A 2017 inspection of Pine Creek Rehabilitation and Nursing found staffers weren’t notifying doctors quickly enough when residents’ blood sugar dropped too low, pharmacists weren’t reviewing medication regimens as often as they should, and residents were drinking from one another’s glasses during meals — creating a risk of spreading infections.

Subsequent inspections turned up other deficiencies at Pine Creek, according to records, and so the Utah Department of Health took action. The Salt Lake City center was placed on a list of nursing homes and other long-term care facilities that could not participate in certified nursing assistant training programs. The two-year ban began Aug. 9, 2019.

At least 19 other facilities have received similar discipline in recent years, according to a roster maintained by the state health department. While families could read the inspection reports online, they weren’t informed that problems were serious enough to warrant the punitive actions.

The list was shared only with programs that train certified nursing assistants — known as CNAs — so the programs knew not to send students to those facilities to conduct their clinical training, a department administrator confirmed in a recent interview.

Advocates for the elderly and their families, who learned of the state list when informed by The Salt Lake Tribune this month, say the list could have been a handy way to inform families pondering where to send their loved ones about the severity of the problems with the facilities. Some advocates also say the list points to problems with how Utah regulates long-term care facilities.

“The question is why would a facility not be safe to train CNAs but be safe to house residents?” asked Nate Crippes, a staff attorney with the Salt Lake City-based Disability Law Center.

Christopher Cherrington | The Salt Lake Tribune
Christopher Cherrington | The Salt Lake Tribune

At least a few of the facilities banned from having CNAs do their clinical studies there have had coronavirus outbreaks, including Pine Creek, 876 W. 700 South in Salt Lake City. After infections there, Pine Creek, on April 4, became the first nursing home in Utah to be designated as a COVID-19-only facility. The Utah Department of Health lifted the designation May 11 and approved Pine Creek to begin taking new residents.

The operators of Avalon West Health & Rehabilitation Center in Taylorsville have said 12 of its residents have died of coronavirus.

There’s no public accounting of how many coronavirus infections or deaths have happened at each long-term care center on the list. Utah is nearing a total of 400 coronavirus fatalities.

Nursing homes, rehabilitation centers, homes for the disabled and other similar types of facilities have accounted for about 45% of those deaths. AARP Utah noted that figure in a statement issued Wednesday.

“AARP Utah believes that information collected by the Department of Health that can help those residents and their families make life and death decisions about their health and safety should be made public,” the statement said. “Now more than ever, we call for more transparency and accountability from state agencies and our residential care facilities to allow Utah families to stay informed and involved.”

Susan Chapman, a professor of nursing at the University of California, San Francisco, recently co-wrote a paper finding a history of previous deficiencies, lower nurse staffing, and lower quality ratings were factors in California nursing homes that had COVID-19 cases compared to those that had none.

“If a nursing home was performing poorly prior to [an outbreak],” Chapman said, “it is not going to be ready to manage COVID.”

Greg Bateman, the long-term care survey manager at the Utah Department of Health, said the list, which is updated quarterly, was not a secret. (The two most recent copies were provided to The Tribune upon request.) While acknowledging there can be a correlation between the quality of care and why a facility winds up on the prohibited list, Bateman doubted families would find it helpful.

“There are other indicators available to the public about ‘Is this a place I want to send my loved one?’” Bateman said.

‘They’re truly the eyes and the ears’

(Francisco Kjolseth | The Salt Lake Tribune) The Utah Department of Health readies staff of of a long-term care center for testing of the coronavirus on Thursday, May 21, 2020.
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The list is a product of the federal and state system for regulating long-term care facilities and the demand for workers in those facilities.

CNAs do much of the day-to-day labor at long-term care centers. They clean the residents, dress and groom them, help them participate in activities and move them around the facility. CNAs can provide some medical care, but only under the supervision of a registered nurse.

The most common form of medical care provided by a CNA is reporting when a resident isn’t feeling well.

“They’re truly the eyes and the ears,” said Terral Bassett.

Bassett is the director of nursing at Seasons Healthcare and Rehabilitation in St. George, which had been banned from having CNA trainees, and she owns a company that trains CNAs — Ridgeview CNA Program. Such schools provide classroom instruction to students wanting to become CNAs and then send them to long-term care facilities to get real-world experience before the students take their certification exam.

