Investigation: 62 NY nursing homes failed at infection control amid COVID-19. What happened.
As COVID-19 ravaged New York nursing homes, 62 of the facilities were cited for violations of infection-control standards, which are crucial to stopping the spread of viruses and other deadly diseases, federal and state data showed.
A USA TODAY Network New York review found the most serious violations revealed how poorly trained workers mishandled COVID-19 contaminated food trays, linens, gowns and mop buckets, potentially spreading the respiratory disease among countless frail and elderly residents.
Many nursing homes also failed to isolate infected residents, including cases of healthy residents left to live with roommates who tested positive for SARS-CoV-2, the virus that causes COVID-19. One facility was cited for potentially exposing 89 residents to COVID-19 due to the violations.
And amid widespread personal protective equipment shortages, one nursing home was cited for keeping its stockpile locked up improperly, endangering workers who complained they lacked masks, gloves and gowns, according to federal and state records reviewed by USA TODAY Network New York.
The investigation, gleaned from state and federal reports, offered the first comprehensive look at infection-control violations during the COVID-19 crisis inside New York nursing homes, where the disease has been linked to at least 6,475 resident deaths.
Among the findings:
- Inspectors cited infection-control violations at 10% of New York’s 613 nursing homes.
- A total of 95 health and safety violations overall were cited at 77 nursing homes, including six designated “immediate jeopardy,” the most serious threat to residents.
- The state Health Department has fined 23 nursing homes $328,000 in connection to the violations, with additional fines being considered at other facilities.
Despite the inspections, advocates warned nursing homes in New York and nationally remained ill equipped, understaffed and at heightened risk if COVID-19 surges again this fall and winter.
“There’s just a lack of urgency and lack of impetus that goes down from the federal to the states to the providers in regard to protecting both residents and staff,” said Richard Mollot, executive director of the Long-Term Care Community Coalition.
State and federal health officials, however, defended results of the inspections, which spanned every nursing home in the country and stemmed from an emergency response to COVID-19.
Jill Montag, a spokeswoman for the state Department of Health, noted the agency has conducted about 1,845 inspections since March 1, with at least one visit to every nursing home and adult care facility in New York.
“The Department will continue to hold providers who violate regulations accountable for their actions,” she said, adding the facilities must also get a plan of correction for resolving violations approved by the agency.
Further, Gov. Andrew Cuomo’s executive order on May 10 gave health officials the authority to revoke nursing homes' operating certificates or place them in receivership for violations of COVID-19 guidance or directives, Montag noted.
Mollot, however, described the government response to COVID-19 threats to nursing homes, in general, as the latest example of authorities failing to address issues that have plagued nursing homes across the country for decades.
“It is so infuriating and offensive that we are at a point where tens of thousands of residents have died of COVID and tens of thousands more have undoubtedly suffered and died because of the poor response,” he said.
What COVID inspectors found at New York nursing homes
A series of infection-control failures uncovered on May 9 at the Villages of Orleans Health and Rehabilitation Center in Albion, Orleans County, underscored the dire situation unfolding in nursing homes statewide at the time.
One violation involved a nurse and certified nurses’ aide delivering food trays to COVID-19 patients without wearing proper personal protective equipment, or PPE.
Without washing their hands, the workers passed between infected and healthy residents. At one point, the aide searched through a condiment caddy for sugar and pulled linens from an uncovered linen cart, potentially exposing all the items to COVID-19, inspectors noted.
Asked about the situation, the nurse described a protective gear shortage at the facility.
“If we have the PPE, then I wear it but most of the time there is no PPE available on the unit,” the nurse told inspectors, adding “we can't do our jobs the right way if we don't have the supplies.”
The facility noted it placed PPE in bins for workers to use, but at least one was empty during the inspection. Meanwhile, a stockpile of 2,900 surgical masks, 480 N-95 masks, 88,500 gloves and other PPE was found in a locked storage closet accessible only to two nursing administrators.
Further, the facility failed to put signs alerting workers of residents being monitored for COVID-19 but not yet confirmed. And despite various infection risks at the time, it allowed resident co-mingling in dining areas and hallways in violation of infection-control standards.
Just days before the inspection in May, Katie Bourke told the USA TODAY Network she had resigned as a certified nursing assistant at the nursing home due to long-standing staff shortages and management issues that worsened when COVID-19 hit.
