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Nursing Homes Oust Unwanted Patients With Claims of Psychosis

In a New York nursing home, a resident hurled a bingo chip. At a home in Georgia, a 46-year-old woman, paralyzed from the waist down, repeatedly complained that no one had changed her diaper. In a California facility, a patient threw tableware.

In all three cases, the nursing homes cited the incidents as a reason to send the residents to hospitals for psychiatric evaluations — and then to bar them from returning.

Across the United States, nursing homes are looking to get rid of unprofitable patients — primarily those who are poor and require extra care — and pouncing on minor outbursts to justify evicting them to emergency rooms or psychiatric hospitals. After the hospitals discharge the patients, often in a matter of hours, the nursing homes refuse them re-entry, according to court filings, government-funded watchdogs in 16 states, and more than 60 lawyers, nursing home employees and doctors.

The practice at times violates federal laws that restrict nursing homes from abruptly evicting patients.

“Even before the pandemic, there was tremendous pressure to get rid of Medicaid patients, especially those that need high levels of staffing,” said Mike Wasserman, a former chief executive of Rockport Healthcare Services, which manages California’s largest chain of for-profit nursing homes. “The pandemic has basically supercharged that.” He said homes often take advantage of fits of anger to oust patients, claiming they need psychiatric care.

About 70 percent of American nursing homes are for profit. The most lucrative patients are those on short-term rehabilitation stints paid for by private insurers or Medicare, the federal program that insures seniors and people with disabilities. Poor people on longer-term stays are covered by Medicaid, which reimburses nursing homes at a much lower rate than Medicare.

The financial incentive to have more Medicare or privately insured patients, and fewer on Medicaid, becomes more pronounced when the Medicaid patients have illnesses, like dementia, that require extra care from staff.

Nursing homes have faced acute staff shortages as the coronavirus has left employees sick or afraid to go in to work. Workers said they faced increased pressure from their employers during the pandemic to get rid of the most expensive, least lucrative patients.

Invoking psychiatric problems is a popular tool. Nursing homes routinely admit patients with dementia, Alzheimer’s or similar illnesses, and angry outbursts are common.

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Credit…Alexis Hunley for The New York Times

In March, the Rehabilitation Center of Santa Monica, Calif., sent Joan Rivers, who suffered from dementia and was on Medicaid, to the emergency room at USC Verdugo Hills Hospital. The nursing home’s staff said Ms. Rivers, 87, had tossed aside her chair, scaring other residents, according to her daughter, Evon Smith, and a government-funded watchdog.

Within 24 hours, the hospital cleared her for discharge.

Ms. Smith said that she had repeatedly asked the Rehabilitation Center to take her mother back, but that it had refused. A social worker at Verdugo Hills said she, too, had tried unsuccessfully to get the nursing home to readmit Ms. Rivers.

Linda Taetz, the chief compliance officer at Mariner Health Care, which operates the Rehabilitation Center and 19 other nursing homes in California, said the center hadn’t known that Ms. Rivers wanted to return.

Ms. Rivers eventually was admitted to the Colonial Care Center nursing home in Long Beach, Calif. There, she contracted Covid-19. She died on July 20.

Federal law requires nursing homes to follow strict guidelines when they intend to evict someone: They must give 30 days’ notice and come up with a plan to transfer the resident to a facility that can meet his or her needs. If a resident goes to a hospital, the facility must hold the bed for a week.

But nursing homes frequently flout these rules, according to employees and state-funded ombudsmen who help oversee the industry. The New York Times reported in July that nursing homes were evicting an increasing number of low-income — and therefore low-profitability — residents into homeless shelters and run-down motels, apparently in violation of federal law.

There is no national data on nursing home evictions. The Times contacted ombudsmen in all 50 states. Some said they had not seen nursing homes dumping patients in hospitals during the pandemic. But in 16 states, including California, Texas and New York, ombudsmen said the problem was continuing. Some said they believed it was getting worse.