CNAs must receive 100 hours of training. Before the pandemic, 24 of those hours had to be in a long-term care facility. For now, to reduce the flow of people into such facilities, the body regulating CNAs has waived the clinical requirement and told candidates to make up those hours in a laboratory setting.

Long-term care facilities aren’t required to participate in CNA training programs, but such programs are assets to places like Seasons, Bassett said. The students provide more help to care for the residents.

Meanwhile, the programs become a recruiting ground for the facilities.

The nursing home industry has a chronic labor shortage. By allowing CNA students into a facility, a student and a potential employer can get to decide if they’re a match.

Federal law gives states the ability to regulate CNA student programs. Banning facilities from having CNA trainees is a tool Utah and other states can use to improve poor performing long-term care facilities.

Utah dulls the tool on occasion. Facilities on the list usually stay there for two years, but they can apply for a waiver to exit sooner. They must demonstrate there is no other long-term care facility nearby where students can get their clinical training — an argument some rural nursing homes make, Bateman said — or there is another compelling reason to allow trainees.

Bassett said Seasons received a waiver after she hired a nursing instructor who hadn’t been involved in any of the deficiencies found on Seasons’ inspections. To Bassett, prohibitions on CNA trainees make no sense, given that labor shortages create some of the resident care problems state and federal government seek to eliminate.

“A lot of these facilities [on the list],” Bassett said, “that’s the reason they’re having a lot of the shortage right now with nurses or with CNAs.”

Crippes, with the Disability Law Center, where staffers have been encouraging Utah to take a bigger role in safeguarding long-term care residents during the pandemic, said depriving the facilities of a way to find help doesn’t seem like an effective fix for deficiencies. He would prefer the state make stronger reports to federal agencies that could threaten to stop reimbursements for residents on Medicare and Medicaid.

“It just strikes me as you wouldn’t want facilities to have to struggle to find staff.”

A punitive approach?

(Photo courtesy Deanna Avis) Janice Blodgett in this undated photo. Blodgett died April 2, 2020, of the coronavirus, according to her family. She was 85.

The Ensign Group, a skilled-nursing company based in San Juan Capistrano, Calif., has three long-term care facilities on the list or which recently exited it — Paramount Health in Millcreek, Cedar Health and Rehabilitation in Cedar City, and The Terrace at Mt. Ogden. Each facility is operated by affiliates of The Ensign Group.

Brad Albrechtsen, an executive with Ensign, said the ban can be difficult because the inspection deficiency that results in the two-year ban would likely have no impact on the CNA trainees’ ability to learn in the facilities. The effects of the penalty can be overstated, though, as only a few of the trainees end up working where they were trained — the rest go to work in other long-term care or assisted living facilities, home care, or hospitals.

“We don’t view it as that big a deal,” Albrechtsen said of being on the prohibited list. “The deficiencies are painful. We don’t want any of those in our facilities, but they do happen occasionally.”

Allison Griffiths, a spokeswoman for Avalon Health Care Group, which operates Avalon West, attributed the coronavirus outbreak there and at its other Utah facilities to the wider community outbreak. She wrote in an email that not having a CNA program at Avalon West was a result of a “low level citation” issued years ago and that it “does not hinder our ability to recruit and retain high-quality staff or provide our residents with the highest quality of care.”

Cascades Healthcare operates Pine Creek and two other facilities that have recently appeared on the state list — Mount Olympus Rehabilitation in Millcreek and Red Cliffs Health and Rehab in St. George. Derek White, senior vice president for Cascades, pointed out that perfect inspections are rare and facilities can be cited for failing to follow any of the hundreds of regulations that apply.

“The specific facilities you are inquiring about are much more concerned about correcting any deficiencies noted in surveys than they are about being disqualified to run certification programs,” White wrote in an email.

Two Pine Creek residents died in the outbreak there. One was 85-year-old Janice Blodgett. When told this week that Pine Creek had been on a list banning it from taking CNA trainees, Blodgett’s stepdaughter, Deanna Avis, said, yes, she wishes she had known but found it counterintuitive that Utah would keep a facility from getting more help.

“If they’re failing,” Avis said, “don’t they need it more than anyone?”