A building with a sign Luis Santana
How did the coronavirus overwhelm a Seminole nursing home so quickly?
A face.
Thomas Minichillo
A face.
Daniel Lewis
A face.
Jean Lasner
A face.
Donald Jack
A face.
Jeanette DeFrank
A face.
Donna Mortensen
A face.
George Egolf
A face.
Anthony Fabrizio
A face.
Sue Stephenson
A face.
Emil Sudol
A face.
Eunice Angelone
A face.
Harry Nash
A face.
Louise Johnson
A face.
Russell Douton
A face.
Verne Strible
A face.
Theresa Szubartowski
A face.
Vincent Narcisi


Ambulances line up in front of Freedom Square.
Dirk ShaddAmbulances line up in front of Freedom Square.

Marjorie Blackman arrived for her shift at the Seminole Pavilion nursing home on a Saturday in April, stopping at the front door for a temperature check. The nurse had been tired and short of breath, and now, she had a slight fever. She didn’t know that a patient had died the day before after testing positive for the coronavirus.

An immigrant from Guyana, Marjorie had gone back to school in her 50s to become a licensed practical nurse. Now 67, her three-hour daily commute was exhausting, and she could have retired. But she loved her job.

Marjorie drove herself to the hospital for a test, then to the home in Spring Hill she shared with one of her daughters, Tamara Blackman, and 8-year-old twin granddaughters.

Tamara had been worried about her mother for weeks, since the first cases of COVID-19 hit Florida.

“Are they testing anybody?” Tamara had asked her mother in early April. “What about the patients?”

Marjorie had shrugged. They didn’t talk about it. Marjorie had a thin cloth mask, which she ``washed again and again.

She later told her daughter that several nurses had quit, and others were sick.

Three days after her mother came home with a fever, Tamara listened at the bedroom door to her raspy breathing. She called for an ambulance.

Last spring, the coronavirus stormed through Seminole Pavilion and another nursing home at Freedom Square of Seminole. Forty people have died, among the largest tolls at long-term care facilities in the state.

Nine months into the pandemic, the virus has killed more than 19,000 Floridians. About 40 percent of the deaths have been among senior care residents. In Pinellas County alone, more than 2 out of 3 coronavirus deaths are connected to nursing homes and assisted living centers.

Overhead photo, map and directory to buildings at Freedom Square

Freedom Square, a 15-acre retirement complex built around a town square and a gazebo, was the early epicenter in Tampa Bay.

At Seminole Pavilion nursing home, staff begged managers for protection as the virus raged through the state in April. They complained they couldn’t get gowns or N95 masks or answers. They saw their ranks diminish as one after another came down with fevers or symptoms.

The facility kept accepting hospital patients for rehab who hadn’t been tested for the virus until April 9, though some state officials and nursing homes raised concerns about the practice weeks earlier. The state took almost two months to mandate testing.

Florida also didn’t require facilities to publicly disclose outbreaks until late April.

Freedom Square kept quiet about the first death and positive cases for almost a week. On April 29, state inspectors found broken equipment and dirty facilities. Communication with families was inconsistent and, at times, chaotic.

For this story, the Tampa Bay Times interviewed dozens of family members who lost loved ones to the outbreak as well as former and current employees. Reporters also reviewed hundreds of emails, inspection reports, legal documents and medical records.

By the end of April, more than half of the 95 residents at Seminole Pavilion had tested positive. They died in waves, at hospitals and hospices across the county, many with no family or friends by their side. Staring down the isolation and uncertainty, some gave up, stopped taking medications and called family members, one by one, to say goodbye.

The Times requested interviews with Freedom Square administrators, who asked for questions in advance. Executive director Michael Mason then declined to answer them and instead provided a statement.

“Our residents’ and staff’s health is, and has always been, our No. 1 priority,” he said. “We are fully committed to the health and well-being of everyone in our community – employees and residents alike. We will continue to do all in our power to keep and maintain a safe and healthy environment here at Freedom Square.”

Mason said there would be no further comment, because of “an ongoing investigation and because of the sensitivity of the matter.” He declined to say who was investigating.

