‘A catastrophic outbreak’: How Oregon failed to slow coronavirus before death overtook nursing home

Oregon’s top nursing home regulators received repeated warnings and even acknowledged privately that the coronavirus could decimate a Southeast Portland care facility but failed to take fast and aggressive action before the first 10 residents died, an investigation by The Oregonian/OregonLive has found.

State officials were told as early as March 25, about a month after Oregon’s first case, that Healthcare at Foster Creek was struggling to protect its residents from coronavirus, records obtained by the newsroom show.

A caregiver who worked in the facility filed a complaint that day, warning the Oregon Department of Human Services of inadequate safeguards and impending death.

“We have residents who I believe will not survive and I’m fearful for them,” the caregiver wrote.

A top state regulator, Jack Honey, expressed alarm over other alleged problems at the facility. “And just between you and me,” Honey later wrote to a colleague, “I am so worried about this erupting into a devastating outbreak.”

That anxiety was prophetic.

Coronavirus cases linked to Healthcare at Foster Creek quickly ballooned, eventually infecting 120 people and killing 34 Oregonians. By the time the last resident was evacuated May 5, the facility accounted for about one out of every four deaths statewide, and it remains Oregon’s deadliest outbreak.

The newsroom’s investigation found that despite warning signs state officials took days and in some cases weeks to act, losing critical time to help slow spread inside the nursing home.

Blaming a lack of protective equipment for state regulators, authorities waited nine days to inspect the facility after the March 25 complaint but inexplicably found no violations during their 47-minute visit – only to return one week later to uncover a slew of problems, including some outlined in the initial and subsequent complaints.

Among them: caregivers wearing the same masks for entire shifts, employees not washing hands between interactions with residents, and workers moving between units with and without known coronavirus infections – potentially serving as conduits to spread the dangerous disease.

It’s impossible to know if the state’s drawn-out response contributed to the immense death toll at Healthcare at Foster Creek. But Charlene Harrington, a professor at the University of California San Francisco, said delays almost certainly cost lives.

“Every day of delay was spreading it,” said Harrington, who has been researching senior care oversight for two decades. “They had the authority. I don’t understand why they didn’t act sooner.”

The state could have put in place a temporary management company, immediately gone into the facility, or sent inspectors to monitor Foster Creek’s workers, Harrington said.

“I feel sad when I see a leadership failure,” Harrington said. “They could have saved lives.”

The newsroom’s findings, based on more than a dozen interviews and more than a thousand pages of documents obtained through public records requests, underscore the chaos of the state’s overall response to the pandemic in the first months after coronavirus emerged Feb. 28 in Oregon.

The state became overwhelmed by an onslaught of unemployment claims filed by laid-off workers. It repeatedly held back information vital to the public. But nowhere was Oregon’s failure more stark than at Healthcare at Foster Creek.

State officials knew how devastating the disease could be if left unchecked inside a nursing home, where residents are mostly elderly and suffer from underlying health conditions, making them the most likely to die from COVID-19.

In Washington, a nursing home outbreak near Seattle drew international headlines and accounted for more than half of all known coronavirus deaths across America by mid March. In Oregon, officials already had two weeks’ experience responding to an outbreak at a veterans home in Lebanon that ultimately infected 38 and killed 8.

It’s true that late March and early April were a different era in the pandemic, with far less access to protective equipment, testing or expertise than there is now. But alleged problems at Foster Creek were so fundamental to preventing infections that officials should have known to act swiftly, senior care experts said.

Officials for the Department of Human Services said they moved with urgency and described an array of actions they took. Any death from COVID-19 is tragic, and the agency has responded to the pandemic with unprecedented measures and collaboration among state and local agencies, agency spokeswoman Elisa Williams said in an email.

Among other things, state officials repeatedly told the nursing home it had to prevent the spread of infections, helped it secure additional staffing and investigated complaints against the facility.

“We responded immediately with actions based on the facts, resources and tools available at the time,” Williams wrote in an email.

“DHS continually escalated its response,” she added, arguing that the agency did take versions of the steps recommended by experts as more became known about the growing outbreak.

In all, 20 residents were evacuated over the weekend of April 11 by medics the state hired, some 2 ½ weeks after officials received the first complaint.

State orders Southeast Portland nursing home struck by the coronavirus to shut down

The action comes weeks after the state discovered a slew of problems.

Regulators effectively shut down Healthcare at Foster Creek less than a month later. Seven families have now sued the facility’s owners and managers, claiming the home’s failure to protect residents killed their loved ones.

