If you were to look at the federal government’s inspection reports for the Dubuque Specialty Care nursing home, you might think the northeast Iowa facility had attained a perfect score from inspectors last June.
The June 10, 2020, inspection report, published on the Centers for Medicare and Medicaid Services’ Care Compare website, is a single page stating, “No health deficiencies found.”
But the actual inspection report, written by the state officials who conducted the on-site visit 12 months ago, is 10 pages long and lists a litany of serious regulatory violations related to infection control. It alleges a nurse aide with a cough was allowed to work in the facility on three separate occasions last April before testing positive for COVID-19. The worker who handled the employee screening felt the aide shouldn’t be working but was overruled by management, according to inspectors.
Also, the aide who was sick reportedly told inspectors she did not have a face shield to wear during the last four night shifts she worked while feeling ill. In addition, the home’s administrator was also allowed to work in the building, despite shortness of breath. She tested positive for the virus five days later, the state report says.
In all, at least 43 residents of Dubuque Specialty Care had contracted COVID-19, and 11 of them died. But the report on CMS’s Care Compare site suggests no violations were found during the June 10 inspection.
The federal website also tells the public that no fines or penalties have been imposed against Dubuque Specialty Care in the past three years. However, when asked, CMS officials said they imposed a fine of $84,825 against the home, which was immediately reduced to $55,136 once the home agreed to forego an appeal. As of April, they say, the facility still had not paid any of that fine.
So why does the CMS website indicate the June 10, 2020, inspection resulted in no violations and no fines?
On April 5, the Iowa Capital Dispatch informed CMS that its website’s stated no fines were imposed, but the agency didn’t explain the discrepancy or correct the site. On Tuesday, agency officials indicated they were unable to offer any explanation. Dallas Urbain, the administrator of the Dubuque facility, declined to comment on the matter.
The Care Compare site is promoted as a tool to provide the general public with accessible information on quality-of-care issues in nursing homes. But CMS has long been accused of disseminating misleading or incomplete information via that site and its earlier incarnation, Nursing Home Compare.
In 2015, the Government Accountability Office began a review of the site in the wake of a New York Times report questioning the site’s accuracy. A year later, the GAO issued a report recommending improvements to the site and warning that CMS officials had “described a fragmented approach to reviewing and implementing recommended website changes.”
In 2019, the Center for Medicare Advocacy analyzed the civil money penalties CMS was reporting that it imposed against nursing facilities. In two-thirds of the cases that were reviewed, the site did not fully and accurately report the violations cited by CMS and the penalties imposed, the center found.
Of 15 cases examined by the center, Nursing Home Compare falsely reported that five facilities had no penalties at imposed during the previous three years, even though judges had sustained penalties against all five.
“The information that is publicly available on Nursing Home Compare is limited and inaccurate and may mislead families into believing a facility has not been sanctioned, when it has,” the Center for Medicare Advocacy reported. “The information also supports the conclusion that the federal government is not fulfilling its ‘duty and responsibility’ under the Nursing Home Reform Law of 1987.’
And in March of this year, the New York Times reported that the newly launched Care Compare site’s five-star rankings of nursing homes was deeply flawed, providing “a badly distorted picture of the quality of care at the nation’s nursing homes.”
Those ratings are based on self-reported data from nursing homes and on-site reviews by state health inspectors. According to the Times, much of the information self-reported to CMC is wrong, and almost always the incorrect data makes the homes seem cleaner and safer than they actually are.
Between 2017 and 2019, health inspectors wrote up about 5,700 nursing homes — more than one of every three homes in the nation — for misreporting data pertaining to residents’ well-being. Despite that, federal official rarely audit the self-reported data used on the federal website, the Times reported.
The Dubuque case was handled in much the same way as most of the COVID-19 outbreaks in Iowa’s nursing homes: Even in cases of “rampant” violations resulting in deaths, the care facilities’ owners were almost never penalized by the state, and in some cases, CMS’ website reports that no federal penalties were imposed, either.
Homes used COVID-positive caregivers
Last year, even as coronavirus-related infections and deaths mounted, nurses and supervisors at Iowa nursing homes came to work while sick after testing positive for the virus, in violation of policies they helped establish. Administrators deliberately had COVID-positive residents sharing rooms with COVID-negative residents who then became infected.
Nurses and aides provided hands-on care for residents after testing positive and reporting to work with chills, vomiting and diarrhea. Other workers wore face masks around their chin, neglected to wash their hands, or screened themselves when reporting for work.
In some cases, no fines were reported by either state or federal regulators.
For example, last June at Oskaloosa’s Crystal Heights Care Center, the home was cited for the “rampant” spread of COVID that resulted in 54 of 74 residents being infected and which resulted in nine deaths.
The inspectors said the home failed to provide appropriate infection control measures and allowed staff to work after showing signs and symptoms of COVID-19. A nursing assistant who was allowed to work while sick may have introduced the virus to the home, inspectors said, and the facility had failed to adequately screen workers for symptoms at the beginning of their shifts. Employees were also alleged to have been screening themselves without independent oversight or monitoring.
An $8,750 fine was proposed by the state, and then held in suspension to allow federal officials to act. But according to the CMS website, no federal fines have been imposed against Crystal Heights during the past three years.
Another Iowa nursing home, the Cedar Falls Health Care Center, was cited last October for failing to have the staff wear the proper protective equipment to slow the spread of COVID-19. The home was also cited for numerous, serious patient-care issues, for a “heavy buildup” of dirt, dust, debris and grime in numerous areas, and for “mud and dirt scattered along the length” of one hall. Inspectors also cited the home for failing to assist residents with grooming, noting that some female residents had a heavy growth of facial hair or long, dirty fingernails.
