Health inspectors have cited about one in seven Oklahoma nursing homes and assisted-living facilities with confirmed cases of COVID-19 for violations that could lead to viral spread, but have issued no monetary penalties. 

State inspectors conducting surveys focused on infection control because of the pandemic have cited nursing homes and assisted-living facilities for bad practices such as failing to require residents and staff to wear face coverings, allowing infected staff to care for residents and failing to properly quarantine at-risk residents. 

Since April, inspectors have reported staff shortages at facilities, employees forgoing hand sanitization when caring for residents and providers failing to wear proper protective gear.

As deaths mount in Oklahoma, surpassing 1,000 as of last week, long-term care residents continue to make up a large portion of fatalities, accounting for about 40 percent of deaths, comparable to the national trend.  

The Frontier reviewed hundreds of inspection reports the state posted on its website for the 279 nursing homes and assisted-living centers with confirmed COVID-19 cases and found that as of Monday, 45 of those facilities — about 16 percent — were cited for at least one violation for shortcomings related to how they responded to the pandemic. 

The majority of the cited facilities, in which 634 staff and residents have tested positive and 52 have died, failed to follow basic Centers for Disease Control and Prevention guidelines aimed to protect residents and staff from becoming infected with COVID-19. 

Of the 45 facilities with at least one violation, 34 were cited for infection control errors.

Advocates for seniors living in long-term care facilities say such violations are unacceptable, and could lead to viral spread and death. 

“It’s alarming because especially in this time of this pandemic to not even follow through on the simplest preventative measures could kill people,” said Brian Lee, executive director of the Families for Better Care advocacy group based in Austin, Texas. 

Esther Houser for more than four decades has advocated for long-term care residents, first as the state’s long-term care ombudsman before her retirement and now as a volunteer. 

Houser said because of the relatively low number of violations, she believes the state health department has served more as a consultant for facilities rather than as a regulator. 

“Considering that this is new to everybody, I can understand them trying to be somewhat supportive,” she said.

But that facilities are still being cited for “basic” violations is “appalling,” Houser said. The health department should issue monetary penalties or place a state monitor in those homes until they come into compliance, she said.  

“That is such neglect,” Houser said of the violations. “That totally appalls me that there are facilities doing that.”

One of the cited facilities was The Mansion at Waterford, an assisted-living facility in Oklahoma City, where 20 people have been infected and two have died.

State inspectors visited the facility on June 1 and found two COVID-positive medication aides providing care to 15 of the facility’s residents, survey records show. 

One provider returned to work two days after receiving a positive test result, records show. Another worked a shift the same day they received the positive result and returned the next day.

An employee at the facility told inspectors they were aware infected staff were not to return to work for at least 10 days from the date of the test, according to the report. 

Inspectors determined the violation had the potential for “more than minimal harm” to residents and called for a written plan of correction.

In a written plan of correction, the facility’s administrator wrote that the errors had “no adverse” effects on residents and that the community received conflicting information from local and state health departments concerning when employees could return to work. 

The Mansion at Waterford and its management company, Milestone Retirement Communities, did not respond to multiple requests for comment. 

The Mansion At Waterford, an assisted living and Alzheimer’s care facility in north Oklahoma City. BEN FELDER/The Frontier

At Tulsa Nursing Center, state investigators found residents who left the nursing home for dialysis were not housed separately from other residents upon their return, according to an inspection report from June 23. Twenty-six people at the facility have been infected and one has died. 

There was no quarantine plan in place for residents who left for dialysis, the home’s nursing director told inspectors.

The CDC’s guidance calls for nursing homes to keep readmitted residents in separate areas of facilities to be monitored for signs of COVID-19 for 14 days, and directs staff to wear full protective gear, such as respirators, gowns and eye protection when caring for those residents. 

Eight residents left the facility to receive dialysis, survey records show, but were housed in the same area as other residents. There was no signage on residents’ doors signaling staff should take precautions when entering their rooms.  

Employees told state investigators that no precautions were being taken for those residents, but staff wore masks and gloves, according to the survey records. Residents wore masks to and from the dialysis facility, employees said. 

Investigators determined the violations indicated a “pattern of deficiencies that constitute no actual harm” but had the potential for more than minimal harm.

Tulsa Nursing Center, a nursing home in Tulsa. KASSIE MCCLUNG/The Frontier

StoneGate Senior Living, a Texas-based company that operates the facility, did not answer questions about whether the violations might have led to viral spread at the home. 

“Thanks for your interest in Tulsa Nursing Center,” the company said in response to The Frontier’s questions. “We are currently in compliance and following the most recent guidelines from the CDC and CMS as well as state and local authorities.”

