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Colorado nursing homes with the most coronavirus deaths were cited for poor infection control

A Colorado Sun investigation found that many of the nursing homes with the highest death counts were told multiple times to clean up hygiene protocols intended to protect residents.

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Last February, a month before coronavirus crawled through a Greeley nursing home, inspectors alerted the center’s managers of infection-control problems. 

Back then, before the pandemic had even arrived in Colorado, state regulators were worried about the way two nurses at Centennial Health Center cleaned a resident’s wound. The nursing home was cited for federal protocol violations after the nurses failed to wash their hands or put on new gloves in between touching the wound, reaching into the pocket of their scrubs and touching supplies and medicine containers.

It was the first of four times in 2020 that the home for some of Weld County’s oldest and most vulnerable residents was hit with infection-control violations. 

And it was an ominous sign of things to come.

This is part of a weeklong series marking a year since COVID-19 was first detected in Colorado. The state’s first confirmed cases were announced March 5, 2020.

>> READ THE REST OF THE SERIES

Once the coronavirus struck, inspectors returned in April, and again in July, and again in August — each time pointing out failures in following federal guidelines intended to protect residents from dying from COVID-19. 

Meanwhile, Centennial Health endured three waves of coronavirus outbreaks. The first began in March and continued through May, infecting 88 patients and staff. The second started in July, with 24 more infections. In December, COVID-19 returned to Centennial a third time.

In all, 22 residents died and 116 residents and staff were infected at the Weld County nursing home, according to state health department data.

Nearly all homes with 20 or more deaths cited for infection control

As the virus was spreading through nursing homes in Colorado, accounting for more than half of the state’s COVID-19 deaths during the first few months of the pandemic, many facilities failed to adhere to strict infection-control procedures created by federal health officials, according to a Colorado Sun review of state health department inspection records. In fact, all but one of the 23 nursing homes in the state where 20 or more residents died from COVID-19 were cited for infection-control problems in the last year. 

And several of them were warned even before the virus came to Colorado to clean up their hygiene protocol. The Sun found multiple instances in which nursing homes that faced massive coronavirus outbreaks in 2020 had been cited in 2019 for failing to follow best practices to prevent the spread of other infections.

I think somebody’s got to answer some questions. It’s outrageous.

Bob Murphy, AARP Colorado

“The industry has had months now to deal with this and to know how to prevent it and it didn’t happen,” said Bob Murphy, the director for AARP Colorado, the state branch of the national advocacy organization for older Americans. “And, in fact, got much worse.”

“I think somebody’s got to answer some questions,” he added. “It’s outrageous.”

At least 2,346 residents and 26 staff members of the Colorado nursing homes, assisted living centers and long-term acute care, memory care and rehabilitation facilities have died of COVID-19, according to the latest data from the state Department of Public Health and Environment.

Their deaths account for nearly 40% of the state’s total.

“These are our most vulnerable loved ones,” Murphy said. “The fact that this has happened is a tragedy of immeasurable proportions.”

Of the 1,424 total citations issued by the state health department in the last year, 602 were for infection-control problems. Combined, the facilities have been fined nearly $4.8 million in penalties so far during the pandemic. 

Nursing homes, among the most federally regulated industries after aviation and nuclear power, are inspected annually for everything from quality of care to security. But when coronavirus came, federal Medicare regulators quickly built an inspection survey sharply focused on stopping the spread of the virus. 

Beginning on March 18, 2020, as the first deaths from the virus were confirmed in Colorado, inspectors from the state health department headed to every nursing home, assisted-living center and group home for people with disabilities in the state. Within 100 days, they had inspected 1,058. 

While some local public health officials and epidemiologists were doing virtual visits to investigate outbreaks, talking to nursing home staff and touring the facilities via Zoom, the state health department’s inspectors went in person.

“There was never a stand-down for us,” said Randy Kuykendall, director of the health facilities division at the Colorado Department of Public Health and Environment. “Even in the very beginning when we were short on personal protective equipment, our folks stayed in the field. They took the risk.” 

Centennial Health Care Center on Tuesday, March 2, in Greeley. (Josh Polson, Special to The Colorado Sun)

In the last year, the division has completed 991 infection-control inspections at Colorado’s 230 nursing homes. That includes inspections conducted on behalf of federal regulators, since state surveyors are charged with handling those, too.