Two families have sued Freedom Square, its current and former corporate owners, management company and Seminole Pavilion administrator Cynthia Ayala.

Relatives of Donald Jack and Christopher Pugh allege in separate 40-page complaints that the facility “chose to place profits over residents and ignore deficiencies in their emergency preparedness plan and in their infection prevention and control program.”

They said the facility waited too long to alert the Department of Health to a potential outbreak.

Bennie Lazzara Jr., an attorney representing both families, said: “It’s a disgrace, really, not just here but all over the whole country. The numbers are staggering.”

In court documents, Freedom Square lawyers argued the company “met the standards of care prevailing amongst similar facilities in this community.” It denied allegations of negligence and blamed Jack for his own death.

‘Everything was circulating’

In mid-March, employees of Seminole Pavilion sat in a break room discussing the pandemic. On the news, they’d learned that the first major U.S. outbreak hit a nursing home in Washington state and saw how quickly it attacked residents and staff.

Jaleysah Gainey, a 22-year-old certified nursing assistant, worried about taking the virus home to her grandparents, both in their 60s. Gainey’s grandmother is a diabetic with bad asthma, and her grandfather is a cancer survivor.

Co-workers were convinced the facility was unprepared.

Hallways were linked like a square, and aides moved between different wings.

“Everything was circulating,” Gainey said.

Employees were especially concerned about new rehab patients coming from hospitals, and they warned their bosses.

“We, the staff, we begged them to not take these admits,” Gainey said. “We all said: It’s going to come into the building, because you guys keep taking in new people that aren’t getting tested.”

At the time, Florida hospitals and nursing homes were not required to test for the virus before patients were transferred. Tests were limited and costly.

“They said, ‘It's okay, oh no, it’s fine, there’s nothing wrong with them,’” Gainey said.

Seminole Pavilion designated one hall for new rehab patients, but all employees passed through to get to the break room and punch time cards. Staffers in that hall were required to wear face shields and gowns, Gainey said, but the gowns were reused every day and rarely washed.

Her co-workers began to panic. One aide had a sick mother. Another worried she’d give the virus to her four daughters. One nurse, who had recently survived cancer, left a meeting with an administrator weeping. “I do not feel safe in this building,” she told Gainey.

In late March, employees learned the facility’s risk manager had quit.

An aide working at one of the rehab halls told Gainey she thought a new patient had COVID-19 because he had diarrhea and a fever. But even the nurses didn’t know for sure, Gainey said.

At a staff meeting in early April, Ayala and another administrator at Seminole Pavilion chided employees for spreading “rumors” about COVID-19, Gainey recalled. They said the facility did not have any coronavirus cases, and people who continued to talk about it would be punished with a “write-up.”

“She basically scolded us like kids,” Gainey said.

A day later, employees said, Ayala and another top administrator stopped coming to the building.

Neither responded to phone calls and emails from the Times.

Soon after, the first cases arrived in the rehab wing.

‘I wonder if anyone is sick there’

On April 1, Carol Valentine called her 94-year-old mother.

“Things are strange,” Ruth Schneiter said.

A face
Ruth Schneiter

Schneiter, a retired Bay Pines Veterans Administration hospital nurse, had spent two weeks at Largo Medical Center for high blood pressure, ending up in Seminole Pavilion’s rehab unit on March 27.

On the phone, Schneiter told Valentine that she had to stay in her room.

“I wonder if anyone is sick there,” Valentine said, but her mother didn’t know.

Valentine called the nurses but could not get a response.

Around this time, Harry Nash, 75, who owned a bookstore on Madeira Beach, told a friend that he thought people at Seminole Pavilion were infected with COVID-19. Nash, who’d arrived for rehab on March 28, said rooms were sealed with plastic.

His friend, Sean Donnelly, asked if the staff wore masks.

“Only half the time,” replied Nash.

A face
Thomas Minichillo

Thomas Minichillo, a retired postal worker who in recent years battled chronic pneumonia and other medical problems, also ended up at Seminole Pavilion after a hospital stay.

His wife, Terri Terzini-Minichillo, said it was difficult to find a rehab that would take him in March. Finally, the doctors called and said he was headed to Seminole Pavilion. He was put in a shared room, which concerned her.

