Forty percent of more than 650 nursing homes nationwide with publicly reported cases of the coronavirus have been cited more than once by inspectors in recent years for violating federal standards meant to control the spread of infections, according to a Washington Post analysis.

Since 2016, the nursing homes accrued hundreds of deficiencies for unsafe conditions that can trigger the spread of flu, pneumonia, urinary tract infections and skin diseases. Dozens were flagged by inspectors only months before the coronavirus pandemic struck the United States.

Among the facilities with infection-control infractions: the Pleasant View Nursing Home in Mount Airy, Md., where 24 people had died as of Thursday; the Canterbury Rehabilitation & Healthcare Center near Richmond, with 49 deaths as of Thursday; and the Brighton Rehabilitation and Wellness Center in southwestern Pennsylvania, where officials have warned that all 750 residents and staff members could be infected.

Nursing homes with publicly reported cases of covid-19 State health departments and media reports have identified more than 650 nursing homes with reported cases of the new coronavirus. Since 2016, about 40 percent had been cited more than once for infection-control deficiencies. More than 1 infection- control infractions 0-1 infection- control infractions Note: Death tolls indicate that there are far more nursing homes with outbreaks whose names have not been released by states or the federal government. Source: Post analysis of data from the Centers for Medicare and Medicaid Services, state and county health departments and media reports. Nursing homes with publicly reported cases of covid-19 State health departments and media reports have identified more than 650 nursing homes with reported cases of the new coronavirus. Since 2016, about 40 percent had been cited more than once for infection-control deficiencies. More than 1 infection- control infractions 0-1 infection- control infractions Note: Death tolls indicate that there are far more nursing homes with outbreaks whose names have not been released by states or the federal government. Source: Post analysis of data from the Centers for Medicare and Medicaid Services, state and county health departments and media reports. Nursing homes with publicly reported cases of covid-19 State health departments and media reports have identified more than 650 nursing homes with reported cases of the new coronavirus. Since 2016, about 40 percent had been cited more than once for infection-control deficiencies. More than 1 infection-control infractions 0-1 infection-control infractions WASH. MAINE N.D. VT. MONT. MINN. ORE. N.H. N.Y. IDAHO MASS. S.D. MICH. WIS. WYO. R.I. CT. IOWA PA. NEB. NEV. N.J. OHIO IND. ILL. DEL. MD. UTAH W. VA. COLO. CALIF. VA. KAN. MO. KY. N.C. ARIZ. OKLA. TENN. S.C. N.M. ARK. MISS. GA. ALA. LA. TEXAS FLA. ALASKA HAWAII Note: Death tolls indicate that there are far more nursing homes with outbreaks whose names have not been released by states or the federal government. Source: Post analysis of data from the Centers for Medicare and Medicaid Services, state and county health departments and media reports. Nursing homes with publicly reported cases of covid-19 State health departments and media reports have identified more than 650 nursing homes with reported cases of the new coronavirus. Since 2016, about 40 percent had been cited more than once for infection-control deficiencies. More than 1 infection-control infractions 0-1 infection-control infractions WASH. MAINE MONT. N.D. MINN. VT. ORE. N.H. MASS. S.D. MICH. IDAHO N.Y. WIS. WYO. R.I. CT. IOWA PA. N.J. NEB. NEV. OHIO IND. ILL. DEL. W. VA. MD. UTAH CALIF. COLO. VA. KAN. MO. KY. N.C. TENN. ARIZ. S.C. OKLA. N.M. ARK. ALA. MISS. GA. LA. TEXAS ALASKA FLA. HAWAII Note: Death tolls indicate that there are far more nursing homes with outbreaks whose names have not been released by states or the federal government. Source: Post analysis of data from the Centers for Medicare and Medicaid Services, state and county health departments and media reports.

It is difficult to say whether past violations contributed to current outbreaks or whether any level of preparation would have been enough to protect against a previously unidentified pathogen, but nursing home watchdog groups say the breakdowns have endangered older, vulnerable residents already more at risk of dying from the highly contagious virus.