The infection-control surveys, which take about one whole day, evolved as scientists learned more about how the coronavirus spread. Early on, the focus was on sterilizing surfaces and hand-washing. Then, when research showed the virus was transmitted through the air, concerns centered on masks. And later, when scientists realized that people without any symptoms — including the staff in nursing homes — could transmit the virus, federal and state guidelines zeroed in on staff screening and restrictions on visitors. 

“It took us a while to realize, for scientists to understand that we had such a thing as asymptomatic carriers,” Kuykendall said. “That’s fighting an invisible enemy and that’s extremely difficult to do in disease control and prevention.” 

“This was a novel virus. We didn’t know what we didn’t know. I think everybody can see that now. It certainly caught the industry by surprise.” 

Kuykendall said most of Colorado’s nursing homes responded quickly to corrective action plans to fix infection-control issues and that inspectors were less likely to find multiple violations at the end of 2020 compared with last spring.

But questions remain about the state’s and industry’s responses.

Doug Farmer, the president and CEO of the Colorado Health Care Association, a trade group for nursing homes, criticized regulators for being overly punitive, saying the state focused more on issuing citations for sometimes small slip-ups than working with facilities to address common problems.

“To me, there’s no way that every single nursing home in the state was experiencing some systemic problem with their infection-control policies and procedures,” Farmer said.

AARP’s Murphy questioned why nursing homes weren’t better prepared to prevent the wave of infections and deaths that swept through again in the fall. 

“So many of these deaths occured in the last quarter of the year when we should have known better,” Murphy said. “Somebody needs to answer that question.”

Homes faced repeat citations 

Similar infection-control problems were found month after month at several of the nursing homes with the largest outbreaks.

“You will find facilities who will say we are too picky,” the state’s Kuykendall said. “By the same token, there have been some facilities that have chosen over time just not to fully comply and we have been in those facilities sometimes more than one time.”

Part of the problem is staff turnover. Nursing homes lost so much of their staff during the pandemic that the state health department launched a website to help move workers where they were most needed and, this fall, sent in the Army National Guard to help cover some of the shifts. 

“We’re talking about a workforce that is mobile,” Kuykendall said, noting that some staff work in more than one facility and carried the virus from one to the next. “A lot of folks come and go, and keeping them trained and keeping them on task is certainly a challenge for the operators.” 

Centennial Health Care declined an interview request for this story, but said in an emailed statement that the nursing home “took the findings of the survey team seriously and immediately put corrective actions in place.” 

Centennial and Four Corners Health Care of Durango, both owned by SavaSeniorCare, completed corrective action plans and were back in compliance after addressing issues including hand-washing, proper use of personal protective equipment, grouping residents into isolated cohorts and virus testing, said Annaliese Impink, a senior vice president of SavaSeniorCare. 

“It has been a difficult period for our residents and staff,” she said. “We thank our staff for all their hard work to keep our residents as safe as possible during this terrible pandemic.”

Four Corners, where 22 residents died and 147 residents and staff were infected, was cited for infection-control problems in May, including not offering residents hand sanitizer or hand-washing as staff delivered their breakfast trays. The virus raged through the nursing home, which has capacity for 133 residents, from November through January. 

A sign in support of caregivers sits on the lawn of the Life Care Center of Longmont in Longmont. (Josh Polson, Special to The Colorado Sun)

At Centennial in Greeley, the first residents to get the coronavirus became ill in March. The multiple infection-control citations reveal similar problems, month after month through the spring and summer. 

The 107-bed nursing home was cited for infection-control issues in April — specifically, a nurse bringing breakfast to residents failed to ask them to wash their hands and a housekeeper used the same rag to wipe down a resident’s room and bathroom, without adding more disinfectant as she moved from the counters, to the mirror, to the bathroom handrails. 

Surveyors returned in July and found more problems. In a detailed citation, inspectors wrote that staff were not properly wearing personal protective equipment when they visited patients with COVID-19 and were not getting residents to wash their hands before meals. A doctor failed to change gloves as he went from one resident with COVID-19 to the next, nor did he sanitize his stethoscope between patients. 

During that July inspection, a resident who had COVID-19 poked her head out of her room wearing a mask below her nose. “Staff passed her and did not acknowledge her,” the report says. 