At first, she spoke to him on the phone several times a day, sometimes while standing outside his window. The couple looked forward to celebrating their 59th wedding anniversary. “He looked at me and said, ‘I cannot wait until you take me to dinner,’ ” she said.

But then, he suddenly went silent. Every time she or their son called, the staff said Minichillo was sleeping or too tired to talk.

On April 5, Seminole Pavilion sent Minichillo to the hospital in an “altered mental state.” He tested positive for the coronavirus on April 9. The next afternoon, the 74-year-old became the first Freedom Square patient to die.

That same day, the facility released Ruth Schneiter.

“I’m home,” the retired nurse said to her daughter, Valentine, on the phone.

Seminole Pavilion had discharged Schneiter to her assisted living facility down the street, also a part of Freedom Square. Valentine was surprised. She didn’t think her mother was ready to leave the rehab unit.

Two days later, on Easter Sunday, Valentine dropped chocolates and a pair of moccasin slippers off for her mother. But Schneiter didn’t feel well and didn’t come to the window.

At 11 that night, a nurse called. Schneiter had a 102-degree fever.

“Oh, crap,” Valentine thought. She knew.

Valentine took her to the ER. It was the first time she’d seen her since mid-March. She looked frail and worn out, and they didn’t say much.

When Valentine got to Morton Plant Hospital in Clearwater, nurses helped her mother out of the car. They would not see each other again for 25 days. “She was by herself until the end,” Valentine said, “when I came in and held her hand.”

‘What are you guys not telling us?’

At work on Friday, April 10, the day Minichillo died, Gainey was required only to wear a cloth mask. When she returned Monday, she was told to suit up with more gear, including a shield, gown, gloves and N95 mask.

“We are like, ‘What’s going on?’ ” she recalled. “What are you guys not telling us?”

Staffers learned the facility had positive cases, 10 of them. But Minichillo’s death wasn’t announced until four days later.

She thought of Marjorie Blackman, who was out sick. Marjorie often appeared when Gainey got overwhelmed, making sure patients still got dressed and their diapers changed. She hoped Marjorie was okay. She’d noticed the nurse was unable to walk far without getting out of breath.

Behind the scenes, the Pinellas County Department of Health and the state Agency for Health Care Administration had conducted a joint inspection on April 9 and found “a widespread lack of hand hygiene upon entry and exit from residents’ rooms,” according to state emails and reports obtained by the Times.

The agencies recommended all residents and employees be tested on the same day to assess how far the virus had spread. That didn’t happen.

On April 14, Gainey came to work uneasy. Since childhood, stress had manifested in physical ways. Now, she had a urinary tract infection, a migraine and a toothache. She attended to her patients, trying to project calm.

After a full day, a supervisor told her that two of her patients had tested positive.

Gainey immediately thought of her grandparents.

“I told y’all what I had going on,” she told the supervisor. “That I just couldn’t, absolutely couldn’t, bring it home.”

She went to the hospital for a coronavirus test. To her relief, she tested negative. But she never went back to Seminole Pavilion.

‘We aren’t a horrible place’

Saturday, April 4, 2020
Good morning dad,I hope your feeling a little better today.
Read 10:12 AM
Got me in wheelchair now. Very dizzy.
10:18 AM
I’m sorry,I hope it gets better.
10:20 AM
I'll let you know
6:12 PM
Ok.Sammy says hi and he misses ya too
Read 6:14 PM
Text between Michael Jack and Donald Jack, April 4, 2020

The night Gainey quit, a flow of ambulances pulled up to the nursing home.

Emergency workers and staff, overseen by the Department of Health, shuttled elderly residents out of Seminole Pavilion, forgetting purses, glasses and hearing aides. Some had symptoms or had tested positive; others were asymptomatic but had been exposed.

