Here are the California nursing homes with infection-control violations, and why that matters

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By Jason Pohl AND Michael Finch II , The Sacramento Bee, March 13 2020

A resident at a Sacramento nursing home was hospitalized last spring after she developed a potentially deadly respiratory infection from Legionella bacteria in the facility’s water.

Staff at Saint Claire’s Nursing Center on 66th Avenue disregarded the health department’s orders for a full month. They kept using a contaminated ice machine. They potentially exposed residents to the pneumonia-causing infection.

“I just winged it,” one of the nursing home employees told inspectors.

A Sacramento Bee review of state and federal records shows the facility is among 18 nursing homes that California inspectors have cited for serious violation of infectious disease rules that put residents in “immediate jeopardy.” These homes spanned the state, including a cluster in the Los Angeles area, according to the Bee review of thousands of inspection reports that detail violations, complaints and mandated improvement plans.

The prevention and control of infection continues to be a widespread problem throughout the nursing home industry. Approximately 82 percent of the nearly 1,200 nursing homes — 976 separate facilities — in California have been cited with some sort of infection prevention and control violation in the past two years, the Bee’s review found.

The overwhelming number of those violations are relatively minor missteps, like failing to wash hands or improperly handling food trays, documents show.

Amid a coronavirus pandemic that is disproportionately killing older adults — including 22 associated with a nursing home in Washington that was cited last year — health experts say even small lapses could give the virus a foothold and spell disaster in facilities that inspectors have already reported for risking the spread of infection.

This week, a woman in her 90s who lived at an assisted living facility in Elk Grove died of complications related to the new coronavirus. Nobody else at the facility, which is not a nursing home, has tested positive, a spokeswoman said. It appears to have been the first senior living facility death in California.

But at nursing homes — which require far more medical care and staff contact with residents than assisted living facilities — the state identified several with potentially life-threatening infection-control violations, records show.

Those include a facility in Modesto that used dirty glucometers employees tried to clean with hand sanitizer, potentially exposing residents to blood-borne infection disease, surveyors found last summer. And at least 29 residents at a nursing home in Fresno last year were moved with a contaminated device that had been used by an incontinent resident, also potentially exposing other frail seniors to a sickness known to be fatal, documents show.

In an effort to avert widespread outbreaks of COVID-19 in the country’s 15,000 nursing homes, the federal agency overseeing them ordered inspectors this month to focus “exclusively” on infection control. Other life-threatening situations and allegations of abuse will still be reviewed, but infection prevention will be the priority, the Centers for Medicare and Medicaid Services said.

Even with the coronavirus outbreak, residents of nursing homes and other long-term care facilities die at alarming rates because of infections — as many as 380,000 a year, according to the U.S. Centers for Disease Control and Prevention. The outbreak of COVID-19 has made the issue of controlling infections all the more urgent.

“It’s not minor. We need to protect patients and residents of nursing homes,” said Dr. Patricia Stone, centennial professor of health policy at Columbia University’s School of Nursing. “The scary news is we’re not there yet and we still need to do more.”

Nursing home administrators note that the deficiencies in California that put residents in “immediate jeopardy” represent a small fraction of the cases. There have been just 18 such infection-related failures documented in the past two years.

“While this represents less than one percent of all infection prevention deficiencies, any lapse is concerning,” said Deborah Pacyna, spokeswoman for the California Association of Health Facilities, which represents the majority of nursing homes in the state. “When this happens, surveyors will not leave the building until the situation is corrected.”

The new emphasis on infection prevention is in effect until further notice, the Centers for Medicare and Medicaid Services said. It comes after an overhaul four years ago aimed at strengthening protocols and oversight for infectious disease inside facilities that work with the elderly.

In 2016, officials added the words “infection prevention” to the book that the 8,200 surveyors, including those in California, are using to grade facilities. Previously it was known only as “infection control.” Changes that year also required nursing homes to designate a person who specialized in preventing infectious disease. The deadline to comply with the changes was last November.

“We’ve seen improvements in their capacity,” said Stone, who has studied the infection prevention changes and also edits the American Journal of Infection Control. “Is it where it should be? Not yet.”