The home was found to have placed residents in immediate jeopardy. An inspector found a resident in a soiled bed, with labored breathing, open sores and blisters on her backside, dried vomit in her hair and a dislocated shoulder the staff knew nothing about. The resident was taken to a local hospital for emergency treatment and died three hours later in the emergency room. A nurse aide and a licensed practical nurse employed by the home later told inspectors the facility wasn’t staffed to properly care for the woman.
A $10,000 fine was proposed by the state, then held in suspension to let federal officials act. But according to CMS’ Care Compare website, the last time the Cedar Falls Health Care Center was subjected to a federal fine was in 2019.
At the Montrose Health Center last November, the home was cited for placing residents in immediate jeopardy by allowing COVID-positive workers to care for uninfected residents; for failing to adequately screen people entering the building; and for having COVID-positive and COVID-negative residents share the same room. In mid-October, at least four aides who worked at the home tested positive for the virus, and 10 of the 28 residents were infected. Within two weeks, three nurses, nine aides and 21 residents had tested positive, inspectors said.
The nursing home administrator allegedly admitted to inspectors that she had allowed one employee to work her shift even though the woman had tested positive that same morning. That worker then passed medication to COVID-negative residents. Records at the home indicated the facility also had at least three COVID-positive residents sharing a room with a COVID-negative resident, despite the home having at least eight rooms that were entirely vacant. All three of the COVID-negative residents subsequently tested positive.
The administrator explained to inspectors that the “corporate office” had approved room-sharing among positive and negative residents on their theory that everyone in the home had already been “exposed.” A nurse aide told inspectors she came to work with COVID-19 symptoms for more than a week and was never sent home, despite reporting her symptoms to management.
The state proposed a fine of $7,250 and then held that fine in suspension to let federal regulators act. But according to CMS’ Care Compare website, no federal penalties have been imposed against Montrose Health Center during the past three years.
In February of this year, the Azria Health Center in Winterset was cited for placing residents in immediate jeopardy for failing to provide appropriate infection control measures; for allowing staff to work after showing signs and symptoms of COVID-19; for failing to ensure all staff were screened before entering the facility; for failing to prevent staff from screening themselves; and for failing to ensure the staff was properly educated on COVID-mitigation protocols.
When inspectors asked why a COVID-positive worker was allowed to care for the home’s only COVID-negative resident (out of 43 residents total), the director of nursing reported that “all of the staff that are here” had tested positive. When the administrator was asked about workers screening themselves for the virus and then working, even after testing positive and displaying symptoms, she said the employees were all “adults” and they didn’t have enough staff to keep someone stationed at the entrance. The director of nursing told inspectors she worked inside the home while ill — with vomiting, diarrhea, headaches and shortness of breath — on five separate days three to four weeks after testing positive for the virus. One worker tested positive on Dec. 28, then was allowed to work two days later while complaining of headaches and the loss of taste and smell.
Another Azria employee tested positive on Dec. 23, then reported for work, with symptoms, on four separate days the following week. Although the home was cited placing residents in immediate jeopardy, that violation was downgraded the same day when the facility developed a plan of correction. With only one of the 43 residents still testing negative for the virus, the home agreed to a comprehensive change in infection-control policies and practices.
The state proposed an $8,500 fine, and then held that penalty in suspension to let CMS take action in the case. CMS’ Care Compare website says no federal fines have been imposed against Azria Health Center during the past three years.
Not all of the Iowa facilities where fines were held in suspension by the state went unpunished by federal authorities.
At the Donnellson Health Center, the facility was cited last June for failing to ensure the staff washed their hands and wore gloves while providing residents with hands-on care.
In August, the home was cited for placing residents in immediate jeopardy by failing to follow infection control practices to prevent or reduce the risk of spreading COVID-19. Inspectors said a symptomatic resident was taken to a hospital for COVID-19 testing but then was returned to the facility and placed in a two-person room alongside another resident. Three days later, lab results showed the tested resident was positive for the virus.
In a separate incident, a new admission to the Donnellson Health Center was not quarantined and was instead placed in a room alongside another resident. At that time, the home was also cited for failing to inform residents and families of a COVIC-19 infection in the facility. A month later, in September, the home was again cited for placing residents in immediate jeopardy, this time by knowingly allowing a symptomatic worker — who later tested positive for the virus — to provide care for residents of the home.
On Aug. 19, a nurse aide at the home texted the director of nursing to tell her she was feeling sick but would be coming to work anyway. The director of nursing texted back, “Okay, I’ll hold you to it.” The aide then texted, “LOL, okay. I promise I am on my way to get my truck. Sick or not, I am coming in.” The director of nursing texted back, “We are all sick.”
Later that night, at the end of her shift, the aide texted the home’s administrator: “Okay so I have been open and honest about running elevated temperature all week long and with them going up to 100. Now as I took my temperature at 9 pm, because I stopped sweating and got cold again with body aches, it is back up to 100.1.” She told the administrator that when she began her shift her temperature was 99 degrees.
The next day, the aide texted the director of nursing, writing: “I need a COVID test done … I just know that I feel like death today and still getting fevers … The guy I am seeing is sick the same way and he has several people at his workplace out with positive COVID.”
The aide was tested that day, with the results showing she was positive for COVID-19. As a result of the August and September inspections, the state proposed a total of $30,500 in fines — but held those in suspension to allow the federal government to impose its own penalties.
According to the CMS website, the federal agency fined the Donnellson Health Center $3,257 last June, and an additional $162,684 in August.