Limited inspection reports show COVID-19 lapses in nursing homes
Inspection reports on six homes are the first to be released.
This story has been updated with a response from an affected nursing home.
Inspections at several Connecticut nursing homes found lapses in infection control and prevention and poor practices for the prolonged use of protective gear necessary during the COVID-19 pandemic, according to a half-dozen reports released Wednesday.
The reports provided by the state Department of Public Health are the first detailed accounts of targeted inspections ordered by the federal government on March 20 and later expanded by Gov. Ned Lamont to cover all 213 skilled nursing homes, where the novel coronavirus has infected 6,000 and is attributed to more than 1,600 deaths.
The reports on homes in Chester, East Haven, Milford, Orange, Seymour and Waterford were released without the DPH saying if they were the only six nursing homes with deficiencies or merely the first subjects in a series of reports on how the industry has handled the pandemic.
None of the reports detailed inspections at homes with some of the highest numbers of people dying from COVID-19, such as Kimberly Hall North in Windsor, Abbott Terrace Health Center in Waterbury and Riverside Health and Rehabilitation Center in East Hartford.
Av Harris, a spokesman for the department, said there is a delay in releasing some reports.
“It takes time to get these completed and posted,” he said Wednesday. “It’s not an overnight process.”
The federal government ordered states on March 20 to work with the Centers for Disease Control and Prevention to select nursing homes for inspections. On April 19, Lamont announced the state would be visiting every nursing home to conduct “infection control surveys.”
Multiple requests over the last several weeks for copies of findings from the first round of nursing home inspections went unanswered, even though the governor regularly pointed to them in highlighting what the state is doing to improve conditions in nursing homes. Lamont said Vice President Mike Pence, who leads the federal coronavirus response, recognized the Connecticut effort in a recent conference call with governors.
“One of the things on the nursing homes you might find interesting is the Pence task force – they did give Connecticut a shout out as one of the leading states in terms of having a physical inspection of each and every one of the nursing homes,” Lamont said.
To date, 1,627 nursing home residents in Connecticut have died from COVID-19 or related complications. That is roughly one out of every 13 skilled nursing home residents. Those deaths account for more than half of all COVID-related fatalities in Connecticut.
Of the six nursing home inspection reports made public, five show infection control lapses. The sixth facility was cited for failing to notify a resident’s conservator of the person’s change in condition.
The five nursing homes with infection control and prevention violations are Aaron Manor in Chester, Whispering Pines Rehabilitation and Nursing Center in East Haven, Shady Knoll Health Center in Seymour, New London Sub-Acute and Nursing in Waterford, and Orange Health Care Center in Orange.
At Aaron Manor, inspectors found in April that managers had failed to ensure their infection control and prevention strategy included the cleaning of frequently touched surfaces and instructions on the proper use of protective equipment among housekeeping staff.
One employee was seen pushing a food cart from a COVID-19 unit to a non-COVID-19 area and then touching a kiosk screen after touching the cart. Members of the housekeeping staff were seen handling soiled clothing without protective gear, and the facility didn’t have a clean space for folding and storing laundry once it came out of the washing machine.
Aaron Manor has recorded 25 cases of coronavirus and 10 deaths.
The chief executive officer for Ryders Health Management, which owns several nursing homes in the state including Aaron Manor, said the care they provide is excellent.
“Aaron Manor has the most dedicated staff and continues to provide outstanding care for our patients. We receive daily appreciation from both families and patients for our staff’s heroic efforts,” said Martin Sbriglio. “At a time when we are facing World War 3 in health care we need to work in collaboration with local, state and federal agencies. Finger pointing is a failed strategy. Working together to correct the last decade of failed policies will result in better care for all Connecticut’s citizens.”
Inspectors who visited Whispering Pines the same month found that staff had failed to appropriately isolate residents who tested positive for COVID-19 or who were suspected to have contracted the disease. The facility also failed to implement a plan for early detection for the residents showing symptoms. Whispering Pines has logged 24 deaths and 52 cases of COVID-19.
Terrance Brennan, the nursing home’s administrator, responded to the issue with this statement: “Caring as it does for the most vulnerable in the community, Whispering Pines was an early victim of the coronavirus at a time when the state, the country and the world were struggling with the pandemic, and when guidance from experts was reactive and quickly changing. It strives at all times to meet the highest standards, and has followed all proper protocols and guidance from both the CT Health Department and the CDC, and consequently it objects to the preliminary findings of the CT Department of Public Health which is now subject to an appeal.”
At Shady Knoll, inspectors in late April cited the home for failing to isolate residents with COVID-19 from those who were healthy. The facility also failed to create and implement policies on the extended use of personal protective equipment like masks and gloves. Shady Knoll has reported 73 cases of the virus and 29 deaths.
New London Sub-Acute and Nursing was cited for failing to ensure infection control practices were implemented to prevent or stop the spread of the disease. The facility didn’t designate an area for staff or visitors to be monitored when entering the building, the inspectors noted, and a staff member removed her mask and stood less than six feet away from the surveyor during the visit.
“The surveyor backed up and requested the supervisor reapply the face mask,” the inspector wrote. Another employee entered the building through a rear door without a face mask.
The nursing home has logged 74 COVID-19 cases and one death.
During an unannounced visit on April 28, inspectors faulted the Orange Health Care Center for failing to develop policies related to the extended use of protective gear in a facility where residents had tested positive for COVID-19. Staff were not required to change out their protective equipment between residents confirmed to have coronavirus and those with test results pending. Orange Health Care had 43 COVID-19 cases and two deaths.
Golden Hill Rehab Pavilion in Milford, which has come under scrutiny for its high number of coronavirus cases and for accusations of not informing residents’ families of their conditions, was cited for failing to notify a resident’s conservator of a change in condition. The resident was moved offsite for testing and given new medication without the person’s conservator being updated, the inspector found. The resident has since died.
Golden Hill has reported 82 cases and 23 deaths.
Supervisors at some of the homes said they disagree with the inspectors’ findings. Others filed plans of correction, but stressed they were not admitting guilt.
Officials at Aaron Manor noted that they had educated staff members on proper procedures and that policies were established to make sure high-touch areas were cleaned regularly.
“The filing of this plan of correction does not constitute an admission that the deficiencies alleged did in fact exist,” they wrote. “[It] is filed as evidence of the facility’s desire to comply with the requirements.”
Attempts to reach the other five nursing homes Thursday morning were not immediately successful.
Matt Barrett, the leader of the Connecticut Association of Health Care Facilities, said nursing homes are performing well, given the circumstances.
“Nursing homes have been performing at an an extraordinary level during the pandemic, especially when considering the constantly changing guidance from public health officials as they learned more about the highly contagious virus and it’s transmission from asymptomatic carriers,” he said. “Nursing homes have also been challenged by the fact that public health officials only recently made nursing [home] testing a priority and the inadequacy of personal protective equipment. Regulatory enforcement is a component of the oversight of nursing homes, but while nursing homes remain in the throes of the public health emergency, they need less of this punitive approach, and more support from regulators.”
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