a prepandemic evaluation found.

So while program administrators relish a rare opportunity to expand their reach, they worry that if Congress doesn’t sustain this higher level of appropriations, the relief money will be spent and waiting lists will reappear.

“There’s going to be a cliff,” Ms. Beals-Luedtka said. “What’s going to happen next time? I don’t want to have to call people and say, ‘We’re done with you now.’ These are our grandparents.”

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Turning Away From Nursing Homes, to What?

The PACE provider manages all of a person’s health care needs that are covered by Medicare or Medicaid. “It becomes your form of health care coverage,” said Peter Fitzgerald, executive vice president for policy and strategy at the National PACE Association, a membership and advocacy organization.

States decide whether to offer PACE programs; currently 30 have programs serving about 55,000 people, Mr. Fitzgerald said.

Some states and regions are moving to address the needs of their aging citizens.

In January, Gov. Gavin Newsom released a master plan for aging for California. It calls for creating, over the next decade, millions of housing units for older residents, one million high-quality caregiving jobs, and inclusion goals such as closing the digital divide and creating opportunities for work and volunteering. Colorado, Massachusetts, Minnesota and Texas have already established master plans, and a number of other states are working on them.

California’s plan also calls for a new state office focused on finding ways to innovate using Medicare funds, especially for low-income, chronically ill seniors who also participate in Medicaid.

“We think this can really help our state by bringing together medical and nonmedical services for people who want to live well in the place they call home,” said Gretchen E. Alkema, vice president of policy and communications at the SCAN Foundation, a nonprofit focused on elder care that has worked with California and other states on age-friendly models.

In the Atlanta metropolitan area, which began tackling these issues head-on in 2002, one in five residents will be 65 or older by 2050, according to the Atlanta Regional Commission, a planning organization. The group has responded by developing a “lifelong communities initiative” to raise awareness in local government of the need for housing that is affordable and convenient to sidewalks, shopping and transportation.

Atlanta and four suburbs have joined an AARP-sponsored network of age-friendly communities, and several city neighborhoods have created plans.

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California Sues Nursing Home Chain, Saying It Manipulated Ratings System

The result, prosecutors said, was that Brookdale “has been awarded higher star ratings than it deserved.” They added, “The chain’s manipulation has allowed Brookdale to attract prospective patients and their families to its facilities by misleading them about its quality of care.”

Prosecutors also accused Brookdale of illegally evicting or transferring residents so that the chain could “fill its beds with residents who will bring in more money.” In one instance highlighted in the suit, prosecutors said Brookdale discharged a 78-year-old resident who suffered from heart and kidney disease without removing his catheter.

The lawsuit seeks civil penalties and an injunction to prevent future unlawful conduct. Under California law, civil penalties are up to $2,500 per violation. In this case, where the violations are committed against seniors or people with disabilities, the law provides for an additional penalty of up to $2,500 per violation.

A Brookdale spokeswoman didn’t immediately respond to a request for comment.

The Times previously reported that a Brookdale facility in Lexington, Ky., told Medicare in 2017 that every resident got an average of 75 minutes of care each day. In reality, nurses at the Brookdale Richmond Place facility spent an average of less than 30 minutes a day with patients. Brookdale received five stars for staffing. Absent the inflated numbers, it probably would have received only one or two stars.

A former Brookdale nursing assistant said in a deposition last year that her supervisors had told her to falsify residents’ medical records to make it look as if they received more care than they did.

Heather Hunter, a spokeswoman for Brookdale, told The Times, “We have detailed policies in place to ensure compliance with C.M.S. reporting rules, and we are not aware of any instance where inaccurate or false information was submitted by any of our communities outside of the confines of the C.M.S. rules.”

President Biden nominated Mr. Becerra, whose office brought the case against Brookdale, for secretary of health and human services, which oversees C.M.S. The Senate has not yet voted on the nomination.

Robert Gebeloff contributed reporting.

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How U.S. Ratings of Nursing Homes Mislead the Public

The pandemic laid bare the flaws in the government rating system.