"Now it's broken out into a nightmare with the coronavirus," she said. "So many residents' lives are being taken and most of them were not even terminal."
At least 23 residents of the nursing home had died due to COVID-19 as of Sept. 13, state records show, and at least 50 of its workers were confirmed or presumed to have been infected with the virus during the pandemic.
The nursing home was fined $20,000 for the immediate risk infection-control violation and related citations.
Meanwhile, the nursing home’s owner, Comprehensive at Orleans, LLC, was approved for a federal paycheck protection loan of $350,000 to $1 million to retain 123 jobs during the pandemic, records show.
The nursing home’s administration did not immediately return two voice messages on Thursday seeking comment on the violations and fine.
‘Immediate jeopardy’ from COVID-19 failures at nursing homes
At Creekview Nursing and Rehabilitation Center in Rochester, inspectors on April 24 discovered various infection-control breakdowns that potentially resulted in “cross contamination for 89 residents not identified as having COVID-19,” records show.
One key finding noted two staff members exited COVID-19 positive resident rooms without removing PPE.
Then, “the staff members either entered the room of a resident that did not have COVID-19 or continued to deliver meal trays without putting on (donning) new Personal Protective Equipment,” inspectors noted.
“Additionally, the facility did not protect three residents…that were asymptomatic and did not have COVID-19” but were living with COVID-19 infected roommates, the report shows.
The two incidents resulted in “immediate jeopardy to resident health and safety that is widespread,” the report stated.
Creekview was fined $16,000 in connection to the violations. It had three resident deaths due to COVID-19 as of Sept. 16, and 76 workers had been confirmed or presumed to be infected at some point, state data show.
Jeff Jacomowitz, a spokesman for Creekview, issued a statement in response to a USA TODAY Network request to interview a member of the nursing home's administration about the matter.
He noted "all clinical staff, from the CNA level to upper clinical management, were given a re-education about the best ways to stop the spread of the virus within the facility" within two days of the April inspection.
Jacomowitz added Creekview has not had a COVID-19 case for months and 68 residents in the facility have recovered after contracting the disease. He noted the nursing home's death toll was five residents as of Friday.
"Our hearts go out to the families of the residents who passed from this terrible virus. They have always been considered part of our family as well," he wrote in the statement.
Violation details for nursing homes in New York are available online at the Department of Health's oversight website, at health.ny.gov.
Questions remain about COVID-19 death data, inspections
The true COVID-19 death toll for nursing homes statewide remains shrouded in secrecy. State officials have refused to release data on resident deaths at hospitals. Some experts asserted thousands of additional fatalities have occurred.
Further, advocates have raised questions about discrepancies between federal and state data released in connection to the COVID-19 inspections nationally, as well as the limited number of immediate jeopardy infection-control citations.
For this report, USA TODAY Network reviewed federal databases released by the Centers for Medicare and Medicaid Services, and the state Department of Health provided statistics related to inspections.
Cuomo has faced criticism over his handling of the pandemic in nursing homes, first with a March order that let COVID patients back into nursing homes if they could be isolated.
In May, as fears lessened over a potential overcrowding in hospitals, Cuomo reversed the policy, requiring COVID patients to stay in hospitals until they were COVID free before they return to the nursing homes.
And it wasn't until earlier this month that he allowed visitors to nursing homes, if the facility didn't have a new case for 14 days.
"The number of nursing homes that have taken the necessary steps to protect residents from the asymptomatic spread of COVID-19 while working to reopen to outside visitors shows that adhering to the DOH visitation guideline is the smart and cautious approach to allowing visitations," health commissioner Dr. Howard Zucker said when the visitation policy was updated Sept. 15.
But Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, said the inspections at nursing homes “probably didn’t cite as many things as they should have considering the history this industry has with infection-control problems.”
Government Accountability Office data showed 82% of nursing facilities in the U.S. were cited with infection-control deficiencies at least once between 2013 and 2017, and 48% of facilities were cited in multiple years, Edelman noted.
The governmental watchdog office called infection-control problems “widespread” and “persistent,” she added, suggesting stronger nursing home oversight efforts are needed to improve quality during the pandemic.
“Problems cannot be fixed going forward if they aren’t even identified and acknowledged,” she said.