Families vs Nursing Homes

Conflicts between staff and families

In a sector where there is no reliable data, we are entitled to consider complaints by families and friends who believe that poor care is being given as red flags. It may well be that the complaints are only the tip of an iceberg and this allegation is actually made in the example below.

A story from Perth: The allegation was that care in a dementia unit started to deteriorate when staffing levels dropped. The facility was Cxxxx of Bicton in Perth WA. It belongs to Lxxx Bixxx, a builder, and its registered approved operator is Baxxxx Pty Ltd. It was in dispute with the unions about pay in 2011.  The complainant indicated that the the staff were always apologetic about their care and their inability to cope with the workload.  His comment about why there are so few complaints is revealing.

Families who complain are banned from nursing homes

It is recognised that many residents and families don't complain because they feel they will be victimised.  Others complain to the agency, but abandon their complaint when the agency simply refers them back to the person they are complaining about.  One of those in the articles below alleges that the intimidation started after she complained to the agency.

There are many stories of family and/or friends being barred from seeing nursing home residents or sometimes having visiting rationed. Sometimes the guardianship regulations are used in order to accomplish this.

There is an advocacy service paid for by the government in each state. What is so revealing about the reports in all these cases, is that in none of them, were advocates involved. From the reports, it is clear that the families are not advised about this service and the nursing homes are not telling them or using it. They know about it because they are all sent information. Alternatively, some have advised family members to go to media, acknowledging the futility of the system.

The only reason that I can see for not using the advocacy service to resolve issues is that the nursing homes are providing poor care and this would expose that. Could this be a cheaper and more effective way for them to deal with these issues?

In September 2015, ABC News reported on two cases where family members believed they had been bullied by the nursing homes when they complained about care. One who supported her complaints with photos was forbidden from taking photographs.

Lxxxx Gxxxx claims she was banned from seeing her 91 year old mother in two nursing homes. Visits were rationed so that she had only very limited access as her mother was dying. She gave evidence to the Senate inquiry into violence, neglect and abuse against people with disabilities in institutional and residential care.

• Nursing home ‘banned me from seeing mum’ The Australian, 28 Aug 2015 (Paywall)
• Woman denied access to dying mother condemns 'monstrous display of evil' by nursing homes ABC 7.30 Report, 8 Oct 2015

The proposed Community Aged Care Hub:  These are situations where  people from  the local community who know both the facility and its staff as well as the resident can mediate.  As proxy customer they have both the power and the credibility to resist and oppose the facility when this is in the best interests of the resident.

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Introduction

The example in the following sliders is simply one of many to illustrate the problem. What I have done in this case is to try to look behind what is happening.  We don't know if the complaint by the daughter had validity or not. To find out, I decided to see what else I could find out about this facility and its owner. As is often the case, it sounded bad and when I explored further it got worse. After a great deal of effort, I found that in spite of the homes claims to an "unblemished record" there were other reports suggesting there may have beeen staffing problems for a long time. 

I found that the home is managed by a single individual over 1,000 miles away in Queensland, and that he had some experience in managing nursing homes many years ago.  It is not clear whether this is as a financial manager or if he had anything to do with care.

I, like anyone else, cannot know how effective he was, how often he appeared in Canberra and whether it was his financial policies that created the alleged problems there. Now, clearly the proposed Community Aged Care Hub would have been in on this from the beginning and would have been in possession of all this information, as well as information which I have not been able to gather. They would not have had to wait for several years to learn what had happened and would have started addressing any issues early.  Here is what I found, and you can see how difficult it was.

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The Jxxxxxx Nursing Home in Canberra

Pressure sores are almost always preventable with really good nursing care and their incidence is a marker of failures in care. Even with the best of intentions, care will sometimes fall short, but a little honesty and contrition about this at the time goes a long way. Instead, we too often see this ending up with a standoff.

The frequency with which reports which are related to staffing problems occur, when considered with the many reports of understaffing and deskilling in the sector gives the complaints credence. In this instance, 11 pressure sores is stretching the credibility of claims about good care just a little too far.

Additionally, the daughter had made a multitude of very familiar complaints about the standard of care in other areas soon after the resident entered the facility. She sounds as if she understands what was required.  She is not the only person concerned about staffing in aged care:

There have been many reports that repeatedly raise concerns about staffing.