“Nursing home residents had targets on their backs the moment the virus hit our shores,” said Mike Dark, an attorney with the nonprofit California Advocates for Nursing Home Reform. “There is an inertia about infection control and it’s too late to catch up.”

[Read the list of nursing homes with publicly identified cases of coronavirus]

Thousands of coronavirus-related deaths have been linked to nursing homes; the state of New York alone earlier this week reported more than 2,400. At a nursing home in northern New Jersey, police found more than a dozen bodies in what was described as a “makeshift morgue.”

The federal government and many states have not released the names of affected facilities.

Through state and county health departments and media reports, The Post was able to identify 662 Medicare-certified nursing homes that have had publicly reported cases of the virus and analyze their track records.

The homes with a history of infection-control deficiencies span 35 states, with dozens in California, the state of Washington and Connecticut, according to inspection data from the Centers for Medicare and Medicaid Services (CMS), the federal agency that regulates nursing homes.

The hardest-hit state, New York, on Friday released only a partial list of nursing homes that have been affected by the coronavirus. Without a full list, The Post has been able to identify only a dozen nursing homes in New York with repeated infection deficiencies.

The hundreds of citations touch on all areas of infection control, inspection records show. Some facilities failed to track residents with symptoms of infections. Others did not ensure that staff members changed soiled gloves, washed their hands or wore personal protective equipment. In some cases, providers used dirty or unsanitized equipment.

One man in his 90s has died and 66 residents of Pleasant View Nursing Home have tested positive for the coronavirus in Mount Airy, Md. (Katherine Frey/The Washington Post)

At Pleasant View, staff failed to put dates on oxygen equipment that requires regular changing or store personal urinals in a sanitary manner in a bathroom shared by eight residents, records show. At Brighton, according to inspectors, officials failed to ensure that caregivers properly cleaned wounds, washed their hands or wore personal protective equipment. One aide left a wet sheet under a resident whose catheter was leaking.

When the coronavirus struck the nursing home, Keri Boyer said she braced for bad news.

“Once we got the phone call that there was a positive case, I told my husband, ‘My dad’s going to get it. I have no doubt in my mind,’ ” said Boyer, whose 73-year-old father, a Pittsburgh Steelers fan who retired from his job at a cement plant, was one of at least five Brighton residents who died from the virus.

“They had four people in a room,” Boyer said. “That’s how my dad lived, with three other men in a room that was as big as a hospital room, separated by curtains. I sometimes feel like they were the dispensable ones.”

An official at Pleasant View said the nursing home declined to comment, and Brighton administrators did not respond to emails. An official with Canterbury said ownership of the facility changed in January.

“In the months prior to the covid-19 pandemic, there were significant improvements in virtually every aspect of operations … and there were also significant changes in facility leadership,” Canterbury administrator Jeremiah Davis said in a statement. “There has been material focus on placing the right people in the right positions, and a significant influx of new protocols prior to the outbreak.”

[Do you work at a nursing home, or have a loved one at a long-term care facility? Share your experience with The Post.]

Industry leaders say even the strongest infection-control measures could not have prepared nursing homes for the onslaught of coronavirus and that facilities with limited personal protective equipment are doing what they can to protect and treat residents.

“Outbreaks are not the result of inattentiveness or a shortcoming in nursing homes,” David Gifford, chief medical officer at the American Health Care Association and the National Center for Assisted Living, said in a statement. “It’s the combination of the behavior of this virus and the unique threat it presents to the people we care for — older adults with multiple underlying health conditions.”

With fragile populations, shortages of personal protective equipment and staff members forced to juggle front-line work with the needs of their own families, nursing home residents were “essentially sitting ducks,” said Karl Steinberg, a San Diego-based geriatrician and palliative care specialist and president-elect of AMDA-the Society for Post-Acute and Long-Term Care Medicine.