The Healthcare at Foster Creek outbreak revealed the numerous, fundamental state failures that must be addressed moving forward, said Multnomah County Commissioner Sharon Meieran.

“There needs to be a real, transparent conversation about what true oversight and accountability means,” said Meieran, who is an emergency room doctor.

The Department of Human Services did not make the agency’s director or top officials directly involved in the outbreak available for interviews in response to a June 25 request.

When asked during an April news conference if aggressive and earlier action by the agency could have prevented deaths, Fariborz Pakseresht, the agency director, said he was “hesitant to get into what could have, should have been done.”

The agency did make available for an interview Nathan Singer, the deputy operations director for senior care, who was assigned to the outbreak response days after it began.

The state’s initial priority was to help Foster Creek curb infections, he said, and certain sanctions aren’t pursued until violations are documented by inspectors. Ultimately it’s a facility’s job to keep residents safe by following state rules, and it’s the state’s job to enforce those rules.

Based on what the state knew about the virus, Singer said he believed the agency acted fast enough. But, Singer said, “We continue to update our practices.”

St. Jude Operating Co., a family-owned business based in California that owns Healthcare at Foster Creek, declined to comment citing pending lawsuits against the company.

“We are devastated that our facility was one of the first to succumb to a COVID-19 outbreak,” the company said in a statement.

Terri Waldroff, a co-owner of the company that managed the home, deferred to St. Jude’s statement for this article. But a spokeswoman for the company said in a May statement that “Healthcare at Foster Creek leadership consistently and repeatedly attempted to communicate collaboratively” with the state.

The management company, Benicia Senior Living, is also being sued by families who lost loved ones.

Kevin Fortune is among those who died at Healthcare at Foster Creek.

Nursing home staff sent Fortune to a hospital in late March because he could barely get out of a chair and was warm to the touch, said his sister, Janis Fortune, whose brother Greg Fortune is suing St. Jude and Benicia.

Nursing home staff thought Kevin Fortune, 59, had a urinary tract infection but, on his way out, they took a sample to test him for the coronavirus, she said.

Fearing her brother had the disease, she said she asked the emergency room to let him stay at the hospital because Healthcare at Foster Creek had so few private rooms that he wouldn’t be isolated.

“She said all care facilities are trained to handle this,” Janis Fortune recalled the emergency room nurse saying.

Even after Kevin Fortune tested positive for coronavirus, Janis Fortune thought he was in good hands back at the facility. Caregivers told her he was getting Tylenol and cold baths to bring down his fever.

“I had faith in Foster Creek to care for Kevin,” she said.

A few days later, she said, the nursing home called to say he wasn’t going to make it.

‘Not taken proper precautions’

Nowhere has coronavirus killed more Oregonians than in nursing, assisted living or retirement homes.

At least 131 people have died in outbreaks across three dozen facilities, according to statistics released this week by the Oregon Health Authority -- representing more than half of Oregon’s total death toll, which stood at 232 as of Saturday.

The Department of Human Services is responsible for regulating many of those facilities. The agency, which reports to Gov. Kate Brown, sets and enforces safety regulations for 685 centers statewide.

Healthcare at Foster Creek served some of the state’s most vulnerable and forgotten residents. Among the approximately 100 residents were those recently homeless, people with significant behavioral issues and individuals with dementia.

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The facility had accumulated 19 violations of state rules in the last five years, including for repeatedly failing to protect residents from each other, according to Department of Human Services records. Last August, a resident was found face down in a pool of blood after another resident punched the person in the face, documents show.

Regulators cited the facility three times in 2019 for inadequate staffing.

It was with that backdrop that officials at Healthcare at Foster Creek identified their first coronavirus infection in March.

A caregiver working at the nursing home became so alarmed with what she saw that she filed a complaint with the state.

She heard there was a confirmed infection at the facility, she wrote, and the nursing home failed to provide adequate masks and gowns to staff, according to the March 25 complaint. At least one resident had gone from a unit with suspected infections to a unit without cases.

“My facility is and has not taken proper precautions to prevent the spread,” the care worker wrote in an email to the state’s complaint inbox. “Instead they put up flyers about social distancing.”

The state already knew there was at least one suspected infection at the facility, records show. But the nursing home did not immediately report that two infections had since been confirmed, as required, state emails show.

“This is completely unacceptable,” Honey, the manager of the department that licenses nursing homes, wrote March 25 in an email about the center’s failure to report the positive cases.

Honey also recognized that sick residents needed to be isolated -- something that wasn’t happening.

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Responding to the suspected outbreak, the state had already ordered Foster Creek to move residents with confirmed or suspected coronavirus infections to private rooms, if possible. The federal Centers for Disease Control and Prevention also recommended facilities prepare to isolate sick residents to prevent broader spread.