Thursday, April 16, 2020
Any news?
Delivered 7:31 PM
no. I called and spoke with admissions director.. I'm trying to find out.
8:23 PM
Ok.i really appreciate your help.if he does test positive what happens then? does he go to the hospital,or does the medical team there just take care of things?
Delivered 8:30 PM
well everyone has been going to hospital I think.. I'm sorry I'm trying. calling again.
8:43 PM
Thank you im sorry that it's so late.do you think it would be better to just go over there and ring the bell to ask the nurses ?I dont live far…
Delivered 8:46 PM
hang on..
9:08 PM
I can't get any help Michael.. I'm sorry. maybe you should..
9:13 PM
Text between Michael Jack and Freedom Square personnel, April 16, 2020

Over the next few days, more ambulances would arrive at the facility. One morning, Michael Jack stopped by to check on his 75-year-old father, a diehard Chicago Cubs fan. He saw a line of four ambulances tended to by medics in Hazmat gear. They pulled away, then another four showed up. He asked an employee at the door if it was COVID. She said she didn’t know.

Later, news reports confirmed his fears: Coronavirus had not only made it into the facility but had overwhelmed it, and dozens of residents were being evacuated to area hospitals. His father, Donald Jack, was not among them.

Before the pandemic, Hodgkin’s lymphoma had crept through Donald Jack’s body, appearing first like a stomach flu.

As he grew weaker, Jack stubbornly refused a wheelchair, opting for a walker instead.

In the spring, after another fall, he went to the hospital, and doctors soon released him to Seminole Pavilion for rehabilitation.

On April 16, Donald Jack called his son to say he’d been tested for the virus. No one had told him the results, but he had overheard nurses talking among themselves that he was positive.

Michael Jack texted a Freedom Square manager: “Do you know if that’s true?” he asked of his father’s result, according to screenshots he shared with the Times. “If so does he need to go to the hospital or anything?”

“I’m sure you’ve seen the news,” the employee texted back. “They always make it seem worse. We aren’t a horrible place. Let me find out. I know you’re worried and so is he.”

Two hours and a few more texts later, he still didn’t have an answer.

“Do you think it would be better to just go over there and ring the bell to ask the nurses? I don’t live far,” he wrote.

A half-hour later, the employee responded: “I can’t get any help, Michael. I’m sorry. Maybe you should.”

Penny Stephenson had missed the news and still wasn’t aware how bad the outbreak was at Freedom Square. On April 17, she called her mother, an 80-year-old in the long-term care wing, who sounded giddy.

“I’m packing up and going home!” Sue Stephenson told her daughter, who was confused - was the facility moving her?

“Nothing like that is going on here,” the nurse assured her.

A few hours later, the entire facility was being evacuated. Freedom Square called to say her mother was headed to Northside Hospital.

Stephenson begged the nurse to take her instead to Morton Plant, where her doctors were. But the nurse said nothing could be done.

A face
Sue Stephenson

At the hospital, Stephenson tested negative, but days later, another test came back positive. She died six days later.

Freedom Square’s letter to families the night of the evacuation said the facility had made the decision to move the remaining residents at noon, about nine hours before Johnson was called.

“The families of all impacted residents have been contacted to let them know of the change,” the letter said.

Several relatives said the notifications came too late.

“Why were we lied to that night?” Stephenson said. “And why did they have to do it in the middle of the night? Would she have lived if we had gotten her moved to Morton Plant somehow?”

Communication issues were among the three dozen questions from the Times that went unanswered by Freedom Square.

Shortly before evacuation, the company announced for the first time that there had been three deaths — Minichillo and two other patients that day.

Michael Jack waited anxiously for news of his father.

He’d wanted to take him out of Freedom Square and bring him home, but it was too late.

A face
Donald Jack

Donald Jack, instead, languished at the hospital alone.

He died April 21. His son said goodbye over a 30-second video call.


Marjorie Blackman, the Seminole Pavilion nurse, was now at Oak Hill Hospital in Brooksville and still struggling to breathe. The mother of five, who had cared for so many of the evacuated patients, had been placed on a ventilator.

Blackman’s daughter Tamara learned of the deaths on the news April 17 and soon realized the first to die — Minichillo — had tested positive April 9. Her mother had subbed for another nurse that day and the next.

On April 24, a National Guard strike team arrived at Freedom Square to help test patients, but they only checked employees and symptomatic residents.