Baltimore firefighters load a patient they picked up from the FutureCare-Lochearn facility, where 129 residents and 41 staff members tested positive for the novel coronavirus. (Jonathan Newton/The Washington Post)

“A lot of facilities could do better,” he said. “But this virus is different. It’s insidious. We don’t know who has it. We don’t know who doesn’t have it. It could live in the air. It could live on surfaces. It’s highly improbable that . . . the best in planning would have prevented this.”

Nursing home watchdog groups, however, say warnings went unheeded for years, even after the Obama administration in 2016 moved to strengthen infection-control practices in nursing homes.

In the past four years, infection-control problems were the most common deficiencies identified at 15,000 nursing homes nationwide, federal records show.

Three-quarters of nursing homes were cited at least once for infection-related infractions since 2016. Four in 10 were repeat offenders, flagged at least twice.

In Florida last year, a nurse failed to disinfect a blood-glucose meter in a facility with 23 diabetic patients; an inspector found one of the devices sitting on a cart, soiled with what appeared to be blood, federal inspection reports show. In California last year, administrators failed to screen dozens of staff members, including 15 licensed nurses and 13 nursing assistants, for tuberculosis and flu vaccinations. In Wisconsin in 2017, a quarantine was lifted and residents allowed to mingle even though a gastrointestinal outbreak had sickened dozens of people.

Even as the coronavirus swept hundreds of nursing homes, inspectors continued to cite breakdowns.

The Centers for Medicare & Medicaid Services last month postponed routine inspections to focus solely on infection control. In a first round of inspections during the week of March 30, officials found that one in three nursing homes did not follow proper hand-washing guidelines and one in four failed to demonstrate the proper use of personal protective equipment.

As of April 10, the agency had inspected 96 facilities, finding 12 that did not follow proper hand-washing guidelines and 18 did not properly use personal protective equipment.

As the death toll continues to mount, nursing homes are struggling to account for what happened.

“Believe me, facilities are scrambling to have these [infection-control] processes as air tight as they can,” said Steinberg, the California doctor. “They really didn’t know what was going on until it was too late.”

Flowers and ribbons adorn trees along the road outside Life Care Center of Kirkland, the center of the coronavirus outbreak in Washington state. A man visits a family member at Life Care Center of Kirkland in Washington state. Judy Layton and her son, Ron, pray for the victims at the Life Care Center of Kirkland in March.

TOP: Flowers and ribbons adorn trees along the road outside Life Care Center of Kirkland, the center of the coronavirus outbreak in Washington state. BOTTOM LEFT: A man visits a family member at Life Care Center of Kirkland in Washington state. BOTTOM RIGHT: Judy Layton and her son, Ron, pray for the victims at the Life Care Center of Kirkland in March.

'There’s no teeth’

The federal government started taking a hard look at infection control four years ago when the Obama administration pushed to require facilities to bring on specialists focused on preventing the spread of illness. More than 3,000 people were trained by the American Health Care Association, which represents thousands of skilled-nursing centers, assisted-living communities and other facilities.

The new regulation, however, did not become effective until this past November, only weeks before the coronavirus started spreading in China.

And even before the requirements took effect, the federal government had put in motion plans to change the rule, striking the mandate for at least a part-time infection specialist and instead relying on nursing homes to ensure that specialists had “sufficient time” at facilities. The proposed changes, criticized by patient-watchdog groups, are still pending.

CMS Administrator Seema Verma told the New York Times last month that the changes, meant to give nursing homes more freedom from federal rules, could mean that providers focus even more on infection control.

With nursing homes now at the center of the pandemic, CMS has renewed calls to nursing homes to comply with federal rules for infection control.

Inspectors have documented the problems for years, but the agency classifies nearly all infection-control deficiencies as a low-level concern, which means they do not trigger penalties or fines. Dark, with the California watchdog group, calls them “paper violations.”

Of more than 20,000 infection-control infractions since 2016, only 151 were classified as higher-level violations that caused significant harm or immediate jeopardy to residents.