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Criticism and solution

Criticism: The big criticism of the current system, particularly the complaints system, is that these issues are not being resolved. Residents are not being protected and alternative arrangements are not being made when this is necessary to provide good care.

The proposed hub: This of course, is the sort of situation that the proposed hub is very specifically intended to address and resolve. They would be there, would have been in touch with the family and helped to resolve the issues. If the care was appropriate, they would have reassured the family. If care could not be provided, then they would have assisted the family to have the resident moved to somewhere where the level of care needed was available. They would also have steered people requiring this level of care away from this facility.

When I challenged an administrator in an international NME hospital (massive US for-profit) with their failure to transfer a seriously ill patient receiving care in their ICU to a neighbouring high quality ICU with expert staff, he replied that this was not company policy and clearly saw nothing wrong with this.  It seems that doctors in this hospital were prevented from doing this. 

I later found that this was true in the USA and a cause of many problems.  But in these hospitals doctors were often unaware of their limitations.  Not only did company marketing convince doctors that they were indeed authorities and experts (eg doctors who did 800 unnecessary operations), but their internal structure, lack of peer review and stigmatisation of those who criticised the profitable doctors they put into leadership positions protected these doctors from criticism and from getting the insight needed to know their limitations. 

One wonders if the overblown marketing of nursing home facilities, muzzling of criticism, and other promotional strategies are having a similar impact on staff in aged care. Are nursing homes and their managers developing an overblown idea of their own expertise and services?  An accreditation process that awards everyone full marks would contribute significantly to this.

On another page in this section I record how a whistleblower alleged that 'the resident who assaulted others was not sent elsewhere because he was a big source of funding.  The allegation was that there was a "strong focus on profitability in XXXXXX Community Services facilities in Queensland (and it) has been positive for the balance sheet but taken a heavy toll on care"'. 

This was a not-for-profit whom you would expect to put the interests of residents who might be harmed ahead of their profitability.  That causes me to speculate whether the same thing might have been happening at Jxxxxxx. 

Could some of the other deaths I discovered in my search have been prevented if more attention had been paid to the staffing needed to care for them rather than profitability and if the profitable but dangerous residents attacking others had been sent elsewhere? 

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The Jxxxxxx nursing home's story

History: Jxxxxxx nursing home was once run by the ACT government but it did not have a good record for care, failing multiple accreditation standards. In 1996, it was sold to a company called Jyyyyyyy Village Services. The reports show that money was spent rebuilding and refurbishing the facility. It provided care to high level dementia sufferers. In 2003, it received an $800,000 grant "to better train and better support staff who deal with the most difficult dementia patients".

Problem 1: The first indication of a possible problem I found was in November 2006. There was a very critical report, on ABC Stateline 24 Nov 2006, of the way an outbreak of flu in the nursing home was handled. Sixty nine people contracted the disease and eight died.

The report alleged that there was a delay in having samples tested, a delay in notifying health authorities, and a further delay in administering appropriate protective medication. This was only commenced 38 days after the outbreak started. The report asked whether these deaths could have been avoided.

Problem 2: In December 2006, a resident was pulled out of her bed by another resident. She fractured her hip and died soon after with multiple organ failure. The perpetrator, another resident, had been seen trying to pull people from their beds on previous occasions.

The coroner who examined the case was sufficiently worried by the circumstances and lack of oversight of these vulnerable residents that he urged the facility to set up video surveillance. He considered that under the circumstances, the safety of the residents should take precedence over concerns about their privacy. The nursing home considered that the residents' privacy was more important and failed to install video surveillance.

Problem 3: In January 2012, a newly arrived resident was battered to death in his bed during the night receiving severe facial injuries. This was not discovered until the next morning. The hospital indicated it intended installing video cameras. At that time the murder investigation was ongoing and the only information was a report in January 2015 indicating that a possible suspect, another resident, had since died.

The Coroner's inquiry finally started on 4th May 2015 - three years later - and took evidence from police over 2 days.

The story the police told reflected poorly on the way in which the nursing home responded to this crisis. The gut panic response of senior staff seems to have been to look to see if there was any way of covering up what happened rather than go to the police. It was a passing doctor who eventually insisted they call police. The case also raises concerns about the adequacy of staffing and the coroner is going to examine that.

