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By Charles Ornstein and Topher Sanders, ProPublica

One by one, toward the end of March, residents of Enumclaw Health and Rehabilitation Center outside of Seattle started coming down with symptoms of COVID-19.

On March 22, residents in rooms 503 and 522 were moved to a wing for COVID-19 patients. Another resident began showing symptoms, too, and was also moved.

In all three cases, their roommates were left in their rooms and staff were given no instructions about using any added precautions to care for them. At least two of the three residents’ roommates subsequently came down with the disease caused by the novel coronavirus.

During an interview with a health inspector days later, a staffer said that “they were told by corporate not to start the roommate on isolation, and continue with surveillance to conserve PPE [Personal Protective Equipment],” according to an inspection report obtained from the Centers for Medicare and Medicaid Services, or CMS. A second nurse gave a similar account.

Enumclaw, the inspectors concluded, “failed to take appropriate actions related to a COVID-19 outbreak. These failed practices may have contributed to multiple residents and staff contracting COVID-19.”

Enumclaw is one of nine nursing homes around the country that federal inspectors have determined have put residents’ health and safety in “immediate jeopardy” for their actions and inaction in stopping the spread of COVID-19. ProPublica requested all records involving such citations since March 1 from CMS. The facilities cited include Life Care Center of Kirkland, another facility outside of Seattle where more than 40 residents died, which became an early epicenter of the virus’s American spread. Others include Aperion Care Chicago Heights, a facility in a suburb south of Chicago, and Advantage Living Center - Roseville, north of Detroit.

Though inspectors have stopped routine visits to nursing homes during the pandemic, they continue to investigate the most serious allegations involving failures to control infections.

Among the problems cited in the reports reviewed by ProPublica: a lack of personal protective equipment, failure to maintain social distancing among residents, inadequate staff, and not acting quickly enough when residents exhibited symptoms of the disease.

Nursing home residents have been among the hardest hit by COVID-19. To date, more than 10,000 nursing home residents have died, according to The Wall Street Journal and the Kaiser Family Foundation, a health care philanthropy. In some states, nursing home residents account for more than half of COVID-19 deaths. The inspection records are a glimpse into the kind of mistakes that could be at the root of the widespread outbreaks occurring in these facilities.

All told, there are about 15,000 nursing homes in the United States, which house about 1.3 million people. The homes offer a high level of care for those who need help with activities of daily living, such as eating, bathing, and getting dressed. They also provide skilled rehabilitation for patients after medical procedures or illnesses. Because Medicaid pays for a substantial share of care at the homes, and Medicare pays for some, CMS sets the standards under which they operate. Many of the homes that received immediate jeopardy citations in recent weeks related to COVID-19 have been cited in the past for violations of those rules.

At Enumclaw alone, 38 residents and 10 staffers tested positive for COVID-19 as of April 2, federal regulators noted. Five residents had died.

Abraham Ritter’s 68-year-old mother, Patricia, has been a resident of Enumclaw since 2004.

“My concern is that my mother has a death sentence being in that nursing home,” Ritter said. “I don’t have anywhere else I can put her. If they’re not going to take reasonable precautions to ensure health and safety, it’s not a matter of if she’s going to catch this, it’s when.”

In a statement to ProPublica, Enumclaw said its top priority is the “safety and wellbeing of our residents.”

“Since the beginning of the pandemic, we’ve continued to work with county and state health departments as necessary,” the home said. “As we identify areas of opportunity, immediate changes are implemented, policies are updated, and education across the company is provided.”

The home said it is following the most up-to-date recommendations on policies and procedures from the Centers for Disease Control and Prevention and CMS. Separately, in its plan to correct the violations, Enumclaw said, “residents at the facility who have been in contact with another resident or staff member with symptoms or became symptomatic are in isolation.”

Nursing home experts said oversight of facilities is critical during the COVID-19 outbreak when most visitors are prohibited from visiting their loved ones, and inspectors are likewise mostly staying away.

“I believe this crisis has overwhelmed nursing homes,” said David Grabowski, a professor in the Department of Health Care Policy at Harvard Medical School. “Nursing homes have struggled with infection control and care quality for a long time. However, this crisis has completely devastated the industry.

“Have certain nursing homes not met CMS guidance? Of course. Is that the major takeaway here? No,” he added. “I think the primary story is that the federal government has largely failed our nursing home residents and their staff. The government’s inaction has led to far more care issues than the COVID-related violations CMS has identified to date.”

At Beaconshire Nursing Centre, a facility in Detroit, an inspector watched a nursing assistant eat lunch while feeding a resident who had COVID-19 symptoms. The nursing assistant didn’t have on protective gloves or a gown, as required in such situations, and her mask was below her chin so she could eat her food. The staffer was immediately counseled by the home’s director of nursing and sent home. A lawyer for Beaconshire told ProPublica that the citations found in the inspection report were based on the actions of just one employee and that the staffer was later terminated.

At The Hearthstone nursing home in Seattle, an inspector watched a nursing assistant without eye protection such as goggles walk into the room of a resident in isolation for suspected COVID-19. The same nursing assistant helped change the resident’s soiled briefs, according to the report. The nursing assistant then removed her gloves, revealing a second layer of gloves. The nursing assistant then fed the resident without washing her hands. The Hearthstone said in a statement that all of its staff were later trained on proper hygiene and use of personal protective equipment. The nursing assistant was “excluded from work” for 14 days based on the possible exposure and tested negative for COVID-19, the home said.