The virus also spread in other buildings on the campus, where staff shared elevators and break time, according to employees.

At the nearby 116-bed Freedom Square Rehabilitation & Health Center, 12 residents and four employees had tested positive by April 28. The Inn at Freedom Square, an assisted living facility, also had a confirmed case that day.

The same week, Gov. Ron DeSantis, after weeks of pressure and a lawsuit filed by several media outlets, began requiring long-term care facilities to report positive COVID cases and deaths to the public.

Some of those lost

Daniel Lewis — “No one was safe from becoming Dan’s new friend,” his son said. The former ambulance driver was kind to everyone he met and a rock for his family, even offering them advice and words of support as his health declined from the virus.(1 of 10) Jonathan Lewis
Jean Lasner — Originally from New Jersey, Lasner worked at a doctor’s office in downtown St. Petersburg for years until she retired. In later years, she loved to get her hair and nails done, and her son took her out to eat once a week. Her favorite restaurant was Cracker Barrel.(2 of 10) Courtesy of Robert Lasner
Tango Jessee — Jessee grew up in a one-stoplight town in the Appalachian Mountains. She came to the Sunshine State late in life to be closer to her daughters. She loved sand sculptures and fireworks on the beach.(3 of 10) Courtesy of Robbie Jessee
Jeanette DeFrank — DeFrank was born in 1918, the same year the Spanish Flu wreaked havoc on the world. A secretary and then a stay-at-home mother, she stayed independent almost until the end, shopping and carrying in her groceries until 98, her grandson said. She was “a very strong woman,” he said. “Very feisty.”(4 of 10) Courtesy of Joseph DeFrank
Eleanor June Schueneman — In her 60s, Schueneman was riding a motorcycle to work. In her 90s, she was crocheting lap robes and shawls for Veterans Administration hospitals. She was “quiet and strong,” her daughter said.(5 of 10) Sandra McKinley
Donna Mortensen — In Washington, Mortensen ran the kitchen at the Wesley Foundation and was considered a mother to the student residents. In Florida, she volunteered at a number of hospitals. St. Petersburg General Hospital gave her the Frist Humanitarian award. She also raised money for Southeastern Guide Dogs through the hospital gift shop. Each holiday, she’d make a tray of favors for the patients.(6 of 10) Courtesy of Rick Mortensen
Emil Sudol — Sudol, a Korean War veteran, was an avid reader, piling up magazines and newspapers at his house, and especially enjoyed military history. Even at 91, he loved nothing more than meeting friends for a beer. “He was kind of free and independent,” his nephew said.(7 of 10) Courtesy of Mike Magur
George Egolf — Egolf grew up in the Panama Canal Zone and first caught sight of his future wife on the first day of high school. People said she was snobby, but Egolf wasn’t dissuaded. The couple eloped when they were 19 and were married 69 years. In retirement, they relocated to Pinellas County, where Egolf enjoyed meeting his brother for breakfast every day and working on furniture and house projects. “He was a mister fix-it,” his daughter said.(8 of 10) Debra Lane
Anthony Fabrizio — For most of his life, Fabrizio began each day with 100 sit-ups. He ran more than a dozen marathons and kept up running into his 70s and was still biking in his 80s, his son said. “Anthony’s obsession with staying strong and healthy was legendary,” his family said.(9 of 10) Courtesy of Daryle Fabrizio
Verne Strible — Baltimore-born, Strible served in the U.S Army in France during World War II, then studied engineering at Johns Hopkins University on the G.I. Bill. An engineer to the core, he wore a pocket protector with a pen and pencil throughout his life, his daughter said. Retired in Florida, he and his wife lived at Freedom Square in Seminole for many years, where they had a large social circle and loved to go out to eat. Strible was always after a good crab cake — but never could find any that rivaled Maryland’s.(10 of 10) Sandy Curry

‘I love you, bye’

At hospitals and hospices across Pinellas County, the disease began to claim Freedom Square residents and rehab patients.

Margaret Lally, 96, a former independent living resident, was supposed to move into Seminole Pavilion following two heart attacks, her son said, but they placed her with a roommate in a quarantine zone, and she got the virus. She died April 20.

