As the COVID-19 crisis continues to unfold, leaders in the skilled nursing space have increasingly claimed that various government agencies have left them in an unwinnable position.

With occasionally conflicting edicts from state and federal authorities, and until recently a lower priority for testing than other care settings, the pandemic has revealed serious gaps in the patchwork quilt of funding and oversight rules that govern the nation’s more than 15,000 nursing facilities.

SNN caught up with a top executive at a regional nursing home provider for the most recent edition of our Confessions series, which gives leaders an anonymous platform to sound off on the major issues that affect their residents and day-to-day operations.

This leader shared deep frustration with the way the Centers for Medicare & Medicaid Services (CMS) and states have handled their shared oversight mandates, and also emphasized the hard work that frontline staff and others have been putting in during this unprecedented crisis.

“There are much easier industries out there, where you’re not dealing with human beings. We do this because we love it, and I want people to know that, because that’s the honest truth,” the leader said. “We do love our residents, and we give them as much fun as you can. There might be a few bad apples out there. But you shouldn’t [confuse] the bad apples for all those that are doing the best they can.”

What’s your biggest frustration right now?

Let’s start with the big picture. We’re in America, which has many states. We feel that the guidance right now is state-by-state — every state that we’re in is almost like its own country.

CMS will tell us: You can hire unlicensed nurses. Then the state will go and make their own rule where they don’t allow it. There’s been a conflict. CMS is where we get our licenses from, for the most part — or they could take away our license, at least — and then our state comes in and tells us something else.

CMS tells us we have to get everyone tested if there’s a resident that might be COVID-positive in our facility. Then we go to our state, and our state is back and forth: Should you test, should you test? We almost feel like they don’t want to get those high numbers on their board.

So there’s been a lot of conflict from what we’re hearing, big-picture — from Washington to the state specifically. That’s been one frustration. Directions have been back and forth.

I had a call with AHCA and CDC. On our conference call, we had something we were dealing with, and they themselves weren’t sure [what] our state should do. They’re suggesting one suggestion; we go back to the state, they’re giving us another suggestion. Direction has been a little bit wishy-washy, and that’s been a confusion for us.

At the nursing home level, I don’t want to say we feel like we’re alone. But with a lot of confusion, we have to keep on digging and digging to make sure we’re doing the right thing for our residents. That’s been one big frustration.

I think we really are seeing the gaps in oversight between the state and federal levels really blowing apart during this crisis.

That brings me to my next point, which is that on a state level, they might see what we’re doing, because we have conference calls with some of our counties once a week, some of our county directors, and they’re very hands-on. The states appreciate, sometimes, all the stuff we’re doing. Knock on wood, I have 10 facilities in [the Midwest], and I don’t have one COVID resident positive. I had a few employees that were COVID-positive..

We’re doing this because there’s been so much back-and-forth. We figured: Hey, let’s just do our own thing. We’re here for the residents. They’re our family. We’re going to do the right thing. It’s worked so far; the state sees it also.

We get constantly thrown under the bus from Washington and CMS. It really hurts us, because we’re all trying our hardest and we’re trying to get everything done. When we hear on the press conferences how we have to take care of our most vulnerable, nursing homes are right now the largest industry in business. Hospitals are laying people off because there are no surgeries going on. People that have wound care are trying to get home health services into their home. Right now, the biggest industry open is nursing homes, and we’re doing our darndest to get it done and to get it done right.

When we hear: “We’re going to be giving citations to nursing homes,” and the residents and their families [should] call the hotlines and report, you know — where’s the support for us, what we’re trying to do? We’re trying to keep them safe, right? We shut down if we don’t have residents. We’re all about the residents. They’re under our care, and they’re our responsibility. We’re trying to do what we can; we just don’t feel like that support is coming back to us.

If you had a seat on the president’s task force, what suggestions would you make?

First, I would take them on a little journey: the day in the life of a nursing home, just so they understand it. I used to be an activities director myself, and I used to always tell my facility: We have to look at every nursing home as a camp, right? We have to have fun; we have to make sure the residents are enjoying themselves. And just like in camp, with little kids, you’ve got to get them dressed, and you have to take them to the infirmary — we have our doctors coming around.

But at the end of the day, a lot of the people — this is their last stop, so we have to make sure they have as much fun as possible. There’s a lot of nitty-gritty; there’s a lot that’s going on every day, because they’re frail, and they are vulnerable. You know, there’s a lot of hiccups that come into our day.

I would try to create a picture from morning to night, how every shift, there’s meds being passed around, and there’s activities that keep them busy. It’s a city. It’s a little city. There’s so much going on.

For the most part, there’s no activities going on in hospitals. The patient is either there for a surgery, or they have a wound — and they’re in and out. Where do they go? They come back to the nursing home, which is their house. We continue a lot of what the hospital has done; we give them their meds, we’re taking care of their wounds. We’re making sure they’re healthy and happy.

With the care we’re giving, it’s so similar to a hospital. We’re so close to what a hospital is, and we feel that we have to be treated that way from the higher-ups as well. That’s one thing I would say.

The second thing I would say, to prevent what happened, is every state has to have a stockpile of PPE. If we stockpile millions of PPE and get it ready, this could have avoided so many deaths, because we would have had the right protection right away — and we would stop the spread right away. That PPE, I think, would be a big thing to stop this in the future.

Another thing is to get clear regulations. Like I mentioned earlier, we’re getting one message from Washington. We’re getting a second message from our state. CDC is giving another message. [Seema] Verma, from CMS, is giving another message.

To really get clarity, [we should] get this core group in Washington to sit together and get everyone on the same page, make the suggestions to states — hear what they have to say.

New York forced nursing homes to take in residents. So even if a resident is COVID-positive, they force you to take them into the nursing home. How is that going to help a nursing home where things could spread so quickly? You’re in one building. The rooms are one after the other.

Have a rule when we can take in residents to the nursing homes, when we don’t take residents to the nursing homes. [In other states], they were pretty open on admission to take it or not to take it. We were able to go and see if this resident was COVID-positive. If they healed, or they took another test that came back negative, we’re able to make our own assessments, which I believe helped us a lot. But I would get this task force to get on the same page with all the different governments and figure out one clear system that works with the doctors.

There’s a lot of anger from families and resident advocates right now — it’s a scary time, and people are rightfully confused and upset about the COVID-19 response from multiple angles. What do you want families and residents to know that maybe hasn’t been said from the operations perspective?

I would try to get them to trust our nurses. Some of our nurses — and this is across the board, all over America — have been in this field for 30 years. They know there’s no one better to have than some of our nurses.

They work day and night, and they work so hard. They love their residents — they cry with them, they clap for them. I would try to get a bigger, stronger trust in the families, to get to know our nurses a little better. I think maybe if we put some bios of our nurses up, let them know about our nurses a little more, they would get a little more trust.

Anything else you want the general public to know?

The industry we’re in, it’s not the food industry. It’s not the garment industry. We’re in the people industry, and we honestly believe it — and we live it. We go above and beyond to care for our residents, and we want that message out there known. People look at nursing homes as if they’re quote-unquote killers, and that’s not the case.

There are much easier industries out there, where you’re not dealing with human beings. We do this because we love it, and I want people to know that, because that’s the honest truth. We do love our residents and we give them as much fun as you can.

There might be a few bad apples out there. But you shouldn’t [confuse] the bad apples for all those that are doing the best they can.

This interview has been condensed and edited for clarity, as well as to protect the identity of the anonymous subject.