But Foster Creek didn’t have any private rooms available, according to a state email. Two infected residents were living with two residents who had not tested positive, according to the state email. Another two rooms had residents with suspected infections living with individuals who had not been tested or had tested negative.

“Maintaining a room with both positive and negative residents makes me think they have not read any information whatsoever,” Honey wrote in an email March 25 to the agency’s top senior care official and six others at the agency. “Let’s talk about this one…”

The state’s regulatory machinery got moving – two days later. Officials launched an “offsite review” that included a conversation with the person who complained, according to the state’s report summarizing the findings.

The precise number of warnings about Foster Creek is unclear, as the Department of Human Services said it received complaints March 26 and March 27 about the nursing home’s ability to control infections. By March 30, the Department of Human Services received yet another warning.

A company that provided on-site mental health services at Foster Creek became so concerned for its workers’ safety that they pulled them out, according to an email the state’s Long-Term Care Ombudsman’s Office sent the Department of Human Services.

A manager at Cascadia Behavioral Healthcare cited concerning “healthcare practices” including a lack of protective equipment and staff who were working both in units with coronavirus cases and units without cases, according to a summary of Cascadia’s comments written by David Berger, a deputy ombudsman.

The same day Berger passed along those concerns, someone living in a separate unit at Healthcare at Foster Creek started showing coronavirus symptoms, according to federal records.

Experts interviewed by the newsroom said nursing home staff and regulators across the country were at a disadvantage to respond to outbreaks inside care facilities into April because they lacked adequate protective equipment and testing.

Five of the experts who reviewed the timeline for Healthcare at Foster Creek and records provided by the newsroom said the Department of Human Services should have acted with more urgency.

Debra Saliba, a professor at the University of California Los Angeles who has researched care homes for about two decades, said the caregiver’s initial complaint should have made it clear to the state that coronavirus could spread and “we immediately have to act.”

“For whatever reason, we already knew they weren’t implementing what they needed to be implementing,” Saliba said. “That could’ve been an opportunity to jump in.”

‘Potential for a catastrophic outbreak’

An inspector for the Department of Human Services didn’t visit the facility until April 3.

Nine days had passed since the initial complaint.

DHS officials said they couldn’t visit in the days immediately following the complaint because inspection staff lacked the necessary protective gear to enter the facility.

The Department of Human Services did not explain why the gear was not available earlier. But Sen. Sara Gelser, a Corvallis Democrat who chairs a human services committee, blamed the delay on the Oregon Health Authority, which is responsible for the public health response to the pandemic.

Gelser said the health authority didn’t inform human services of the facility’s first confirmed infections, failed to give DHS protective equipment to go into the home and didn’t provide testing kits.

“DHS has tried time and again to do the things they need to, to help the vulnerable people that they serve,” Gelser said. “The Oregon Health Authority gets in the way of that.”

The health authority did not directly address Gelser’s allegation. A spokesman said officials responded to the outbreak with the best information they had and with as much supplies as they could get amid a nationwide shortage of protective equipment and testing kits.

“We are saddened by the incredible losses suffered during this pandemic by residents, staff and families at Healthcare at Foster Creek and at other long-term care facilities around the state,” spokesman Jonathan Modie said in a statement.

When a regulator from the Department of Human Services did obtain protective equipment, the state’s inspection of Foster Creek lasted just 47 minutes. It found no violations of infection control practices, records show.

Workers wore N95 masks the whole time, according to an inspection summary. Staff put on and took off their equipment just like they were supposed to, the summary said, and they washed or sanitized their hands between every resident.

The rest of the investigation – which included 11 interviews and reviews of 12 residents’ care records – turned up no violations, either.

“No facility deficient practice was identified related to infection control practices and the COVID-19 virus,” the report concluded.

The agency told the newsroom its complaint investigation was just one component of a larger response to the outbreak and that the results reflect only what investigators could find at the time.

State records show the Department of Human Services also completed a distinct infection control inspection at the same time, which similarly did not find any violations. State officials have not answered questions about what that inspection entailed.

The caregiver who filed the March 25 complaint said in an interview she was dismayed and in disbelief to learn that the agency’s reviews found nothing.

“If we did all the things right like they said we did, then we wouldn’t have 34 dead residents,” said the caregiver, who asked for anonymity to protect her future job prospects.

Despite the clean April 3 inspection, other agency officials privately expressed deep concern that same day. Multnomah County, which was the first to respond to the outbreak but lacked regulatory power, asked the state to step up its involvement that day because Foster Creek had stopped answering health officials’ questions.

