Report reveals testing botched, no hand soap during deadly outbreak at Georgia nursing home

State took months to release information to the public about dangerous conditions
A newly released inspection report of Riverside Health Care Center nursing home in Covington found that basic infection-control practices were lacking even as a COVID-19 outbreak sickened dozens of residents.  (Curtis Compton /

Credit: Curtis Compton / Curtis.Compton@

Credit: Curtis Compton / Curtis.Compton@

A newly released inspection report of Riverside Health Care Center nursing home in Covington found that basic infection-control practices were lacking even as a COVID-19 outbreak sickened dozens of residents. (Curtis Compton /

As a deadly COVID-19 outbreak sickened dozens of residents at Riverside Health Care Center in Covington this summer, the nursing home was doing without the most basic infection-prevention tool imaginable: hand soap.

Some sinks had no soap at all. Others had bottles of shampoo and body wash. Real hand soap, an inspector was told in mid-August, “had been on backorder for over a month.”

The dangerous conditions inside Riverside went well beyond hand hygiene, according to a newly-released inspection report. In July, as its outbreak became deadly, the home failed to immediately redo COVID-19 tests that were rejected by the lab. Riverside also ignored its own medical director’s order on testing, opting instead for a less-accurate version.

“We have to do what corporate directs,” the home’s administrator told inspectors.

The home didn’t properly screen workers as they entered. It violated PPE protocols and endangered residents by failing to properly separate those who tested negative for COVID-19 from those who may have been exposed. It didn’t tell families, who were barred from visiting the home, about outbreaks as required.

And the state agency responsible for protecting nursing home residents, the Department of Community Health, released none of these findings for months as the pandemic continued to claim lives.

The disturbing details of what took place inside some of the state’s nursing homes during the worst days of the pandemic have largely been hidden and are still being obscured by the agency’s slow inspection process that favors a back-and-forth with facilities over transparency and prompt public notice, an Atlanta Journal-Constitution examination found.

During a survey inspection of Riverside Health Care Center's COVID-19 infection control, the facility's administrator is quoted as saying that corporate recommendations on COVID-19 testing overrode doctor recommendations.

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The AJC learned that DCH has determined that at least eight Georgia nursing homes, including Riverside, placed residents in “immediate jeopardy” with infection-control violations during the pandemic — a finding that means the homes' violations caused or were likely to cause serious injuries, impairment or deaths. But so far Georgia has only released the reports on five of the homes.

Inspection reports on dozens of other homes cited for lower-level violations dating back as far as June have only recently been posted for public review, the AJC found.

State inspectors in August had documented the infection-control failures at Riverside and found they led to a devastating outbreak that infected more than 100 residents and 40 workers. The latest data show 34 Riverside residents died with COVID-19, almost all during July and August, making it one of the state’s most deadly nursing home outbreaks.

Yet only in the last week has the agency posted its inspection findings. Even then, the public could not know just how bad conditions really were. The AJC found the inspection report posted to the DCH website was missing about half the pages included in the full report.

The complete version, which the AJC obtained from another state agency, is one of the most blistering issued in Georgia during the pandemic.

Riverside, which is part of the Wellington Healthcare chain, did not respond to the AJC’s phone calls seeking comment. The federal nursing home ratings system gives it 1-star — the lowest possible rating in its 5-star system.

Reports posted for other homes caught putting residents in jeopardy also appeared to be missing sections or pages. The agency said it was working to correct the problem after being informed of the issue by the AJC.

The state agency also waited until this week to post a late July inspection report exposing devastating infection-control failures at Dunwoody Health and Rehabilitation, a Sandy Springs nursing home where 118 residents tested positive for COVID-19 and 28 residents died. The posted version of the report also was missing critical pages, the AJC found.

A woman enters the main entrance of Riverside Health Care Center nursing home in September. The AJC learned that DCH has determined that at least eight Georgia nursing homes, including Riverside, placed residents in “immediate jeopardy” with infection-control violations during the pandemic. (Curtis Compton /

Credit: Curtis Compton / Curtis.Compton@

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Credit: Curtis Compton / Curtis.Compton@

DCH says it follows federal guidelines and posts inspection reports to its public website once the survey is “closed.”

