If Jesus Medina had a chance to speak with his aunt one last time, he would simply say, βIβm sorry.β
Yolanda Cervantez, 63, was only supposed to be at Sapphire of Tucson Nursing and Rehabilitation for a couple of months to recover from hip surgery.
It was there that she contracted the coronavirus. She died of complications related to COVID-19 on April 2.
βIβm sorry for letting her down. I wasnβt there when she needed me most,β Medina said. βShe would have been fine if I would have brought her home to my house.β
Cervantez is one of 38 long-term-care residents to die from the coronavirus in Pima County as of Thursday, representing more than half of the countyβs known deaths related to COVID-19, according to an analysis of data obtained by the Arizona Daily Star.
With at least 58 residents and 36 staff members testing positive for the virus as of Friday, Sapphire accounts for about a third of Pima Countyβs known cases at long-term-care facilities. While the facility confirmed those numbers, it has not disclosed how many people have died there of the virus.
The Star spoke with family members of those who have lived at Sapphire and looked at its past state and federal evaluations, which show it is the most-cited nursing home for deficiencies related to care and emergency prevention in Tucson city limits over the last three years.
In response to the growing numbers of cases and to prevent further spread inside the home, Sapphire spokeswoman Jeanine LβEcuyer told the Star on Saturday that the facility is no longer accepting new patients based on recommendations by the county and state health departments. They are also screening staff members as they come into the building.
The revelation comes as the state has refused to provide specific data about known COVID-19 cases at nursing homes, despite a number of long-term-care facilities, including 25 assisted living and long-term-care facilities in Pima County, having confirmed outbreaks.
During a press conference last week, Gov. Doug Ducey called long-term-care facilities his top priority. In one of his executive orders aimed to control the spread of the virus, he advised facilities to provide a way for families to communicate with their loved ones electronically as many have stopped in-person visits. Facilities are also encouraged to notify families after their first confirmed case.
βMy grandmother lives in one of these long-term-care facilities,β Ducey said. βI want every Arizonan to have the same care and protection she has. She has the same risks. Although Iβm able to talk to her on the phone and so is the rest of my family, none of us have been able to visit face-to-face with her.β
In response to questions about the lack of information, he said, βwe want to not only protect public health but public privacy.β
βThis is the definition of vulnerable how we understand it,β Ducey said. βI want everyone to know that if you have a loved one in one of these nursing homes and they contract COVID-19, you will be notified immediately of that fact.β
In a release Saturday, Pima County interim health director Dr. Bob England acknowledged the difficulties those settings face. The Health Department has assigned a team of nurses and disease investigators to provide them with guidance, education and resources.
County representatives also said the Health Department has allocated much of its limited medical supplies like masks, gowns and gloves directly to long-term-care facilities so they can keep their staff and residents from passing the virus to one another.
βOnce the virus gets in, it can be extremely difficult to keep it from spreading,β England said. βBy nature of the work they do, staff members and residents come into close contact with one another multiple times per day, increasing the risks for both. These health-care workers are heroically dedicated to their residents, and we are dedicated to supporting these workers with every resource we have.β
βPaying their respectsβ
Medina received a call from the Sapphire nursing home Thursday, March 26, telling him that his aunt was transferred to the hospital after the staff couldnβt get her fever under control. When he spoke with her doctor at Banner-University Medical Center South on Saturday, March 28, he learned her COVID-19 test had come back positive.
From there, her health deteriorated. After attempting to complete her dialysis, which she had three times a week, Cervantez had what the doctors thought was a seizure. She remained unresponsive for several days and died a week after being admitted to the hospital.
For Medina and his family, not being able to be with Cervantez during her last days was the most difficult part. They visited her several times earlier in the month, including March 5 for her 63rd birthday.
Medina said he and his family were concerned that Sapphire didnβt inform them an outbreak had occurred at the facility. His other aunt recalled speaking on the phone with Cervantez in the weeks before her death and hearing someone coughing βnonstopβ in the background.
βWe were not informed at all,β he said. Sapphire βdidnβt say anything about an outbreak of the virus. When I talked to the doctor, I asked if they knew where she contracted it from, and the doctor told me that several people at that facility had already tested positive.β
Since his auntβs death, Medina said his family still has not been contacted by the nursing home. He reached out to Sapphire on Thursday asking for a copy of Cervantezβs file and medical charts but said he was told the person in charge of records was out sick. He is awaiting their return.
In the meantime, the family is waiting for Arizonaβs stay-at-home order to lift so they can hold a proper service for Cervantez. In her obituary, Cervantez was described as a caring and generous person who will be remembered for her famous fudge and cheesecakes that she made for family and friends during the holidays.
βItβs been very difficult. They said we could do online services, and everyone could stream it, but we decided to wait until we can all gather,β Medina said. βShe was very popular and had lots of friends that want to pay their respects.β
Lacking Transparency
Other states have started releasing information about coronavirus outbreaks in specific nursing homes, but Arizona has not followed.