Saint Claire’s Nursing Center in south Sacramento has a consistent history as one of the most troubled nursing homes in the state. In 2005, the 99-bed facility had the third-highest number of deficiencies in the city and was among the most in California.

A California nursing home surveyor was likely braced for problems when they walked into the facility last May.

High on the list was investigating the case of a woman with an immunity deficiency and heart failure who had been hospitalized a month earlier with shortness of breath, despite having no history of lung problems.

Officials called a meeting with Sacramento County Public Health, the inspector wrote, and they said the woman had apparently been infected with Legionella bacteria while at Saint Claire’s.

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A woman wearing a medical mask walks from Saint Claire’s Nursing Center in south Sacramento on Friday, March 13, 2020. The center has a consistent history as one of the most troubled nursing homes in the state. Jason Pierce JPIERCE@SACBEE.COM

Legionella bacteria causes a severe form of pneumonia, known as Legionnaires’ disease, that is fatal for about 10 percent of cases, according to the CDC. It is found in water systems and sickens people when they inhale the bacteria in water mist — whether from contaminated water or ice. (California’s prisons have had a long-running Legionella problem that killed at least one person in custody last year.)

Sacramento County health officials demanded Saint Claire’s avoid tap water and ice completely.

But during that inspection over several days in May, the facility’s “infection preventionist” seemed oblivious to changes to the water management plan, an inspector wrote. And a director at the facility said they had not changed their processes in response to a risk assessment intended to help fix the problem.

“I just winged it,” the director said, according to the survey report. “(I) don’t think anyone at the facility could put together protocols and parameters.”

The inspection report noted the employee “could not remember if a topic related to a water management program was discussed at the management level in the past year.” In addition, the facility’s Director of Environmental Services, told the inspector “he never did anything physical, just normal stuff like cleaning the ice machine and checking the water temperature.”

The Stockton Boulevard facility continued using potentially contaminated water to make ice. That ice was used to keep residents’ drinks and food trays cold, and the inspector soon saw how residents could easily access it, risking exposure to the pneumonia-causing bacteria.

Alarmed at the facility’s disregard of health department orders, the inspector said the situation put residents in “immediate jeopardy,” setting in motion a process that requires administrators to find a fix immediately.

The inspector required staff undergo new training and demanded the facility haul in clean ice and water until water testing showed there were no signs of the pneumonia-causing bacteria.

The nursing home’s staff also failed to clean glucometer devices used to test blood-sugar levels. They put a dirty blood-pressure cuff on a prep table and left personal purses that could have carried contagions on the medication room countertop, records show.

Saint Claire’s case was the only immediate jeopardy case in Sacramento last year, data show. The facility has a one-star rating on the federal government’s nursing home comparison website, “much below average.”

An employee who answered the facility’s phone midday Thursday said there were no managers or directors working and, thus, nobody who could provide comment.

Earlier in the week, a reporter’s call to the facility was disconnected


By far the most common infection-related violation in California nursing homes involved “Level 2” failures such as improper or infrequent hand-washing. They accounted for 98 percent of 1,588 infection-related deficiencies in California that The Bee reviewed.

These types of errors haven’t yet risen to immediate harm. But they could.

A surveyor hit Life Care Center of Kirkland, Washington, with a Level 2 infection-prevention violation last spring after seeing an employee not wearing protective equipment while with a resident diagnosed with pneumonia. (The staffer later said that was a mistake and she should have worn a mask.)

That facility’s infection-control protocols have been put under the microscope in the past two weeks amid the most deadly outbreak so far of COVID-19. It’s unclear what, if anything, staff could have done differently to prevent the spread of the new coronavirus.

But seemingly minor mistakes like these can have far-reaching repercussions for three big reasons, experts say. Residents in nursing homes already have compromised immune systems, whether because of their age or other underlying health ailments. Plus, the facilities they live in are their homes, recreation areas and treatment centers, meaning there is a constant churn of people and potential for infection.

And older residents, as well as those with dementia and other cognitive impairments, might be less willing or able to communicate when they do get sick. That can allow an infection to spread undetected for hours, days or weeks.

“The problem in the nursing homes isn’t a nursing home problem,” Stone, the infection expert, said. “These people, they get sick, they get transferred to the hospital, they get exposed to more germs or they bring their organisms into the hospital. It’s a societal problem.”