The state health inspections do little to penalize homes with poor records of preventing and controlling infections. From 2017 to 2019, The Times found, inspectors cited nearly 60 percent — more than 2,000 — of the country’s five-star facilities at least once for not following basic safety precautions, like regular hand washing. Yet they earned top ratings.

In San Bernardino, Calif., inspectors wrote up Del Rosa Villa for four different infection-control violations. It kept its five stars. Ninety residents at the 104-bed facility have contracted the coronavirus, and 13 have died.

Del Rosa Villa officials didn’t respond to requests for comment.

Life Care Centers of Kirkland, Wash., the first nursing home in the United States to have documented coronavirus cases, was found in 2019 to have weak infection controls, despite its five stars. State inspectors wrote it up for failing to “consistently implement an effective infection control program.”

Thirty-nine of the facility’s residents have died from Covid-19. The home has 190 beds.

Leigh Atherton, a Life Care spokeswoman, said that citation was the only lapse in infection control that inspectors had identified over 32 previous visits. She said the home quickly fixed the problem.

If the rating system worked as intended, it would have offered clues as to which homes were most likely to have out-of-control outbreaks and which homes would probably muddle through.

That is not what happened.

The Times found that there was little if any correlation between star ratings and how homes fared during the pandemic. At five-star facilities, the death rate from Covid-19 was only half a percentage point lower than at facilities that received lower ratings. And the death rate was slightly lower at two-star facilities than at four-star homes.

A facility’s location, the infection rate of the surrounding community and the race of nursing home residents all were predictors of whether a nursing home would suffer an outbreak. The star ratings didn’t matter.

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Elderly, Vaccinated and Still Lonely and Locked Inside

TORONTO — Devora Greenspon is among the lucky ones. She is one of the 1.4 percent of Canadians who has received two shots of a coronavirus vaccine. So have 90 percent of the residents in her nursing home.

How has it changed her life?

“It’s like it never happened,” says Ms. Greenspon, 88, who is still sequestered mostly in her room. Her walks have been confined to the corridor; she has not been allowed to leave the center for nonmedical reasons since October.

Long-term care homes, as they are called in Canada, were prioritized for the first precious doses of vaccines, to few objections — they were ground zero for the pandemic’s cruel ravage. Around 66 percent of the country’s terminal Covid-19 victims lived in nursing homes, among the highest rates in the world.

But while the vaccines have given the majority of nursing-home residents protection from death by the virus, so far they have not offered more life. Some residents have compared their lives to those of prisoners and caged animals.

game night or choir practice. And some homes are permitting indoor visits under U.S. federal guidelines put in place in September that allow them if a home has been virus-free for 14 days, and county positivity rates are below 10 percent, regardless of the home’s vaccination rate.

But elsewhere, homes are about to reach a full year of being closed to visitors, despite the plummeting of coronavirus cases.

AARP and other advocacy organizations have called on the U.S. government to ease visitation guidelines as vaccines are rolled out in nursing homes. Many note that with vaccinations, the likelihood of residents contracting and dying from Covid-19 is lower, but the harm to residents from social isolation continues unabated.

Ms. MacKenzie noted that the extended periods of isolation are having detrimental effects on residents’ health in Canada as well.

large survey of nursing-homes residents and their families by Ms. MacKenzie’s office found the majority reported a marked decline in cognitive function and emotional well-being, and almost half reported their physical functioning had worsened. The survey also found that the proportion of residents on antipsychotic medication — traditionally prescribed to manage behaviors like agitation related to dementia — had increased by 7 percent over six months.

The question of how to care for the country’s senior population during a pandemic isn’t unique to Canada and the United States. Many nursing homes around the world banned visits as the coronavirus arrived around a year ago. Soon after, geriatricians sounded the alarm about the rapid decline in health and well-being of residents, triggering a debate about the balance between protection and quality of life, as well as the rights and autonomy of residents. As a result, many jurisdictions reintroduced some sort of visitor policy, as the first wave subsided.

Many are calling for a similar discussion to happen again in Canada.