“The survey may remain open if additional review and/or enforcement activity is pending,” DCH said in an email. “It is an automated process based on whether or not the survey is still open in the system.”

Amanda Crowe, whose 79-year-old father is a resident at Riverside and was infected with COVID-19, said she and others hounded the facility trying to get information as the outbreak engulfed the home. But she said the nursing home stonewalled families, leaving them terrified about what might be happening inside.

“It felt like a nightmare,” Crowe said. “It’s almost like I feel like my dad is down in a pit, and I can’t get him out. You want to rescue them, but you can’t do anything.”

Families still can’t visit Georgia nursing homes. State advocates couldn’t go inside the homes, either, until recently. In the early months of the pandemic, not even state inspectors went inside to check on conditions.

“The hope was that facilities were doing what they could to assure that people were staying safe,” said Melanie McNeil, Georgia’s long-term care ombudsman, whose office advocates for residents of nursing homes and other care facilities. “The reality is what we were worried about — they weren’t doing everything to keep people safe. So these are the terrible things that are being revealed.”

Little to go on

While it may take weeks or months for the state to release the findings when inspectors find damning violations, when none were found DCH tends to quickly post the reports.

That can leave consumers with a false impression of a home’s status, said Susan Carini, whose mother was among those who died with COVID-19 at Dunwoody Health.

Until this week’s updates, recent reports for the facility showed no violations. When the July 30 inspection was finally posted, it revealed widespread failures of both infection control and tracking of the outbreak.

“It’s a huge problem,” Carini said. “If someone were considering that facility for their loved one — what would they have to go on?”

Susan Carini's mother Patricia Carini, right, was a resident at Dunwoody Health and Rehabilitation and died after testing positive for COVID-19. Susan, left, says, “If someone were considering that facility for their loved one — what would they have to go on?” (Family photo)

Credit: Contributed

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Credit: Contributed

For information specifically on the pandemic, families do have other sources of information. But those sources also are flawed.

Families across Georgia can tap into a separate COVID-19 report for long-term care facilities posted to the DCH website. The report, which is updated most weekdays, is supposed to capture the cumulative number of COVID-19 cases and deaths among residents.

As of Thursday, the DCH report showed a total of 16,398 long-term care residents — including those in assisted living facilities and large personal care homes, as well as nursing homes — had tested positive, and 2,762 had died.

But the AJC found that homes routinely drop off of the report or show a decline in case numbers, with no explanation. Hundreds of reported COVID-19 cases and dozens of deaths have been lost from the state’s totals, the AJC found.

DCH doesn’t verify the information the homes provide.

Windermere Health and Rehabilitation Center in Augusta was the site of one of the state’s first large COVID-19 outbreaks. For months, the home had reported that more than 70 residents tested positive. But in September, it started reporting 0 cases. Windermere is part of SavaSeniorCare, the same national chain that operates Dunwoody Health. “There is much confusion nationally regarding how to report the second wave of positive cases,” said Annaliese Impink, a spokeswoman for the Atlanta-based chain.

She said the home decided to “zero out” its positive cases and start over to count cases for a second wave. After the AJC inquired, the facility returned to cumulative reporting, reporting 77 COVID-19 cases over the pandemic, with 11 of the residents dying and 66 recovering.

Public information on outbreaks in nursing homes is also available on the website of the federal oversight agency, the Centers for Medicare and Medicaid Services. The AJC found that dozens of Georgia nursing homes have reported more cases and deaths to the federal system than to the state’s, though the federal website also has gaps.

Anthony Ozburn contracted COVID-19 during an outbreak this summer at Riverside Health Care Center in Covington, where he is a resident. (Family photo)

Credit: Contributed

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Credit: Contributed

Several Georgia homes operated by Florida-based Beacon Health Management have dropped off the Georgia report after reporting dozens of COVID-19 cases. Homes in the chain have also failed to report to the federal system as required.

Tammy Royal, a senior vice president for Beacon, said technical issues and leadership changes at some homes have created reporting issues. She said the company is addressing the issues, “as we continue to face these trying times.”

