Nursing Home COVID-19 Infection Control Reports Reveal Problems With Patient Care

By Katy Seiter

The Waters of Rogers, a nursing home in Benton County, had 12 residents die from COVID-19 and 52 residents infected with the virus as of Dec. 9. A review of inspection reports shows The Waters of Rogers was one of 24 nursing homes reviewed as deficient in COVID-19 infection control regulations, illustrating the challenges nursing homes face in keeping residents safe during the pandemic.

Inspection reports, obtained through a Freedom of Information Act request to the Arkansas Department of Human Services (DHS), described how regulators found deficiencies in staff and resident testing, patient care and a lack of follow-up on COVID-19 lab results at The Waters of Rogers. The reports also described a lack of personal protective equipment, or PPE, and issues with following COVID-19 safety guidelines for residents.

In one case, the staff failed to identify a positive COVID-19 case in a timely manner according to the reports; the resident died on July 15. 

“All the staff that took care of [the resident], including me, suspected that he had COVID-19. He just wasn’t the same,” a nurse told state surveyors in an Aug. 5 report. “He was visibly sick, and this was reported to our supervisors.” called The Waters of Rogers four times and emailed the administrator copies of the report, by request, but the administrator did not respond to questions or requests for an interview.

These instances are examples of the COVID-19 problems identified in Arkansas nursing homes infection control reports, prepared by the Centers for Medicare and Medicaid Services (CMS) and conducted by the Arkansas Office of Long Term Care (OLTC) surveyors. obtained from the Department of Human Services more than 400 documents that spell out infection control inspections and correspondence for 33 nursing homes. The Department of Human Services reported a loss of several infection control reports due to a computer crash. 

Overall, most of the nursing homes surveyed were complying with the regulations, according to the reports. There were 117 infection control reports, and 74% of those showed nursing homes complied with infection control measures. But in 26% of the reports obtained from DHS, the nursing homes weren’t complying with infection control regulations.

“We have heard reports of people feeling like their loved one wasn’t getting the care that they needed and that their health, as a result, was declining,” said Vanessa Nehus, associate state director of AARP Arkansas.

The COVID-19 virus has been a persistent problem in Arkansas nursing homes. According to ADH data released Dec. 9, there have been 8,179 total resident cases and 1,235 total resident deaths. More than one-third of the total cases and deaths were reported between Nov. 2 – and Dec. 9.

The problems identified in the infection control reports align with an AARP study of federal data that found Arkansas nursing homes had the highest COVID-19 resident infection rate in the nation in September. An AARP study released Nov. 12 reported Arkansas nursing homes having nearly triple the national average rates for both COVID-19 cases and deaths per 100 residents. 

Nehus suggested that the worsening condition of Arkansas nursing homes is a result of state healthcare regulations being unprepared for the challenge posed by the pandemic. It looks like nursing homes were caught on their heels with the pandemic outbreak,” Nehus said. 

State infection control regulations are broad but require policies and procedures to address key infection control needs, such as aseptic and isolation techniques, according to DHS. Since the onset of the pandemic, federal regulators have provided state surveyors with additional infection control criteria to specifically address uses of masks, personal protective gear and COVID-19 testing requirements.

The AARP has appealed to Gov. Hutchinson to reconsider long-term care ombudsmen as essential personnel, which would allow them routine access and visitations in nursing homes. Nehus added that during this time of restricted visitations from loved ones, ombudsmen are needed more than ever to check on the status of residents.

At Fayetteville Health and Rehabilitation Center, the Sept. 4 inspection report showed deficiencies with infection control and care of residents, such as one nurse reported not wearing personal protective gear because she had already tested positive for COVID-19.

The original survey report stated the facility failed to provide residents in COVID-19 isolation with personal belongings, such as toothbrushes, toothpaste or combs, or their personal clothing. Residents in isolation reported that they were not allowed to bring any personal clothing and were told their belongings would be put into storage. 

A resident found in an isolation room told the surveyor, “I haven’t had my glasses in three weeks. I have three pairs of glasses, but I can’t have one pair to wear.” An amended version of the report found the lack of personal belongings to be reasonable due to the isolation requirements and removed the deficiency.

A second resident was asked how long he had been in the clothes he was wearing.

“About 14 days, maybe a little longer than that, and I have no idea when I have had a bath last,” he told the state surveyor. The director of nursing stated residents should be offered a shower or bath two times a week, yet according to records, four of the residents in the COVID-19 unit had not received a bath in 3-4 weeks. 

