‘They just gave us gowns today’: Inspection reports fault four Maryland nursing homes on coronavirus infection control

An inspector found deficiencies in coronavirus infection control practices at The Village at Augsburg on Campfield Road in Baltimore.

Since the coronavirus pandemic reached the state, health regulators have faulted four Maryland nursing homes for failing to follow infection control guidelines designed to prevent the spread of COVID-19 in the facilities, according to federal documents.

At the Village at Augsburg in Baltimore, residents suspected of coronavirus infection were not separated from others, and employees told regulators they weren’t informed which residents tested positive for COVID-19.


An administrator at Bedford Court Healthcare Center in Silver Spring told a health regulator the facility did not establish a separate unit for COVID-19-positive residents because it is a small community and, at that point, had not confirmed any cases.

Regulators observed a staff member at Althea Woodland Nursing Home in Silver Spring wearing a protective gown inside out and with a large hole in it, and said an administrator told them he was overseeing infection prevention though he was not trained in it.


And the state last month fined Sagepoint Nursing and Rehabilitation Center tens of thousands of dollars for what it called “widespread deficiencies” that put its staff and residents at risk. At least 37 coronavirus deaths are linked to the facility.

The lapses are detailed in forms the Maryland Department of Health has submitted to the federal Centers for Medicare and Medicaid Services, or CMS, since March 1, provided to The Baltimore Sun through a Public Information Act request.

The forms do not say whether the state ordered the nursing homes to pay fines, but a spokesman for the Maryland Department of Health said facilities with deficiencies have faced “substantial civil penalties."

The spokesman, Charlie Gischlar, said the state fined Sagepoint $380,000. He referred questions about any penalties assessed for the other three nursing homes to CMS, which he said conducted those surveys.

A CMS spokeswoman did not respond to questions and directed a Sun reporter to submit them on the agency’s website. Citing 26,000 COVID-19 deaths in nursing homes across the country, the agency this month announced it was increasing potential civil penalties for nursing homes with repeated infection control deficiencies, up to $5,000 per instance, or $10,000 if problems are found to be “widespread.”

State health officials also provided forms to The Sun showing they have fined two dozen nursing homes $250 for each day they failed to provide updates on COVID-19 cases and deaths. The facilities are required to submit reports daily to the Chesapeake Regional Information System for our Patients, a regional health information exchange database.

Allison Combs, a spokeswoman for the Village at Augsburg, confirmed that CMS completed a survey there May 4. The agency accepted the facility’s plan to correct its deficiencies May 28, and did not require a follow-up inspection, she said.

The surveyor’s report said multiple staff members interviewed expressed concern about a lack of information as they worked to protect residents and themselves, and found that in some cases, residents suspected of being infected were kept in rooms with those who were not otherwise believed to have been exposed to the virus.


“They didn’t tell us nothing. We don’t know who has the infection or COVID-19,” one was quoted as saying. "They just gave us gowns today when you came.”

Though a resident room had signage indicating isolation precautions were needed, an employee said he or she did not know what precautions were required. “I think I am only required to wear gown and gloves," the employee said.

The surveyor saw another employee going into a room of a resident who was not suspected of having COVID-19, but still wore a face shield, gown, gloves and two surgical masks, one on top of the other. Asked why she was wearing PPE, the employee said: “I need to protect myself because I don’t know who has the virus. This is the first time we got these gowns. People are coughing. They don’t tell me who has covid.”

Denise Falco, vice president of operations for Sunrise Senior Living, which owns Bedford Court, said administrators submitted a plan of correction with health officials that has been accepted.

“We have taken all corrective actions in regard to our infection control protocols and policies including isolation, signage and appropriate use of PPE. Importantly, at this time, we have no confirmed cases of COVID-19 in our community,” she said in a statement.

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At Bedford Court, a surveyor reported April 28 that an employee almost entered the room of a resident who was presumed to be infected without a face shield on, until the surveyor questioned the employee about it.


Adam Sanders, administrator of Althea Woodland, did not respond to requests for comment.

A surveyor’s report on that facility, dated April 30, said that an administrator said he was leading infection prevention efforts because a director of nursing and unit manager were “missing in action.”

The report also documented lapses in staff protective equipment, with one Althea Woodland employee wearing a disposable gown with a large hole in it. The surveyor said an employee was seen outside, talking on a cellphone near a dumpster, wearing a gown they had also been observed wearing inside the facility.

Sagepoint officials have said they “strongly disagree" with regulators’ findings and said they would dispute them with the Maryland Office of Health Care Quality. The state faulted the facility for failing to obtain lab results in a timely manner, use appropriate hand hygiene and protective equipment, and separate residents known or suspected to have tested positive for COVID-19 from others. Regulators issued fines of $10,000 per day.

As of Wednesday, Maryland officials said there were 9,531 COVID-19 cases at elder care facilities, including nursing homes and assisted living facilities, and that 1,347 people have died at facilities that are currently reporting “active” coronavirus outbreaks.

But, as The Sun reported Wednesday, those totals do not include the toll of COVID-19 at facilities that have not reported any new cases or deaths within the past two weeks. Cumulatively, there have been about 12,000 cases and more than 1,700 deaths linked to elder care facilities in the state, according to a Sun analysis of state data.