The next day, two people died: Jean Lasner, 90, and Jack, the Cubs fan.

Christopher Pugh, 84, died April 22. Susan Jones, 78, died two days later.

On April 25, Eleanor Schueneman, 94, and Jeanette DeFrank, 102, took their last breaths.

Donna Mortenson died on April 27, 13 days after leaving Seminole Pavilion. At 98, she had almost reached her goal to live to 100.

Four people died the next day, including Sue Stephenson. In her last days, her daughter had been trying to lift her spirits with video calls. Her usually bubbly mother was barely able to speak. “I love you, bye,” was all she would respond.

Emil Sudol, who arrived at Seminole Pavilion from the hospital with a foot infection following a fall, died a little more than an hour after Stephenson. At 91, the Korean War veteran still lived in his own house and enjoyed sharing beers with friends at haunts like the Casual Clam Seafood Bar & Grill.

George Egolf, 89, a former machinist in the Panama Canal Zone, died April 28, as did Anthony Fabrizio, a 93-year-old who was checked out at a hospital and sent back to Freedom Square even as the outbreak spread.

Blackman, the nurse, remained on a ventilator as one of her daughters, Earlene Blackman, pleaded on Facebook for blood plasma with antibodies of the virus.

“Who knows if this will even work, but it never hurts to try,” she wrote.

But on April 29, Blackman died.

Identity badges on a photographic portrait of a woman
Marjorie Blackman’s name tags and company pin. Douglas R. Clifford

Eunice Angelone, 95, who met her husband in London during World War II and came to the U.S. on a ship, died April 30. Avis Lilly, 98, and Constance Bentler, 85, died two days later.

“I don’t want to live anymore,” Bentler had told her daughter. “I’ve tried. I’m done.”

A face
Louise Johnson

Alice Ford, 90, died May 4.

Louise Johnson, 79, died the next day, as did Nash, the Madeira Beach bookshop owner.

Beverly Dikman, 86, died May 5, after being in Morton Plant Hospital for 22 days.

On May 6, five people died, including Russell Douton, a 92-year-old magician known as “Windy” who was still performing balloon animal shows at a Seminole restaurant twice a week.

Patricia Lewandowski also died that day, after breathing through a ventilator for 25 days.

A face
Theresa Szubartowski

Verne Strible and Theresa Szubartowski died the next day. Both were 99.

In the span of a month, 32 had died.

Toward the end of that stretch, the state began requiring hospitals to provide two negative COVID-19 tests before they could release a patient to a nursing home.

On May 9, Todd Brusko raced to see his father.

A face
Vincent Narcisi

Vincent Narcisi, a Seminole Pavilion resident who tested positive upon admission to Morton Plant Hospital, was dying.

The 91-year-old Korean War veteran was a tough man, his son said, born amid the Great Depression, raised in Philadelphia where he “learned very early to hustle and fight.” His nose was plum-shaped from the many times he broke it. Narcisi spent decades running an electronics business in St. Pete Beach and had moved into Freedom Square about two years ago.

After about three weeks and several more positive tests in the hospital, he stopped taking his medications and ceased any treatment for COVID-19. Brusko thinks his father couldn’t deal with the thought of being hospitalized long-term.

“That was the thing that kind of broke him,” he said.

Ever since the lockdown, Narcisi’s only contact was with workers, who were bouncing from room to room, going home to their families, then coming back.

Brusko, an immunologist at the University of Florida, doesn’t blame them. They’re just not trained or equipped for a situation like this, for a virus this contagious.

‘They need to be regulating them much tougher’

Even before the pandemic, staff at Freedom Square was stretched thin, employees said.

Lucia Torres, a nurse who began working the overnight shift at Seminole Pavilion last August, said she was shocked by what she saw there. It was dirty and smelled of mold. She spotted roaches. She said supervisors brushed off her complaints.

She was often the only nurse in her hall, caring for 35 to 40 residents with two certified nursing assistants.

That was too few to manage the litany of patient needs, she and other employees said, from feeding and showering to making sure everyone got the proper medication. The staff woke residents at 4 a.m., so they would have enough time to get everyone dressed and into the dining room by 7 for the morning shift. It was awful, she said, to watch them lined up half-asleep in their chairs.

