The line of nursing home employees waiting to report for duty formed around 6:45 a.m. one day in early May, stretching from the reception desk to the sidewalk.

But there was no one to take their temperatures, as required by federal regulations to minimize the spread of the coronavirus.

“I can’t do this,” said one exasperated employee at Annandale Healthcare Center, leaving the line and heading into the facility.

Some employees started screening themselves.

By the time a nurse arrived, groups were squeezing into the elevator — violating social distancing policies as they entered the building, where 24 residents had already died of covid-19.

The chaotic scene, detailed in a federally mandated infection-control survey, offers a window into failures at the skilled-nursing facility that has had the most coronavirus infections in Virginia.

The Annandale facility was one of at least 27 Virginia nursing homes cited recently by inspectors, who paused inspections nationwide at the start of the pandemic but now must examine infection-control practices at all facilities by July 31 in order for states to receive funding for nursing homes through the Cares Act.

Common mistakes at Virginia facilities included staffers failing to wear masks or wash their hands and allowing residents who had tested positive for the coronavirus to mix with those who had not, according to public records reviewed by The Washington Post. Most facilities, including Annandale, quickly submitted corrective plans and have not been fined. Only two, in Richmond and Luray, received the most severe citation.

Advocates for the industry say the inspections offer just a snapshot of the care being provided at facilities as they have dealt with the unprecedented challenges presented by the coronavirus.

Fred Stratmann, a spokesman for the Annandale facility’s parent company, CommuniCare, said inspections helped identify areas for improvement and “showed that we needed to reeducate staff on a couple of areas.” A nurse is now assigned to screen employees at the front desk from 6 a.m. until the receptionist arrives at 8 a.m. Signs have been posted in the elevators saying only two people should be inside during each ride.

Relatives of some of those who died at Annandale Healthcare say the inspection reports are proof of missteps and oversights that increased the risk to their loved ones, especially as the virus overwhelmed long-term care facilities and left employees struggling to keep relatives informed of who was sick.

“It’s just a mess there,” said Chris Duncan, whose mother, an Annandale Healthcare resident, died on her 75th birthday, three days before the inspector arrived. “Probably how it started was one person didn’t get the [temperature] check. One person was contaminated and lit the gas on fire.”

Inspectors' findings

Statewide, there had been 1,180 covid-19 deaths at long-term care facilities as of Wednesday, according to state data. That is 59 percent of the total deaths reported in Virginia. Fifty-five of those deaths were reported at Annandale Healthcare, along with 156 infections.

Stratmann disputed the state’s death toll, saying that 55 represents the total fatalities since the pandemic began but that only 31 of those residents tested positive for the coronavirus.

Virginia Department of Health officials say that all deaths reported in long-term care facilities on its covid-19 dashboard are attributable to covid-19 and that facilities should request corrections if figures are inaccurate. Stratmann said Annandale has requested a correction.

Kimberly Beazley, deputy director of the health department’s Office of Licensure and Certification, said the vast majority of the state’s 280 nursing homes have already received the coronavirus-focused inspections but that some reports are still being written and uploaded to the health department’s website.

Among the issues at facilities where deficiencies were found: Staffers at a nursing home in Petersburg wore their masks improperly, leaving their noses exposed. The receptionist and physical therapy director at a facility in Richmond did not wear masks at all. Staffers at a nursing home in Virginia Beach failed to enforce social distancing measures at mealtimes. And employees failed to separate three “very strong-willed” women who insisted on sitting close together at a nursing home in Amherst.

Skyview Springs in Luray and Westport Rehabilitation and Nursing Center in Richmond received the most-severe citations, with inspectors warning that conditions there posed “immediate jeopardy” to residents — meaning they had caused or were likely to cause serious injury or death.

At both facilities, inspectors said, staffers did not pull privacy curtains in rooms that held patients who had tested positive for the coronavirus and those who had not.

Westport’s administrator, Paul Conradt-Eberlin, said the facility now separates patients who have tested positive for the coronavirus, those who have tested negative and those who are under observation. He also said the facility, which had 107 infections and nine deaths, had no active cases as of Thursday.

April Payne, a vice president at the Virginia Health Care Association, said the coronavirus-focused surveys should not be used as a barometer for how well equipped a nursing home is to handle an outbreak.

“It’s just not that simple,” she said. “There are so many factors. . . . There are staff having to quarantine and patients having to be cohorted. How readily is the nursing home able to obtain the supplies that it needs?”

'Silent . . . no more'

When the inspector arrived at Annandale Healthcare Center, a 222-bed facility on Columbia Pike, in the first week of May, 25 of the 80 residents who had tested positive for the coronavirus had been transferred to a hospital; 24 had died. Twenty-seven were still sick at the facility, and four had recovered.

On one tour, an inspector observed a blue disposable gown and gloves on the steps leading to a covid-19 unit — which violated requirements to dispose of personal protective gear to prevent possible transmission.

“I can’t believe this,” said the nurse leading the tour, who then disposed of the gear.

The report said a member of the cleaning staff failed to change her gloves or wash her hands as she went between rooms with coronavirus-positive patients and those who had tested negative. The housekeeper and her supervisor also frequently touched their masks and face, the inspector noted.

The facility has a rating of three out of five stars for health inspections by the Centers for Medicare and Medicaid Services, which regulates nursing homes nationwide. In a 2018 inspection, the most recent before the coronavirus-focused inspection, the nursing home received 17 health citations — related not to infection control but to issues including mouse sightings and failure to properly monitor residents. The average number of citations per inspection in Virginia is 12.

Constance Duncan had moved into the facility in 2018. Her son Chris Duncan knows the importance of taking precautions: He works in sports medicine at George Washington University but, since the pandemic began, has been screening employees at the university’s hospital for virus symptoms.

He said he rarely got information from the staff after his mother contracted the coronavirus in April. Ten days after she tested positive, she was rushed to the intensive care unit at Inova Fairfax Hospital, where Duncan was allowed to say goodbye.

“I should have never brought her here,” said Duncan, who had moved his mother to the area from North Carolina to be closer to him. “It was all on me.”

Stratmann said a review of the facility’s records showed that staffers made regular attempts to update Duncan on his mother’s condition.

Kim Ramos, a real estate agent in Northern Virginia, moved her mother, Brenda Roozen, into the Annandale facility this fall. She said the 68-year-old, who was on dialysis and had struggled to recover from knee surgery last year, told her daughter that staffers wore masks at the beginning of their shifts but that they would be hanging around their chins by the end of the day.

Roozen noticed that some nurses stopped coming to work in late March and early April, her daughter remembered, and called her attorney to make changes to her will.

She soon fell ill and was sent to a hospital, where she tested positive for the coronavirus. She died April 21.

Ramos said she has not heard anything from the facility since her mother’s death. She said she had been mourning by herself, almost embarrassed to tell others that her mother had contracted covid-19. She did not learn just how bad the situation was until she was watching the news in June, after the state released data on deaths at individual nursing homes.

“I was silent before but no more,” she wrote on Facebook that night. “No one told the patients or families the virus was brought into the building by staff.”

Six weeks after Constance Duncan’s death, the facility gave her son five trash bags of what it said were her things. The items turned out to belong to another resident who had died.

Chris Duncan returned the bags — which contained the resident’s Social Security and bank information — to the family Thursday.

He still did not have his mother’s belongings.