Maryland health regulators levied a $70,000 fine on Pleasant View Nursing Home in Mount Airy for failing to properly isolate newly admitted residents to prevent spread of the coronavirus over a two-week period in May.
The fine comes more than two months after Pleasant View became the site of the state’s first known major outbreak of COVID-19 in a nursing home. The virus infected 126 residents and staff there and caused 29 deaths.
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Inspections of three other nursing homes around the state also revealed issues related to COVID-19 infection prevention, according to documents provided to The Baltimore Sun under a public records request: Carroll Lutheran Village in Westminster, Hebrew Home of Greater Washington in Rockville and Ellicott City Healthcare Center.
The documents also show regulators added to a list of deficiencies found at Sagepoint Nursing and Rehabilitation Center in La Plata last month. Sagepoint, where at least 37 residents have died, is the site of one of the state’s deadliest nursing home outbreaks.
The regulators’ findings suggest that problems have persisted in nursing homes even as cases and deaths tied to the facilities have eased. Elder care facilities, also including assisted and independent living centers, have accounted for nearly two-thirds of the COVID-19-related deaths confirmed in Maryland, but outbreak numbers and deaths have declined steadily over the past two months.
At Pleasant View, for example, after the outbreak was reported in April, the Carroll County facility was reporting no new cases or deaths by mid-May. It reappeared in state reporting in mid-June with three new infections, bringing its total confirmed cases to 132.
Inspections by the Maryland Office of Health Care Quality from May 14-28 found that Pleasant View staff were not properly isolating newly arriving residents from May 7 through May 20, creating what regulators called “immediate jeopardy” to the nursing home’s population. The office levied a $5,000-per-day fine, the second time state regulators have publicly reported issuing monetary penalties to a nursing home amid the coronavirus pandemic.
Maryland health officials announced a $380,000 penalty for Sagepoint last month amid what it called “widespread” deficiencies in infection control. Administrators have said they dispute those findings, and under state Office of Health Care Quality policy, they have the right to appeal and strike findings of deficiencies from the record.
In a letter to the facility dated June 2, state regulators told Sagepoint they were adding one additional deficiency and expanding the scope of another. It was not immediately clear what those revisions included.
Sagepoint officials “are shocked and astonished” that state health officials would release information about inspectors’ findings “before we have had our due process,” spokeswoman Joyce Riggs said. The company filed for a dispute resolution with the state to contest the findings on May 15 but said it has not received a response.
“This action is punitive and not consistent with protocol or how any other survey dispute for a nursing homes in the State is being handled,” she said.
[ Maryland nursing homes hard hit by coronavirus and related racial disparities ]
The state inspectors at Pleasant View found that one resident who was known to experience hallucinations and delusions and to behave aggressively was admitted to an area reserved for COVID-negative residents, but with a COVID test pending, and took to wandering the facility’s halls. The resident’s test eventually came back positive.
The report also says that the nursing home’s director of nursing had resigned in April, but administrators did not inform state health officials, as required by regulation. And it describes insufficient staffing levels to meet required patient-to-staff ratios and monitor all residents.
Rebecca Travels, Pleasant View’s administrator, hung up on a Sun reporter calling about the findings.
At Carroll Lutheran Village, inspectors found in early June that residents were being treated for COVID-19 without established care plans, which are required to be developed for each patient. Some staff members also told inspectors they had not recently received hand hygiene training.
Carroll Lutheran has had 59 confirmed cases among residents and staff and 12 deaths, state data shows.
Ken Connelly, vice president of operations for Lutheran Social Ministries of Maryland, said the facility has not reported any new cases in 33 days and is “taking the corrective steps necessary to ensure we are in full compliance with state regulations.”
“Without a doubt, wearing masks and other PPE as required, practicing social distancing guidelines, and following stringent infection control protocols at all times is vital to protecting our residents and staff, whose safety and health remain our priority,” he said in a statement.
A survey conducted at Ellicott City Healthcare Center in Howard County from May 14-18 found issues with coronavirus infection control, including a staff member neglecting to remove protective equipment and wash their hands upon leaving a COVID-positive area. Inspectors also said they saw residents known to be COVID-positive in hallways not wearing masks.
The Ellicott City facility has had 142 resident and staff cases and 17 deaths, according to the state.
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Fred Stratmann, a spokesman for CommuniCare, the nursing home’s owner, said Ellicott City Healthcare Center disputes the findings.
“We have requested informal dispute resolution with OHCQ and look forward to having the opportunity to have the matter discussed and hopefully resolved,” he said.
And at Hebrew Home of Greater Washington, inspectors said staff did not follow proper protocol in removing protective equipment during a June 17 inspection. In one case, instead of removing the equipment in a designated area, a staff member took it off in a dining area, placing a used gown into a plastic bag and setting goggles and a face mask on a dining table that the staff member then used for his or her lunch break.
A spokesperson for Charles E. Smith Life Communities, which operates the nursing home, could not be reached for comment.
The state inspection reports, released to The Baltimore Sun after a Public Information Act request, included a report for two inspections conducted this month at FutureCare Lochearn in northwest Baltimore, site of one of the state’s largest outbreaks with 257 cases, resulting in 24 deaths.
“This survey did not identify non-compliance with Federal or State requirements related to infection control,” the cover letter concluded.
Regulators have not reported any deficiencies there during the pandemic.
This story has been updated to correct that the outbreak at Sagepoint Nursing and Rehabilitation Center is no longer the state's deadliest. Outbreaks at three other facilities including Charlotte Hall Veterans Home have resulted in more deaths. The Sun regrets the error.