Coronavirus is spreading in Texas nursing homes. But the state won't share the details.

At least 320 residents and staff members at Texas nursing homes have tested positive for the new coronavirus. At least 18 people have died. And at least seven nursing homes, across five metro areas, are grappling with infections of 10 or more people.

But those numbers, collected by The Texas Tribune from various public health departments and local news reports, likely underrepresent the extent of the COVID-19 outbreak in Texas nursing facilities. That’s because Texas, unlike some other states, is failing to disclose comprehensive data on nursing home residents and staffers who have fallen ill — even though state officials acknowledge they are privately tracking that data.

Before the COVID-19 pandemic arrived in Texas, many of the state’s nursing homes had long records of citations related to poor infection control. And now some of those same nursing homes are seeing major outbreaks.

One Texas City facility has seen more than 80 residents and staff members test positive for the virus, and a doctor there is now using an unproven drug touted by President Donald Trump to treat residents. At least 78 people at a Lubbock facility became infected, while a San Antonio facility has had at least 67 people test positive.

Families and advocates for nursing homes residents are calling on the state to release the numbers and names of facilities where coronavirus infection has been reported. Texas officials have not released that information, though some of Texas’ 254 counties have.

“It is, frankly, my hope that there will be a public release of this information soon,” said Patty Ducayet, the state’s long-term care ombudsman who advocates for nursing home residents.

“Certainly, anyone living in a facility where there is a confirmed case or even a presumed case of COVID, because they are vulnerable by nature of them living in the setting, they deserve to know,” she said. “And I think a family member, who can be a decision maker ... I think they need to know.”

A spokeswoman for the Texas Health and Human Services Commission said the agency investigates nursing facilities for compliance with health and safety rules when there is a report of a staff member or resident testing positive for the disease.

“Protecting the health and safety of the people we serve is our top priority,” spokeswoman Kelli Weldon said in an email. “We are working closely with long-term and acute care facilities in Texas to ensure they have up-to-date, clear information on preventing infectious diseases such as COVID-19.”

Weldon also confirmed that the health commission was tracking COVID-19 cases in nursing homes statewide, though she declined to release its figures.

People with chronic health problems and the elderly are at higher risk of death from COVID-19, which leaves nursing home residents especially vulnerable, experts said. Heart disease, diabetes, cancer or a weakened immune system is associated with worse health outcomes, according to the Texas Department of State Health Services.

Texas is not the only state to see large numbers of nursing home infections. Nationwide, at least 450 nursing home deaths have been attributed to the virus as of last week, according to an Associated Press analysis. Washington, Ohio, Tennessee and Maryland all reported major outbreaks in long-term care facilities.

But Texas stands out for its limited release of information.

In New York, which has been the nation’s epicenter for COVID-19 cases, the state’s health department last week reported more than 1,000 nursing home infections and at least 179 deaths, comprising nearly 15% of the state’s reported coronavirus death toll, according to The Wall Street Journal.

And in Louisiana — another growing coronavirus hot spot — nursing home fatalities account for about 16% of the state’s death toll, and state officials have regularly reported the total number of infected residents and deaths. As of last week, the state reported 60 long-term care residents had died. But officials there stopped publishing the names of nursing homes where there are clusters of coronavirus infection, according to local media reports.

In the months since the new coronavirus was first reported in China, inspectors have increased oversight of facilities with histories of infection control problems, state and federal officials said.

But even recent inspections found that more than one-third of nursing facilities nationwide did not follow hand-washing guidelines and one-fourth did not properly use personal protective equipment meant to limit the spread of the disease, federal officials said. That came as the Trump administration announced last week that nursing homes had become “an accelerator for the virus.”

About 93,000 people live in Texas nursing homes, and the vast majority of Texas’ more than 1,200 licensed nursing homes have recent citations for deficient infectious disease prevention measures. Inspectors found problems — many of them deemed minor, such as staff failing to wash hands properly or change gloves — at more than 80% of Texas nursing homes in the past three years, according to a Texas Tribune review of regulatory records.

Of the 988 nursing homes that were cited for infection control and prevention, 39 were flagged by the government for having a history of serious quality issues and are subject to more frequent inspection and increasing penalties this year. Nationally, Texas has the second-highest total number of infection-related citations over the past three years with 1,855 — second only to California — and had the 11th-highest rate of citations among all states.

Difficult decisions for families

For Texans with loved ones in nursing homes, visitations have been off limits since mid-March following an order from Gov. Greg Abbott. Many have called for the state to increase transparency about which nursing homes have reported coronavirus infections as they face difficult decisions about their relatives’ care.

