” she says. “That is a huge challenge to keep everyone separate.”

Vicki Bromble’s father, Charles Colona, 88, lived on the same dementia unit as Cy Butler. During his 20 years in the Army, he served in both Korea and Vietnam, earning a Purple Heart and a Bronze Star. But his body couldn’t handle the combination of covid and Alzheimer’s. The staff connected with the family over Zoom so they could say goodbye. “They let us stay on for as long as we wanted. They kept saying how sorry they were,” Bromble says. The family talked for two hours. Colona died early the next morning, on June 24.

The last shift of the VA mission ended two days later, on June 26 at 7 a.m. The mood wasn’t triumphant. It got weirdly quiet, a VA employee says. They gathered up the extra supplies to donate, providing thousands of gowns, gloves and masks to Charlotte Hall. The rates of positive tests had finally slowed to a trickle, and the outbreak was getting under control. And yet, so much had already been lost. In the span of one week, 22 residents died of covid. In little more than three months, 60 people had died and 298 residents and staff were infected.

Bill was among the lucky ones. He never had any symptoms after testing positive. Still, he waited in his private room on one of the covid units. It was lonely and tedious. When he arrived, he hadn’t bothered to have his things unpacked because he expected to be there for only two weeks. Instead, the weeks turned into two months.

In better times, he loved taking his wheelchair out on the trails that surround the home. An avid photographer, he would snap nature pictures with a camera mounted to his chair. One of his favorites showed the vanishing point of a horizon, where it appeared as though the trail went on as far as the eye could see. By comparison, his room and world were now very small. He watched a lot of movies and television to pass the time, but there was only so much to stream.

He grew depressed. During phone calls, it was the saddest and most frustrated that Patty had ever heard him, and that included when he found out he would never walk again. “I was actually scared that he would just die of sadness, and that’s the truth,” Patty says. Bill didn’t know how many people had succumbed to the virus around him or who was gone, aside from snippets he heard from his nurses. One kindly let him know that his former roommate had died.

Other residents also struggled. Retired Army Sgt. 1st Class Harvey Greene, a longtime assisted-living resident, would dress every day, only to sit and stare at the television. He avoided the virus, but two close friends died of covid. “It was very difficult,” he recalls. He knew that a lot of people had gotten sick, but he wasn’t sure how many were gone. What haunts him the most is that his mother died while the home was locked down. Because he was under quarantine orders, he says, he couldn’t attend her funeral. “It still hurts me today.”

Retired Marine Lt. Col. Philip Forbes, who served in Vietnam, says the staff has “taken real good care of me,” but it didn’t make the isolation easier. “You get very frustrated,” he says. He missed dinners with his wife, smelling the grass outside, getting to Mass on Sundays. “Thank God for news channels,” he says, “or we could be on the moon when they lock you down.”

In isolation, Bill began writing an essay. The work was painstaking. He has some movement in his arm, so he used those muscles to propel his hand toward the keyboard. He hit each keystroke with the side of his thumb. One letter at a time, for 1,145 words, he worked out his thoughts, spending two days on his draft. “These men and women deserved better than they got. Those of us who survive this, we deserve better too,” he wrote. He was angry now, and Patty thought it was better when he grew angry — that at least he had something to fight for. He wrote, “I’ll add, the state of Maryland failed its most vulnerable residents.”

He critiqued the staffing requirements as too low, noting that he regularly saw two or three nursing aides caring for 42 people on a shift. He lamented the veterans who died alone of covid, and he advocated for better PPE stockpiling. He criticized politicians who came for photo ops with veterans but then failed to ask them what could be better.

He emailed the essay to Kate Ricks, a founder of Voices for Quality Care, a nonprofit advocacy group. Bill had been a member of the organization for years. The public didn’t hear enough from people in long-term care, Ricks believed: “We don’t listen to the people really involved.” Ricks put the essay on the group’s website and its listserv. On June 19, 2020, she emailed it to Maryland politicians and officials with the subject line: “A COVID-19 message from a Veteran living at Charlotte Hall Veteran’s Home.”