“We have been seeing these kinds of illegal discharges all the time, because nursing homes seem to have figured out that they will rarely, if ever, be penalized,” said Alison Hirschel, senior legal counsel to the Michigan ombudsman program. “It’s devastating for residents and their families all the time, but especially horrible and dangerous during a pandemic.”

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Credit…Alexis Hunley for The New York Times

Medicaid patients who require lots of staff attention “have a target on their back,” she said.

The problem predates the pandemic.

Gloria Single was a resident of the Pioneer House nursing home in Sacramento. She had dementia and pulmonary disease and was on California’s version of Medicaid. Pioneer House was receiving about $400 a day for her care.

In 2017, Ms. Single got upset and threw utensils, according to a lawsuit against Pioneer House filed in state court by Ms. Single’s lawyer. The nursing home called 911, and Ms. Single was taken to a hospital for an involuntary psychiatric hold, in which patients are held until they are determined not to be a danger to themselves or others. The hospital determined later that day that there was nothing wrong with Ms. Single aside from her pre-existing dementia.

But Pioneer House would not let her return. The California Department of Health Care Services concluded that Pioneer House had violated the law and ordered it to let her go back. The home still refused. After about five months at the hospital, Ms. Single was moved to another nursing home. She died last year.

“You can get $1,000 extra a day by getting rid of the Gloria Singles of the world and replacing them with someone on Medicare,” said Matthew Borden, Ms. Single’s lawyer.

John Supple, a lawyer for the Retirement Housing Foundation, which operates Pioneer House, said that its medical director had deemed the home unsuitable for Ms. Single’s medical needs and that Pioneer House had never received the medical records it needed to readmit her. (Ms. Single’s lawyer disputes that. The lawsuit is ongoing.) Mr. Supple said Pioneer House had held Ms. Single’s bed for months and had not replaced her with a Medicare patient.

During the pandemic, nursing homes in Illinois and Michigan have repeatedly sent elderly and disabled Medicaid patients to NeuroBehavioral Hospital in Crown Point, Ind., said Kimberly Jackson, a discharge planner at the psychiatric hospital. In one case, a resident who yelled at a staff member was branded as being violent and having a psychotic break.

“The homes seem to be purposely taking symptoms of dementia as evidence of psychosis,” Ms. Jackson said. (Christy Gilbert, the chief operating officer of the hospital’s parent company, said instances when nursing homes dumped patients in her company’s hospitals were “very few and far between.”)

In June, Life Care Center of Plainwell, Mich., sent Nicki Safapour, a Medicaid patient who needs a wheelchair, to NeuroBehavioral Hospital. Because of a developmental disability, Mr. Safapour, 55, has the mental capacity of a 5-year-old, according to his brother John, who is his legal guardian. He said Life Care had told him that Mr. Safapour assaulted an employee and another resident.

A state health inspector later determined that the discharge was illegal, according to a copy of the inspector’s report reviewed by The Times.

“It seemed like they were just trying to get rid of Nicki,” John Safapour said. “He took up a lot of staff time.”

A spokesman for Life Care, Davis Lundy, said that privacy rules prohibited him from discussing Mr. Safapour’s case, but that Life Care had a significant number of residents on Medicaid and that “we never discharge patients based on their payer source.”

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Credit…Nick Hagen for The New York Times

The families of some evicted patients have had to take them into their homes, although they lack the training or equipment to care for them.

In June, Connie Rodina got a phone call from the Richmond Healthcare and Rehabilitation Center in Richmond, Kan. Her 63-year-old brother, Jon Fowler, who suffers from mental illness and dementia, had hit another resident. Ms. Rodina, her brother’s guardian, was told that she needed to pick him up immediately.

By the time Ms. Rodina arrived, Mr. Fowler was already being transported to an emergency room. The hospital was ready to discharge him a couple of days later, after treating him for a urinary tract infection. Ms. Rodina said Richmond Healthcare wouldn’t take him back.

“You can’t just put somebody out like that,” said Camille Russell, a regional ombudsman who filed a complaint against the facility with the Kansas Department for Aging and Disability Services. The complaint is pending, she said.

