Where have billions in covid aid for nursing homes gone?

A survey of nursing homes published in August by the American Health Care Association/National Center for Assisted Living found that 55 percent of facilities across the country were

operating at a loss. Nearly three-quarters of industry respondents said they would not be able to sustain their operations for another year at the current pace. At smaller nursing facilities

 and nonprofit operations, federal dollars have helped keep the lights on. Nursing home occupancy is down almost 30 percent since February at the Eliza Bryant Village nursing home and senior

care community in Cleveland, says Marc Rubinstein, the chief financial officer. The nonprofit has received more than $1 million through federal and state support this year. But revenue is

down between $150,000 and $200,000 per month. And costs have skyrocketed, Rubinstein says, rattling off personal protective equipment (PPE), supplies for outdoor visitation and tablets and

other communication devices as “the tip of the iceberg." Janet Snipes, executive director of the 133-bed Holly Heights Care Center in Denver, says the roughly $800,000 her for-profit

facility received through the Provider Relief Fund has been “so very helpful” in covering expenses like testing, PPE, staffing, new filtration systems, air purifiers and more. And federal

funds have also blunted COVID-19's impact at larger for-profit operations. Genesis HealthCare, one of the country's largest health care and skilled nursing operators, estimates

that the pandemic reduced the company's earnings by nearly $60 million in July, August and September — even though it received roughly $64 million in federal and state aid during the

third quarter alone. Genesis received more than $250 million in relief grants and government support between April and September, according to its latest earnings report. “The business is

still burning cash,” CEO George Hager Jr. said during a November earnings call with reporters. The industry has pointed to steep losses as evidence that more money is needed to keep

facilities afloat through the winter. Mike Cheek, senior vice president of reimbursement policy at American Health Care Association/National Center for Assisted Living, says his organization

supports “reasonable efforts to ensure this federal aid has been properly directed to providers to cover COVID-related costs and potential losses.” But he says more funds will be needed to

help nursing homes weather “a huge financial crisis, threatening access to long-term care for millions of seniors." 'THERE ARE JUST SO MANY WAYS TO HIDE THIS STUFF' But the

aid packages to large for-profit operations have raised eyebrows among industry watchdogs. Brian Lee, executive director of the Families for Better Care advocacy group, points to Ensign

Group, a publicly traded skilled nursing company that in August announced it was returning all $110 million it had received through the Provider Relief Fund. The organization enjoyed strong

profitability during the second quarter of the year. “We know that there's a high degree of responsibility that accompanies government reimbursement,” CEO Barry Port said on an earnings

call. Despite the pandemic, Ensign's stock price has soared to record levels. Zacks Equity Research recently ranked Ensign an “incredible growth stock,” estimating its cash flow growth

is up more than 18 percent over the year. “They're trading at the highest level they've ever traded at, in the middle of a pandemic in which they're supposed to be bleeding

money,” Lee says, suggesting Ensign's success challenges the notion that for-profit homes are struggling — and raises the possibility that other companies on comfortable financial

footing received government funds and opted to keep the money. But many publicly traded nursing home companies saw their stock prices plummet in February and March and haven't

rebounded. Yet the way nursing homes are structured makes it difficult to gauge how well or how poorly for-profits are doing financially. These facilities are often set up as small nursing

companies owned by larger corporations. Those corporations may own a group of separate companies that hire nursing home staff or lease real estate, keeping the day-to-day nursing home

operations separate from the rest of the organization. It's a structure that allows a parent company to potentially shield many assets if a nursing home is sued for negligence.

"These big companies all have separate property companies, management companies, staffing, therapy, financing,” says Charlene Harrington, a professor emeritus of sociology and nursing

at the University of California in San Francisco. “If you're only looking at the operating company, you're not able to figure out what's happening with the money."