Residents at Valley Hi Nursing Home in Woodstock were in “immediate jeopardy” during a deadly December COVID-19 outbreak after the county-run facility failed to properly isolate COVID-19-positive patients, according to a federal report earlier this year.
During an outbreak that began with two staff members and a resident testing positive on Dec. 8, Valley Hi would keep a positive resident with their exposed roommate, even if the roommate tested negative, state inspectors found. After a few days, the once negative roommate often tested positive, according to the report.
The finding was part of a report by the U.S. Department of Health and Human Services and Illinois Department of Public Health that the state posted online. Investigators also found Valley Hi was not correctly following other guidance from the Centers for Disease Control and Prevention, including not changing personal protective equipment when going from the room of a resident who had tested positive for COVID-19 to one that did not have the virus.
As a result of the violations, the Illinois Department of Public Health fined Valley Hi Nursing Home $25,000, but both parties settled on a $16,250 fine, according to Valley Hi records. At the federal level, Valley Hi was denied an unspecified amount of Medicare payments for its handling of the outbreak.
According to the report, 10 of 21 residents reviewed were put in “immediate jeopardy” from Valley Hi’s handling of the outbreak. The outbreak resulted in four residents dying and 43 residents and staff members testing positive for the virus as of Jan. 1, the Northwest Herald reported at the time. It’s not clear if any of the exposed roommates died.
A total of 67 staff members and residents at Valley Hi tested positive for COVID-19 during the pandemic and 11 residents died, according to the IDPH.
When the federal report was completed on Jan. 5, investigators noted changes were made to correct the processes that put residents at risk. A survey by the IDPH on Feb. 2 found the facility was in compliance with COVID-19 guidelines.
Multiple attempts to reach Valley Hi Administrator Tom Annarella this past week were unsuccessful.
An investigation conducted on Dec. 29 shows five pairs of residents were handled improperly following exposure to COVID-19. Four of the five times, one roommate would test positive while the other would test negative, but then test positive for the virus a few days later, at which point Valley Hi would separate the infected roommates. Even when Valley Hi staff attempted to separate roommates, the investigation shows, they were sometimes placed in a room with a curtain to divide the pair and masks were not used.
“If a roommate tests positive and the other roommate tests negative, we keep them together because they are exposed. ... Our thought was because they have been exposed to keep them together,” Valley Hi’s assistant director of nursing and infection preventionist, who is not named in the report, told investigators.
The assistant director of nursing went on to say they didn’t have the space to separate roommates and as of Dec. 29, there was only three open rooms on the building’s second floor where residents with COVID-19 were being housed.
The assistant director of nursing also said this was the guidance received from the McHenry County Department of Health. But further examination by investigators found this was not true, according to the federal report.
“We have not discussed that situation, keeping COVID positive roommates with their COVID negative roommates. ... [T]hat is not something I would recommend,” a McHenry County Department of Health public health nurse in communicable diseases, who is also not named, told investigators.
Investigators confirmed the McHenry County health department sent the IDPH’s guidance for long-term care facilities to Valley Hi on Dec. 11 because the facility did not have it. According to the guidance, residents confirmed to have COVID-19 should be placed in their own rooms, per a CDC guidance update on Nov. 20.
Even after receiving the guidance from the McHenry County health department, the report shows Valley Hi failed to isolate residents infected with COVID-19 from their roommate four more times. In one case, a resident was not separated from their infected roommate for 12 days. The resident ultimately never tested positive for COVID-19, however.
Valley Hi put all its residents with COVID-19 on the facility’s second floor. However, according the report, the resident who was exposed, but never tested positive, was the only person on the dedicated COVID-19 floor not infected with the virus.
The McHenry County health department followed all its processes for the outbreak at Valley Hi, including providing up-to-date COVID-19 guidance from the CDC and the IDPH verbally and via email, county Public Health Nursing Director Susan Karras said in an email to the Northwest Herald.
“I cannot speak to what decisions were made by Valley Hi to manage this outbreak, nor how the guidance was interpreted that we provided,” she said.
When speaking to investigators on Dec. 29, Valley Hi’s medical director, who is also not named in the report, acknowledged roommates should be separated when one tests positive and the other negative.
“If they are kept in the same room, that puts the negative resident at a higher risk of contracting COVID-19,” the director said.
Investigators also observed issues with how Valley Hi staff members cared for residents during the outbreak, such as not changing personal protective equipment when going from the room of a person with the virus to the room of a person without the virus.
Karras said the health department did its part by declaring the outbreak, offering guidance and tracking new infections, but implementing actions to stop the virus from spreading is Valley Hi’s responsibility.
“Our role with outbreaks in long-term care facilities is to declare the outbreak and provide guidance and consultation on controlling [and] ending the outbreak,” she said.
By the time the report was completed on Jan. 5, Valley Hi had made changes to correct the processes that put residents at risk, according to the report. A survey by the IDPH on Feb. 2 also found the facility was in compliance with COVID-19 guidelines.
Before the December 2020 outbreak, compliance checks by IDPH in June and July 2020 found Valley Hi was following proper COVID-19 mitigations.
Vaccines became available to staff members and residents shortly after the outbreak in January. As of Sept. 12, the most recent data available through the IDPH, 97% of residents and 75% of staff members are vaccinated.
McHenry County Board member Paula Yensen, D-Lake in the Hills, said she was concerned about December’s outbreak, but believes Valley Hi officials know people are paying attention to how they handle health risks to their residents and are trying to keep people safe.
“I think they need to follow the science and best practices by the CDC. If they follow those measures, I think Valley Hi will be good,” Yensen said.
She also gave Annarella a vote of confidence for how he currently is handling pandemic precautions at Valley Hi.
“I think Tom Annarella is working very hard to ensure the safety of the residents,” Yensen said.
Attempts to reach board member Lori Parrish, R-Crystal Lake, who is the County Board’s liaison to Valley Hi, and board chairman Mike Buehler, R-Crystal Lake, were unsuccessful.