In mid-March, federal inspectors went to the Life Care Center of Kirkland, the Washington state nursing home linked to more than 40 deaths and more than 100 cases of coronavirus infection. They found the facility had failed to properly identify and manage sick patients or alert authorities to an outbreak of respiratory illness.

State inspectors also investigated, finding the lack of care had resulted in hospitalizations and resident deaths and that an ineffective infection-control system resulted in a “widespread and unmanaged respiratory outbreak.”

CMS threatened to cut off Medicare and Medicaid funding if the deficiencies are not corrected by September. The agency also fined the facility more than $600,000, though the amount could change if Life Care complies with a correction plan. The state banned Life Care from accepting new admissions until fixes are made, including training staff in infectious disease management.

Candace Goehring, Washington state director of residential care services, said state agencies now know more about controlling and responding to outbreaks. “I’m sure we will all be going back … to understand how do we better prepare,” she said.

A year ago at Life Care, records show, inspectors found respiratory equipment mixed in with bed covers and socks, kitchen staff who handled clean dishes with soiled gloves and a staff member who failed to wear personal protective equipment while caring for a resident with a suspected respiratory infection.

In a laundry room, inspectors noted that clean linens were at risk of being contaminated by air blowing in from a dirty utility room with a broken exhaust fan. Two outbreaks of the flu had affected at least 17 residents and seven staff members.

The infection-control citation that followed was classified as low-level. Life Care corrected the deficiencies, state records show, and went on to receive an overall rating of five stars, the highest rating from CMS.

“There’s no teeth,” Toby Edelman, senior policy attorney with the nonprofit Center for Medicare Advocacy, said of the infractions. “[CMS] could . . . actually do something about it — take action. They could treat these problems as the serious problems they are.”

Cami Neidigh photographs her mother, Geneva Wood, 90, as she arrives home after recovering from coronavirus. Wood is a former resident of the Life Care Center in Kirkland. (David Ryder/Reuters)

Tim Killian, a public information liaison for Life Care Centers of America, said the nursing home has followed all guidance from the state and federal government. The facility regularly makes adjustments to improve patient care based on feedback from CMS, he said.

No amount of preparation, he said, could have prepared the facility for a virus that started spreading from patient to patient before staff even knew it was there.

“This is an unprecedented viral outbreak,” Killian said. “It is outside the scope of anything that we had seen, anything that federal agencies had seen, anything that our . . . public health departments had seen, and no agencies had given us specific guidelines or provided … additional resources to us to prepare our facility.”

Cami Neidigh said she is just grateful to have her 90-year-old mother home.

After developing a fever at Life Care, the great-great-grandmother was sent to an isolation room in a Seattle hospital, diagnosed with covid-19, the disease caused by the coronavirus. Neidigh and the rest of the family, draped in protective gear, were called in to say goodbye.

Seeing family likely helped, Neidigh said. Within 24 hours, her mother rallied and soon insisted on a bowl of potato soup, served for years in the family as an antidote to the common cold.

“When she … was taken out of that facility, it saved her life. It gave her a fighting chance,” said Neidigh, whose mother is now recovered and once again living in her own apartment.

Billie Namath, 83, looks out of the window of her daughter’s home where she is now living in Monaca, Pa. Namath’s daughter, Connie Sluzynsky, removed her from the Brighton Rehabilitation and Wellness Center in Beaver, Pa. (Justin Merriman/For The Washington Post)

Deaths mount in Tennessee, Pennsylvania homes

Northeast of Nashville, the Gallatin Center for Rehabilitation and Healing has also struggled with infection control, federal records show. In recent years, inspectors found that staff did not follow hand-washing procedures, properly dispose of wound care materials or appropriately handle soiled linens.

More than 100 residents and staff at the center have been infected with the coronavirus, according to local media reports. Late last month, the facility was temporarily shut down and sanitized.

Officials at the nursing home provided a written timeline to The Post noting that the facility in February and March conducted additional training on hand-washing techniques and infection control, restricted visitors and screened staff for fevers. At an inspection earlier this month, inspectors did not find deficiencies related to covid-19, records show.

