The first, most deadly cluster of new coronavirus cases in the United States started at a nursing home in Washington state.

Last year, before COVID-19 was a concern, authorities saw a vulnerability at Life Care Center of Kirkland, which is now linked to at least 35 deaths from the virus. The nursing home was cited for failing to follow federal standards to best prevent the spread of infectious diseases.

About half of Arizona nursing homes have been similarly cited for infection control violations during their last three published inspections, according to an Arizona Republic analysis of Medicare data compiled from reports by state inspectors. That's 74 homes with about 8,400 beds, collectively.

Most of those inspections were within the last three years.

Violations occurred even when staff knew inspectors were present and watching.

Some caretakers' missteps involved medical technology, like reusing equipment without disinfecting it between patients. Other violations were as simple as not washing hands properly.

But even seemingly mundane oversights, experts say, point to why coronavirus can become so lethal in nursing homes. Their residents are at greatest risk of death or severe illness from COVID-19, which is caused by the new coronavirus, because many are elderly and have underlying medical conditions. And the highly contagious virus presents an unprecedented challenge to nursing home staff, many of whom are already stretched thin in facilities that have a checkered history complying with infection controls.

The Arizona Department of Health Services said as of Tuesday, there have not been any reported cases of COVID-19 in Arizona nursing homes. On Friday, the Maricopa County Department of Public Health said the county has a "couple of cases" of COVID-19 in nursing homes and long-term care facilities. They declined to name the facilities for privacy reasons.

But some nursing homes are likely to see half of their residents stricken with the new virus, said Tony Chicotel, staff attorney at California Advocates for Nursing Home Reform, a patient advocacy group. He especially worries about homes with track records of lax infection control.

"Can they turn it around overnight? I worry that at some facilities they can’t," he said. "When one gets sick, God help the rest of the residents."

At three homes, residents 'in immediate jeopardy'

In Arizona, 74 facilities had at least one infection violation in recent years.

Violations weren't limited to any particular type of facility, and included homes run by nonprofits, for-profit corporations and government agencies.

Errors at three homes put residents in immediate jeopardy, the most serious violation, according to inspection reports.

Last year, a resident at the Sun City Health and Rehabilitation Center should have been isolated while waiting for lab results to confirm a suspected infection. But therapy staff entered the resident's room without personal protective equipment and allowed the resident to use the therapy gym.

The home had to monitor other residents for 48 hours for symptoms after that.

Only two other nursing homes made errors that rose to that level in the last few years: Estrella Center in Avondale and Lake Pleasant Post Acute Rehabilitation Center in Peoria.

The Estrella Center had a sick resident sharing a room with another resident with a weakened immune system. In addition, a nursing assistant left that room without removing gloves and came back without a gown or gloves as required.

Since then, both the Avondale and Sun City homes had additional staff training and submitted a plan of correction to the state, said Lori Mayer, spokesperson for the Sun City Health and Rehabilitation Center and the Estrella Center.

She said the homes' management teams, clinical leadership and chief medical officers have met regularly about the possibility of the coronavirus affecting the home. The team has "enhanced employee and patient screenings and precautions" and are restricting visitors, offering video conference calls instead.

At the Lake Pleasant nursing home, a visitor entered a resident's room without protective gear and carried a briefcase out of the room, though the resident was under “contact precautions” for an infection.

Scott Osterneck, executive director of the facility, pointed out that the incident happened almost two years ago. He said the state approved the home's plan of correction and placed it back in compliance. Since then, the home hasn't hasn't had any infection control or prevention issues.

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Most of the infection control deficiencies in Arizona were classified as inspectors as not causing harm but with potential for more than minimal harm.

Among those violations: A nursing assistant in Mesa who used a glucometer, which tests blood sugar levels, on residents without disinfecting the device in between.

A nursing assistant in Yuma refilled a resident’s cup with ice and water, allowing the scoop and the dispenser to touch the brim of the resident's mug. The resident was in isolation for scabies.

And other instances in which staff didn't properly wash their hands while caring for residents, let residents' catheter tubes drag on the floor or lacked paperwork showing they were free of tuberculosis, a requirement for all health-care workers.

