At the time of the on-sight inspections, 45 residents had already died inside the Virginia facility, where the death toll from the virus would eventually rise to 50.
The resulting inspection report, provided to ABC News by the Virginia Department of Health, marks the latest instance where federal monitors have alleged violations in nursing facilities that were in the throes of deadline coronavirus outbreaks. In the wake of the inspection, Canterbury said it has taken disciplinary action in at least one case.
Meanwhile, there were new reports issued this week about another scene of a deadly outbreak, the Andover Subacute long-term care facility in New Jersey.
Inspectors from the Center for Medicare and Medicaid Services, the federal agency that regulates nursing care, said the Andover home where 70 residents died and 17 bodies were discovered in a makeshift morgue “was not in substantial compliance” with infection control regulations.
“The facility was not following infection control safety practices and guidance,” the report said.
The owner of the facility, Mutty Scheinbaum, said in a statement that federal investigators "noted areas of improvement for Andover Subacute II, but determined that the facility's remediation plan was acceptable as fatalities continue to drop at the facility."
"We look forward to continuing our cooperative relationship with CMS and the New Jersey Department of Health as we, and nursing home patients and staff across the country, continue to battle this deadly virus," the statement said.
The facility is among those to which New Jersey has dispatched the National Guard to help.
And last month, federal inspectors wrote to the Life Care Center of Kirkland, Washington, the scene of one of the earliest deadly COVID-19 outbreaks in the U.S. The letter said the nursing home had for two weeks failed to report the outbreak as required by law, gave inadequate care to its residents during the outbreak and failed to provide 24-hour emergency doctor services – and faced more than $600,000 in possible fines.
The Life Care Center issued a statement saying it was “working hard to address their current concerns in a timely and respectful manner so as to provide our residents the best care.”
At the Canterbury nursing home in Virginia, inspectors said they found that between April 14 and April 16 some health care workers failed to take basic infection control precautions such as wearing gloves and failing to wash their hands. In one incident, a staff member did not wear an isolation gown and sanitize her hands before providing care to residents.
“It was determined that the facility staff failed to implement the infection control program to prevent infection and the transmission of communicable diseases, for one of ten residents in the survey sample,” the report said about the facility, which had 140 residents at the time of the inspection.
The report described specific incidents inspectors observed, such as when a certified nursing assistant did not wear gloves while delivering meals in a hallway with COVID-19 positive patients. She touched a resident, moved items in the supply cart and put gloves on without sanitizing her hands first. The same nursing assistant then entered another resident’s room, touched a resident and some personal belongings before removing her gloves and not washing her hands after.
The nursing assistant had been educated on personal protective equipment and hand washing multiple times in March, according to the inspection report. When asked by an official why she wasn’t wearing a gown in a coronavirus-positive hallway, the nursing assistant replied, “I wasn’t even thinking about not wearing a gown. I wasn’t thinking.”
Dr. James Wright, the medical director at Canterbury said in a statement that disciplinary action was taken on one of the employees mentioned in the report.
"A multitude of factors are considered during a [federal] survey, however the finding that even a few items require correction is not acceptable,” Wright said. “Throughout this crisis our nurses, doctors, aids, housekeepers, members of the dietary teams and other staff that have worked tirelessly, going above and beyond on heroically caring for members of our community. We continue to work hard both individually and as a group to provide our residents with the best care humanly possible.”
Since the outbreak began, the nursing home in Richmond has seen more than 100 residents and staff members test positive for the coronavirus and has reported 50 deaths.
“The general public knows hand hygiene is crucial in preventing infections – nursing home staff must know that as well,” said Eric Carlson the Directing Attorney at Justice in Aging, a national advocacy group for low-income older Americans. “There’s no excuse at this point for nursing home staff members who don’t scrupulously use gloves and wash hands. The failure to carry out these simple tasks is a matter of life and death when COVID-19 is present.”
Dr. Danny Avula, the health director for the city of Richmond, said some of the challenges inside Canterbury may be because the facility was bringing in new staff to supplement mid-pandemic shortages who were less familiar with the infection control requirements.
“The transmissibility of this disease is not like anything that other nursing homes are typically dealing with,” said Avula. “Nursing homes are leaning on nurses who may have never worked in a nursing home before.”
Avula said he hopes the National Guard can step in to monitor staff and provide training with the protective equipment.
What to know about coronavirus:
But for Bernice Stafford, who hasn’t seen her brother since late March, the news is upsetting and says it raises concerns about the quality of care he is receiving at the Canterbury facility.
“I can’t see my brother and I don’t think he is being taken care of,” said Stafford, a lawyer in Richmond. “The department of health or the government needs to do something.”
Stafford said the reports “aren’t surprising” and that she has seen staff fail to take infection control precautions before. Her brother recently tested negative for COVID-19 after testing positive a few weeks ago.
“On Easter Sunday, I sat in my car after delivering flowers to the nursing home and I saw some nurses wearing gloves and some without any protection and grabbing flowers and touching the front door,” she said. “They aren’t following simple guidelines.”
Stafford says her brother shares a room with another patient who she believes also tested positive.
“There’s only a thin curtain between them,” Stafford said.
“The residents need better care,” she said. “I hope something changes because my brother deserves it.”
This report has been updated to include a statement from the owner of the New Jersey facility.