About an hour later, the woman left her room without a mask and headed down the hallway. A nurse worked to persuade her to return to her room, and the woman agreed after drinking a glass of water in the hallway, according to the report.

Inspectors also observed multiple residents walking past the rooms of COVID-19-positive patients to get to the nursing home’s designated smoking area. Staff told inspectors that it was the only available route.

Centennial was also cited in July for failing to follow screening protocols put in place to make sure any new cases of coronavirus among residents and staff were discovered as quickly as possible. Nursing homes are required to screen residents and staff once each per day before coronavirus has entered the facility, then screen or monitor symptoms twice per day after there has been a positive case, and then three times per day for residents who are sick with coronavirus. The inspection discovered that some residents did not receive the required temperature, oxygen and blood-pressure checks.

The July inspection resulted in a $19,500 fine for Centennial, according to federal records.

A month later, in early August, inspectors returned again and found continued problems with infection control. Centennial Health was cited on that visit because residents were not keeping their mouth and nose covered and that staff were wearing contaminated gloves in and out of residents’ rooms. And again, inspectors noted problems with a housekeeper’s reuse of the same rag to clean a room and bathroom.

Bethany Nursing and Rehab Center in Lakewood, where 20 residents died and 105 residents and staff were infected with coronavirus, was hit with an infection-control violation before the pandemic began. The nursing home, which has previously been singled out by federal regulators as one of the most troubled in Colorado, was cited in December 2019 for haphazard sanitary practices, including a housekeeper not changing gloves or using clean rags when she cleaned patient rooms. And in 2020, the home was cited three more times for infection-control problems.

Bethany was hit with a $9,750 federal fine following an August inspection.

Broomfield Skilled Nursing Center was cited twice in 2019 for infection-control issues, and then five more times in 2020 as the nursing home endured three coronavirus outbreaks and 37 deaths.

Cherry Creek Nursing Center had one infection-control citation in 2019, then four in 2020. The nursing home received a $9,750 fine after an inspection in June.

And Life Care Center of Pueblo, where 25 residents died of COVID-19, was cited twice in 2019 for infection-control issues and five times in 2020.

A resident walks along the sidewalk in front of the Broomfield Skilled Nursing & Rehabilitation Center. (Josh Polson, Special to The Colorado Sun)

Farmer, with the Colorado Health Care Association, said not all of the infractions were grave ones. For instance, he said inspectors might write a citation if they saw a staffer wash their hands for 15 seconds instead of the required 20 seconds.

“I think if you go in looking to find something that you can cite, you’re going to find it,” Farmer said.

But he said it was part of a pattern of regulators being prescriptive and punitive toward nursing homes. The pandemic produced a gusher of guidance and rules for nursing homes to follow, emanating from multiple federal, state and local agencies.

“It was literally every couple of days there would be a new piece of guidance or a tweaked piece of guidance,” Farmer said.

And, while state officials said they worked closely in partnership with nursing homes to address infection-control, Farmer said, “There wasn’t a two-way conversation taking place.” He thinks the state should have done more to listen and respond to nursing homes’ needs, rather than taking an enforcement-heavy approach.

“That was a systemic failure,” Farmer said. “And I think we would have had better outcomes if it had been a partnership.”

Problems with tests used to screen staff

That nursing homes would become such a problem spot in the pandemic was hardly a surprise to state officials.

Even before Colorado recorded its first coronavirus case, Gov. Jared Polis held a phone call with Washington Gov. Jay Inslee, whose state suffered a devastating nursing home outbreak in the pandemic’s first days in this country. Inslee’s advice: Protect your long-term care facilities.

CDPHE’s first public health order of the pandemic — issued on March 12, 2020 — restricted visitation to nursing homes and required temperature checks of staff and residents.

But it soon became clear that this wouldn’t be enough. In tests run as part of a study at Colorado State University, researchers discovered huge numbers of asymptomatic coronavirus infections that were going undetected among nursing home staff. What’s more, the researchers found that these asymptomatic carriers had high viral loads capable of spreading the virus to others.

If such a large percentage of people are carriers but asymptomatic carriers, it’s nearly impossible to stop that from getting through the doors of one of these care centers.