A state health department representative declined to discuss conditions at the facility. At a news conference, Tennessee Department of Health Commissioner Lisa Piercey called the nursing home “an excellent partner.”

More than 10 people linked to the Gallatin center have died from the virus, including 80-year-old Homer Barr, a father of four and retired fire captain.

“I let my dad down and I can’t go back,” said Barr’s daughter, Deneen. “I pray to God that he didn’t have to suffer.”

In Beaver County outside of Pittsburgh, the Brighton Rehabilitation and Wellness Center was cited multiple times in recent years for infection-control lapses. In January 2019, inspectors also reported that Brighton had no heat, with indoor temperatures as low as 58 degrees. One resident reported that she used her oxygen mask to breathe beneath six blankets, records show.

Tamera Witherspoon, a licensed practical nurse at Brighton Rehabilitation and Wellness Center, stopped reporting to work because, she says, she was not provided adequate medical equipment. (Justin Merriman/For The Washington Post)

Tamera Witherspoon, a 41-year-old licensed practical nurse who logged 50-hour weeks at the center, said staffing shortages were also a problem. During some shifts, she said, there were dozens of patients who needed tending. She barely had time to wash her hands, she said.

In March, the virus swept the nursing home. During an early-morning shift, Witherspoon, a mother of three who earns $26 an hour, said she did not have enough medical equipment or an N95 mask, which experts say provides the highest level of protection.

She said she told her supervisors that she would not be returning until she got a mask. Witherspoon decided to self-quarantine, and after she spoke out publicly, she received a donation of eight masks from a local business owner. She gave one to a neighbor in a wheelchair and one to another nurse at the facility. She said she is still waiting for an apology from Brighton.

“I’m sitting at home, not compensated,” she said. “I’m just in a limbo.”

Nate Wardle, spokesman for the Pennsylvania Department of Health, said Brighton was on a provisional license, with inspections twice a year because of prior health deficiencies. Wardle said health officials have so far found no breakdowns in the days leading up to the outbreak.

Wardle said health officials have been in touch with Brighton and have so far found no breakdowns in the days leading up to the outbreak.

“We are not aware of anything that has been done that would be of serious concern to the department,” he said. “But of course we’re not in the facility every day observing everything that’s going on.”

Connie Sluzynsky removed her 83-year-old mother from Brighton Rehabilitation and Wellness Center in Beaver, Pa., after she learned hundreds of residents and staff were said to be infected with coronavirus. (Justin Merriman/For The Washington Post)

“We are not aware of anything that has been done that would be of serious concern to the department,” he said. “But of course we’re not in the facility every day observing everything that’s going on.”

Connie Sluzynsky said her 83-year-old mother was one of the lucky ones.

The retired courthouse clerk and great-grandmother was living at Brighton when officials locked down the facility to stop the spread of infection. Sluzynsky said she spent days calling for updates and finally reached a nurse.

“She said, ‘I will tell you with 100 percent certainty that everybody here is going to get that virus,’” Sluzynsky recalled.

On March 30, Sluzynsky pulled her mother out of the nursing home. A week later, with multiple deaths and dozens of cases, Brighton officials announced they would stop reporting a count of new cases because it was possible that all residents and staff had contracted the virus.

At home after two weeks in self-quarantine, in a bedroom with family photos and a television tuned to “Dr. Phil,” Sluzynsky’s mother has shown no signs of infection.

“When I see how people are taken care of there . . . and when I look at my mom, I think, ‘Is this what your life has come to? Is this it?’” Sluzynsky said. “I just didn’t want to see my mother’s life come to this.”

Jacobs and Mulcahy are graduate students in journalism at Northwestern University’s Medill Investigative Lab. Post database editor Dan Keating and researcher Alice Crites contributed to this report, along with Sidnee King, Arnab Mondal, Areeba Shah, Alexa Mikhail and Dan Rosenzweig-Ziff at the Medill Investigative Lab.