State guidelines published this week say nursing homes should report coronavirus cases to the Texas Health and Human Services Commission and tell residents, staff and family when there is “exposure, presumptive and confirmed cases in the facility.” The state also directs nursing homes to use separate staffing teams for residents who have tested positive for COVID-19 “to the best of their ability.”

Velinda Rubio has been making FaceTime video calls a few times each week to stay in touch with her 76-year-old mother, who has Alzheimer’s and lives in a Mansfield nursing home. Her mother recently fell and fractured her shoulder, requiring her to be taken to the hospital.

Rubio said she wished the state would publish a list of nursing homes with known coronavirus infections, especially after local news outlets reported cases in several nearby North Texas facilities. She said she routinely calls her mom’s facility to inquire about any coronavirus infections since she’s no longer allowed to visit in person.

On a recent call to the facility, she asked the staff, “Is there somewhere you’re going to post this? Is there an email that goes out?’” Rubio said. “They said no.”

“I am concerned,” she said. “How would I know this unless they’re honest with us when I do ask?”

For Tammy Benford, video calls have been vital to staying in touch with her mother, who is 75 and lives in an Austin nursing home.

Her mother, who had a stroke and is unable to speak, nods and gestures to her over the internet connection.

“It’s still hard,” Benford said. “Just seeing her through a phone, I can’t give her a hug, I can’t touch her, I can’t comfort her.”

Some public officials, including Dallas County Judge Clay Jenkins, have encouraged families to remove their loved ones from nursing facilities to keep them safe from COVID-19.

But experts say those decisions should not be taken lightly.

“What are your resources to care for that person?” said Tracie Harrison, a professor of nursing at the University of Texas at Austin. “Do not rush into a decision. … Can you manage their fundamental health problem? Can you also, on top of that, keep them isolated?”

Harrison said that many low-paid nursing home employees work at multiple facilities. To limit the risk of employees spreading the virus from one facility to another, nursing homes should ask them to work at only one location, she said. But doing so will come with costs to workers.

“You have to supplement their wages in order to do that,” Harrison said.

Large-scale outbreaks

In Lubbock, where the Whisperwood Nursing and Rehabilitation facility has been associated with 78 coronavirus infections and five deaths, city officials announced they would put the facility under a quarantine order to ban employees from working anywhere else.

“Those residents are really our most vulnerable and as we’re working towards trying to contain and control this disease it’s those older adults, people that would be in a nursing home are really the ones that we want to protect during this outbreak,” Katherine Wells, Lubbock’s director of public health, said in the announcement.

Texas inspectors cited the facility for 10 health deficiencies, and it received an overall rating of one star out of five during its most recent inspection in 2019. One citation led to a penalty of over $7,000 after a resident suffered a fractured leg when a member of the staff tried to improperly move them.

However, in the last three years, none of the deficiencies that the Lubbock nursing home received were for infection control problems.

Phone calls to the facility were not returned. A letter shared by its management company, Creative Solutions in Healthcare Inc., said the challenges posed by COVID-19 were “unlike anything we have known in our time.”

“Creative Solutions in Healthcare, Corp. will rise to that challenge with the same commitment and resolve we have always demonstrated for those entrusted to our care,” the letter said.

In Texas City, local health officials said one nursing home had more than 80 people test positive for the coronavirus.

Records show the Resort at Texas City has received an overall rating of two out five stars, with a total of 10 health deficiencies in 2019. The average in Texas last year was about seven. Over the last three years, the nursing home received one infection-related health deficiency for putting three residents at risk in 2017 by failing to practice good hygiene, such as properly washing hands and donning gloves.

In San Antonio, local health officials have reported 67 cases of coronavirus associated with the Southeast Nursing and Rehabilitation Center, including at least eight employees. Local officials said Tuesday there had been eight deaths related to COVID-19 at the facility, whose administrators had not revealed all of the deaths until county health workers made inquiries after local news reports.

The facility received a one-star rating and was cited for 17 health deficiencies in 2019. One incident involved a patient who was not treated for a lack of bowel movement, which resulted in the patient suffering fecal impaction. That led to the nursing home being cited for neglect and came with a penalty of over $62,000.

Over the last three years, Southeast Nursing and Rehabilitation Center received a total of three deficiencies related to infection prevention and control. These citations were mostly for the staff not following proper hygiene practices, including hand-washing while caring for patients.

Reached by phone, a facility spokesperson declined to comment.

Disclosure: The University of Texas at Austin has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.