Reports also described how staff members were not practicing the recommended hand hygiene before and after contact with residents, in addition to inconsistent and inappropriate use of personal protective equipment. 

Staff underwent intensive inservice training following this report to ensure that employees were educated on COVID-19 precautions and PPE usage, said Joe Perkins, spokesperson for Fayetteville Health and Rehabilitation. Perkins added that NHS Management, administrative manager of Fayetteville Health and Rehab, has spent millions of dollars on PPE for all of their facilities.

The COVID-19 isolation hall does not have showers, so residents should receive bed baths twice a week in place of showers, according to Perkins. Perkins suggested that isolated residents likely received hygiene care in that 3-4 week timespan, but due to a lack of record keeping by staff and cognitive impairments with residents, there is no support for this claim. 

Through Dec. 9,  Fayetteville Health and Rehabilitation reported 85 resident COVID-19 cases and 26 resident COVID-19 deaths, according to the ADH. categorized noncompliant infection control reports into five main categories: improper COVID-19 isolation protocols, risk of cross contamination, lack of / improper wearing of masks by staff and/or residents, inadequate / improper wearing of PPE by staff and deficient COVID-19 resident care.

Reports from The Waters of Rogers raised a number of concerns. 

In the Aug. 5 report, a resident was COVID-19 tested and moved to a precautionary isolation hall after displaying symptoms. The resident had to be re-tested eight days after initial symptoms because the laboratory lost the original test results. The second test was initially reported as negative, and the resident returned to the general population hall. However, a laboratory review of the test a day later showed the resident was COVID-19 positive. 

The resident’s condition worsened and he was moved back to an isolation hall, where he died two days later.  The COVID-19 positive result was not reported to the facility until three days after receiving the negative result, according to the administrator, who also suspected the laboratory had mixed-up the resident’s results with another resident. The day after his death, the third test was reported as COVID-19 positive.

The report stated The Waters of Rogers failed to sustain a “humanizing environment” that promotes the well-being of COVID-19 positive residents. Infected residents were moved to makeshift COVID-19 units that had no privacy curtains and no access to call bells or lights. Residents in COVID-19 units reported having to use their cell phones to alert the staff when they needed assistance.

“The call lights don’t work. They haven’t worked for a while… They don’t answer the phone at night or sometimes it takes forever for them to get over here. I have had to wait over an hour for somebody to come in here,” one COVID-19 positive resident reported to state regulators. 

Regulators described instances when staff members at The Waters of Rogers didn’t follow prescribed COVID-19 precautions. The designated COVID-19 staff entrance room lacked alcohol-based hand sanitizer, thermometers and a COVID-19 screener log. Staff reported being responsible for screening themselves prior to entering. 

A month after this survey, on Sept. 4, an additional 19 positive resident cases, nine positive staff cases and three resident deaths were reported.

On Sept. 21, regulators revisited The Waters of Rogers. This survey reported a failure to ensure residents were monitored for COVID-19 symptoms three times a day, a failure to ensure staff wore appropriate PPE when conducting COVID-19 tests and concerns about precautions to avoid cross-contamination in the medication room. 

The Waters of Rogers reported 14 new resident cases on Oct. 7 and four additional COVID-19 resident deaths on Oct. 12.

Charlotte Bishop, Arkansas statewide ombudsman, told that while ombudsmen have stopped routine visits, they can still enter the facilities to investigate a high category complaint, such as abuse or neglect.

In the months since the pandemic started, Bishop has seen a decline in complaints, which she speculated was linked to a lack of outside visitors. Because of this, ombudsmen have come up with new ways to check in on residents amid the COVID-19 restrictions on visitation.

“Some ombudsmen have been going to their facility weekly, even if it’s just pulling up in the parking lot and monitoring the outside visitations, or going up and doing outside visitation with residents,” Bishop said. “They’ve not stopped working. They have tried to think outside the box and do as well as they can during this pandemic… They’re doing anything and everything they can to keep advocating.”

Katy Seiter

Katy Seiter is graduate student in the School of Journalism and Strategic media and an intern with


The University of Arkansas School of Journalism and Strategic Media operates this site as an independent source of news and as a community service for Arkansas residents. Students produce the content here under the supervision of Rob Wells, Ph.D., Assistant Professor of Journalism. The data presented here is collected at roughly the same time each day from the Arkansas Department of Health website.

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