There were three press reports:

• Body left unsupervised, staff told not to call police after dementia ward killing - The Canberra Times, 4 May 2015
• Dementia ward fatal attack inquest prompts policy for nursing homes to deal with suspicious deaths - ABC News, 5 May 2015
• Police recommend nursing home develops suspicious death protocol - Canberra Times, 5 May 2015

Staff were interviewed  by the Coroner in September 2015.  There are three more reports:

The Coroners Inquiry was finally completed in April 2016 when there were more reports in the press

• Nursing director denies attempted cover up of dementia patient killing The Canberra Times 20 April 2016
• Canberra's Jindalee nursing home had no policy to deal with patient's suspicious death ABC News 20 April 2016
• Coroner flags major recommendations for nursing homes after suspicious death ABC News 21 April 2016

In mid-August 4 months later we still don't have a Coroners report and any recommendations.  Will they still be relevant four and a half years later?

In summary

• Two new dementia patients had been admitted to the dementia unit.  “No full care plans had been developed for either” of them even though one had a criminal history including offences of assault.
• This resident had already attacked others in the dementia unit prior to the assault. One of the three people he attacked indicated "He grabbed my hair, he grabbed my throat. I'm afraid he's going to kill me.”.  In addition he “had been in a fight and punched another man earlier that morning”
• The victim was found when “staff pulling back his bed covers to found him bloody and with significant facial injuries
• “The registered nurse panicked, and went to her director of nursing, telling her she was going to call the police but was instructed not to call police, but instead to get a doctor in from the after-hours locum service”. The justification for this was ”no one had seen what had happened,"
• There were other staff around and the demented patient who had assaulted others was suspected of the assault. In spite of this the body was left unattended for some time in the same room with the person suspected of the assault.
• During that time the body was interfered with.  A pillow was placed over the face and either then or earlier paper towelling was stuffed down its throat.
• A passing doctor found what was happening and insisted that the police be called.
• There was a significant delay before the police arrived to investigate.
• Staff later found another resident with facial injuries, her head covered by a bloodied pillow. The woman survived the attack.
• The demented resident who is thought to be responsible has died and the case will not be prosecuted.

The issues that emerged from the inquest included:

• "The inquest is examining systemic issues highlighted by the killing - including whether supervision was adequate, whether CCTV should be used to monitor dementia sufferers, and whether increased staff-to-resident ratios were needed for safety".
• That new residents were not being assessed and proper care plans made.
• The man's body was unsupervised for long stretches, allowing it to be interfered with, while the suspected killer was left free to roam the ward and assault other residents.
• What was done was out-of-step with one part of Jxxxxxx's policy, which directs staff to call police first should they believe a coronial-related death has occurred.
• The ease with which certain residents were able to move between wards, as another two residents were allegedly attacked on the same day
• That this is the third coronial inquest into deaths at the aged care home.
• Concerns about the appropriateness of staff-to-resident ratios at Jxxxxxx. The registered nurse looking after the dementia ward was also taking care of another three wings, and 60 people in total.
• None of the staff checked if the patient was actually dead
• The notes were altered by the nurse
• No one filed an incident report
• The nurse was intimidated by the manager and feared losing her job so did not report to police

It is not clear from the reports whether the homes intention in 2012 to install video surveillance had ever been implemented.

Problem 4: In August 2012, there was another mysterious death. On this occasion, the man was thought to have died of natural causes until a blood test taken at post mortem revealed very high levels of alcohol. He was a teetotaller and alcohol was kept locked away. Consumption in the home was controlled. Who administered the alcohol? The investigation is still continuing more than three years later.

Once again, one wonders how a demented man being observed and cared for by trained staff could obtain and consume enough alcohol to kill him.  One wonders if the CCTV promised in January 2012 had been installed.  It is now 4 years later and there has been no further mention of it in the press, and a search of the Coroners court web site did not reveal any investigation.  As mysterious as the source of the alcohol is the dissapearance of the issue from view.

There is plenty of advertising on the homes web site and many claims to good care and to employing long time dedicated staff.

Summary of information: We have a company that has invested about $15 million in upgrading the facility, provides care to severely demented residents and claims to be well equipped to do that. The nursing home seems to have been very slow off the mark when influenza broke out and several people died. There have been three worrying deaths, two violent and one still unexplained and under investigation.