Doug Farmer, Colorado Health Care Association

“If such a large percentage of people are carriers but asymptomatic carriers, it’s nearly impossible to stop that from getting through the doors of one of these care centers,” Farmer said.

In May, Polis announced that the state would work with CSU to run 45,000 tests on nursing home workers. But even that wouldn’t be enough. In the absence of a national testing strategy, Colorado needed its own long-term solution to testing at nursing homes. The state found it in a company called Curative.

Based in Southern California, Curative was formed in January 2020 by a 25-year-old Oxford University dropout. The founder of the dating app Tinder was among its biggest investors. But with the need for disease surveillance surging, Curative quickly became one of the biggest coronavirus testing companies in the country, with labs in three states.

In early November, CDPHE announced that it was working with Curative to provide testing kits to every nursing home in the state at no cost to them. The facilities would be required to test their staff members at least once per week.

“Expanded testing at long-term care facilities will further protect many of the Colorodans most at risk of experiencing severe COVID-19 symptoms,” Jill Hunsaker Ryan, CDPHE’s executive director, said at the time in a statement.

By the end of November, more than 700 nursing homes were using Curative tests. That figure grew to 775 — 94% of all nursing homes in the state — using Curative tests by the first week of January.

But then, on Jan. 4, a thunderbolt struck in the form of a federal Food and Drug Administration alert.

“The U.S. Food and Drug Administration (FDA) is alerting patients and health care providers of the risk of false results, particularly false negative results, with the Curative SARS-Cov-2 test,” the agency announced, using the scientific name for the coronavirus that causes COVID-19.

A test tube containing a patient sample awaiting testing for the coronavirus SARS-CoV-2, the virus that causes COVID-19. (Provided by the Centers for Disease Control and Prevention)

The tests had particular problems catching people who were asymptomatic, according to the FDA — exactly the people who needed to be stopped from carrying the virus into nursing homes.

Kuykendall, with the state health department, said state officials had also begun to hear worrying things about the tests.

“A couple of the nursing homes started picking up differences in re-tests,” he said. “That was the first indication. And we started hearing the same thing from other states.”

Still, in the two weeks that followed the FDA’s announcement, more than 700 nursing homes continued to use Curative tests, according to data from CDPHE. On Jan. 21, CDPHE announced that it would discontinue the use of Curative tests at nursing homes.

State officials say now that it appears the damage from using the error-prone tests was minimal, at worst.

Analysts at CDPHE compared infection and fatality rates during the fall and winter surge at nursing homes that used Curative tests to rates at those that didn’t. There was no clear trend showing that facilities using Curative suffered worse results.

“That’s been reassuring for us to see,” said Dr. Rachel Herlihy, the state epidemiologist. “It was useful to do this analysis to feel reassured that we didn’t see impact or harm from Curative.”

Farmer, though, remains uncertain about how well the state’s testing program has been able to identify and stop coronavirus cases from entering nursing homes. The percentage of Colorado’s overall coronavirus deaths that occured in nursing homes is in line with the national average.

Ultimately, infections and deaths in Colorado nursing homes rose and fell in unison with the trends in the state as a whole — suggesting that the virus was finding a way in regardless of how much testing was taking place.

“I think the accuracy of the tests, when they’re accurate, they’re probably the best tool we have to prevent bad outcomes,” he said. “How effective have they been? I don’t know yet.”

Nursing home capacity dropped, resulting in lost funds

The testing issues were just another problem in a brutal year for nursing homes.

Staff worked in fear of getting sick. Patients they had spent months or years caring for, forming bonds with them, fell ill and died — sometimes multiple patients per day. And those patients who didn’t get sick were still subjected to crushing isolation from their friends and family.

Farmer said that, in normal times, nursing homes do everything they can to bring the public into their facilities. They host music groups, high school classes, community speakers. But this past year had none of that.

“It was terrible,” Farmer said. “At the same time, those workers were doing everything they knew to do and could possibly do given the circumstances. And then to have people suggest they weren’t doing enough or didn’t care enough, that had an impact on them as well.”