DCH said it will continue to encourage accurate reporting by facilities. But it said the daily report is “not a substitute” for each facility’s communication. State law requires residents and families to be informed by 5 p.m. on the day following a single confirmed COVID-19 infection. The home must include information on the actions it is taking to mitigate the spread of the virus, the agency said.

“The hope was that facilities were doing what they could to assure that people were staying safe. The reality is what we were worried about — they weren't doing everything to keep people safe. So these are the terrible things that are being revealed."

- Melanie McNeil, Georgia’s long-term care ombudsman

Yet families across the state say they have had difficulty gaining information even about their own family members. Magnolia Manor of Midway was cited in an October report for failing to inform a family about a resident’s status after he was found in August on the floor with a 103-degree fever and was sent to the hospital. Two days later, the hospital called the family to inform them of his death. The family didn’t even know he had been hospitalized. A spokeswoman for the home said the facility was relying on emergency staffing due to the pandemic, and the home’s policies weren’t followed. She said the issue was being addressed to make sure families are always kept informed.

“Families need more information, more timely, whether it comes from the regulatory agency or the facilities themselves reporting timely what is happening,” said McNeil, the ombudsman. “Here is what we’re finding — residents are dying and families are in the dark about it.”

She said she recently spoke with a woman who had gone to her mother’s nursing home to “visit” her by looking through her window. Hours later, she was called to say her mom was actively dying.

Families are allowed into homes if a resident is at the end of life. She arrived within 15 minutes, McNeil said, but her mother had already died. “The family member was so distressed that her mom died alone,” McNeil said.

Administrator unaware

The first notice of the massive outbreak at Riverside Health Care came in July, when the number of residents testing positive went from 2 to 60 in a single week, according to the daily reports made to DCH. On Aug.18, when inspectors were inside the facility, 100 residents had tested positive, and 24 had died.

Walking around the home with the facility’s director of nursing, the inspector noted that all but two soap dispensers in the staff handwashing areas were empty. While the top nurse said hand sanitizer was available, the inspector asked what was done when hands were visibly soiled or someone had just used the restroom. “We have to do the best we can with what we have,” the nurse replied.

On Aug. 18, inspectors visiting Riverside Health Care Center in Covington found a lack of soap available for handwashing.

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The home’s acting administrator was asked about the soap shortage. He said he had been working at the facility for two months and “was not aware that there was no actual soap available for staff and resident use," according to the report.

Inspectors found much more that had gone wrong. The facility’s doctor said the lab had terminated its contract “due to sample collection and reporting concerns with the facility.”

The lab on July 15 had rejected tests that arrived without being labeled for 19 residents. The home didn’t retest until Aug. 2. By then, about half the residents in the group came back as positive. The medical director told the inspector that residents should have been retested the same day the lab reported it could not run the tests.

The inspector also observed a worker caring for a resident who had tested negative right after caring for a resident who tested positive, without changing her PPE.

“It’s especially frustrating when you have a corporate entity who has responsibility for a number of facilities and the lives of all the people who live in their facilities, for them not to be able to provide the basic things like soap and hand sanitizer and other supplies and the proper training,” McNeil said. “It’s indefensible, and it’s kind of unbelievable that the corporate folks either didn’t know or knew but didn’t do anything about it.”

The same day the inspectors were on site, Amanda Crowe was desperate to speak to her father. It was his birthday. And he recently had survived a bout with COVID-19.

“He really completely thought he was going to die,” she said. “He begged God to please give him another day.”

Normally, she would have called him, but the nursing home washed his phone with his laundry, and she was having difficulty getting a new phone to him.

She would go to the home and to his window and try to get someone to open the blinds and put him on a phone. But for a while, she said she couldn’t even get anyone to open the blinds.

“For three days around his birthday they would not let me talk to him,” she said. “I was so angry.”

Since the inspectors were there, she said, some things have improved. The facility tests weekly and then puts out a call to families with updates on new cases. She was able to get her dad another phone, so he can keep her updated. But she’s not certain the changes the state required will be enough.

“It’s still got a long way to go,” she said.