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Some nursing homes now battling COVID-19 previously cited for infection-control failures

At least eight of the nursing homes in the U.S. with coronavirus cases had serious infection-control deficiencies reported in past inspections, according to analysis by InvestigateTV.

By Jill Riepenhoff and Lee Zurik

Originally Published: April 23, 2020

InvestigateTV – During their annual survey of a Louisville assisted living home last year, state inspectors found that the facility’s lack of infection control procedures was so serious that residents’ health was in immediate jeopardy.

Treyton Oak Towers received the second worst score possible for the March 2019 inspection, federal records from the Centers for Medicare and Medicaid show.

The facility corrected the failures within nine days.

Now, the facility, home to about 150 residents, also is home to one of Kentucky’s largest COVID-19 outbreaks in long-term care facilities.

Nearly three dozen residents in the home have fallen ill; 13 have died. In addition, 14 staff members have tested positive for COVID-19.

Treyton Oak Towers is one of eight long-term care facilities that has been cited for the most serious categories of failure to prevent infections in the past three years and now is dealing with COVID-19 cases, according to an InvestigateTV analysis of state and federal data.

The failure to provide and implement an infection prevention and control program is the most cited deficiency, with more than 9,100 violations found between May 2017 and February 2020, an analysis of the federal data shows.

A total of 7,304 different nursing homes have been cited, representing almost half of all these long-term care facilities in the U.S.

The vast majority of these critical failures were detected during annual, routine surveys of nursing homes by state health inspectors, who report their finding to the federal government.

But complaints from residents, staff or visitors prompted inspectors to call on nearly one out of every five cases in which infection-related deficiencies were found.

Complaints led to the detection of serious violations last August at Deltona Health Care in Denton, Florida, where an untold number of patients or staff have tested positive. Nursing home administrators did not respond to requests for comment.

A complaint also uncovered violations at Life Care Center of Kirkland in Washington – the site of the first nursing home outbreak now threatened with loss of federal funding.

All told, complaints and annual inspections show that 122 nursing homes have been cited for the most serious infection-related failures – those that pose an immediate danger to residents.

Combing available state data and news reports, InvestigateTV identified the eight nursing homes in Florida, Illinois, Michigan, North Dakota and Oregon that have had these most serious, potentially life-threatening infection deficiencies and now have COVID-19 cases.

Of the 122 nursing homes with the most serious infection control problems over a 3-year period beginning in spring 2017, eight of these facilities (indicated in blue) now have at least one – and in some cases – dozens of COVID-19 cases. The most serious deficiencies are those that pose actual harm to residents or put them in immediate jeopardy. Click on the points on the map to learn more about the reported deficiencies and inspection dates.

Data Sources: Inspection reports from Centers for Medicare and Medicaid. COVID-19 cases from state data and local news reports. 

The number may be higher, but many states shroud the names of impacted facilities or the number of positive cases in individual nursing homes in secrecy.

In 2014, the Centers for Disease Control and Prevention reported that about 380,000 nursing home residents die each year because of an infection.

“And that’s on a good day. That’s not when we’re faced with a deadly worldwide pandemic,” said Wes Bledsoe, founder of A Perfect Cause, an Oklahoma-based nursing home rights’ advocacy group.

Thus far, COVID-19 has claimed some 7,000 nursing home residents.

“You have minimally trained employees, paid less than minimum wage with no benefits . . . and they don’t have any viral-protective gear,” Bledsoe said.

Some even lack a paper or cloth mask.

“You have staff in nursing homes that are providing very personal care. They’re bathing. They’re clothing. They’re toileting. They’re changing soiled clothes. They’re lifting,” he said.

It creates a match-to-flame environment.

But, he said, the situation becomes all that more dire in nursing homes with histories of infection-related deficiencies.

Nursing homes hit with violations last year now among the hardest hit by COVID-19

The nation’s first COVID-19 outbreak happened at a Washington State nursing home.

Since then, there have been some 120 positive cases and 37 deaths tied to Life Care Centers in Kirkland.

