Before coronavirus, 2 out of 3 Mass. nursing homes broke the rules for preventing outbreaks

Violations ranged from staff not following basic hygiene measures to failing to track and monitor infection.

The National Guard arrived at the Life Care Center of Nashoba Valley in Littleton on April 3 to help perform COVID-19 tests on patients.John Tlumacki/Globe Staff

When the coronavirus began creeping into the state, posing a particular menace to older residents, many nursing homes already were struggling to comply with federal standards designed to prevent the spread of infections.

Nearly two-thirds of nursing homes in Massachusetts were cited at least once within the past three years for a deficiency in infection control, violations that ranged from staff not following basic hygiene measures to failing to track and monitor outbreaks, according to records from the US Centers for Medicare & Medicaid Services.

Even weeks into the coronavirus outbreak, nursing homes across the nation have been failing to follow rudimentary infection-control rules in startling numbers.

Federal inspectors visited numerous facilities in late March and reported staff weren’t properly washing their hands at more than one-third of facilities they visited; officials didn’t release state-level findings. Personal protective equipment wasn’t properly used at a quarter of the locations, even though both are longstanding federal requirements, officials said.

“And that was right in front of the inspectors. So you know what it must be like when there are no inspectors around,” said Charlene Harrington, professor emerita at the University of California, San Francisco, who has closely studied nursing home quality for decades.

Experts say the track record of infection-control deficiencies, coupled with the abrupt arrival of a new, fast-spreading virus that is particularly troublesome for older populations, has left many nursing homes outmatched.

As of Wednesday, there were 1,236 confirmed cases of coronavirus among residents and staff at 140 long-term care facilities in Massachusetts, according to state health officials. The figures are believed to vastly undercount the actual number of cases because testing remains widely unavailable.

The violation data for Massachusetts nursing homes, from the US Centers for Medicare & Medicaid Services, largely tracks with national statistics that show more than 70 percent of nursing homes were cited at least once within the past three years for a deficiency in infection control.

Such deficiencies are the most common type levied against such facilities in the United States. Many nursing homes have been repeat offenders.

In their defense, industry leaders say many of the deficiencies cited are isolated cases and don’t necessarily point to carelessness or neglect at skilled nursing homes.

“I’m not saying there aren’t facilities that have infection-control issues,” said Helen Magliozzi, director of regulatory affairs for the Massachusetts Senior Care Association, a Waltham-based trade group for nursing homes. But, she said, “the numbers are misleading” because the individual incidents cited in most cases don’t amount to a pattern of negligence.

Magliozzi said that many of the deficiencies flagged by regulators were corrected quickly, and that data shouldn’t be interpreted to suggest facilities weren’t prepared for an outbreak.

She said nursing homes take infection-control procedures seriously, but “this virus has proved to go beyond what any [infection-control standards] could have anticipated.”

Industry leaders say the challenge in fighting the pandemic has less to do with infection protocols than the lack of testing that would let them know who has the virus, inadequate supplies of protective gear, and a workforce shortage aggravated by employee illness and school closings.

The Massachusetts Department of Public Health said that when its inspectors find problems, nursing homes are required to provide a written plan on how and when each deficiency will be fixed. The department said it takes other measures to ensure that nursing homes are meeting standards, including providing training around infection prevention and control.

In a statement, CMS said it had been “laser-focused on improving the quality and safety of nursing homes well before COVID-19 became an unprecedented challenge,” including providing training and reminders about infection control.

Nursing homes, which house some 1.3 million residents nationwide including more than 37,000 in Massachusetts, regularly battle spreads of a range of viral and bacterial infections, including the flu, norovirus, C.diff, and MRSA.

The US Centers for Disease Control and Prevention estimated, before the coronavirus pandemic, that each year there are between 1 million and 3 million serious infections inside long-term care facilities leading to as many as 380,000 deaths annually. But this pandemic is something else.

Nursing homes have become an accelerator for the virus because residents, who are generally vulnerable to complications from it are even more so in an enclosed environment, according to the CMS.

Nursing homes are typically inspected by federal and state surveyors once every 12 months as well as in response to complaints.

Over the past three years, 234 of 377 nursing homes in Massachusetts were cited at least once for failing to meet infection-control standards, according to federal inspection data. (The records are for nursing homes and do not account for other types of long-term care facilities that undergo different inspection processes.)

Even facilities with a top federal government rating, five out of five stars, have been cited for such a violation.

The Life Care Center in Kirkland, Wash., the nursing home with the first major COVID-19 outbreak that has been linked to dozens of deaths, is a five-star-rated facility. Prior to the outbreak, it had been cited for infection control during its most recent annual inspection last April. Limitations in infection control have been cited as a factor in the recent outbreak.

Federal records show most infection-control deficiencies in recent years were labeled as “isolated” and put in the second-lowest of four possible categories measuring severity. The category describes the deficiency as causing “minimal” harm or discomfort with the potential to result in “more than minimal harm that is not immediate jeopardy.” Others were considered to be a “pattern,” if not “widespread.”

Harrington, the UC San Francisco professor emerita, said the figures downplay how common and serious such problems are. She said inspectors tend to go easy on nursing homes.

“It’s a huge undercount," she said. “These places get so many deficiencies and they’re so bad that I think the inspectors sometimes feel sorry for the homes.”

Specialists said understaffing, insufficient training, high turnover, and poor oversight were key drivers of the violations. Low pay and benefits can leave workers hesitant to use the limited, if any, sick time they have.

“It’s one of those areas where it’s super easy to cut that corner — to not wash your hands between people or to not follow the exact proper procedure because you’re rushing and people are waiting for you,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care.

The facilities themselves also pose a challenge, experts said. The building is a home, and not a sterile medical facility. There are shared spaces where residents congregate. There’s not always space to practice social distancing or to separate infected residents.

Amid the coronavirus pandemic, CMS has told inspectors they should shift their focus to monitoring for compliance with infection control.

But with nursing homes now turning away visitors, Alison Weingartner, executive director of the Massachusetts Advocates for Nursing Home Reform, said she worried about a lack of accountability.

“There’s less eyes on them,” she said. “Now that family members can’t get in, that’s exacerbated the problem and the ombudsmen can’t get in, either — so who is watching them?”

Among the Massachusetts nursing homes grappling with coronavirus outbreaks, at least a half-dozen were cited last year for an infection-control deficiency. (There may be others; state officials have declined to name facilities where COVID-19 cases have been found.)

Among them was Life Care Center of Nashoba Valley in Littleton, which was cited during an inspection in August. The deficiency was considered “isolated” and was rated in the second-lowest of four possible categories of severity.

Inspectors, for instance, found that staff at the facility failed to maintain sanitary storage of nebulizer masks — used to help some residents breathe. A cook was cited for handling food with a contaminated glove after touching surfaces in the kitchen. And dust and grime were found in the laundry area, along with a “black and brown unidentified substance” in the sink.

Tim Killian, spokesman for Life Care Centers of America, the Tennessee chain that operates the Littleton facility, said those deficiencies were “fixed pretty quickly.” He described the inspections as “fairly routine procedures” that can sometimes be subjective amid changing criteria. “We try to be up to date,” he said.

The company said Tuesday that five residents have died of COVID-19 in Littleton, while 65 have tested positive and 14 are hospitalized.