Marcella Reed’s grandfather struggled to breathe.
On March 29, she called 911 to transfer him from Elmcroft of La Mesa, an assisted living facility where he contracted COVID-19, to a hospital. Reed claims Elmcroft resisted the move, even though the facility lacked the medical know-how or resources to pump enough oxygen to his lungs.
“It’s beyond their hands,” Reed told the dispatcher, according to a recording obtained through a public records request. Walter Anderson died in the hospital on April 5.
About two weeks later, when an Elmcroft staffer phoned 911 to report an unresponsive resident with labored breathing, a dispatcher asked if a nurse or doctor was with the resident. No, only caregivers, the staffer said.
Nationally, about half  of assisted living facilities have a registered nurse on staff, while on-site doctors and facility medical directors are less common. Beyond help with daily tasks such as feeding and bathing, many residents rely on their own outside doctors.
Without medical professionals in the building, it’s more likely that a resident’s change in condition goes undetected, experts say. Care can also be delayed. Thin medical staffing faces greater scrutiny – even from within the assisted living industry – as COVID-19 cuts a deadly swath through elder care facilities.
“COVID laid bare the flaws and holes in the system,” said Phil Lindsley, a founding attorney at the San Diego Elder Law Center. At Voice of San Diego’s request, Lindsley reviewed Elmcroft’s 911 calls from February through May.
He said nonexistent medical staff, evident in some of the recordings, is emblematic of an industry that’s too often ill-equipped to deal with resident falls, let alone a pandemic that requires strict infection control.
In an emailed statement, Elmcroft executive director Wes Hebner said that “health and safety are our top priorities.” The assisted living facility, he added, falls into a licensing category “established decades ago, as residential, non-medical living environments.”
“Our model of senior living is defined by state regulations and is about offering the public choice. And fortunately, there are many options along the senior care continuum of services when it comes to a consumer’s long-term care needs,” Hebner said.
In San Diego, there are nearly 600 assisted living facilities, ranging from small homes to memory care campuses like Elmcroft that cater to residents with Alzheimer’s disease and other forms of dementia.
Industry backers tout a home-like feel, combined with medical care from residents’ own doctors and hospice nurses. For many elders, assisted living offers the “level of care they want and need, in a setting they prefer,” said Sally Michael, president of the California Assisted Living Association, in an email.
Over time, assisted living facilities have accepted frailer residents, and the industry’s population increasingly overlaps with that of nursing homes. But unlike nursing homes, assisted living facilities aren’t required to have medical directors or round-the-clock licensed nurses.
Many staffers in the industry are direct care workers, a category that requires relatively little training : 40 hours initially and 20 hours annually, with some additional training to care for those with dementia.
Reed said it doesn’t make sense that Elmcroft of La Mesa – which markets “exceptional memory care” on its website  – qualifies as non-medical.
Regardless, she said the facility failed her grandfather, a retired Navy master chief who had dementia. He was 83 years old. Reed said a caregiver alerted her family to Elmcroft’s poor care, but facility staff resisted the hospital transfer.
“I told them, ‘You can’t provide the level of care my grandfather needs, and I’m not going to leave him there to suffer,’” Reed said.
Elvia Sandoval, Anderson’s daughter, blames Elmcroft for his death. She called him a “pillar of the family,” who before the pandemic enjoyed perusing pictures of farm animals and nature, a nod to his past.
“He was a farm boy from Idaho,” Sandoval said.
In San Diego’s deadliest assisted living outbreak, 34 Elmcroft residents contracted COVID-19 since the pandemic began, and of them, 14 died, according to state data . In addition, 18 staffers got the virus.
Last year, a state inspector faulted Elmcroft for inadequate staffing when a resident hit another resident in the shower, a finding that the facility has appealed. In 2017, the 56-bed facility was put on probation after three resident fights, one of which was deadly.
A year later, Eclipse Senior Living took over  management of the facility and 75 other senior living properties. As part of the deal, Eclipse pledged to hire most of the staff of Elmcroft Senior Living, the properties’ prior licensee.
A sticking point to adding nurses and doctors in assisted living: cost. Facilities are largely private pay, and so more medical staffing could increase prices – or reduce profits.
Sheryl Zimmerman, an industry expert and professor at the University of North Carolina at Chapel Hill, advocates financing reforms, including assisted living facilities sharing in savings if they reduce hospitalizations. That would incentivize bringing in nurses and doctors who are versed in preventive care, and could keep down resident fees, she said.
In assisted living, it’s long fallen on families to assess their loved ones and coordinate doctor appointments, a job made tougher by visitation restrictions  amid the pandemic. Families shoulder these responsibilities because about 70 percent  of assisted living residents have some form of cognitive impairment, including dementia.
“Staff members typically aren’t trained to look for health status changes,” said Zimmerman.
Some in the industry have fit medical professionals into the budget. In San Diego, Bayshire manages five assisted living facilities, each one with a medical director and at least one nurse always on site.
Scott Kirby, the CEO of Bayshire, said higher occupancy rates partly offset steeper labor costs.
“Having physicians more involved, and having nurses more involved, it improves our care, and we’re able to market that,” Kirby said, adding that Bayshire’s facilities are competitively priced.
San Diego’s Majella Assisted Living hired in-house nursing – and contracted outside medical staff who regularly visit.
“It’s a different model,” said CEO Jim Morrison. “Rather than only call the doctor when something major happens, we’re trying to get ahead of that and prevent big declines.”
Some operators fear the U.S. Centers for Medicaid and Medicare Services – which oversees nursing homes – could also bring assisted living under federal oversight.
But Christopher Laxton, the executive director of AMDA – The Society for Post-Acute and Long-Term Care Medicine, said more in the industry are embracing getting out in front of federal regulations, rather than fighting them altogether.
“COVID has changed people’s thinking,” said Laxton.
AMDA is working on model agreements to integrate medical directors into assisted living facilities. The process predated the pandemic but took on added urgency in recent months.
The organization is also exploring nurse staffing recommendations, though Laxton said the group favors “staffing adequately based on the complexity of residents” over specific staffing ratios.
Over time, increased Medicare restrictions on nursing home eligibility pushed many frail seniors into assisted living, said Chris Murphy, executive director of Consumer Advocates for RCFE Reform, a San Diego nonprofit. The problem requires multi-pronged regulatory overhauls, Murphy said.
Murphy also advocates for increased medical oversight by way of folding the state division that regulates assisted living into the state agency that regulates nursing homes. Nothing along these lines has been formally proposed.
A spokesman for the California Department of Social Services, which regulates assisted living, said in an email that the agency “licenses facilities in accordance with state law.”
When it comes to testing and government funding, assisted living facilities have taken a backseat to nursing homes during the pandemic, despite caring for a similar population.
Only recently were assisted living facilities able to tap the same federal funding  that’s been available to nursing homes for months.
In May, California called for universal  testing in nursing homes, while a less-ambitious testing plan for assisted living facilities rolled out a month later. That said, the sheer number of assisted living facilities – many of them six-bed homes – compounds the challenge of mass testing.
Nationally, about 40 percent of coronavirus deaths have been linked to nursing homes and assisted living facilities. Some of these seniors spent their final days in near-isolation. Among them: Anderson, upon being transferred from Elmcroft to the hospital, where COVID-19 barred visitors, his family said.
A hospital nurse held the phone up to his ear as family members talked. His breathing constricted, he could only listen.
Jared Whitlock reported this story with support from the 2019 Impact Fund, a program of the USC Annenberg Center for Health Journalism .