They got a few responses, including some emails that confirmed receipt. The governor’s office sent a form response about covid protocols. Bill was touched when state Del. Benjamin Brooks from Baltimore County, himself a Vietnam veteran, spent nearly two hours on the phone with him on July 3. He listened to Bill’s complaints on everything from the food at Charlotte Hall to low morale because of covid. Brooks reached out to Owings and Murphy. His office followed up with Bill, explaining that they had passed along his concerns. (“These concerns were reviewed and determined to be unsubstantiated,” HMR told me in a statement.)

Around the same time, on July 4, 2020, as a thank-you from HMR for their work during the outbreak, some Charlotte Hall staffers were treated to a “Salute to America” event at the White House. Keogler, the Charlotte Hall administrator, later told Provider magazine that guests were “encouraged” to wear masks and “most people complied.” HMR had received 10 extra tickets through its relationship with the American Health Care Association, the largest lobbying organization for the long-term-care industry. That month, not long before Bill was moved back to a regular room, it was announced that Keogler had been promoted to regional vice president at the company, in part because of his leadership during the pandemic. He now works at the company headquarters and oversees homes in South Carolina and Maryland, including Charlotte Hall.

Bill liked Keogler, an HMR employee, just fine. He called Murphy, who was a state of Maryland employee, “one of the good ones.” Murphy, a beloved figure on the campus, had been with the home since it opened and retired this year after 37 years of service. Bill said she listened anytime you went to her office. But he still had nagging questions about the outbreak. “If they did such a good job, how come so many of my buddies are dead?”

“We’ve known for years that more staff, and more registered nurses in particular, means better care,” says Toby Edelman, senior policy attorney at the nonprofit Center for Medicare Advocacy.

Sen. Chris Van Hollen’s office flagged Bill’s essay for the Maryland Department of Health, which then reached out to Bill. It would take almost 10 months before anyone investigated his concerns. Inspectors arrived at Charlotte Hall on April 5, 2021, to investigate 26 complaints, according to records from the Centers for Medicare & Medicaid Services (CMS), which is part of the Department of Health and Human Services. Bill soon received a letter from the Maryland Office of Health Care Quality stating that inspectors “were not able to find that a specific regulation was not being met” in reference to his complaint. Inspectors did find the home in noncompliance for six other issues, though. In the most disturbing account, from June and July 2020, a resident sexually abused two other residents with dementia. In both instances, a month apart, the perpetrator was found naked in the other residents’ rooms, committing sexual acts, and police were notified. The resident had a history of wandering and sexually inappropriate behavior. Inspectors faulted the home for not providing adequate supervision.

The complaint inspection reports from April 2021 did not detail incidents related to covid-19 and infection control. Many inspections were suspended early in the pandemic, and a CMS spokesperson confirmed that no CMS inspector went into Charlotte Hall in April or May 2020, when the facility was most overwhelmed by the virus. An “off-site” review was done instead. No regular VA inspections happened at the home at all in 2020, according to the agency. A CMS inspection focused on infection control was completed on June 11, 2020, only after VA had provided extra staff and resources and the home was starting to get a handle on the outbreak. That inspection found no deficiencies.

Charlotte Hall now scores three out of five stars on CMS’s nursing home rating system. Its health inspections are deemed “below average” by CMS, and its quality of care for long-term residents earns one star, meaning it is “much below average.” By many measures — the amount of antipsychotic medicine given; the number of residents who have major falls — it receives negative marks. As of this summer, a red hand symbol appears next to Charlotte Hall’s name on Medicare’s website — a warning that the home has been cited for abuse.

Even after everything, many family members remain protective of the caregivers at the home, recalling all they did for their loved ones. Sandi Junge remembers the woman who cleaned the floors and how she would dance with her father. “We loved the staff,” she says. Alex Kavounis received a card after his father died, and nurses had signed it and put little stories about his dad in there. “I thought that was a really nice touch,” he says. Fewer than half of eligible Charlotte Hall family members responded to a state survey sent out in late 2020, but of those who did, 96 percent said they would recommend the facility.