All three instances suggest that there may not be enough staff around in this high care dementia unit to keep a close watch on the residents some of whom the reports indicate were prone to become violent - but we do not know as staffing levels are not disclosed.

A family member of a resident is claiming that she was worried within weeks, that her mother was not being fed properly, was not walked, was not nursed properly in bed, and she believed, was being left in the same spot for 12 to 14 hours at a time.

While there is no documentary evidence of it, there are good reasons for suspecting that the daughter's observations were accurate and that this nursing home has not been adequately staffed to care for the residents it treats.

We could look at the home’s accreditation record, but that is unlikely to help because almost all homes get full marks and the reports are formulaic in nature, based on (paper work) processes and not outcomes.

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Importance of ownership structure

There is now abundant and clear evidence that the ownership structure is probably the most important factor in determining staffing levels and so standards of care, yet ownership structure is hidden in the USA (see review by Sacramento Bee), in the UK and in Australia.

Obtaining that information and finding out who will be responsible, or who was responsible if something goes wrong can be very difficult -- finding where the buck stops. Fortunately the situation in Australia is not nearly as bad as in the USA - as revealed in this US quote:

The Bank of home care in the UK (site since taken down) had an excellent list of the things that a prospective resident's family needs to investigate before they take any decision. The first and the most important is the ownership structure - who the people are and their records.  With their agreement several of their recomendations have been included in Aged Care Crisis checklist for prospective residents.

How many families would ever try to track them down if they were not warned to do so? The Bank of home care listed exactly what prospective residents need to know and what they can do to try to find out.

Who are Jyyyyyyy Village Services

What information is available on the internet about Jyyyyyyy Village Services and the Gxxx Jyyyyyyy who is described as the MD? To his credit, he has been quoted in the press about some of these issues. Too often the owners and managers leave the front line staff to cop all the flack. He may be MD, but he is not listed on the Jxxxxxx home's website as one of the team - but maybe he is not around much of the time.

A search for the company revealed that Jyyyyyyy Village Services Pty Ltd is located at Southport Central Tower One Lvl 6, 56 Scarborough St, Southport QLD 4215. It is a "privately held company". Its director is Gxxx Dxxxx Jyyyyyyy. There is also a Jyyyyyyy G Family Trust in the paper trail somewhere.

An internet and news search revealed that in 2014 Jyyyyyyy Village Services bought expensive new office space for their head office, paying $1.454 million. It was described as "a developer and operator of aged-care and retirement-community villages and has facilities across NSW and Queensland".

I could not find out what retirement villages and other aged care facilities apart from Jxxxxxx it was currently developing or operating. A search of the government May 2013 list of approved providers shows that Jxxxxxx was the only nursing home Jyyyyyyy Village Services were approved to operate. But the government does not keep a record of owners that use a subsidiary to manage the nursing homes they own. It is the subsidiary that is approved.

Gxxx Jyyyyyyy himself is about 69 years old, a wealthy businessman who bought a 300 sqm unit for $2 million in 2007 and an island mansion for $3.9 million in 2013.

Past history: I have been able to track press reports back to 1987 when Jennings Industries, a large development group with a health and aged care portfolio, formed a new 50-50 joint venture, Jennings Health Care Ltd (JHC), with the Jyyyyyyy Group. Gxxx Jyyyyyyy became Managing Director of JHC. They invested in seven nursing homes in NSW. Five of them, accommodating "545 patients", were managed by Mr Jyyyyyyy.

In 1988, Jyyyyyyy Village Services became involved in "a charter and holiday package operation based on Hamilton Island".

On 15 November 1990, the The Australian Financial Review described JHC's intended rapid expansion into retirement villages. Each was to contain an aged care facility that residents could move into when they needed more care. They planned to spend $250 million on 16 resort style projects in a market that was expected to exceed $5 billion. JHC targeted 70 and 80 year olds. By 1991 it had seven retirement villages based around nursing homes as well as seven stand alone nursing homes. They were building three more.

Issues in the retirement industry: Retirement village contracts had been designed by and largely for the benefit of developers and it was alleged that the elderly were trapped in contracts that seriously disadvantaged them when they moved on or died. On 12 February 1992, The Sydney Morning Herald described it as "wrinkle ranching" and noted rising discontent among ageing residents about the contracts they had to sign.

