A long-term care facility at the center of a COVID-19 outbreak in Waldo County has a history of health violations and the lowest possible rating from federal regulators.

The Commons at Tall Pines in Belfast is rated one star out of a possible five by the Medicare program. The facility did not substantially meet program requirements in 2018 or 2019, according to state records.

In May 2018, the Commons at Tall Pines was cited for five deficiencies, including three relating to cleanliness and sanitation, according to records from the state, which inspects facilities that receive Medicare and Medicaid payments.

The facility was told to provide and implement an infection prevention and control program after inspectors determined that staff “failed to ensure urinals, bedpans, and graduate containers were handled in a manner to prevent the spread of infection.”

A 2019 inspection by the Maine Department of Health and Human Services noted issues with cleanliness, including surfaces in common areas such as dining rooms. It also noted that one of two nurses reviewed had not undergone a mandatory 12-hour training in infection control and dementia.

It’s unclear what role, if any, these issues could have played in the outbreak. The facility was not fined over the violations, which were categorized as having minimal harm or potential harm.

Matthew Griswold, executive director of Tall Pines, said the issues in the two inspections have been addressed and the facility has been following guidance provided by the Maine Center for Disease Control and Prevention.

“These issues, which have been addressed, have no role to play in our current situation,” Griswold said. “Please understand that we have a major fight on our hands with an enemy that cannot be seen and often times not even detected. We are doing our very best to fight this outbreak to the absolute best of our abilities.”

Amanda Nickerson, 31, said she is concerned about her 51-year-old father, Alan Cross Sr., who lives at Tall Pines and has serious health problems, including cardiac obstructions and a stroke that left him partially paralyzed. She commended the Tall Pines staff for helping her stay in touch with her father through phone calls and video chats, but she has been vocal with them in the past about the care he was receiving. She said he wanted to live at Tall Pines to be closer to family.

Nickerson said the last time she saw her father was a few days before the facility prohibited visitors. So far, he has not tested positive for COVID-19, the disease caused by coronavirus that is particularly harmful to older people and those with underlying health conditions, but she’s already discussed end-of-life care with his doctor.

“It’s not the first time I have had to have those conversations,” she said. “There was always the option I could be with him, and now there isn’t. They’re not lifting those protocols for patients who are positive and who may be facing their last days.”

“I was told I could stand outside his window and wave to him,” she added.

As of Monday, Maine had reported 698 COVID-19 cases, though public health officials warn that’s likely only a fraction of the actual number of cases, since testing remains limited. Of those, 29 cases were in Waldo County, far fewer than harder hit areas such as Cumberland and York counties, which reported 299 and 151 cases, respectively.

The outbreak has led to clusters of positive test results in long-term care facilities. Tall Pines has had 23 cases, including 19 residents and four staff. Two deaths have been recorded there. The Maine Veteran’s Home in Scarborough has had 32 cases, and the Augusta Center for Health and Rehabilitation has had 55.

The three facilities reporting outbreaks carry a range of rankings, according to the Medicare website.

The Augusta Center for Heath and Rehabilitation is owned by National Health Care Associates Inc., which operates 40 facilities in seven states in the northeast, including eight in Maine. A spokesperson for National Health Care Associates declined to provide any additional information about the cases in Augusta.

“Augusta Center for Nursing (sic) and Rehabilitation can confirm that it has residents that have tested positive for COVID 19,” spokesperson Genevieve Worthington said in an email Monday. “We continue to follow the guidance and directives of state and federal officials, including the CDC and local agency. No further comments.”

The most recent state inspection did not list many issues there. Medicare gave the facility an overall below-average rating, despite giving it an “much above average” rating in quality and average rating for staffing. It received a “much below average” for health inspections, though it did not say why.

Maine Veterans’ Homes received five stars, or much above average, from Medicare. The facility has a “much above average” rating for staffing and “above average” ratings for health inspections and quality measures.

That’s despite a July 2018 inspection listing 10 deficiencies, including issues relating to infection prevention and disease control. A surveyor found personal protective equipment stations outside residents’ doors, but no conspicuous signs listing precautions needed before entering the room, thus leaving residents, employees and visitors vulnerable to infections.

A licensing inspection conducted by the state last summer indicated the facility was in substantial compliance. No corrective action plan was on file.

Tall Pines operates three programs at its Martin Lane campus: The Commons, The Residence and the Fusion Outpatient Therapy Clinic. It’s owned by Tall Pines Health Care Inc., whose officers list a Portland address in corporate filings with the state.

The Commons, a 53-bed facility, has a Medicare rating of one out of five stars, or “well below average,” according to the federal agency. It received one star each for health care and quality measures, which are based on inspections and clinical data, respectively.

It also received a “much below average” rating for staffing. A footnote indicates that’s because the facility either didn’t submit the information, reported a high number of days without a registered nurse on-site or submitted data that could not be verified through an audit.

The May 10, 2018, inspection also found that the facility:

• Failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior and exterior.

• Failed to ensure the kitchen was clean and sanitary for air vents, ceiling tiles, the food slicer and the dish room floor.

• Failed to ensure urinals, bedpans and graduate containers were handled in a manner to prevent the spread of infection in shared bathrooms.

The following year, the facility was required to file corrective action plans stemming from its recertification process.

Griswold, the Tall Pines director, said protective equipment, which is critical for protecting health care workers and preventing outbreaks, has been a challenge.

“PPE is short everywhere and presents a significant problem in the effort to contain the virus,” he said. “Thanks to the support of our management company, many surrounding community businesses and the CDC, we have in recent days been able to build up a reasonable supply of PPE based on our current situation. I am in constant contact with the CDC with our needs and current inventory levels.”

Dr. Nirav Shah, director of the Maine CDC, said the state is sending more personal protective equipment to long-term care facilities. That equipment is in short supply nationally and critical for protecting health care workers from becoming infected and transmitting the disease.

Shah praised health care workers in long-term care facilities Monday during his media briefing for being willing to put themselves in harm’s way to care for other people’s family members.

“These staff are working in homes across the state keep our extended family healthy and they do so every single day while putting themselves in the coronavirus’s path each time they go to work,” he said. “With these types of homes, the front line is the bedside of our parents, our veterans and our families.”