More than 20 patients have died. Dozens more are still hospitalized. And residents who had already been sent back to a nursing home in Gallatin, Tennessee, have turned up with new cases of COVID-19.

An investigation finds that the facility downplayed the outbreak to first responders on 911 calls in late March. But the nursing home administrator told WPLN News that the coronavirus was unstoppable in Tennessee’s largest outbreak yet.

Dawn Cochran, the administrator of the Gallatin Center for Rehabilitation and Healing, said department heads were summoned to a Saturday night meeting within 20 minutes of learning a staff member had tested positive for the coronavirus. And all employees were notified on March 21, a full week before a mass evacuation began.

But COVID-19 was not a concern expressed in multiple 911 calls made on behalf of patients being sent to the hospital with trouble breathing in the days following that staffer’s positive test, WPLN News learned through recordings obtained from an open-records request.

First Responders Not Informed Of Cases

As the Gallatin Center found residents needing more care than it could provide to help with breathing, it began to call 911 to transport patients to the hospital, recorded calls show.

“Do you know if she’s been in contact with someone who tested positive for the coronavirus?” the dispatcher asked on March 25.

“No,” the nurse responded, after a pause.

Staffers did not warn 911 dispatchers, who asked specific screening questions so first responders could take precautions and wear protective gear.

Another patient needed to go to the hospital the next day, March 26, after several employees had already tested positive and multiple patients were being tested.

“Do you know if she’s been around anybody who has traveled to the airport or on an airplane or been confirmed with coronavirus?”

“No,” the caller said, cutting off the question.

And on March 27, just hours before a mass evacuation would begin, another patient was short of breath and unconscious.

“Do you know if he’s been in contact with someone who tested positive for the coronavirus?” the dispatcher asked.

“We don’t know. We have no clue,” the caller said.

That weekend, every patient and staff member would be tested. Nearly 100 residents had positive tests along with 33 staff members, most of whom had no symptoms. As of Friday, the Gallatin Center outbreak remained the largest in Tennessee, with at least 20 of the state’s 142 deaths.

A Deadly Front In The War On Coronavirus

The guidance from federal regulators changes by the week, but the nursing home with the country’s first deadly outbreak, in Washington state, was faulted by regulators for not moving rapidly enough to identify and manage ill residents.

In Gallatin, federal surveyors told WPLN News they have completed their review but won’t release their list of deficiencies until later this month. Patient families expect flaws to be identified.

“I think a lot of it could have been prevented,” said Tammy Howell. Her mother lives at the Gallatin nursing home and spent three weeks at the nearby Sumner Regional Medical Center, which took nearly all the COVID-19-positive patients. She had to test negative twice before returning to the nursing home.

Howell and other family members said the nursing home dismissed ailments that turned out to be COVID-19.

“Don’t tell me that you’ve got a couple of cases and tell me my mom doesn’t, and she has some of the symptoms, just because you want to cover your butt,” she said.

Howell said the hospital gave her more information than the nursing home ever did.

The home has already been put on notice that some families intend to file lawsuits. They accuse the facility of making nurses work even though they weren’t feeling well and failing to make everyone wear masks and gloves.

Local officials have been displeased with the response, as well.

“We were being told at first that basically they had this situation under control,” Sumner County Mayor Anthony Holt said. “And it wasn’t under control. It was completely out of control.”

Holt said the nursing home continued to ignore the advice of local officials who wanted patients to stay in area hospitals longer. Those who tested negative had been transported to neighboring counties so Sumner Regional hospital could focus on the patients who tested positive for COVID-19.

After everyone was moved out of the nursing home and it was deep-cleaned, the nursing home started moving people back immediately — which was the plan, endorsed by state regulators, all along. But Sumner County emergency management chief Greg Miller doubted the Gallatin Center had enough nurses who hadn’t been exposed.

“We thought they were rushing the decision to move them back in,” he said. “We just weren’t getting many answers.”

In the following days, after supposedly negative residents were moved back to Gallatin Center, at least three more residents fell ill and were moved to the hospital. On those 911 calls, though, staffers were more direct with dispatchers.

“Have you obviously been in contact with anyone who has tested positive for the coronavirus?” one asked a caller from the nursing home on April 6.

“Oh yeah, everybody here has,” she said with a laugh. “I’m sorry. I just have to say that and laugh because that’s all I can do.”

‘You Cannot Stop It’

The nursing home’s administrator has also become more open about the experience. In an interview with WPLN News, Dawn Cochran acknowledged she was overrun, even though she didn’t think so at first.

“Once you get one sick patient, it’s a tidal wave. You cannot stop it,” she said in an April 7 interview.

Cochran said she was doing everything the Centers for Medicare & Medicaid Services recommended, often ahead of schedule, like screening employees for symptoms.

In recent years, though, CMS has cited the 200-bed Gallatin nursing home for deficiencies in infection control. They’re minor lapses — people sticking their hands in the community ice machine or poor management of bed linens. But they’ve resulted in below-average ratings.

New Jersey-based Care Rite Centers purchased the nursing home in 2016 and owns nine facilities in the Nashville area.

Cochran has a long career as a nursing home administrator but has been in the Gallatin facility only since early March. She said she could speak only for the time since she took over. As for the 911 calls without disclosing COVID-19 concerns, she said nurses were genuinely confused.

“What appears to be COVID-like symptoms wasn’t in two residents we had tested,” she said. “So we just don’t always know.”

Cochran said she has cooperated with state health officials from the beginning and saw them as a partner in planning the evacuation. Even as they await the federal findings, state officials have said they find the nursing home’s response to be “perfectly adequate.”

“I’m hoping everybody can learn from it,” Cochran said. “But at the same time, I don’t know what we could have done better at the time —  I don’t.”

At least 16 other Tennessee nursing homes also have multiple confirmed cases. Whether those get out of hand will shed light on whether an outbreak is truly inevitable.

This story is part of a partnership that includes WPLN, NPR and Kaiser Health News.