A year ago, a complaint prompted state inspectors to visit the home, where they found infection-control deficiencies that according to records, if left unaddressed, could put residents in harm’s way. According to federal data, the nursing home fixed the problems six weeks later.

But when inspectors visited again on March 16, after the COVID-19 outbreak had taken hold, they found such serious infection-related violations that they threatened to terminate their eligibility for Medicare funding. A move that could effectively put the nursing home out of business.

“This survey found the most serious deficiencies to be widespread and constituting immediate jeopardy to resident health and safety,” inspectors wrote in a letter to the nursing home obtained by NPR.

Life Care Centers of Kirkland did not respond to requests for comment from InvestigateTV.

The nursing home also is facing at least one wrongful death case, involving a woman who died of COVID-19.

Two other nursing homes with some of the largest outbreaks in the nation also have had infection-related deficiencies before the pandemic began.

At Brier Oak on Sunset in Los Angeles, 62 staff members and 80 residents have tested positive for COVID-19, state data shows.

Inspectors noted an infection-control deficiency during a visit in September that was corrected by early October.

“We are working around the clock, doing everything in our power – and everything medical experts know as of at this time – to protect and keep our patients, residents and employees as healthy and as safe as possible,” said Budgie Amparo, Brier Oak’s chief clinical officer. “That’s why we have been so stringent on visitation restrictions and other precautions across all of our centers – not only following recommended protocols and guidelines from the Centers for Disease Control and Prevention (CDC), and Centers for Medicare and Medicaid Services (CMS), but also often getting out in front of them.”

Canterbury Rehab & Healthcare Center in Richmond, Virginia is battling one of the nation’s largest outbreaks among long-term care facilities.

According to news reports, there have been 130 positive cases and 49 deaths involving the nursing home. The state does not report COVID-19 case information related to nursing homes.

Inspectors found infection-related deficiencies during an October visit.

Nursing home administrator Jeremiah Davis said in a statement that any reference comparing the now-corrected violation to the current outbreak “would be inappropriate.

“In the months prior to the COVID -19 pandemic, there were significant improvements in virtually every aspect of operations including review and upgrade of all policies and procedures and there were also significant changes in facility leadership,” Davis said. “There has been material focus on placing the right people in the right positions, and a significant influx of new protocols prior to the outbreak.”

Nursing home failed to follow all safety guidelines during pandemic

In Oklahoma, nurse Sue Johnson was horrified by what was happening at a nursing home where she worked.

In mid-March, there was an outbreak of a respiratory infection among at least nine of the facility’s 40 residents. Two of them later died.

She questioned the nursing home’s doctor about the cases and how the facility was documenting these illnesses for the state.

His response, she said, shocked her. He likened the cases to someone battling “a cold sore.”

The face that the patients had respiratory illnesses – a key symptom of COVID-19 – didn’t prompt any testing at the facility, either, she said.

She reviewed the CDC guidelines for nursing homes battling infection-related outbreaks and counted that only 13 of the 38 recommendations were being followed.

She quit on March 27 and filed a complaint with the Oklahoma State Department of Health.

State records show that COVID-19 has since hit the nursing home.

Veterans’ home violation was a blessing in disguise

At a Michigan veteran’s home, the violation it received last fall better positioned them to deal with COVID-19, its administrator said.

In September, inspectors found the most serious infection-control violation at the D.J. Jacobetti Home for Veterans along the shores of Lake Superior in Marquette.

Within six weeks, the veterans’ home had corrected the violation which, if left untouched, would have left residents in immediate jeopardy.

The Jacobetti home is one of veterans’ homes run by the state of Michigan.

Executive director Anne Zerbe said that the violation found last fall led to changes in policy and practice at all the state’s home for veterans.

“These efforts have proven instrumental in the homes’ efforts to combat the COVID-19 pandemic,” she said.

The virus was detected and confined to a single resident, she said.

“The one and only resident at DJJHV confirmed positive for COVID-19 was cared for using appropriate precautions to limit exposure risk to other residents and staff,” she said. “This demonstrates the significant steps we have taken and the outstanding work our staff is doing in regard to infection control at the home.”