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8 of the 10 nursing homes with the deadliest COVID-19 outbreaks in Colorado were cited for cleanliness problems

Health inspectors also found problems in 91 nursing homes without an outbreak, according to a 9Wants to Know data analysis.

COLORADO, USA — Many of the nursing homes with the highest number of COVID-19 deaths in Colorado were cited multiple times for infection control infractions like not washing hands, cleaning equipment or wearing masks, a 9Wants to Know review of health inspection data shows. 

Randy Kuykendall, director of health facilities and emergency medical services for the Colorado Department of Public Health and Environment (CDPHE), said keeping consistent infection control practices is key to preventing an outbreak. By not washing your hands, you could accidentally be spreading the virus and never know it, he said.

“Individuals can carry the disease, spread the disease and have no symptoms themselves of the disease,” Kuykendall said. “And that is a silent enemy that we’ve had to learn how to deal with going forward in terms of day-to-day care.”

That “silent enemy” has killed at least 824 residents and staff members at Colorado nursing homes. That’s at least 43% of all deaths among COVID-19 cases in the state as of Aug. 26. 

According to a 9Wants to Know analysis of inspection data from CDPHE, inspectors cited eight of the ten deadliest nursing home outbreaks for cleanliness problems since the pandemic began. The data pulls from infection control surveys CDPHE conducted from March 1, 2020 to Aug. 7, 2020, and merged it with outbreak data released on Aug. 26. The first case of the coronavirus in Colorado was announced on March 5.

RELATED: Man visiting Colorado, woman in DougCo test positive for coronavirus

“COVID-19 is not creating the scandal...it’s revealing the scandal,” said Anna Holland Edwards, a Colorado attorney who works for a firm that has been taking nursing homes to court since the 1970s. “But [now] the stakes are so high because we have this disease process that tears through congregate living environments.” 

Facilities were cited for not washing hands correctly, not wearing the proper protective equipment and not cleaning tools. Kuykendall said inspectors went on 1,500 individual visits, sometimes more than once, to the 1,058 facilities in the agency’s purview. 

In addition to trying to directly protect Colorado’s “most vulnerable citizens” in nursing homes, he said the investigations protect the general population outside of the facilities. The people that live and work there also go to the nearby grocery stores and doctor offices. 

“They are part of your community,” Kuykendall said. “And so the community can certainly be a threat as the result of an outbreak in a nursing facility.” 

Cherry Creek Nursing Center

Cherry Creek Nursing Center in Aurora is the site of the deadliest COVID-19 outbreak in Colorado. According to the CDPHE outbreak data, at least 27 residents and one employee died there. The facility was cited three times since the pandemic began for failing to maintain proper infection control practices. 

Kuykendall said the state health department is investigating why Cherry Creek has the largest outbreak. 

 “I cannot comment on that,” he said. “These inspections take time.” 

Cherry Creek has a history of infection control problems. In 2019, a CDPHE citation said a nurse did not wash her hands properly while caring for a resident with tracheotomy problems and in between changing gloves. 

In April 2020, a spokesman for the owner of the facility said the problems were fixed

RELATED: Nursing homes with coronavirus outbreaks have citation, investigation history with state

“You are mentioning 2019 reports that were rectified with approval of state authorities well before COVID-19 was even recognized as a disease,” Spokesman Joe Gimenez said in an April 2020 email. He added the fixes were in place before the current outbreak.

But, Cherry Creek was cited three times in 2020 for a similar lack of handwashing: 

  • On April 24, a nurse “did not offer the resident a way to sanitize his hands, prior to eating.”

  • On May 15, a registered dietitian “did not offer hand hygiene” while serving food. A nurse “did not perform hand hygiene between going in and out of the resident's room.”

  • On June 9, staff members did not clean hands for the correct amount of time or offer hand hygiene while delivering food and drink. 

According to CDPHE’s health facility search database and a document provided by a spokesman for the Cherry Creek Nursing Center, the facility is now “in compliance” for “previous deficiencies.” Inspectors visited again on Sept. 1 to verify that the problems were fixed.

Gimenez, the representative for Cherry Creek Nursing Center, declined an opportunity to speak with 9Wants to Know on-camera. He provided an emailed statement:

“The daily, ongoing concern of our staff for residents requires extensive safety and sanitary measures,” Gimenez said. “Our staff manage those processes hundreds of times each day for the hundred-plus residents at the Cherry Creek Nursing Center. They will continue to do so. Any deficiencies found by officials are quickly corrected, as evidenced by both instances you mention, in 2019 and now 2020. Cherry Creek and its staff continue to work hard during this pandemic to provide quality care to our residents.”

Other facilities

Cherry Creek is not the only facility that has had problems during the pandemic, according to the content of citations reviewed by 9Wants to Know. 

For example:

  • At the Colorado State Veterans Home at Fitzsimons, staff members were cited for not washing hands properly and not wearing a mask correctly. At least 25 residents died with a confirmed case of COVID-19. At least 61 residents and 20 staff members have had a confirmed case of the virus. 