Gregg MacDonald holds hands with his 84-year-old mother, Chloe MacDonald, at a “hug tent” set up outside the Juniper Village assisted living center in Louisville. The tent includes a construction-grade plastic barrier with built-in plastic sleeves to prevent the spread of the coronavirus. (AP Photo/Thomas Peipert)

Nursing home finances suffered, he said. Rules imposed during the pandemic prevented facilities from accepting new patients for weeks at a time following a case being discovered. In normal, pre-COVID times, nursing homes in the state typically operated at slightly more than 80% capacity. But, in part due to the coronavirus restrictions, today they are operating at 67% or below, Farmer said.

By Farmer’s rough estimate, that means $200 million in lost revenue for Colorado facilities in the last year. And it came at a time when nursing homes were also spending like never before on PPE, which they normally don’t keep on hand in great quantities. During the spring, Farmer said, N95 face masks that usually go for under a dollar per mask were selling for $6 to $9.

“They’re in a very, very tenuous position right now on their finances,” Farmer said.

The strain on staff and residents showed up in other ways, too. Complaints lodged against nursing homes to the state’s long-term care ombudsman rose overall in 2020, and, unlike previous years, the No. 1 complaint centered on residents’ quality of care. 

The ombudsman’s office received 1,082 complaints about quality of care issues in the federal fiscal year that ended Sept. 30, encompassing everything from bathing and eating to medical care related to COVID-19. Typically, the highest number of complaints center on residents’ rights and autonomy, said Leah McMahon, Colorado’s long-term care ombudsman. 

One of the things that they are finding out is that some of those nursing homes that had infection-control problems to begin with, they were hit pretty hard with the spread of COVID.

Leah McMahon, Colorado’s long-term care ombudsman

“At a national level, in conversations regarding infection control, one of the things that they are finding out is that some of those nursing homes that had infection-control problems to begin with, they were hit pretty hard with the spread of COVID,” she said. 

McMahon did not name specific nursing homes in Colorado, but said “there is always room for improvement.” 

“Our residents have the same rights as people living in the community and actually additional rights that protect them,” she said. 

Many complaints, too, focused on the well-being of residents who were not allowed to connect with loved ones thanks to visitation restrictions, which are still in place.

“People are fatigued,” McMahon said. “The emotional impact and mental health impact that the pandemic has caused is in the forefront of everyone’s mind at this time.”

Vaccine is “true light we’ve been waiting for”

But health officials are now hopeful that nursing homes, at long last, are nearing the end of their darkest days.

In recent weeks, infections at deaths at the facilities have fallen to some of their lowest levels of the pandemic. Fewer than 1% of the state’s cases are currently in long-term care facilities. About 24% of the state’s deaths are now coming from the facilities — down from a high of more than 60% in the spring and a year-long average of around 38%.

When there are outbreaks, the size of them has decreased, to an average of around 5 cases per outbreak as opposed to 20 cases per outbreak seen earlier in the pandemic. Herlihy, the state epidemiologist attributed this to better testing and surveillance methods.

Things have improved so much that state officials have begun to consider allowing indoor visitation, so long as the facilities and the surrounding community hit certain target numbers for case rates.

“We know how long this year has been for the residents of these facilities, their family, their staff.” said Scott Bookman, the incident commander for CDPHE’s pandemic response. “It has been incredibly difficult to navigate the challenges associated with this pandemic.”

But there’s one more reason to be optimistic, Bookman said: vaccines. The state put nursing homes at the front of the line for vaccination, and now every nursing home in the state has had at least two vaccination clinics at their facility.

To date, nearly 73,000 residents — more than 90% of all residents — and more than 62,000 staff members have been inoculated. And Farmer, with the Colorado Health Care Association, said vaccine acceptance among staff members has increased in recent weeks, after early concerns about hesitancy.

Bookman said the drop in coronavirus cases and deaths in nursing homes — “an absolutely dramatic decrease,” he said — has coincided with this vaccine rollout. It’s exactly the sign state health officials, advocates like AARP’s Murphy, nursing home residents, staff and managers wanted.

“This,” Bookman said, “is the true light we have been waiting for.”

Army Veteran Phil Ross, 73, right, celebrates after receiving a COVID-19 vaccine from registered nurse Ola Arije, left, at Veterans Community Living Center at Fitzsimons in Aurora on Dec. 22. Ross was the first senior-care center resident in Colorado to receive the vaccine. (Pool photo by Hyoung Chang/The Denver Post)

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