Dr. Cara Christ, the stateβs health director, said this week that the department wonβt be releasing information about specific nursing homes βuntil we feel that there are enough individuals to be de-identified,β citing the Health Insurance Portability and Accountability Act.
βWe want to make sure that weβre protecting the public health and that weβre not releasing protected health information on an individual that could allow somebody else to identify who that individual is in that facility,β she said.
For now the state is releasing the total number of congregate settings where outbreaks, or at least one case, of COVID-19 has been confirmed, without identifying specific facilities.
That list included 102 assisted living and long-term-care facilities as of Saturday, including the 25 in Pima County.
In response to a request for information, the county provided total numbers regarding those homes without identifying individual facilities.
Long-term-care centers are responsible for roughly one-quarter of the countyβs 1,047 coronavirus cases, as of Thursday, with 180 residents and 100 staff members diagnosed with COVID-19, according to the data. Eighty-nine residents and nine staffers have been hospitalized, representing 43% of the countyβs hospitalizations.
The Star has received confirmation through spokespeople or family members of residents at four facilities, including Santa Rita Nursing and Rehabilitation Center in Green Valley and Handmaker Services for the Aging in Tucson.
Santa Rita Nursing and Rehabilitation confirmed at least six cases earlier this month. Emails provided to the Star from Handmaker showed the staff informed residents about a βnumber of casesβ on April 8. A representative did not respond to requests for comment.
Earlier this month, the AARP of Arizona, which represents more than 900,000 members in the state, wrote a letter to Ducey, pushing him to publish a list of long-term-care facilities that have reported at least one case.
Dana Marie Kennedy, state director for AARP Arizona, told the Star that as of Wednesday she had not received a response β despite nursing-home workers, families of patients and patients themselves asking her to continue to push for that information out of fears for their safety.
βWe need to be transparent with people. We need to put families before facilities,β Kennedy said. βWe need this information.β
She said concerns cited by Christ donβt apply.
βThey say they canβt share this information because of HIPAA, but thatβs not correct. HIPAA says you canβt release names; it does not say that you canβt release the addresses,β she said.
Representatives from the state health department did not respond to a request for comment.
The Kaiser Family Foundation has been tracking state-by-state data related to nursing-home outbreaks of COVID-19. There have been over 10,000 reported deaths due to COVID-19 in long-term-care facilities (including residents and staff) across the 23 states that report data, representing 27% of deaths due to COVID-19 in those states.
One of the largest outbreaks that alerted the nation to the threat COVID-19 posed was the Life Care Center of Kirkland, Washington, which has reported at least 129 cases and 37 deaths related to the virus.
Kennedy said transparency at that facility served as a warning beacon to other states.
βThat was good for not only that facility, but it was also good for other states and other nurses, to say this is very deadly to that population,β she said. βWe can all learn from whatβs happening in these nursing homes. That doesnβt mean theyβve done anything wrong, but if they arenβt transparent, then people assume theyβre doing something, because why else wouldnβt you come forward with information to let people know?β
Residents and staff members of skilled nursing facilities can be especially vulnerable to COVID-19 outbreaks and have unique challenges when it comes to the level of care and procedures they perform, said Aaron Pacheco, the county Health Departmentβs community relations program manager.
βThe physical and sometimes cognitive limitations of residents in these facilities makes the simple things we are telling people to do for protection, like hand-washing, cleaning, and isolating, very difficult and often impossible,β Pacheco said. βThis means that once a few cases pop up, it can be extremely difficult to keep it from spreading.β
Kennedy agreed.
βTheyβre very frail, they have underlying conditions. They live close to each other. Itβs a very communal atmosphere,β she said. βTheyβre pretty much dependent on an assistant for all their activities of daily living, so most likely they have several people touching them every day.β
She also pointed to the staff workers at the homes as being vulnerable. Many are working minimum wage, donβt have good health care, may not get paid sick time, may work at multiple facilities and may not have enough personal protective equipment.
βThis is a very dedicated workforce. They should not harbor the guilt that they might have exposed somebody,β she said. βThey also need to be protected, and we also need to be worried about them and their own health.β
She said efforts that can be taken include temperature checks for everyone, including employees, and training on infection control and how to effectively use and dispose of PPE.
But first she wants to start with the release of more information.
βWe canβt hit the reset button, so the first thing I would want to see is the transparency,β she said.
A history of deficiencies
Over the last three years, Sapphire has been cited by federal regulators 34 times for deficiencies, more than any other nursing home in Tucson city limits, according to an analysis of the most-recent data available from the U.S. Centers of Medicare and Medicaid Services.
The for-profit facility has 240 certified beds, federal data shows.