A subsequent inspection on July 21 found the facility was following CDC guidance.

Houser said that by late June, Tulsa Nursing Center should have been competent in its pandemic response, and the health department should have issued a more severe violation. 

Not only punitive

Oklahoma State Department of Health investigators have conducted hundreds of COVID-focused inspections in long-term care facilities during the pandemic, sometimes visiting a home more than once. There are more than 475 nursing homes and assisted-living facilities in Oklahoma. 

State inspectors report violations to the federal Center for Medicare and Medicaid Services, an oversight agency. 

CMS in March ordered states to suspend routine surveys and focus on infection control during the pandemic and later gave a deadline of July 31 to complete initial infection control inspections. Last month, the agency announced routine inspections could resume.

Nursing homes and other care facilities across the U.S. have reported more than 80,000 deaths during the pandemic, accounting for more than 40 percent of fatalities, according to the nonprofit Kaiser Family Foundation

In August, CMS reported it had doled out more than $15 million in fines to thousands of nursing homes during the pandemic. 

No fines related to COVID-19 response had been issued to Oklahoma facilities as of Wednesday, a health department spokesman said. 

Steven Buck

The virus’ presence in facilities doesn’t necessarily signal wrongdoing, said Steven Buck, president and executive director of Care Providers Oklahoma, a trade group. Asymptomatic staff, and changing protocols and best practices could explain the relatively low number of violations. 

Travis Kirkpatrick, the Department of Health’s deputy commissioner of prevention and preparedness, said because COVID-19 is a novel virus, responding has been unlike anything facilities have experienced. 

He disagreed that the relatively low number of violations compared to the number of facilities with COVID-19 cases indicated the state wasn’t being punitive enough. 

But while inspections may result in violations, the health department didn’t want visits to be only a “punitive engagement,” Kirkpatrick said. The agency also wanted surveys to be a collaboration aimed to keep the virus out of facilities, offering homes protective equipment, guidance, and sanitation and testing resources. 

“We don’t want anyone to see us as only punitive because we are also here to help,” he said.  

Nursing home operators told The Frontier in April they struggled to secure protective equipment and paid 1,000-percent markups for gloves and masks. Oklahoma formed a task force in May to focus on slowing the virus’ spread in long-term care facilities, following calls from advocates and facility operators for more testing and protective equipment.

In late April, Gov. Kevin Stitt and the task force started to send protective equipment to all 308 nursing homes in the state, issued more protocols for the equipment’s use and deployed the National Guard to disinfect nursing homes. In late June, the state designated $35 million in federal CARES Act funds to go to long-term care facilities to cover costs such as protective gear. 

Member of the Oklahoma Medical Reserve Corps. Prepare boxes of personal protection equipment (PPE) and medical supplies to send out to facilities in the state at a warehouse where the State of Oklahoma has amassed a stockpile for its COVID-19 response in Oklahoma City, Okla. on Tuesday, April 7, 2020, in a [Chris Landsberger/The Oklahoman]

State investigators cited none of the 10 nursing homes and assisted-living facilities with the largest number of infections, records show. 

Among those facilities is Ignite Medical Resort Oklahoma City, a nursing home that has reported 90 infections and 11 deaths, according to the state health department. 

The number of infections at the facility is actually higher because the nursing home didn’t start reporting cases until May, when the federal government mandated it, said Tim Fields, CEO and co-founder of Ignite Medical Resorts.

State inspectors have paid five visits to the facility since March but have cited no deficiencies, records show. 

State inspectors made an unannounced visit on July 29 in response to a complaint that the facility was making infection control errors. Investigators saw nursing home staff wearing surgical face masks and proper protective gear when taking care of infected residents, according to a July 29 survey. 

The facility properly quarantined residents and had dedicated staff to work only with sick residents, according to the report, which determined the nursing home was in compliance with CDC guidelines.

Ignite has designated a unit to care for COVID-positive patients who might have gotten a physician’s order for skilled nursing and rehabilitation services, Fields said. The facility has admitted more than 150 COVID-positive people from hospitals in the Oklahoma City metro area, he said.  

“Our COVID-recovery unit has had incredible outcomes, including a very low mortality rate and no violations from five infection control surveys by the Oklahoma State Department of Health,” Fields said in an emailed statement. 

In September, long-term care facilities reported 66 new deaths and 1,065 cases.  

Houser said ultimately it’s the facilities’ jobs to protect residents and the state’s duty to enforce rules. 

“The resident has a right to be protected,” she said. “The facility has an obligation to protect the wellbeing of residents, and that includes doing what the guidance provides. … And then actually enforce those standards within the facility.

“They’re paid to provide care. They’re paid to follow the rules and meet certain standards.”