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Dozens of nursing homes cited for infection-related deficiencies early this year and now have COVID-19 cases

Nursing homes says there’s no link between past issues and an unprecedented virus

By: Jill Riepenhoff and Lee Zurik

Originally Published: May 14, 2020

(InvestigateTV) – During Thomas Minichillo’s brief stay at a Florida nursing home, his wife and sons did not know of the facility’s poor inspection history.

“They told me it was a 5-star facility. I trusted that,” said Terri Terzini-Minichillo, Thomas’ wife of 53 years.

The family didn’t know that two months before Minichillo died with COVID-19 that state inspectors had cited Freedom Square Rehabilitation and Nursing Services for infection-related failures.

According to the Feb. 7 report by state surveyors, staff failed to wear gowns in the room of a patient with MRSA. They failed to change one patient’s dressing every three days as ordered and left another in the same bandage for 21 days.

Thomas and Terri Terizini-Minichillo pose for a photo during an unnamed occasion. The couple had been married for 53 years when he died in April after a brief stay at a Florida nursing home. Family-provided photo.

“I am so worried about getting a worse infection because nobody even thought to look at it until you surveyors came,” the patient told Florida inspectors, according to their Feb. 7 report.

Thomas Minichillo checked into the facility on late March with chronic pneumonia and gangrene in a leg, according to his family. On April 10, after testing positive for COVID-19 the previous day, he died.

His death – the first of more than two dozen at that nursing home in Seminole, Florida as reported by local media – has left his family with many unanswered questions including about his quality of care.

“Had we known that, I’m pretty sure we would have sent him somewhere else, given that he did have open wounds,” his son, T.J. Minichillo, said.

Freedom Square executive director Michael Mason told InvestigateTV that the deficiencies cited by inspectors on Feb. 7 happened in a different building than where Minichillo had stayed and that there is no link between those issues and the outbreak at his facility. The deficiencies, he said, were immediately corrected.

“I don’t think it does correlate. COVID was a game changer,” Mason said. “COVID-19 is very, very infectious.”

Freedom Square is one of at least 144 nursing homes across the U.S. that both had a coronavirus case and were cited by state inspectors for infection-related problems between Jan. 2 and March 2, according to an InvestigateTV analysis. The examination compared inspection data from the Centers for Medicare and Medicaid and a list compiled by the Washington Post of nursing homes with at least one positive COVID-19 case.

Inspection reports from CMS show that deficiencies cited in some of those nursing homes included improper hand washing, lack of isolation signs on doors of patients with infectious diseases and not using personal protective gear when treating sick patients.

One Florida nursing home failed to offer flu shots to residents, resulting in a facility-wide outbreak.

A nursing home in Ohio inserted a catheter into a patient with a history of urinary tract infections caused by the devices.

A Michigan nursing home failed to warn staff entering a room that the patient had a highly-contagious infection that is transmitted through droplets from speaking, sneezing or coughing – much like the transmission of COVID-19. Staff did not wear PPE and the specific name of the infection was redacted from the report by state surveyors.

At a Georgia nursing home, a staff member didn’t wash her hands after administering eye drops to a patient.

Infection-related inspections at a glance

At least 144 nursing homes with at least one positive COVID-19 were cited by state surveyors between January and early March for an infection-related deficiency, based on data from the Washington Post and the Centers for Medicare and Medicaid.

This map shows their locations and links to their inspection reports. InvestigateTV reached out to the 144 nursing homes for comment and provided those statements in full, if provided.

The American Health Care Association, which represents 14,000 nursing homes, said there is no link between prior deficiencies and cases of coronavirus.

“Nursing homes have had a poor track record for a really long time, and it goes back to lax oversight by survey agencies,” said Brian Lee, executive director of Families for Better Care, a Texas-based nonprofit that advocates for patients across the U.S. “You don’t have the staff. You don’t have training. You don’t have good oversight.”

Those failures may have become a perfect storm for a pandemic with its frail and elderly population, Lee said. COVID-19 has hit more than 3,500 nursing homes, according to the Washington Post.

Advocates said they knew that nursing homes would be fertile ground for the coronavirus.

“But the problem became a lot worse because of the poor staffing levels in nursing homes and poor infection and control practices,” said Toby Edelman, senior policy attorney at the Center for

Medicare Advocacy, based in Washington, D.C. “The longstanding problems we’ve seen in infection control are still happening.”

The American Health Care Association and National Center for Assisted Living represents more than 14,000 long-term care facilities in the U.S.

President and CEO Mark Parkinson said past infection-related deficiencies have no bearing on the present crisis in nursing homes.

“The constant, continued criticism of a really flawed past survey system has nothing to do with what caused this,” Parkinson said. “The only way we would have stopped this is if we had less COVID-19 in the community.”