Ms. Rodina couldn’t find another nursing home that would admit Mr. Fowler, who needs near-constant care. After her brother had been in the hospital for weeks, she reluctantly moved him into her home.

“It’s basically taken my life away from me,” Ms. Rodina said. “It’s impossible for me to care for him.”

Representatives of Richmond Healthcare didn’t respond to requests for comment.

In some cases, nursing homes have ignored orders from regulators to take back patients they sent to emergency rooms or psychiatric hospitals.

Charles Borden, a stroke victim with dementia, had been staying at the skilled nursing facility at Tahoe Forest Hospital in Truckee, Calif. Medicaid was covering his long-term stay. But in April, after Mr. Borden elbowed a nursing assistant and cursed at her, the nursing home sent him to the hospital’s emergency room for a psychiatric evaluation.

Within hours, the emergency room cleared Mr. Borden to return to the nursing home. But it wouldn’t take him back, according to court records. (While the nursing home and the main Tahoe Forest hospital share a campus and are owned by the same organization, the nursing home is financially independent from the hospital.)

Later that day, the nursing home dropped off all of Mr. Borden’s possessions at the E.R. and moved another resident into the room that Mr. Borden had shared with his wife, Beverly.

Two days later, on April 22, Mr. Borden’s son appealed the decision to California’s health care agency. It determined that the nursing home was legally required to take Mr. Borden back. The nursing home refused.

The state agency said it had no authority to force the nursing home to let Mr. Borden return, aside from fining it $50 for every day it refused.

Matt Mushet, a lawyer for the nursing home, said it “is committed to the optimal safety of all patients and team members.” He said that he couldn’t comment on Mr. Borden’s case but that “it’s important for the public to understand there is more than one side to this story.”

Mr. Borden has spent the past five months marooned in the hospital. His dementia makes it hard for him to understand what is going on, his son said, but Mr. Borden asks every day to see his wife.

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Nursing Homes With Safety Problems Deploy Trump-Connected Lobbyists

Some want direct government aid. Others want tax breaks. Many want protection against lawsuits.

Nursing homes have been the center of America’s coronavirus pandemic, with more than 62,000 residents and staff dying from Covid-19 at nursing homes and other long-term care facilities, about 40 percent of the country’s virus fatalities. Now the lightly regulated industry is campaigning in Washington for federal help that could increase its profits.

Some of the country’s largest nursing-home companies — including those with long histories of safety violations and misusing public funds — have assembled a fleet of lobbyists, many with close ties to the Trump administration.

Eliezer Scheiner, a nursing-home owner and major donor to President Trump, recently retained Brian Ballard, a friend of the president who used to lobby on behalf of Mr. Trump’s business. Genesis Healthcare, the largest nursing-home chain in the United States, hired two former top White House aides, including Jim Schultz, a former special assistant to Mr. Trump. LifeCare Centers of America, whose Kirkland, Wash., facility had the country’s first coronavirus outbreak in March, brought on four former Republican Senate aides. The industry’s main trade group enlisted Haley Barbour, a former chairman of the Republican National Committee.

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Credit…M. Scott Mahaskey, via Politico

It is hardly unusual for embattled industries to seek help from Washington. But the fact that individual nursing-home companies are hiring lobbyists, not just relying on trade associations, reflects the ambitious nature of the industry’s mobilization.

Nursing homes are not only seeking assistance in surviving a pandemic. They are also capitalizing on the public health crisis to pursue a long-sought wish list that, until now, has remained mostly out of reach.

The industry has already notched one potentially lucrative victory. LifeCare Centers and others successfully pushed the Trump administration in July to exempt nursing-home companies from a 2017 law that curtailed how much interest big companies can deduct from their taxes. The change could effectively lower the federal tax bills for many nursing-home operators.

Nursing homes — many of which were in deep financial trouble even before the pandemic — are also on the hunt for government cash infusions through the federal economic rescue that became law in March, as well as any future stimulus bills.