The state’s top official on senior care, Mike McCormick, got on a 7 p.m. conference call that night with officials from Multnomah County and the Oregon Health Authority to talk about Healthcare at Foster Creek.

The nursing home needed extra staff and still hadn’t isolated residents with the coronavirus to a specific area, nor was it moving roommates out, according to the notes McCormick took during the meeting. Healthcare at Foster Creek had less than 40 rooms for nearly 100 residents.

Honey, who participated in the call, emailed a colleague afterward with his foreboding concern “about this erupting into a devastating outbreak.”

Honey also asked state employees for detailed information that apparently had not yet been collected, more than a week after the initial complaint.

Honey asked for the facility’s history of violating state and federal regulations, a diagram of the nursing home to see if there was space to separate people with the disease, and information about other homes in the area in case residents had to move.

“I know everyone is beyond busy,” Honey wrote. “But we’ll need to assign some staff to this.”

McCormick also shot off an email after the meeting to Waldroff, the co-owner of the company that managed Healthcare at Foster Creek.

McCormick asked her to give him detailed information about each resident and said the agency had to “immediately” start planning in case residents had to be moved out.

“I’m very concerned about the potential for a catastrophic outbreak at Healthcare at Foster Creek,” McCormick wrote Waldroff at 8:13 p.m.

The email appeared to surprise Waldroff.

“Why do you think this is catastrophic?” she replied. “What hysteria have you started?”

At least four residents had already died.

‘Hard to reconcile’

It would take another week for state regulators to get a full handle on the extent of problems at Healthcare at Foster Creek.

Officials began by trying to find a stop-gap solution to the nursing home’s staffing shortage, which likely played a factor in spreading disease. Workers told the newsroom that staff had to go from unit section to unit section because there weren’t enough employees, forcing managers to choose between risking infecting more residents or not providing them with any care at all.

The federal government recommends that each section of a nursing home has its own dedicated workers to prevent the spread of COVID-19.

Morgen Crumpacker, who worked at Foster Creek as a licensed practical nurse until April 5, told the newsroom that workers asked managers if they should follow that guidance.

“We can’t,” Crumpacker recalled being told.

Added a second former caregiver, the one who filed the initial complaint: “If we had enough staff, we wouldn’t have to cross units.”

Both caregivers said they ultimately tested positive for coronavirus.

‘They were going down fast’ – Families describe coronavirus chaos and death at SE Portland nursing home

For these three families, state efforts to curb the outbreak have come too late.

State officials took the highly unusual step of making calls late April 3 to find more workers for Foster Creek, records and interviews show. McCormick’s notes from that night’s conference call noted “staffing deficits” and that the facility needed seven caregivers during the day and three in the evening.

Steve Allen of the Oregon Health Authority spoke to a Providence Health & Services executive asking for help immediately. He worried there wouldn’t be enough employees the following day, Robin Henderson said in an interview.

A Providence hospital took four Foster Creek residents that night to lighten the facility’s load and put the Oregon Health Authority in touch with Cross Country, a company that provides temporary healthcare workers, DHS and Providence said.

Cross Country had caregivers and nurses ready to work at Foster Creek on April 4, according to Henderson and a health authority email.

But once those extra workers were available, it took the state six days to hash out a contract and figure out how to pay for them.

The state’s staffing agreement didn’t kick in until April 9, records show. The Department of Human Services did not answer a question about whether the state secured workers any earlier.

Asked about the time it took for the state to help, Singer, the agency official, said the Department of Justice needed to be consulted to figure out how to pay for the extra staff at the private facility.

“It took time to get the legal documents, to connect them with a staffing agency,” Singer said.

Modie, the spokesman for the Oregon Health Authority, said the agency considered pulling staff from the Oregon State Hospital or the state’s registry of volunteer healthcare workers but concluded neither approach would work. The Cross Country contract was fast-tracked, Modie said, and in place “very quickly.”

At the same time officials were dealing with staffing issues, the health authority did a remote assessment of the nursing home, producing a three-page list of recommendations specific to Foster Creek that the agency shared verbally April 4 with the human services agency on a conference call.

Among other things, the health authority recommended that Foster Creek start keeping track of residents’ coronavirus symptoms, not allow sick workers to show up for their shifts and reiterated the need to tell government officials when they had new cases of the coronavirus.

Conditions apparently did not get any better through the week, with state officials April 5 questioning if Foster Creek was still keeping sick residents in rooms with people who were not infected.