On the one hand, there were compassionate acts by so many of the staff who risked their own lives, and on the other hand, the entire long-term-care system seemed broken. “The system failed them,” Junge says. “Because the workers, they were crushed. They had to watch these people that they care for lose their lives.” Junge couldn’t understand why it wasn’t a bigger deal that dozens of veterans at Charlotte Hall had died. Vicki Bromble didn’t blame the nurses either. “Even though I was angry, it wasn’t their fault.” And yet, she was troubled that Charlotte Hall was run by a private company.

It bothered Bill too. “That’s a question I’d like to ask the state of Maryland. Why is the veterans home a for-profit facility? It should not be.” He had lived in both nonprofit and for-profit facilities, and, hands down, he thought that nonprofit homes were better. Better care, better food, all around better — a sentiment that some studies back up.

“Most of these nursing home for-profit companies are trying to make money, and they cut corners on the staffing,” says Harrington, the nursing-home expert at UC San Francisco. Over and over, family members mentioned that Charlotte Hall did not have enough staff, even before the pandemic. A recent audit of the Maryland Department of Veterans Affairs found that it could have revoked $277,000 from HMR’s contract because the company had not filled enough staff jobs, including seven nursing positions that had been vacant for up to a year. In response, MDVA cited nursing shortages as an industry-wide problem and said the vacancies were not necessarily HMR’s fault.

But many of these difficult jobs are also notoriously low-paid. HMR confirmed that some positions at Charlotte Hall start at $11.75, Maryland’s minimum wage. One former employee who recently left says she was making little more than $15 an hour after 13 years of service.

Charlotte Hall’s staffing ratio for registered nurses is low, according to CMS data. “Their staffing rating isn’t bad,” Harrington told me, “but their RN staffing rating is very bad.” On average, according to CMS, the home’s registered nurses spend only 37 minutes per day with each resident who requires nursing care. The statewide average is 58 minutes. Harrington says the minimum should be at least 45 minutes, and more with acute residents. Charlotte Hall has more than the average time logged for nursing aides and licensed practical nurses, who do the bulk of the caregiving in nursing homes but lack the credentials that RNs have. They are also cheaper for companies to hire, as they earn lower wages.

The number of RNs matters for overall care, since they are more highly trained, including in infection control. One study of Connecticut nursing homes, from the Journal of the American Geriatrics Society, found that every 20-minute increase in RN staffing was associated with 22 percent fewer covid cases. For homes with at least one covid death, 20 more minutes of RN staffing predicted 26 percent fewer covid deaths. “We need more registered nurses in nursing homes,” says Toby Edelman, senior policy attorney at the nonprofit Center for Medicare Advocacy. “We’ve known for years that more staff, and more registered nurses in particular, means better care.”

HMR manages 12 state veterans homes in four states, including four in South Carolina, where the company is headquartered. Its struggles during the pandemic reached beyond Charlotte Hall. A Texas Tribune-Houston Chronicle investigation found that Texas’s nine state veterans homes had more than double the death rate from covid compared with other nursing homes in Texas. Three of those homes are run by HMR, and the investigation found that HMR’s facilities “accounted for 40% of the fatalities among sick veterans home residents.” (HMR notes that veterans homes care for residents with more risk factors than other nursing homes.) A state official has vowed not to renew the company’s contract. According to the Wall Street Journal, an HMR facility in Alabama — which as of December had 46 deaths and 96 cases — did not “sufficiently separate” sick residents with coronavirus, family members said. (HMR disputes this claim.)

There were also troubling incidents before the pandemic. In 2018, one of HMR’s veterans homes in Walterboro, S.C., was fined $260,746 by CMS and cited for deficiencies that put many residents in “immediate jeopardy.” An inspection stated that the home failed to fully investigate incidents of abuse, and that the staff used “misleading and unclear” wording in their descriptions, as first reported by the Greenville News. According to inspectors, staff members had been told to use “soft” language that downplayed the severity of incidents. (HMR disagrees with the “surveyor’s interpretations,” adding that “these findings will remain in dispute.”)