  • Pikes Peak Center was cited for failing to regularly check the temperature of residents. At least 26 residents have died from COVID-19. At least 91 residents and 48 staff members have had a confirmed case. 

  • The Mountain Vista Health Center did not provide hand sanitizer for the facility. At least 22 residents have died from COVID-19. At least 76 residents and 31 staff members have had a confirmed case. 

A total of 140 of the 275 infection control issues mentioned in new data obtained by 9Wants to Know happened in 79 nursing facilities with an outbreak. 

Click here if you can't see the map. Note: It is best viewed on desktop

Kuykendall said science fuels the exact regulations they have in place, especially around washing hands or using hand sanitizer. 

“Doing it for 5 to 10 seconds may not kill it at all….we know that risk continues to exist,” he said. “We have to be exact.” 

Health inspectors also found problems in 91 nursing homes without an outbreak, according to a 9Wants to Know data analysis. 

Edwards, the lawyer specializing in nursing home litigation, said these issues are important even when there’s not a pandemic happening. She said other diseases, like pneumonia, MRSA and other infections, can pass between nursing home residents.  

“There are many communicable infections in nursing homes and they rage through nursing homes because of the lack of sufficient infection protocols,” she said. 

According to the data, 53% of tags went to nursing homes without an outbreak.

Kuykendall said CDPHE is still working on figuring out why those 91 nursing homes have outbreaks while others do not. But, the first pattern the agency has identified is outbreaks tend to happen at facilities located in counties with a large number of new cases, not counties with a low rate of viral activity. 

“[The facility] may be in a community with a lower level of spread within the community,” he said. “We know our rural communities across Colorado had less numbers in terms of fewer cases out there, which certainly is a benefit to the facilities.”

That observation may have factored into the requirements around being able to visit a loved one inside a nursing home. A prerequisite for allowing indoor visitation in nursing homes includes having low community spread across two weeks or that potential visitors have evidence of a recent negative test if a county has 26 to 175 new cases per 100,000 people. Visitors are not allowed indoors at facilities with more than 175 new cases per 100,000 people over the past two weeks.  

RELATED: Here is the official state guidance for indoor visits at nursing homes

If you don't see the map above click here. This map is best viewed on a desktop. Search by address and click on the dot to view the details of the infection control tag at that location. Click "Show Related Records" to see more information on the tags at each location.

Peter Myers, a spokesman for CDPHE, said in a phone call on Wednesday that the agency has not announced any additional punishment for facilities outside of the citations. 

Myers said the harshest penalty CDPHE could impose would be closing a nursing home. He said that could happen at a nursing home “if a facility was so poor at infection control practices that they couldn’t get them fixed...” 

The majority of the time the agency issues a citation, helps make and institute a plan to fix the problem, and then follows-up with another inspection to see if the problem is still happening.

Anna Hewson, 9Wants to Know photojournalist, edited the broadcast portion of this story. The web portion was edited by 9Wants to Know team members Nicole Vap and Kevin Vaughan. 

DOCUMENT BELOW: Facilities with outbreaks and tags

DOCUMENT BELOW: Facilities with tags

Below is the full statement from Joe Gimenez, a spokesperson for Nexion Health. Nexion owns the Cherry Creek Nursing Center:

- Cherry Creek’s efforts to try and mitigate the virus

Today there are no Covid+ patients at Cherry Creek.

 Since the outbreak began in March the Center has collaborated closely with the Tri-County Health Department to protect residents and staff by minimizing social contact, encouraging social distancing, ending communal dining and group activities and promoting handwashing.

 Increased availability of testing in the last few months has enabled more complete cohorting measures, to group and treat Covid+ patients. 120 in-house residents are Covid-negative after recent testing.

- A response to the three tags for infection control violations (the three since March)

We have submitted a plan of correction of citations in response to the most recent state survey.  Our plan is under review by the health department. 

 We believe we have taken appropriate corrective measures and have been in substantial compliance with the federal and state requirements since August 20.

- Cherry Creek’s response as to why this location has the most COVID-19 deaths

Cherry Creek is one of the largest facilities in Colorado.

 Shortages of personal protective equipment in March, April and May impacted us greatly. Other long term care facilities were similarly affected.

 The lack of access to Covid-19 tests in those months hindered effective grouping of Covid positive and negative residents and staff.

 Doctors and the medical community did not know the best treatment protocols in the early months of the pandemic. They’ve learned and treatments are better today.

- Cherry Creek’s message to families who still have loved-ones in the facility        

Cherry Creek Nursing Center works hard to provide individualized care plans for all of its residents and to supervise the care of all residents.

 We have established programs with our staff and the Center’s community to help us keep residents spirits up. We are dedicated to fostering an atmosphere of hope and engagement at Cherry Creek.

- Cherry Creek’s message to families who lost family to COVID-19

 We extend our most heartfelt condolences to all the families who lost loved ones due to Covid-19.

 Residents and our staff become one big family over time and we similarly wish to extend our condolences to our staff as well for the loss of our cherished residents. 

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