A retired Supreme Court Judge was leading the protest. He called the contracts "unconscionable". "Whopping profits" had been made but this was qualified with "until recently" in the article. An industry spokesperson was scornful of residents who were pressing to exercise control over village management. The Sunday Age revisited this issue on 2 Jan 1994 comparing the contracts adversely with what happened in facilities owned by government and charities.

Rising debt: The bubble burst and banks came demanding repayment of the large loans. In April 1994, Jennings and other indebted aged care groups were planning to solve their difficulties by floating themselves on the share market as a single entity, Emeritus. This was so that they could pay off debt. But by July, the plans were in a "smouldering heap" and the companies were blaming this on the state of the market. The other groups tried to recover but Jennings was too deeply in debt and had to sell its aged care businesses. By December, Jennings Health Care was being offered for sale in a tender conducted by corporate advisers Grant Samuel & Associates.

In 1995, Jennings Retirement Living (I think this was probably most of Jennings Health Care) was acquired by DCA and its subsidiary Delfin became Retirement by Design. In 1998 DCA started selling off most of its other businesses and focussed most of its efforts on its consolidated DCA Aged Care Group. This must have become Amity Group, which was sold to Citigroup's Asian Venture Capitalist arm in 2005 and then to BUPA in 2007.

Little information after 1995: The trail of Jyyyyyyy Village Services and Gxxx Jyyyyyyy's business runs cold after 1995. We do not know if they extricated themselves in 1995, if they stayed with DCA in some role and then benefited from the sale to Citigroup in 2005, or whether they got involved in other businesses.

Recent: Jyyyyyyy does not seem to have suffered badly in the sell off. In 2001 he personally funded quite extensive works on a Gold Coast golf course. He was the spokesman for the Weeroona Nursing Centre in Cowra NSW when it sought approval for a $3.5 million expansion in 2008. I believe this is operated by the Salvation Army. The acquisition of expensive office space in 2014 shows that the company is still actively involved in something and making money. It can hardly all come from the Jxxxxxx Nursing Home.

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Summarising information about Jxxxxxx Nursing Home

Jxxxxxx is owned and managed by Jyyyyyyy Village Services which seems to be a wealthy business man's family company as there is only one director. Gxxx Jyyyyyyy is a wealthy 69 year old who is also MD of Jxxxxxx Nursing Home. He runs the nursing home from offices on the Gold Coast over 1,000 km away and this is the only nursing home he operates. We don't know how often he comes to Canberra. Neither he nor Jyyyyyyy Village Services are approved providers for any other nursing homes.

We know that Jyyyyyyy Village Services was a major player in a market boom in aged care in the late 1980s and early 1990s. It was involved in a 50-50 joint venture with Jennings called "Jennings Health Care (JHC)". Gxxx Jyyyyyyy was Managing Director of this business. There was a wild scramble to grow and they borrowed heavily. Jennings became heavily indebted and was in trouble when the enthusiasm bubble burst in 1993/4. In 1995 Jennings sold off its health and aged care businesses including JHC to pay off debt. Most of the business was sold to DCA. We do not know what the role of Jyyyyyyy was in getting the company into this position, whether he had any responsibility for care, what the care in the nursing homes was like or how well or badly Jyyyyyyy Village Services emerged from this.

Soon after in 1996, Jyyyyyyy Village Services bought Jxxxxxx Nursing Home and invested money to refurbish this, presumably some of the money that was preserved or was paid by DCA for their share of the business. I could find no information about what other businesses, if any, the company was involved in. It is difficult to believe that there would be any need for the large very upmarket headquarters that has just been purchased on the Gold Coast if there was not plenty of other business being transacted. We do not know how much of Jyyyyyyy's wealth and his company's success is based on profits taken from Jxxxxxx Nursing Home.

In conclusion Gxxx Jyyyyyyy sounds like a nice guy and a good citizen who has done well out of his business ventures. We don't have any information about his management of the nursing home in Canberra, how often he visited, whether he was close enough to see what was happening or whether this was all simply delegated to the nurses in the facility, and whether his past experience was in financial management of in care. We don't know enough to form any sort of opinion about this and we cannot reach any conclusion as to whether Jyyyyyyy Villages Service's success is not in part due to their taking too much profit from Jxxxxxx and not leaving enough to employ more staff.

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The proposed hub and addressing complaints

If the proposed hub had been present then the hub would have known what was happening in the nursing home. They would have known and been partly involved in resolving the issues surrounding the flu epidemic and the subsequent three violent deaths.