Employees were always overworked, she said. She recalled Marjorie Blackman staying sometimes until 2 a.m. to fill out paperwork. Her shift ended at 11.

Seminole Pavilion scores “above average” for meeting national staffing requirements, according to the Centers for Medicare & Medicaid Services.

But Torres said the standards didn’t seem high enough, especially to meet the challenges of the pandemic.

In late March, after she moved to the memory care unit, two of her patients developed fevers. Torres wanted to have them tested for the coronavirus, but her supervisor disregarded her request, she said.

It was not safe and going to get worse, she believed. So she stayed home.

What happened at Freedom Square has been repeated across the country, revealing an industry starkly unprepared to confront a crisis of this scale.

The retirement complex had long been owned by a company backed by private investors — Brookdale Senior Living, which leases and owns more than 700 senior properties around the country.

On Jan. 31, Brookdale sold its share of Freedom Square to a real estate investment trust, Healthpeak Properties Inc., headquartered in California. The facility’s operations did not change noticeably, employees and family members said. Records show the same administrators remained in place at Seminole Pavilion.

Healthpeak, in a statement, defended Freedom Square, saying the facility had “done their utmost to ensure the health and safety of their residents, as well as their dedicated employees.”

In for-profit nursing homes, investors often split the business into separate operating and property companies.

This is the arrangement at Freedom Square.

The split-business model can be a way of pumping up profits and protecting the company from liability, said Charlene Harrington, professor emerita of nursing at the University of California, San Francisco. It allows the company to lease back the building to itself and charge management fees.

The facilities then operate on razor-thin margins, and profits that might go to hire extra staff or stock up on protective gear instead go to the separate company, Harrington said.

She has not researched Freedom Square but has authored multiple studies on the for-profit nursing home industry. Almost 70 percent of nursing homes are run by for-profit owners.

Research suggests patients suffer as a result, even in prepandemic times. Mortality rates increase 10 percent when a patient goes to a private equity-owned nursing home instead of a nonprofit, according to one New York University study.

In the spring, Brookdale was hit with a class-action lawsuit alleging it boosted profits by keeping staffing at levels that were “chronically insufficient.”

According to the lawsuit, Brookdale facilities in North Carolina used proprietary staffing software to deliberately underestimate the labor required to address resident needs. The lawsuit also alleges the company did not fully document services provided to avoid paper trails.

Brookdale said the lawsuit is “completely without merit,” and, in a court response, asked that it be dismissed.

The company said the lawsuit does not identify deceptive acts, only insinuates that Brookdale made staffing decisions based on financial considerations “as all businesses do.”

Harrington said for profit-nursing homes were more vulnerable to COVID-19 outbreaks because of limited staffing.

Governments should increase staffing requirements, she said, because “that’s the root of all the problems…They need to be regulating them much tougher.”

Research at the University of Rochester Medical Center points to staffing levels as a key indicator of whether nursing homes are able to quickly identify and contain outbreaks once they start.

Yue Li, one of the researchers on the study, said facilities like Freedom Square should hire extra staff during the pandemic. “One nurse to 40 patients — that is not a high enough staffing ratio,” he said.

Employees said there was no talk of hiring extra staff at Freedom Square, even once the threat became clear. Instead, they said, administrators talked about bonuses for maintaining perfect attendance.

Then people began testing positive.

Testing requirements came in July

The same day Blackman died, a state surveyor arrived at Seminole Pavilion for an inspection. By then, more than half of the residents had tested positive.

A worker offered an inspector a thermometer with “exposed probes.” When asked for another thermometer, the employee pulled out a no-contact version, which produced a reading of 95.4 degrees. The worker acknowledged the thermometer was broken.

Inside, resident rooms looked like they hadn’t been touched by housekeeping. Several staff members failed to clean their shields properly. The assistant director of nursing reused gloves, after applying hand sanitizer.

The practice of reusing gloves has been shown to transmit the virus, according to the state agency’s report.

Five days later, on May 4, the state inspected the adjacent nursing home, Freedom Square Rehabilitation & Nursing Services, and found one employee still wearing a cloth mask.