A study in China — among the largest examinations of the COVID-19 outbreak to date — measured the death rate of nearly 45,000 people. It found more than half of the 1,023 people who died were over the age of 70, with death rates increasing for every decade in age after 50.

California nursing home representatives said they recognize the extreme urgency of the current pandemic.

“Our providers are facing an unprecedented and potentially catastrophic scenario,” Pacyna said. “Preventing the coronavirus from getting into a facility is the highest priority at skilled nursing facilities right now.”


Facilities in Yuba City and Williams both had immediately life-threatening violations last year. So did Fresno and Walnut Creek, as well as a cluster of facilities in the Los Angeles metro area.

A long list of failures at a nursing home in Modesto shows just how close to a deadly disaster facilities can be, even when inspectors are scrutinizing every move.

At Windsor Post-Acute Healthcare Center of Modesto, a surveyor in July noticed staff used one glucometer among all of the residents who required blood-sugar testing. The devices prick the skin for a small amount of blood to measure.

Nursing staff repeatedly used alcohol pads to clean the glucometer before testing another resident’s blood. It had been a long-standing practice, staff told the inspector. One employee even walked into a resident’s room with the device in her bare hands, held them under a hand sanitizer machine, and rubbed the foam on her hands and the glucometer.

Then the staff member wiped it with a tissue.

The problem? Alcohol alone does not kill all blood-borne pathogens. Testing machines call for bleach-based cleaners and wipes, otherwise people can be exposed to potential deadly infections.

Of the correct cleaner, one employee told the inspector “we don’t have it anymore. I’m not sure if it was expensive.”

The inspector said the failures put residents at risk for the spread of infection and called an “immediate jeopardy.” Staff was forced into basic training. Managers immediately stocked carts with the bleach-based wipes and the facility was ordered to not to use hand sanitizer to disinfect glucometers.

“We’re committed to compliance to not only our own standards but all state and federal recommendations,” said Josh Sable, a spokesman for Windsor Post-Acute Healthcare Center of Modesto in an interview Thursday. “Infection control is very important to us, and we’re committed to protecting our residents.”

A housekeeper at a nursing home in Walnut Creek failed to properly disinfect bathrooms shared by a half-dozen residents. Dozens of staff at a nursing home in Williams, north of Sacramento, lacked documents showing whether they had been tested for tuberculosis. It was also unclear if they’d been vaccinated for the flu.

And 355 residents at a facility in Temple City could have been exposed to infection because the facility did not use hot enough water when washing their bedsheets, blankets and clothes.


By Friday morning, more than 128,000 people globally had tested positive for the coronavirus, with increasingly growing pockets outside of China, according to a map maintained by Johns Hopkins University. That country has also suffered the vast majority of 4,300-plus deaths from new coronavirus, though Italy’s death toll has quickly surpassed 800.

The World Health Organization this week labeled it a pandemic.

The federal agency overseeing nursing homes has been publishing memos about steps health care facilities should be taking. The most significant step is limiting visitation.

“Our priority right now is to prevent the virus from getting into long term care centers and if it does get in, to prevent it from spreading,” Dr. David Gifford, chief medical officer of the American Health Care Association. “We believe providers must take dramatic action to limit individuals from entering our buildings and to ensure that employees who are sick stay home.”

The California Department of Public Health, which oversees nursing home inspectors in the state, did not return a request for comment. But in an Wednesday advisory to facilities, officials further discouraged visitor access in an effort to minimize the potential spread of infection.

“CDPH understands the importance of maintaining contact with family and friends to (long-term care) residents and encourages facilities to carefully consider the effect of visitation limitations on resident well-being,” officials said.

Complaints and concerns about resident rights can also be filed to the Long-term Care Ombudsman Program. The group, with volunteers and paid staffers, is not a regulatory agency but can help people navigate a complaint process before the state inspector shows up.

“We are not in the business of trying to shut down nursing homes because, if we shut them down, where are these people going to go,” said Sergio Landero, the program’s manager. “We’re not the regulators here. We’re the advocates. We’re the problem solvers. We’re the voice for the people who can’t speak for themself.”

“There’s no such thing as a perfect facility.”