The hub would be involved in dealing with the issues and supporting the daughter unhappy about the care he mother received when she first started complaining about care. If better care could not be provided they may even have arranged to transfer the lady to another better facility long before she developed 11 pressure sores, if that is what actually happened here.

Aged Care Commissioner's views: Rae Lamb, the current Aged Care Commissioner gave an excellent interview to Australian Ageing Agenda (12 Feb 2015) about how complaints should be handled stressing "open, honest, and timely disclosure of medical error", prompt apologies, early resolution, and "fixing deficiencies and addressing what has gone wrong" in such a way that the family see that this has resulted in an improvement in care.

Lamb draws attention to the "power imbalance and (indicates that) consumers should be encouraged to use advocacy services for support". How many would know let alone consider this? This is what I stressed in my 2009 submission to the Walton Review (Complaints), and I believe its omission was the main reason why early resolution has often not worked.

Aged Care Crisis disagrees with Lamb's claim that resolution by the nursing home itself has been successful and many reports suggest that this is not so. The information Aged Care Crisis is getting is that residents' families prefer not to complain because of the power imbalance and the fear of ridicule or victimisation of the resident. This is why there are fewer complaints, which has been misinterpreted as success of the system.

The proposed hub would be there to help, support and empower the family - an advocacy service. This would ensure that open disclosure occurs, would monitor the response to the complaint, and would ensure families see that their complaint was valued and did contributed to change. The hub would take steps to prevent angry staff from taking it out on the resident. This does occur and the family can do nothing about it.

The hub and the owners background: The long exercise in tracking Jyyyyyyy's ownership was not to point fingers, but to show just how much effort may be needed in the UK and in Australia to track down a facility's track record, its ownership structure, and then find out who and what sort of owner they are dealing with and what their expertise is - finding out where and with whom the problems really lie. As here, the questions may not always be answered fully.

In this case, the amount of background information collected was only possible because I had built up a large personal data base tracking health and aged care businesses in the USA and Australia in the late 1990s and early 2000s when I was studying them. Few families would be able to gather this sort of information as it is no longer readily available.

If the proposed hub were present, then the hub would know what was happening in the nursing home and whether there were problems in staffing and in care.

They would know how much money was going to staffing and who the owners were. The hub would have the interest to look at the background of those involved in serving the elderly in their community. This information would then be available to prospective residents and families, so helping them to be effective customers when they make the most important choice of all - who will care for them. There would be a much better chance of this market working for the residents.

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A not-for-profit example

In a 2013 news article, a woman in Tiwi Residential Care Centre an aged care facility in Darwin, had maggots in her pressure sores on two occasions - flies laying their eggs in the dead tissue. The woman's daughter claims she had been fighting for improvements in care for more than a year. The outright denials by management simply don't ring true and reveal an inability to handle situations properly - but all too often this is how they think and behave. Any complaint is a criticism and the response is rejection. The person is seen as a trouble maker.

A video was published on YouTube:

Once again the response is to reject the information, deny everything and lean on the flawed and unreliable accreditation process to ridicule the critics. In 2013, this facility situated in Darwin was owned by NFPCompanyZ  (It markets itself as Experienced, Conscientious and Hospitable), a not-for-profit community group located in Adelaide at the opposite side of Australia. Their website no longer shows them owning this facility. They own homes in South Australia and the difficulties of effectively managing something as sensitive as a nursing home from thousands of miles away is obvious. Perhaps they realised this, as the home is not shown on their website any more.

The news report indicated that this home "as well as Tracy Aged Care in Darwin and Terrace Gardens in Farrar - have all been penalised in the past year for failing accreditation standards". In 2013, the other two were operated by Uyyyyy Ltd (the NFP CompanyT church) whose main offices are in far away Sydney but they may have a local branch.

Rural and remote nursing homes are a particularly difficult problem because of the distance and many other factors. It is the not-for-profits who take on the challenge. We need to recognise and understand the problems they have and not be excessively critical - but we don't expect the sort of response to allegations exhibited by Tiwi Residential Care Centre and NFPCompanyZ.  I think responsible management should have been aware of what its chief executive was doing and rebutted it.

If the proposed hub had been present they would have been in contact with the managers and owners of these facilities much earlier.

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