And yet, for some families, an HMR facility like Charlotte Hall was still the logical choice. “It was our only option,” Kavounis says. His family couldn’t afford other facilities for his father’s dementia care. With his father’s combined benefits, he says, they paid nearly nothing out-of-pocket at Charlotte Hall.

For Bill Meck’s family, too, the choice made sense. In the fall of 2020, his own father made the difficult decision to move into Charlotte Hall as he was dying from heart disease. A Vietnam veteran, he was no longer able to live in his own home. Bill said it was his and his father’s greatest fear that they wouldn’t be able to see each other before the pandemic was over, a surety if they were in separate nursing homes. His sister says, “His one wish was he wanted to see his son before he died, and so he got to.”

Their father was quarantined as a precaution when he arrived from the hospital, but Bill got to greet him through a window with a balloon on his 93rd birthday. Soon, Patty and her daughter received permission to visit so they could say goodbye. Together with Bill, they spent three hours in their father’s room. “Promise me you’ll take care of your brother,” their dad told Patty. He died nearly a week later, on Dec. 17 around 2 a.m. When Patty got Bill on the phone, she cried as she told him the news. “He said, ‘They didn’t even tell me.’ And he’s right down the hall.”

Meck with his father, William H. Meck Jr., also a veteran, at Charlotte Hall Veterans Home in Maryland in 2019. (Courtesy of Bill Meck)

Some leaders of state veterans homes argue they have been unfairly blamed during the pandemic. Melissa Jackson, who heads the Vermont Veterans’ Home, told me, “The moment this pandemic hit, we became the scapegoat, the whipping boy, whatever you want to call it for everything that went wrong with this pandemic.” Jackson is the immediate past president of the National Association of State Veterans Homes (NASVH), a volunteer advocacy organization for the industry. She says the entire country was unprepared for the coronavirus, but state veterans homes were singled out because of the important population they serve. “If it doesn’t have the word ‘veteran’ in it, it’s not as enticing to the press,” she says.

Heyward Hilliard of HMR is the new president of NASVH. He says HMR did the best it could with the information available, when guidance and best practices changed rapidly early in the pandemic. “Company-wide, I don’t sit here and claim by any means that HMR was the perfect warrior in this fight,” he told me. “I think we were super attentive. I think we had the support of great resources at all levels. I credit the staff.” In terms of Charlotte Hall’s handling of the outbreak, he says, “Nobody’s perfect, but I think they did a good job with it.”

They were also dealing with a fragile population. Hilliard points out that residents of state veterans homes, when compared with the general long-term-care population, are more likely to be male and older than 85 — two traits that make them more vulnerable to the virus. Charlotte Hall’s residents are 83 percent male. The average age is 82, and 40 percent of the residents are over 85, according to the Maryland Health Care Commission. A registered nurse who used to work at the facility estimated that at least half the residents had mental health issues — yet another complication in managing infection control.

These traits, however, do not guarantee poor pandemic outcomes. California’s eight state veterans homes have experienced only 11 covid deaths among residents, despite their vulnerable population, high community covid rates and large facilities. A home in Yountville has had just one covid death among 650 residents. The state of California — not a private company — manages the homes directly, and its secretary of veterans affairs is a physician.

For all the homes, there is still the issue of VA oversight. A 2019 Government Accountability Office report found that VA inspections of state veterans homes were lax and corrections were not adequately enforced. In July 2020, the GAO reiterated those concerns. Though most GAO recommendations have now been implemented, VA still does not post inspection data for state veterans homes on its website.

There is also the question of whether Veterans Affairs should be more involved in the homes’ operations. Charlotte Hall was able to get its outbreak under control with extra VA resources, but could more lives have been spared if the facility had that backup from the very beginning? Linda Schwartz, a former VA assistant secretary who once led a state veterans home, bristles at the idea that these facilities are not deemed an integral part of the agency. “They are not the bastard children. They’re augmenting the care that VA provides to the aging veteran population,” she told me. State veterans homes care for more than 20,000 vets each day — more than half the veterans in VA institutional long-term-care programs. And yet, they receive less than a fourth of VA’s institutional long-term-care budget. The amount VA pays them per nursing home resident is nearly 40 percent lower than private community nursing homes.

