In early May, a health inspector paid a surprise visit to Annandale Healthcare Center to observe the nursing home’s infection control practices at work during the pandemic. The center was home to one of the largest coronavirus outbreaks in a nursing home in Virginia.

The inspector found the first issue even before stepping foot in the door.

Early that morning, there was no one at the front desk to oversee screening staff for COVID-19 symptoms — a process that includes taking and recording staff temperatures and asking basic screening questions. The desk remained unstaffed from roughly 6:30 a.m. to just before 8 a.m.

So some workers screened themselves with an infrared thermometer. The inspector observed a few people who skipped the line entirely, saying they needed to clock in and would come back later to be screened. Several wondered out loud where the supervisor was to oversee the arrival of the morning shift staff. One enterprising nursing aide tried to solve the bottleneck herself, and started screening people with the infrared thermometer — but she had trouble working the device.

Several other nurses and nursing aides also pitched in at various points to take temperatures, but there was no official designated staff member at the desk to perform the screenings. The night shift supervisor, according to a wound care nurse, may have been tied up setting an IV for a resident, and there was no one to take her place.

Those are some of many breaches in protocol documented by the inspector, whose findings were included in a Centers for Medicare and Medicaid survey report in May. Another report from July found similar issues of staff not obeying social distancing and hand washing rules, and a continuing bottleneck of people at the front desk. Both times, Annandale Healthcare Center failed to meet federal guidelines and did not pass inspection.

The two inspection reports are a window into the scope of the challenge facing nursing homes — whose staff, budgets and supplies have been stretched to the breaking point — in planning for every contingency during the pandemic.

What the inspection reports found

Like many nursing homes in the D.C. region, Annandale was already hit hard by the coronavirus by May: The 222-bed facility had just 127 current residents. Of those, 80 contracted the coronavirus, 25 were transferred to a hospital, and 24 people had died, according to the May inspection report.

The outbreak was detected in early April, when two residents tested positive for the virus, according to Fred Stratmann, a spokesperson for Annandale’s parent company Communicare. Stratmann said he had no way of knowing how the virus spread, but noted that as many as 30 to 50% of the COVID-19 positive residents in Communicare facilities have been asymptomatic.

“Despite all of the hygiene procedures and all of the other protective measures that we we have taken, there have been asymptomatic, COVID positive people in our buildings,” Stratmann said.

He also noted that Annandale has an in-house dialysis unit and serves a number of patients with serious renal disease, adding to their risk for a severe COVID-19 case.

Stratmann said Annandale began grouping COVID-19 patients into specific areas and set up negative-pressure rooms with double plastic walls.

But in May, when the inspector visited, the outbreak was not yet contained. More residents and staff would fall sick, and some would die. According to the Virginia Department of Health, Annandale accounts for 156 coronavirus cases and 55 deaths in total since March — the one of the most significant long-term care facility outbreaks in the state. Stratmann said an internal audit revealed the facility only had 141 cases in total and 28 deaths due to reporting errors.

In May, the inspector saw a used hospital gown disposed of in a stairwell near the unit with most of the COVID-19 positive patients; N95 masks improperly stored for reuse; and a housekeeper who did not switch gloves or wash hands between cleaning rooms.

Until COVID-19 negative residents were moved off of the unit where these issues were observed, “the concern remained whether the housekeeping staff would clean a negative room from a positive room without appropriately donning and doffing PPE,” the inspector wrote.

New issues popped up in July: While there was now a nurse assigned to screen staff as they arrived for the morning shift, workers still bunched up in the vestibule, despite signage and instructions from the nurse telling them to keep a safe social distance of at least six feet. More than two people got on the elevator at the same time, another breach of social distancing. A refrigerator repairman cut the screening line. A milk delivery man found his way into the facility through a back entrance without being screened at all.

Those details can add up to the difference between sickness and safety for staff and residents.

The situation at Annandale concerned U.S. Rep. Gerry Connolly (D-VA). He wrote a letter in July to the Virginia Department of Health and the Fairfax County Health Department, urging officials to continue their scrutiny of the facility. The letter, and reports from the Washington Post and NBC4, detail allegations from residents and their families, who say the facility’s communication over the course of the outbreak has been poor and further reinforce staff failures to wear PPE properly and take infection control measures.

“Recent allegations suggest that the facility may require further support and that there are patterns of misconduct and mismanagement that endanger the health of residents and employees,” Connolly wrote.

“These allegations, from before and during the pandemic have led to residents believing that the facility’s inadequate precautions have contributed to the facility’s high rate of COVID-19 cases and deaths,” he continued.

In the most recent pre-pandemic health inspection, in 2018, Annandale Healthcare Center received 17 health citations. But it has a 4 out of 5 star “above average” total rating in the CMS nursing home ratings database.

Stratmann acknowledges that the COVID-19 inspection reports found errors at Annandale, but he doesn’t believe they are systemic.

“I’m not going to kid you and say that the inspection reports that everything was perfect at Annandale,” he said. “An inspection report is a snapshot of what happens in time on the time that that inspector is there.”

After failing both inspections, Annandale submitted “corrective action plans” within a month. The plans are designed to address the issues identified in the reports.