Inspectors also cited nursing homes for failing to establish programs to prevent Legionella from spreading through their water systems. Legionella is a bacteria that can cause a type of pneumonia called Legionnaires' disease.

Those homes weren’t penalized when inspectors found water program deficiencies. But most of the homes with infection-control issues were not penalized.

Majority of homes not penalized

Of the 74 nursing homes that were cited for infection control deficiencies, only seven received penalties on the date of that inspection. It is unclear whether infection control errors had anything to do with the penalty.

Eight others received penalties from inspections in which they were cited for problems other than infection control.

That leaves 59 nursing homes that did not get penalties during their last three published inspection cycles even though they failed basic infection control measures, many while being watched by inspectors.

"We have seen troubling infection control problems for years, maybe decades, that just kind of went unchecked, downplayed, pooh-poohed, disregarded," said Brian Lee, executive director of Families for Better Care, a nursing home watchdog group. "It never manifested better practice, better preparation, better prevention. And now we’re living out the nightmare from the lack of preparation."

About once a year, inspectors do comprehensive surveys at nursing homes that participate in the Medicaid or Medicare programs. They may make separate visits if there are complaints. Inspections are unannounced. But Lee said nursing home administrators can usually anticipate their arrival because they tend to occur on a regular cycle and homes are likely to hear from other nearby homes when the inspectors are making their rounds, he said.

Lee said his organization hears from families that they can usually tell when inspectors are soon to visit because the food gets better and more staff are available.

"They're prepped. They're rolling out the informal red carpet. They're making sure everyone on staff knows the surveyors are there," Lee said. "They're on their A game and yet they still have these findings. And it's the residents who suffer."

He suspects that infection control mishaps are far more widespread than the citations show. It's just that not everyone gets caught, he said.

And when they do get caught, he said: "If you're not washing your hands you're probably not going to get penalized. That's the problem. A lot of this stuff is stick-your-head-in-the-sand oversight ... all it is a paperwork infraction," Lee said. "There is no disciplining to incentivize better behavior."

A Centers for Medicare and Medicaid Services spokesperson said many infection control citations are not severe enough to warrant fines. Instead of issuing penalties, inspectors require homes to improve practices when they identify problems that "could lead to resident harm" but haven't yet.

Most learn from their errors, according to CMS.

"Infection control and prevention has been a longstanding challenge for nursing homes, and one that this Administration has been working to address for quite a while," the spokesperson wrote in an email.

In 2019 CMS and the Centers for Disease Control and Prevention issued new training on infection preventing and launched a nursing home antibiotic stewardship training program to help staff manage and prevent infections. And last month, the CMS released a toolkit for nursing home bed-side staff to help them prevent the spread of infections, the spokesperson wrote.

"While there are clearly facilities that can still improve, there is no way to know how many infections didn’t happen because of our surveyors’ attention to identifying issues early, and the impact our tools have had," the spokesperson wrote.

Repeat offenders

Five long-term-care facilities in the state had deficiency citations for infection control in three different inspections.

They were: Allegiant Healthcare of Mesa, Archie Hendricks Sr. Skilled Nursing Facility in Sells, Desert Cove Nursing Center in Chandler, Desert Haven Care Center in Phoenix and Oasis Pavilion Nursing and Rehabilitation Center in Casa Grande.

Desert Cove had deficiencies for infection control in 2017, 2018 and 2019, according to records. The facility failed to document annual tuberculosis screenings last year for four of 10 staff members. The previous year, an inspection report stated that a nurse didn't sanitize scissors before removing and changing a wound dressing and didn't wash or sanitize her hands afterward. In 2017, a food service worker was observed washing dirty dishes with a plastic apron onbut then not removing or changing the apron as she emptied freshly washed dishes.

“The same dirty/contaminated apron remained on as the worker removed the food trays and dishware. The items were held against the worker's apron,” the inspection noted.

The staffer later admitted to the inspector that she should have changed her apron.

In a statement, the facility's executive director, Tim Bouseman, didn't address the inspection reports but said resident safety is a top priority. He said there have been no confirmed cases of COVID-19 at the facility, and staff is taking precautions to protect residents.