Florida has the highest share of elderly residents in the U.S., but it straggled behind other states when it came to expanding testing. West Virginia, Tennessee, Texas and New York launched universal testing plans early on for long-term care centers, hoping to locate asymptomatic cases.

Florida relied on a piecemeal plan that included randomly testing staff at some facilities and sending strike teams to centers with an outbreak. These measures were voluntary, and some facilities did not participate.

Finally, on July 7, when about 2,000 Floridians from long-term care centers had died from the virus, the state began requiring those centers to test staffers every two weeks. Testing became easier the next month, after the federal government sent kits that could get results within 24 hours.

Cindy A. Prins, an associate professor of epidemiology at the University of Florida, said employees should be tested at least once a week. That won’t prevent every case, but it allows a facility to react quickly and avoid more transmission.

Prins said nursing homes also need to provide more robust care, almost like hospitals. They should be staffed with someone whose sole job is infection control.

Seminole Pavilion had no infection preventionist on staff when the outbreak began, and the facility’s 68-page emergency plan has no guidance on infectious diseases. Such guidance is not required by the state.

Even with increased testing, the virus has continued to ravage Florida nursing homes. More than 91 percent have had COVID-19 cases, according to the Centers for Medicare & Medicaid Services.

Freedom Square has been hit again. In October, at least 22 staffers had tested positive at Freedom Square Nursing and Rehab. At least four employees had positive tests at Seminole Pavilion. In November at The Inn, the assisted living facility, one employee tested positive and eight residents with the virus were transferred to hospitals.

Many employees remain haunted by the outbreak, still angry at the company’s response. Some were shocked to hear from the Times how many of the patients and residents ultimately died.

Gainey went back to work this fall as a certified nursing assistant at a different nursing home. Months into the pandemic, she said little had changed — the facility also was short-staffed, and supervisors pressed her to work double shifts.

She was scared but needed the money.

‘It took them too long to do anything’

At her open-casket service on May 18, as pictures looped on a screen above, Marjorie Blackman’s family reflected on her life.

Her sister reminded mourners that after their mother immigrated to America, Marjorie was left to care for seven siblings at age 17. Marjorie would not leave Guyana until 1980, when she was married with four children. Her fifth child was born in the U.S.

Marjorie’s daughters said she was a strict disciplinarian and even went looking for sticks in New York City to fashion into switches. She made sure her children were educated and went on field trips.

“My mother, through her example and harsh lessons, always sought to teach us to respect the money that people have worked hard to earn,” one of her daughters said at the service. She taught her children to lean on each other and not complain.

Tamara Blackman said she pulled out her mother’s company awards and pins recently. That made her angry.

A woman holding a framed photograph of her mother
Tamara Blackman, 46, holds a picture of her mother, Marjorie Blackman. Douglas R. Clifford

“It took them too long to do anything,” Tamara said. “For them to say, ‘You know what? Okay, I think we have a problem.’ ”

As the pandemic started surging, Tamara remembers her mother bringing home paperwork about the ownership change in January, filling out forms for human resources. At that point, she said, Freedom Square should have been focused on protecting patients and staff.

“My mom gave to that company, but they didn’t give back to her,” she said. “Honestly, I don’t know who can put my mind off that.”

This story is part of a collaboration with Frontline, the PBS series, through its Local Journalism Initiative, which is funded by the John S. and James L. Knight Foundation and the Corporation for Public Broadcasting.

Contact Leonora LaPeter Anton at [email protected] or 727-433-1446. Follow @WriterLeonora.

Contact Kavitha Surana at [email protected] or 727-266-0616. Follow @ksurana6.

Contact Kathryn Varn at [email protected] or 727-238-5315. Follow @kathrynvarn.

Additional credits

  • Editor: Maria Carrillo
  • Design: Martin Frobisher, Sean Kristoff-Jones
  • Photography: Douglas R. Clifford, Luis Santana, Dirk Shadd
  • Graphics: Paul Alexander
  • Copy Editing: Peter Couture
  • Lead Engagement Producer: Ashley Dye
  • Data Analysis: Connie Humburg