In the past year, Congress has allocated an additional $1 billion for state veterans homes through VA. The money includes coverage for emergency expenses as well as construction and renovation grants — part of making large, outdated facilities safer during an outbreak. In response to an extra $6.2 million in federal money that Charlotte Hall has already received, the Maryland legislature briefly considered reducing the home’s state budget by $1 million for a year, as part of a fund swap. It was a controversial proposal. As a Charlotte Hall employee wrote on Facebook: “we’re barely making ends meet as we speak our veterans deserve more than what they’re getting … now you’re trying to take what little they have.” The measure didn’t pass. HMR said the extra federal money has gone toward increased pandemic-related costs. Its base contract with the state estimates that the cost to operate the facility for four years is more than $170 million. That contract just renewed for a two-year term; it is up for another renewal in October 2023. Soon Maryland will also have another veterans home to run: The state is in the planning stages for a second facility. HMR will have to bid on the contract to manage it.

NASVH held a conference in Biloxi, Miss., this summer. Jackson says there was venting and commiseration among the members about the previous 18 months. Her general sentiment was: “Why do they have to make us look like the bad guy?” She and other leaders of state veterans homes are trying to prepare for the next pandemic. Her facility plans to build a wing with more private rooms and bathrooms for better infection control. She says some homes want to have at least six months’ worth of PPE in storage. She adds, “We’re not going to be caught with our pants down ever again.”

In August, there was another outbreak at Charlotte Hall. Two more residents died of covid, according to HMR and Maryland covid data. Between the weeks of Aug. 18 and Oct. 20, Maryland reported that 15 residents and 17 staff members tested positive. Bill Meck didn’t know how the outbreak started. He suspected that vaccinated residents had breakthrough cases and were too vulnerable to withstand the virus. “It still makes me mad,” he says. “They were at the end of their lives, but you don’t need to shove them out the damn door.”

Ninety-six percent of the home’s residents had gotten a vaccine, but by Sept. 5, not long after the governor mandated that Charlotte Hall employees get vaccinated, only 58 percent of the facility’s staff had been, according to CMS. “You have to have a 90 or 100 percent vaccination rate to be safe,” Harrington told me. In September and October, news releases from the Maryland Department of Health ranked Charlotte Hall among the 10 facilities with the lowest staff vaccination rates in the state.

With the outbreak came another lockdown and a cessation of visitation. For Bill, the resumption of normal life had been short-lived anyway. Starting last fall, he had been able to visit with his family outside, and he looked forward to more activities after his vaccination in February. But in the spring, a nurse noticed that his knee was red and swollen. It turned out to be a spiral fracture in his femur. Though he couldn’t feel it, the break made for a long recovery. It wasn’t prudent to ride far in his wheelchair, or around the grounds or trails, lest he bump his injured leg and make the problem worse.

By September, he had spent the better part of five months back in his room, and mostly in bed, waiting to heal. Bill didn’t blame the staff. Forty years of immobility and these things happen. Patty thought someone had turned him wrong, but she didn’t suspect abuse. Her brother, after all, was not afraid to call 911 if he suspected anything. “He has done it before.”

There was nothing Bill could do about the leg, so he tried not to let it “p--- him off.” He could feel himself taking it out on the employees sometimes, which he didn’t want to do. “It’s not y’all’s fault,” he’d tell them. It was the isolation that got to him. After his leg fracture, his sister had received special permission to see him indoors occasionally, but with the second outbreak, even that was put on hold for two months.

Bill still saw his care team, of course, and he appreciated that they were no longer decked out in full PPE, like they were entering a lab, when they came into his room. A staff member had asked him recently if he would help with a resident council meeting. He was thinking about saying yes and getting involved again. But he also debated whether it was time to take a step back from nursing-home advocacy. “How do you stop caring?” he wondered. “How do you get to that point?” He didn’t know yet. He was still looking for answers.

Tiffany Stanley is a writer in Washington.

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