“If we really don’t allow people more civil and social liberty, and allow them to meaningfully engage in social activities in some way, these people are going to give up, as many of them have already done,” said Dr. Nathan Stall, a geriatrician at Toronto’s Mount Sinai Hospital.

Betty Hicks, 82, broke her hip a couple months before her nursing home went into lockdown and she never regained her ability to walk, says her daughter Marla Wilson. Without the regular visits from her large family, the mother of eight deteriorated quickly, losing nearly 20 pounds and the ability to even pick up a phone, her daughter says.

Now that Ms. Hicks has been vaccinated, like everyone else in her nursing home, the argument that she’s locked up for her own safety seems painfully weak, her daughter says.

“You always hear people say, ‘Oh they lived a long life,’” said Ms. Wilson. “Right now, they aren’t living. They are existing.”

While overprotective government regulations have prevented long-term care homes from adjusting their restrictions, they are only partially responsible, said Dr. Samir Sinha, co-chair of the National Institute on Ageing and director of geriatrics at Toronto’s Sinai Health System and University Health Network.

Many facilities have been so focused on preventing outbreaks that they’ve been unwilling to develop creative ways of keeping their residents mentally and physically stimulated, he said.

“The majority of nursing homes across the country have found an excuse to not do something,” he said. “You even have these homes who are marketing it, ‘We’re going above and beyond to keep you safe.’ We translate that to mean, ‘We are locking you in your room for good.’ They are actually violating people’s human rights.”

And for many residents, Dr. Sinha pointed out, time is running out: The average stay in a Canadian nursing home, to put it gingerly, is just two years.

“I’d like to take them on a bus to Niagara Falls, or anywhere, even if we can’t get off the bus. When can we do that?” said Sue Graham-Nutter, the head of two nursing homes in Toronto where 98 percent of residents have been vaccinated. She is haunted by last spring’s outbreak that killed many of her residents, but she worries many more will die before they are afforded some basic joy.

“They want to go and hang out with their friends,” said Ms. Graham-Nutter, the chief executive of Rekai Centres. “When can we do that?”

Lawyers say the rules restricting residents from leaving breach rights laid out in the Canadian Charter of Rights and Freedoms. “Long-term care residents should be able to come and go like everybody else,” said Jane Meadus, a lawyer at the Advocacy Centre for the Elderly, a legal clinic for seniors. “Does the fact you live in long-term care give you less charter rights?”

Few of her clients are willing to challenge their home’s restrictions, however.

“They are afraid the home will somehow retaliate, or try to remove them from the home,” said Ms. Meadus. “We are talking about institutions that have a lot of power over a very vulnerable population.”

Jonathan Marchand is one exception. Last summer, he slipped out of his care home near Quebec City and moved into a makeshift cage erected near the provincial legislature, to stage a protest. Mr. Marchand, a 44-year-old network engineer, suffers from muscular dystrophy and requires a ventilator to breathe. For years, he’s fought to leave the institution and spend the government money to hire his own caregivers at home.

The pandemic gave him another powerful argument. After five nights sleeping in his motorized wheelchair and on a cot, he returned to the facility, with a government promise to work on a pilot project for community living.

Since then, he has not been allowed to leave the property except for medical reasons, he says. While he calls the rules unjust and unfair, he understands why they are there — because of the devastation an outbreak from variants could wreak.

“Long-term care facilities were the first things to close down; they will be the last thing to open up,” he said. “I think they will be very cautious in opening up, and I can’t blame them for it.”

Still, some people have decided not to wait for the rules to change, but to relish the small joys vaccination provides.

Suzanne Charest rushed to an Ottawa hospital last month after being notified by her father’s nursing home that he had suffered what seemed like another heart attack. He was in so much pain, she said, he talked frantically through the night, as if it might be their last time together. Thankfully, it was a false alarm.

The next day, after he was back in the nursing home, Ms. Charest, who like her father has been vaccinated, did something she hadn’t done in almost a year.

She hugged him.

Catherine Porter reported from Toronto. Reporting was contributed by Allison Hannaford in North Bay, Sarah Mervosh in New York and Danielle Ivory in New Jersey.

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