In the earliest outbreaks in King County, Washington, researchers have found that COVID-19 likely spread from facility to facility by workers employed at numerous nursing homes, according to the New England Journal of Medicine.

The virus outbreaks, Parkinson said, have “nothing to do with the quality of the facility. It has to do with what community they are in. Perfect infection control . . . wouldn’t stop COVID.”

Most infection-related infractions are labelled as minimal harm to patients

Of the 170 infection-related citations issued this year to nursing homes with COVID-19 cases among staff and or patients, the vast majority were related to a single patient or incident.

In January, state inspectors cited The A.G. Rhodes nursing home in Atlanta for failing to have an isolation sign on the door of a patient with a blistering wound that would have prevented anyone from entering without first speaking to a nurse.

Inspectors also noted that there was not a PPE cart parked outside of the room.

Nursing home spokeswoman Mary Newton said that as soon as administrators learned of the problems, they were immediately corrected.

“We understand we are caring for the most vulnerable people,” she said. “There’s a perception that we’re dirty when we get an infection infraction. But so many of us are doing our very, very best.”

The goal is always to have zero infractions.

As of early May, the 116-year-old nonprofit nursing home has had two cases of COVID-19 among its patients and eight cases among staff members.

Edelman, the attorney, said those so-called “no harm” citations mean that the nursing home isn’t fined.

The most frequently cited infection deficiency, she said, is the failure of staff members to properly wash their hands, which is largely considered a “no harm” deficiency.

Those types of violations also don’t require follow-up inspections by state regulators.

Parkinson from the health care association said the current inspection system is too punitive and encourages surveyors to find deficiencies.

But even minor deficiencies can cause harm, advocates say.

In February, Illinois inspectors cited St. James Wellness Villas for leaving a catheter bag on the floor of a patient’s room and failing to secure the tubing to the patient’s leg both of which can lead to an increased risk for infection.

A spokesman for the nursing home said that since then the facility has ramped up its infection-control procedures to ensure the safety of patients – and that it’s not fair to conflate past infection-related deficiencies with the COVID-19 outbreaks.

“Much like we wouldn’t blame victims of hurricanes and tornadoes, we shouldn’t blame Nursing Homes either,” said Ron Nunziato a consultant for the nursing home in Crete, Illinois. “This too is the perfect storm.”

The coronavirus, Parkinson said, burst into nursing homes that have never before seen anything like it.

“This is a horrible tragedy that’s been thrust upon facilities who are trying really, really hard to stop it,” he said. “The only solution is stopping it in the community.”

Patient’s family struggles for answers

Thomas Minichillo’s family never stepped foot inside Freedom Square. The first five days he was there, they visited through a window, on the phone or by video.

He cheered as he watched his granddaughter take her first spin on a bicycle. It was the last time he spoke with his family, his son Brian said.

When Thomas Minichillo arrived at the nursing home, he had a room to himself.

Thomas Minichillo’s son shares a photo of his father in a Facebook post from his bed at Freedom Square Rehabilitation and Nursing Services in Seminole, Florida. Minichillo went there to rehab after a hospital stay. He died on April 10 and had COVID-19. Family-provided photo.

Four days later, he was moved into a room that he shared with another patients. His family said they didn’t know why he was moved or where he was in the facility.

But they said that the move did seem odd for a man with open wounds and chronic pneumonia.

When the family would call to speak with him, they said staff told them that he was too sleepy to talk.

“I was telling them something was not right with my husband,” Mrs. Minichillo said. Previously, they spoke five or so times a day.

Then the staff told the family that Mr. Minichillo was “kind of unresponsive. The next call we got from them was (telling) us that he had already been transferred to the hospital,” Brian said.

They family said that they later learned that the nursing home staff called 911 to take him to the hospital and that he had been frothing at the mouth.

Two days later, he was dead and had COVID-19.

Mrs. Minichillo had hoped that the stay in rehab would have improved his quality of life so that they again could enjoy outings or going to a restaurant.

Now, she just tries – but often fails – at trying not focus on the final days of his life.

“I can’t sleep. I can’t do anything,” she said. “Those four days . . . it’s kind of hard to forget about.”

The family has hired an attorney and have been reviewing his medical records in hopes of piecing together what happened.

“If they had properly quarantined an infected man, maybe the outcome would have been different,” T.J. said. “We’re enraged. It’s happening all over the country. It’s like the most at-risk people are being forgotten. It’s sickening.”

Full Statement from Freedom Square:

Those deficiencies have all been resolved. As per regulation, plans of correction were submitted immediately and approved by the appropriate agency thereafter.

The safety of our residents and employees remains our top priority and we continue to follow all protocols, including guidance and recommendations from federal, state, and local health authorities.

News contest specialists Tess Rowland and Emma Ruby contributed to this report.

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