The facility has reported no new confirmed cases of coronavirus to the Centers for Medicare and Medicaid since mid-July, and 69 residents and 52 staff have recovered from the disease. One staff member died. The Virginia Department of Health currently lists the outbreak at Annandale as “pending closure,” and Stratmann said it has started to accept new admissions from hospitals.

‘I can’t always catch everything,’ one nurse said 

There are consistent challenges common to both reports, like a number of staff not following proper infection control procedures.

In May, a nurse manager told the inspector that it was “a challenge to ensure the housekeepers understood when to change PPE.” In July, the nurse in charge of screening at the door repeatedly reminded staff in line to keep their distance from each other.

“The RN was observed perspiring as she stated, ‘I try to do the best I can to control and redirect staff, but I can’t always catch everything,’” the inspector wrote.

Communicare, Stratmann said, put in place staff education requirements on hand hygiene and infection control in early March. But he recognized that the reports found issues “that we had to brush up on with the staff.”

Mary Helen McSweeney-Feld, a professor of health sciences at Towson University and an expert on nursing home administration, reviewed the two inspection reports for WAMU/DCist. She questioned the efficacy of the training provided to staff.

“How good is your training program? That’s the first question that I would ask [Annandale’s administrators],” she said.

McSweeney-Feld notes that most of Annandale’s infection control challenges appear to be on the administrative side of things — anticipating and responding to issues with people flow and social distancing or staff education, for instance — as opposed to the direct clinical care given to patients.

Annandale, she said, deserves credit for creating and implementing corrective action plans to address the issues raised in the first report. But leadership didn’t then go the extra step to anticipate “the whole range of administrative issues with this temperature taking and screening process,” she noted.

“This is what many administrators are taught to do. You address what’s sitting in the report,” she said. “You don’t necessarily have to talk about all other possible scenarios.”

Imagining and accounting for the array of administrative concerns presented by the pandemic might be helped, McSweeney-Feld said, by training for nursing homes in COVID-19 infection control procedures by the Centers for Medicare and Medicaid. But that training doesn’t exist yet, and the resources that do mostly focus on clinical care, she said.

A community-based approach to coronavirus response

Early in the pandemic, nursing homes’ responses to the crisis were hindered by several factors: access to personal protective equipment, access to testing and staffing challenges. The human failures at Annandale Healthcare Center came against the backdrop of a healthcare system and supply chains struggling to meet the moment, and to understand exactly how the coronavirus spreads in the first place.

McSweeney-Feld said nursing homes are supposed to take “an all-hazards, community-based approach” to responding to an emergency like a COVID-19 outbreak, with extensive support from state and local health departments, federal agencies and even area hospitals.

A spokesman for the Fairfax Health Department would not comment on individual facilities, but said the department assigns a public health nurse to nursing homes with COVID-19 outbreaks for guidance and support. The department may also send teams in to the nursing home to “perform additional fit testing and training on the use of personal protective equipment” if needed, the spokesman wrote in an email. It’s not clear if such a team was deployed to Annandale.

Federal support for nursing homes has lagged. The government has allocated close to $10 billion to support the response to COVID-19 in such facilities, but almost half of that money hasn’t yet reached nursing homes.

In the May Annandale report, the inspector noticed a number of N95 masks were hung up for reuse, though they were not stored properly. The practice of reusing N95 masks is sanctioned by the Centers For Disease Control and Prevention when necessary, due to high usage rates and supply scarcity.

Stratmann told WAMU/DCist that Communicare spent more than $4 million on emergency PPE supplies for its 90 facilities across the country; a third of the funds went to facilities in Maryland and Virginia, including Annandale.

In July, Annandale accepted a donation of about sixty homemade cloth masks from St. Alban’s Episcopal Church, which has run Sunday services at the facility for decades, according to Rev. Theresa Lewallen. Lewallen said the congregation put the donation together after staff at the facility said cloth masks would be useful.

Testing is also a well-documented challenge. Stratmann said that while the Fairfax County Health Department provided the majority of the tests administered to residents at the beginning of the outbreak, Communicare also had to provide some on their own, though he didn’t provide a specific breakdown of how many tests came from where.

And once a large portion of Annandale’s staff started to get sick — more than 50 across the entire outbreak — the facility had to find and bring in new staff quickly from outside agencies, Stratmann said. The staff who stayed at work were under an enormous amount of pressure.

“I give them credit,” he said. “I mean, it’s not an easy thing to do to go into work every day knowing what you’re facing is the greatest pandemic of our time.”

Annandale Healthcare Center’s location is another factor outside of its immediate control. Fairfax County is one of the counties hit hardest by the coronavirus in Virginia. The locality of Annandale is a racially and socioeconomically diverse part of the county; about a third of the population is Latinx, a community that has borne the brunt of the outbreak in Northern Virginia.

That’s relevant, McSweeney-Feld said, because one of the strongest indicators of whether a nursing home will experience a COVID-19 outbreak is the incidence of the virus in its surrounding community — not its quality rating or infection control track record. Independent researchers at the University of Chicago, Brown University and Harvard University have all reached similar conclusions.

The outbreak — and the tragic loss of life — at Annandale Healthcare Center may be over for now. But the pandemic, especially in nursing homes, is far from over, McSweeney-Feld emphasizes.

“It hasn’t stopped. We’re still in crisis. We still have hard hit facilities. They still need testing and resources and support and help,” she said. “And, I might also add in there, our prayers for them as well.”