And at Advantage Living Center - Roseville, an inspector wrote a 69-page report concluding that the facility waited too long to send one resident to the hospital despite evidence of a “severe decline in health.” According to the report, the resident eventually died in a hospital from probable COVID-19. The resident’s test results were pending, the report stated. The inspector also wrote about significant understaffing because of employees not showing up to work. One nursing assistant, for instance, was responsible for 41 residents during a shift, and another nursing assistant was responsible for 31. The report said the nursing assistants weren’t able to provide care for all the residents during the shifts.

“It feels horrible,” one of the nursing assistants told an inspector.

A facility executive pushed back against the report, saying the home was contesting it based on multiple errors and inaccuracies. Kelsey Hastings, a partner and chief executive of Advantage Living Centers, said in an email that the nursing home had provided a detailed response to federal officials, including evidence that contradicts the inspector.

Specifically, Hastings told ProPublica, the inspector “did not confirm the number of staff members on the shift, and the nurse who she spoke to was not aware of all staff members on the unit of which we have documentation as well.”

“Our staff has been providing a high level of care under difficult and extenuating circumstances,” Hastings wrote in an email. Hastings would not provide ProPublica a copy of the response, citing privacy laws, and an inability to redact personal information by the deadline.

“We have followed CDC guidelines and have altered guidelines almost daily as a result of constant changes in recommendations. Our other facilities have been following the same guidelines, and surveyors have given no citations and have complimented teams on the processes in place.”

Records show that Advantage Living has been cited for inadequate infection control in the past at the facility. Hastings did not respond to a question about the facility’s prior violations.

Aperion Care Chicago Heights did not respond to requests for comment. Life Care Center said in a statement this month it would “continue to work with CMS to find solutions” to the citations in the report, which led to a $611,000 fine. “We are working hard to address their current concerns in a timely and respectful manner so as to provide our residents the best care,” the statement said.

Organizations that represent nursing homes said they are doing the best they can.

The American Health Care Association, the industry trade group, said long-term care facilities had not received the support they need from federal, state, and local agencies during the COVID-19 pandemic.

“The reality is that many of these citations have occurred because long term care providers are facing an unprecedented situation that has left them begging for testing, personal protective equipment (PPE), and staffing resources,” Mark Parkinson, the group’s president and CEO, said in a statement. “Just like hospitals, we have called for help. In our case, nobody has listened.”

LeadingAge, an association of nonprofit senior service organizations, said that regulators should take a collaborative approach to work with facilities during a pandemic. “By that, we mean working constructively with providers to not only identify infection control issues but problem-solve and meaningfully address issues on the spot,” Janine Finck-Boyle, the group’s vice president for regulatory affairs, wrote in response to questions from ProPublica.

“We do expect our members to comply with all CMS requirements, including guidance issued during this time of crisis,” she added. “That said, CMS guidance has been limited and vague in response to the response to the detailed questions we receive from members on a daily basis. Often times, CMS has referred to CDC guidance, which offers recommendations — not requirements.”

LeadingAge wrote to Trump administration health officials this week to complain about a new requirement that nursing homes report data on COVID-19-positive residents to the CDC or face fines, saying it “will lead to inconsistent and contradictory data, and exacerbate public confusion.”

CMS first told nursing homes to prepare for the coronavirus on February 6, saying, “Every Medicare participating facility in the nation’s health care system must adhere to standards for infection prevention and control in order to provide safe, high-quality care.” It has followed up with additional guidance to restrict nonessential visitors and related to the use of PPE.

CMS also suspended routine nursing home inspections and said it would only focus on situations in which residents are in immediate jeopardy for severe injury or death. It said if inspectors lacked adequate PPE, they couldn’t enter homes.

CMS did not respond to questions about concerns raised by nursing homes and their trade groups.

The challenges facing nursing homes are expected to grow, not only as outbreaks continue to sweep through homes but also as COVID-19 patients are released from hospitals and require skilled nursing care as part of their recovery. Advocates have cautioned about the risk they pose to already frail patients who don’t have the disease.

Richard Mollot, executive director of The Long Term Care Community Coalition, an advocacy group for nursing home residents, said he believes that nursing homes have responded to the crisis poorly overall, “but we do hear of some nursing homes that are truly working to honor their legal and moral commitments to residents and families.”

“For the most part, we see facilities that failed to take steps in anticipation of the pandemic (especially after it hit the Kirkland, Washington facility), nursing homes that are taking in new residents even when they have woefully inadequate staffing for their current residents and, even, numerous reports of facilities discharging current residents so that they can take in COVID-19 patients (for whom there is considerable reimbursement),” Mollot said in an email.

Back at Enumclaw Health and Rehabilitation Center, the nursing home outside Seattle, the citations went beyond failing to take proper precautions after some residents began displaying COVID-19 symptoms.

The facility “failed to operationalize their infection prevention and control program to provide a safe, sanitary environment, and to help prevent the development and transmission of communicable diseases and infections, in particular COVID-19,” inspectors wrote. And it failed to immediately notify the state Health Department about the illnesses there.

The problems were on full display when the inspector arrived on March 26. The administrator escorted the surveyor down the hallways, past ten resident rooms, through resident care areas, to a nursing station in the 500 unit, the epicenter of the facility’s COVID-19 outbreak, to be screened for a fever. The only thermometer available at the nurse’s station was oral, so the surveyor had to remove their facemask.

When asked about the use of an oral thermometer, the administrator said, “That’s all we have.”

In its plan of correction, the home said it is now in close touch with the state Health Department about infections and has moved a thermometer to the facility entrance to check visitors there.

Ritter, whose mom is in the home, said the COVID-19 crisis has simply exacerbated long-known problems with the nursing home care industry, specifically around staffing.

“Low-paid employees are stretched, even before this crisis, far too thin,” he said. “They didn’t have enough employees doing enough work.”

This story was originally published by ProPublica.