He said employees follow infection control procedures set forth by the federal government, CDC and local health departments. Visitors, nonessential health-care personnel and vendors are restricted from entering the facility.

Staff is being screened before they begin work, he said, and anyone with a fever over 100.4 degrees is being sent home and told to see a doctor.

"Our facility is still fully operational, and we will continue to take all appropriate measures to ensure the safety and well-being of our residents, our associates and the community," he said in the statement.

Allegiant Healthcare, Archie Hendricks, Desert Haven, and Oasis Pavilion did not return calls seeking comment.

Ratings don't tell the whole story

It's hard to identify which nursing homes have had problems with infection control by looking at their ratings, which are calculated using a five-star scale by the federal Centers for Medicare & Medicaid Services. The rating reflects health inspections, staffing and other quality of care measures.

Roughly half of the Arizona facilities cited for infection control were rated "above average," or five-star "much above average."

The Life Care Center of Kirkland, near Seattle, received a five-star rating from federal regulators. But the facility got a citation in 2019for infection control and an inspection report described a resident’s daughter saying an open wound on her mother's heel often touched the ground while nurses cleaned the wound as she sat in her wheelchair.

Inspectors found other problems at Life Care, such as kitchen staff not properly washing their hands or changing gloves, records state. “These failures placed residents at risk for harm and transmitting/acquiring infections,” the inspection noted.

Public health officials say they've identified 129 cases of COVID-19 among patients, staff and visitors to the Life Care facility, with 35 deaths. In a report issued this month, they concluded that ineffective infection control and staff members working in multiple facilities contributed to the spread of the virus.

Life Care Center said it has implemented infection control recommendations from the CDC and from state and local health departments. The facility also said it is limiting visitors, monitoring residents and employees, and asking staff to stay home if they are sick.

No visitors for now

COVID-19 is a new disease and its transmission is still being studied, but the CDC believes it spreads through respiratory droplets when an infected person coughs or sneezes. That's why people are being advised to stay at least 6 feet away from one another.

The CDC says it also may be possible to get the disease by touching a surface or object that has the virus on it and then touching one’s mouth, nose or eyes. A recent study in the New England Journal of Medicine reported the virus is detectable for up to 24 hours on cardboard and up to three days on plastic and stainless steel.

"This virus is quite transmissible through relatively casual contact, making this pathogen very hard to contain," said James Lloyd-Smith, a co-author of the study and a UCLA professor of ecology and evolutionary biology.

Infection control in long-term care facilities can be even more difficult than hospitals because there are typically more soft surfaces in nursing homes and more close contact among residents.

"That creates more opportunity for the disease to spread," said Kelly Reynolds, a University of Arizona professor in the Zuckerman College of Public Health, who has studied infection control in hospitals and nursing homes.

The Arizona Department of Health Services earlier this month issued emergency rules for long-term-care facilities to address the COVID-19 public health emergency. The policies require screening of employees before they enter the facility and disinfection requirements for frequently touched surfaces.

For example, door handles, tables and light switches should be cleaned with an alcohol solution containing at least 70% alcohol, a bleach solution with 4 teaspoons of bleach per quart of water or an EPA-approved household disinfectant.

In the wake of the coronavirus, the federal government has issued stringent guidelines that ban nearly all nursing home visitors. The restrictions are designed to prevent visitors from infecting residents whose age or underlying health conditions make them susceptible to the virus.

Facilities are also being advised to cancel residents' communal dining and group activities and to screen staff before their shifts for fever and respiratory symptoms.

Experts say such a vast closure of nursing homes to visitors is unprecedented in this country. The restriction on visitors has received a lot of attention with news reports showing relatives pressed up against the closed windows, waving and blowing kisses to their loved ones.

But they worry that even visitor restrictions may not be enough to protect the most vulnerable, if infection controls break down within the nursing home.

Reach Caitlin McGlade at caitlin.mcglade@arizonarepublic.com or 602-444-0582. Follow her on Twitter @caitmcglade.

Reach Anne Ryman anne.ryman@arizonarepublic.com or 602-444-8072. Follow her on Twitter @anneryman.