The Cedar Rapids nursing home where more than 100 residents and staffers have tested positive for COVID-19 has a history of not meeting federal standards for infection control and prevention. An Iowa Public Radio analysis shows state inspectors found a pattern of issues at Heritage Specialty Care dating back more than a decade. One expert told IPR the reports show the facility wasn’t adequately prepared for the new coronavirus.

Heritage Specialty Care, housed in a long, red brick building shaded by trees on the west side Cedar Rapids, has become one of the hotspots of Iowa’s COVID-19 outbreak, driving up the case counts in Linn County, which currently has more confirmed cases of the disease than any other county in the state.

As of Monday, 102 residents and staff members at Heritage Specialty Care have tested positive for the disease. Seventeen residents at the facility have died.

A review of public records dating back over a decade show that state inspectors repeatedly found the facility was failing to take adequate steps to prevent and slow the potential spread of infectious disease among its residents. In 2007, 2009, 2010, 2011, 2013, 2015, 2016, 2018 and 2019, staffers at the Iowa Department of Inspections and Appeals determined that the center was not meeting federal requirements for infection control.

There were multiple incidents of staffers not adequately cleaning medical equipment that was shared between patients.

In some instances, staffers did not adequately isolate a patient who had tested positive for an infectious disease, or didn’t properly use personal protective equipment when treating those patients.

“[Staffers] put on gloves but failed to put on disposable isolation gowns,” reads a report from March of 2015, describing how staff cleaned up after an episode of incontinence by a resident who had tested positive for C. diff, a contagious bacterial infection. “Assistant Director of Nurses had to direct [the staffers] how they clean the resident’s bed properly and dispose of linens appropriately.”

There were multiple examples of staffers not adequately cleaning catheters of residents, or allowing them to drag along the floor.

In April of 2019, a state inspector observed staffers wheeling a resident “in the wheelchair, through the hall and into the shower room. The resident’s urinary bag, dragged on the carpet floor, approximately 8 to 10 feet,” the report reads.

Two days later, a similar incident followed, with a different staff member.

Observation revealed “[a staffer] rolling the resident out of the shower room via a wheelchair. The resident’s personal catheter bag, dragged on the floor,” the report continues.

[A staffer] rolling the resident out of the shower room via a wheelchair. The resident's personal catheter bag, dragged on the floor. - an excerpt from an April 2019 report detailing infection control deficiencies at Heritage Specialty Care

In some cases, residents who required considerable help with their most personal needs were themselves not adequately cleaned after episodes of incontinence.

One expert told IPR the reports demonstrate the facility should’ve taken more steps to insulate their residents from future disease outbreaks.

“Based on the data that we've seen, and also repeat citations over time, it just feels like there is more this facility could have done to address this issue before it started,” said Hari Sharma, a professor in the College of Public Health at the University of Iowa, who studies quality metrics of nursing homes. Sharma reviewed state reports on Heritage Specialty Care at the request of IPR.

An analysis of the reports shows similar incidents happened repeatedly year after year, such as the mishandling of catheters, even after state inspectors pointed out the issues to administrators.

There were also repeated instances of staffers not properly handling bundles of dirty laundry as they moved from one resident’s room to the next.

“This could very well be the way they could transmit [an infection] from one room to the other,” Sharma said.

Based on the data that we've seen, and also repeat citations over time, it just feels like there is more this facility could have done to address this issue before it started. - Hari Sharma, professor at UI College Of Public Health

Sharma says the Cedar Rapids facility is certainly not the only nursing home to not meet these standards, nor the only one to be found deficient multiple times for the same issues, only to repeat them in the following years. Pointing to his own analysis of nursing homes across the country, Sharma said that of the facilities cited this year for infection control, some 80 percent are likely to be cited again in the next three years.

Sharma also pointed out that Heritage Specialty Care is understaffed; health care staffers spent less time with residents than the state or national average. Staff shortages, low morale and high turnover may have also contributed to the facility’s vulnerability to an outbreak of the virus, he said.

A spokeswoman for the Iowa Department of Inspections and Appeals, which fields complaints and conducts reviews of nursing homes in the state, declined multiple interview requests. In an email, spokeswoman Stefanie Bond said “it is not our position to speculate on any individual facility's preparedness.”

A representative with the Office of the State Long-Term Care Ombudsman also declined an interview request.

A spokesman for Care Initiatives, the parent company of Heritage Specialty Care, also declined interview requests, but directed IPR to a written statement that posits there is no connection between the past reports and the current outbreak.

“[W]e find absolutely no distinct, related connection between the information contained in Heritage SC’s DIA reports and the worldwide Covid-19 pandemic that has now reached Iowa. To cite those matters would be misleading and inappropriate,” the statement reads in part.

But to the contrary, Sharma says the reports demonstrate that for years, state inspectors and facility administrators had an indication that Heritage Specialty Care was not adequately prepared to control and prevent the spread of infectious diseases among their residents, who may be especially vulnerable to the virus due to pre-existing conditions like cancer, diabetes, and heart and lung disease.

So far, residents of Iowa’s nursing homes have been among the state’s most vulnerable to the disease, which in some cases has left even young and otherwise healthy patients in critical condition. According to state officials, as of Monday, more than half of all Iowans who have died of COVID-19 were residents of long-term care facilities.

Unfortunately a nursing homes is almost a breeding ground for something like this to happen [...] They are working very, very hard and very diligently to care for their residents, for their staff. - Heather Meador, Linn County Public Health Department

Heather Meador, the supervisor of Clinical Branch Services at the Linn County Public Health Department, says local officials have been in daily contact with Heritage Specialty Care to support them as they’ve implemented new policies such as isolating residents, prohibiting visitors and screening staffers for symptoms of the virus.

“Unfortunately a nursing homes is almost a breeding ground for something like this to happen,” Meador said. “They are working very, very hard and very diligently to care for their residents, for their staff. They have put every procedure in place that we have recommended.”

But Sharma says more could’ve been done to lessen the risk of an outbreak before it hit. Additionally, Sharma says based on his research, the citations and fines issued by state inspectors aren’t sufficient, and that state lawmakers should consider strengthening oversight of the facilities.

“I think enforcement is really important,” Sharma said. “The state can definitely do more in terms of enforcing the penalties and probably thinking a little bit more about…maybe the penalty amount has to change as well.”

With the Iowa Legislature adjourned until April 30, any action by state regulators may come too late for the residents and staff of Heritage Specialty Care and their families. Meador, the Linn County public health official, estimates the outbreak there could last for weeks as the highly contagious virus works its way through the facility.