The Department of Human Services sent back inspectors April 10 who this time substantiated some of the allegations that the state was warned about in complaints first submitted 16 days earlier.

Five minutes into their visit, inspectors saw a medication aide walk out of a room with a suspected infection, take off her gown, roll it up into a ball and put it on top of her medication cart, according to a federal document describing the findings. Some residents who had the coronavirus shared rooms with those who didn’t, surveyors found. A worker said she got only one mask per shift.

Once, when a worker tried to go between resident rooms without changing protective equipment state inspectors “intervened to ensure the resident’s safety.”

And in a finding that paralleled the concerns the ombudsman’s office raised nearly two weeks earlier, investigators found that employees worked across multiple units.

The same aide who plopped her gown on the cart told surveyors she worked in two units -- one that had patients positive for the virus and another that, at the time, did not.

“This staffing practice resulted in the potential for all residents to be infected with COVID-19 virus with the likelihood of serious illness and death,” the state wrote.

During three days on-site the state noted more than 20 violations.

The DHS spokeswoman, Williams, said investigators went back that second time because officials got new information. She did not disclose specifics to the newsroom.

It’s perplexing why the allegations against Foster Creek were not corroborated during the state’s April 3 inspection, rather than a week later, said Yale School of Public Health epidemiology professor Sunil Parikh.

Parikh, who said he has been advising Connecticut officials’ response to outbreaks at nursing homes, said a longer first inspection could have revealed the deeper problems that were eventually found -- and led to more aggressive state action sooner.

The issues officials discovered April 10 through April 13 were so severe that it would have been very unlikely some weren’t already happening April 3 when the state visited and found no problems, Parikh said.

“This is certainly really hard to reconcile,” he said.

State officials said that as the outbreak grew, so did demands on staff at the home. They also emphasized that inspections are a “snapshot in time” based on what investigators see on the ground.

As state officials scrambled to find workers and launched their multi-day inspection, they also signed an agreement with the facility that allowed paramedics to evaluate all Foster Creek residents with the coronavirus.

When paramedics arrived April 11, they found so many residents in bad shape that 20 ultimately had to be evacuated to local hospitals that weekend.

The agency also assigned two state nurses to regularly be at the facility, found a consultant to help run it and mandated daily reports on how many workers were on each shift.

In the end, it wasn’t enough.

State officials evacuated the nursing home’s last residents in early May and suspended the home’s license, effectively shuttering it. The one-story facility, along Southeast 136th Avenue in Portland’s Powellhurst-Gilbert neighborhood, is now cordoned off behind a chain-link fence.

‘More to learn’

Outbreaks continue to kill seniors in care facilities and retirement homes across Oregon, with more than 60 new deaths since Foster Creek’s closure.

Meanwhile, more than 120 licensed care homes have had at least one confirmed or presumed infection since the pandemic began, and the number grows every week.

Fred Steele, the state’s ombudsman for seniors in long-term care, pointed to multiple lessons that state agencies – including the one he runs – have learned.

Among other things, the state now has detailed plans for what to do when outbreaks grow and the Department of Human Services visits facilities with new outbreaks within 24 hours, returning at least once a week thereafter.

The Oregon Health Authority also must immediately tell the Department of Human Services when there’s a case of the disease in a facility, according to a response plan signed July 2. The document outlines, step-by-step, four strategies for how to help facilities struggling with outbreaks.

The state has also paid two nursing homes to convert into emergency holding centers for seniors recovering from the coronavirus, one in Tigard and one in Portland.

“DHS definitely changed their practices after Healthcare at Foster Creek,” Steele said.

Still, no care home can match the death toll at Foster Creek. Asked what he thought the agency should have done when that outbreak began, Steele was unequivocal.

“The tools being applied now were available then,” Steele said.

Battling the pandemic has been challenging, the Department of Human Services said. It is tragic when, despite the statewide efforts, infections continue to occur and in some cases kill people in nursing homes, an agency spokeswoman said in an email.

“We share in the sorrow that this has caused,” Williams, the spokeswoman, wrote. “Our hearts go out to those who have suffered unimaginable loss.”

Outbreaks continue to erupt in nursing homes.

A facility in Canby now has more than 110 cases, putting it on track to overtake Foster Creek for the most confirmed or presumed infections in Oregon. At least 10 people associated with that facility have died.

Steele said the state must keep trying to better understand the past.

“There’s more still there to learn,” he said. “That virus does not have to spread like wildfire in a building.”

Data Expert David Cansler contributed to this report.

-- Fedor Zarkhin

fzarkhin@oregonian.com

desk: 503-294-7674|cell: 971-373-2905|@fedorzarkhin