During their four surveys over the last three years, regulators marked deficiencies, primarily related to quality of life, resident assessment and care planning, and residentsβ rights. Those deficiencies are rated on a scale of A to L, with the latter being the most-severe.
The vast majority of deficiencies were rated D or E, meaning no actual harm was found but there was potential for more than minimal harm. In 2019, residents told surveyors that staff workers did not promptly respond to call lights. In 2018, residents and workers reported an inadequate supply of towels and washcloths for residents. In 2017, surveyors found one resident was not effectively told the risks of a psychoactive medication he was prescribed. That same year, the Arizona Department of Health Service issued Sapphire a $250 civil penalty for failing to provide services that maintain a residentβs highest practicable well-being.
In 2019, the home was cited with a level G deficiency, which means actual harm was found, after a resident with a limited range of motion did not receive proper treatment to prevent further decrease in range of motion, and Sapphire failed to adhere to a physician-ordered treatment.
The nursing home provided correction plans for all the deficiencies and was not fined. A CMS spokesperson did not respond to questions about why citations were issued but not fines.
The state conducts these annual surveys on behalf of the Arizona Department of Health Services. Although CMS data shows 34 citations since 2017, the facility has been cited by the state health department 70 times, including 49 citations from the three surveys conducted in 2019. The reason for this discrepancy in citation numbers is unclear.
In 2019, the state health department determined that Sapphire failed to include a process for cooperation and collaboration with local, state and federal emergency preparedness officials in its emergency plan. The deficiency has since been corrected.
βThe very first day, March 24th, which was the first day that COVID-19 was found in a resident, the Pima County Health Department was at Sapphire within hours,β LβEcuyer, the Sapphire spokeswoman, said. βEvery day since then, Sapphire has been in close collaboration with Pima County and the Arizona Department of Health Services. Theyβve also been following the guidance of the Centers for Medicare & Medicaid Services and the Centers for Disease Control.β
Based on an executive order from Ducey earlier this month, LβEcuyer said the nursing home has created isolation areas for its positive COVID-19 cases, and the staff is doing everything it can to minimize the risk for other residents and staff members. All staff members are being screened for COVID-19 symptoms before entering the building. The state and county health departments have advised the facility to stop accepting any new residents at this time.
βNo Sapphireβ
Beatrice Ard sent a message to her family through a nurse after emerging from a surgery earlier this month to correct a broken hip suffered during a fall.
βNo Sapphire,β recalled her grandson, Gerren Ard.
That surgery was the culmination of an eventful month for Beatrice, a 77-year-old Tucsonan who was initially taken to Sapphire in mid-March to rehabilitate from a broken ankle she had suffered days earlier after a fall at home.
Gerren said the family had limited contact with her at the facility, until she contracted the coronavirus and was transferred to a hospital.
βWe were like, βCan we talk to her?βββ he said. βAnd they wouldnβt let us for several days. It got to the point where my mother had to get nasty with them and say, βI need to speak with my mother now.βββ
They did not know about Sapphire and were referred to the care center by the hospital that evaluated her ankle. He said her grandmother has early signs of dementia, affecting her short-term memory, and that the first time they learned of her experience there was through her roommate.
That roommate told him they need to take her out βbecause theyβre not looking after her the way should she be,β Gerren said. It was the roommate who notified Beatriceβs family of the coronavirus outbreak in the facility. The same day, March 29, Sapphire notified them of an initial coronavirus outbreak, and the day after that released information that there were 27 cases in news reports.
That prompted concern for Beatrice due to a number of preexisting conditions, including chronic obstructive pulmonary diseases, heart disease, diabetes and high blood pressure.
βIf it really is 27 people, it doesnβt seem anymore like itβs a matter of, if my grandmother is going to get the virus, itβs a matter of when. We were totally on pins and needles,β Gerren said. βWe were very nervous.β
Days later, they were told that she was positive. She was transferred back to the hospital, where doctors found a new injury β a broken left hip. The family doesnβt know when she broke the hip, only being told she suffered a fall, and theyβre still unclear where or how.
She beat the coronavirus but is not out of the woods yet, as doctors have told the family she may face complications from the surgery.
She is expected to return home in early May to her library of more than 1,000 books and her husband, Roosevelt.
βWeβre going to make her the biggest meal,β Gerren said. βShe deserves a good home-cooked meal.β
Gerren, who has been outspoken about his grandmotherβs ordeal, said he has heard from a number of people associated with Sapphire, including former employees, former residents, and families connected to the home.
βThereβs a lot of things they could have done differently,β he said of his grandmotherβs care. βThey did not give her the care she properly deserved. And it seems as though sheβs not the only one.β
Ultimately, theyβre just grateful that she survived COVID-19.
βShe had so many things working against her that the virus should have taken her out,β he said. βShe beat it. She beat that virus. Glory to God.β