The industry has received about $7.6 billion in federal grants through the federal economic stimulus package, according to the American Health Care Association, an industry group, and will soon get another $5 billion. Nursing homes have also received an estimated $11 billion more in government loans and advance Medicare payments, according to an analysis of federal data by Good Jobs First, a progressive research group. Executives at Genesis, which has reported 1,500 deaths at its homes nationwide, told investors last week that the company had received nearly $190 million in federal grants and was looking for more.

On Saturday, Mr. Trump seemed to indicate that more aid was on its way. “We will announce additional measures to protect nursing home residents in the coming days,” he said at a news conference at his golf club in Bedminster, N.J. “We’ve worked very hard with nursing home companies.”

Among the industry’s biggest goals is for the federal government to block residents and their families from suing nursing homes for wrongful deaths and other malpractice claims — even those that have nothing to do with Covid-19.

Senate Republicans introduced legislation last month that would make it virtually impossible for families whose relatives died from neglect or the coronavirus to hold nursing homes accountable in court. The legislation would apply retroactively to 2019 and extend through 2024.

The Senate majority leader, Mitch McConnell, has said the liability-protection law — which would also apply to a range of other industries worried about being sued if they reopen during the pandemic — must be included in any new economic stimulus package.

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Credit…Anna Moneymaker for The New York Times

Mr. McConnell’s former chief of staff Kyle Simmons was recently hired by the American Health Care Association, the powerful trade group representing for-profit nursing-home companies, to work on legislative issues related to the virus, according to federal lobbying records. He is among the lobbyists who have championed the bill in the Senate, according to three people with direct knowledge of the matter.

Nursing-home operators have argued that they should not be held responsible for the deaths of residents, including many who were already uniquely vulnerable to the virus, because they were hit by a pandemic that no one could have anticipated. Many homes have argued that they struggled to get testing kits and other essential protective gear that might have helped them contain the spread.

“Without legal protections, many nursing homes and assisted-living communities could shut down completely, threatening access to long-term care for thousands of individuals and precious jobs for caregivers,” said Beth Martino, a spokeswoman for the American Health Care Association.

But even before the coronavirus, many nursing homes had poor records when it came to safety and staffing. A report this spring from the Government Accountability Office found that the industry failed to maintain basic infection-control standards like quarantining sick residents or requiring frequent hand washing.

Some of the nursing homes with high death tolls from the virus have been cited by regulators for safety and other problems. LifeCare Centers, for example, paid $145 million in 2016 to resolve allegations, without admitting wrongdoing, that its nursing homes had bilked Medicare. After the virus spread among LifeCare patients and staff in Kirkland, government inspectors faulted the home for failing to properly notify the state authorities.

Davis Lundy, a spokesman for LifeCare Centers, said the company is “fully compliant with any requirements of the settlement” with the Justice Department. He said that staff at the Kirkland home “deserve high praise, not criticism,” and that the company was appealing the decision by the state health department.

The industry has successfully lobbied at least 20 states to gain immunity from lawsuits in state courts. But the federal Safe to Work Act would go further than anything on the state level because it would cover lawsuits that had nothing to do with the coronavirus and apply to deaths that occurred months before the virus began spreading.

“The industry is using this epidemic to win a get-out-of-jail-free card,” said Toby Edelman, a senior lawyer at the Center for Medicare Advocacy, a nonprofit legal assistance group for the elderly.

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Credit…Eric Gay/Associated Press

With Mr. Trump in the White House, nursing-home companies have won numerous victories. In 2017, the Trump administration, under pressure from industry groups, adjusted how nursing homes were fined for violating federal rules. Under the new guidance, the average fine dropped more than 30 percent, according to an analysis last year of federal data by Kaiser Health News.

The Trump administration also proposed weakening infection-control rules, imposed under President Barack Obama, that required all nursing homes to employ at least one person who specialized in preventing infections.

In November, a group of nursing-home operators gathered in a ballroom at the InterContinental hotel in Midtown Manhattan to raise more than $3 million for Mr. Trump’s re-election campaign. Mr. Trump stood onstage and thanked Mr. Scheiner, who donated $750,000, the most of any attendee, “for doing such an incredible job.” Mr. Scheiner, who owns more than 20 nursing homes, received a thunderous round of applause, according to video of the event.

Mr. Scheiner and his company, TL Management, have faced serious problems. This year, he settled allegations, made by a federally appointed bankruptcy court trustee, that he and his partner fraudulently transferred more than $1 million in assets out of a nursing-home operator before it filed for bankruptcy. (Mr. Scheiner denied wrongdoing.) This year, 43 residents have died at homes owned by Mr. Scheiner, according to state records reviewed by The New York Times.

In May, Mr. Scheiner donated an additional $50,000 to a different political action committee bankrolling Mr. Trump’s campaign, federal records show.

TL Management has hired four lobbyists. One is Mr. Trump’s friend Mr. Ballard. Another is Emily Hargan, whose husband is a top official at the Department of Health and Human Services, which oversees the nation’s nursing homes.

The lobbyists’ mandate was to help win legal immunity for the industry and to secure financial aid from the federal government, records show. Since the pandemic began, Mr. Scheiner’s homes have received roughly $26 million in federal grants and loans, according to Good Jobs First.

Mr. Ballard’s lobbying firm had an additional goal: to help cut TL Management’s tax bill, according to two people familiar with the matter. The 2017 overhaul of the federal tax code limited how much interest companies can deduct from their taxes.

TL Management, along with LifeCare Centers and other large nursing-home companies, asked the Treasury Department to exempt the industry from some of those limits.

On July 28, they got what they wanted: Treasury proposed allowing companies that operate a “qualified residential living facility” to be able to deduct a larger amount of interest from their taxes.

But the protection against lawsuits may be a higher-stakes issue for Mr. Scheiner’s network of nursing homes.

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Credit…Matthew Busch for The New York Times

At Mr. Scheiner’s Southeast Nursing and Rehabilitation Center in San Antonio, which has been cited by regulators for failing to control infections three years in a row, 18 residents have died during the pandemic. That is the most deaths at any nursing home in the city, according to The Times analysis of state records.

The families of some of those residents have sued. In a lawsuit last month, the family of Jose Velasquez, who died after contracting the coronavirus, said Southeast staff repeatedly minimized the gravity of his illness. An hour before he died, employees told the family that Mr. Velasquez was “doing fine and showed no symptoms of the disease,” according to the lawsuit.

Texas is not among the 20 states that have shielded nursing homes from pandemic-related lawsuits. But if the federal liability bill passes, the families’ lawsuits would most likely be derailed.

At the November fund-raiser in New York, Mr. Trump also paid tribute to a longtime friend, Ruby Schron, who in 2003 agreed to pay more than $700 million to buy dozens of properties from Mr. Trump. “Ruby, I want to thank you,” Mr. Trump said at the event. “You’re a great guy.”

In 2010, Mr. Schron and SavaSeniorCare, one of the country’s largest nursing-home chains, agreed to pay $14 million to settle Justice Department allegations that they solicited kickbacks from a pharmacy to provide drugs to nursing-home patients. In a separate 2015 case, the Justice Department accused Sava of routinely submitting bogus claims to Medicare. The case is ongoing.

The Justice Department said in a 2010 court filing that Mr. Schron “controlled” Sava. In a 2016 report prepared with the input of Sava’s financial advisers, the bond-rating firm S&P Global said Mr. Schron “effectively owns most of the equity in Sava.”

Annaliese Impink, a spokeswoman for Sava, said Mr. Schron “is not involved in the operations” of the company. “He is the landlord of several of the centers.”

This year, the Trump administration has provided Sava with roughly $74 million in loans and grants through the economic stimulus package, according to Good Jobs First.

In June, the Democratic-controlled House committee overseeing the federal response to the coronavirus said it would be examining the records of the five largest for-profit nursing-home chains, including Sava, Genesis and LifeCare. It is looking at how the companies are spending the federal stimulus money they have already received.

As it looks for victories on Capitol Hill, the industry is trying to soften its image.

Mark Parkinson, who runs the American Health Care Association, told members this summer that the group was preparing a $15 million ad campaign in Washington. “We hope to shape the national conversation,” he wrote.

Kitty Bennett contributed research.

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