For nearly two months, San Juan County has maintained its unfortunate lead among Utah health districts for the highest coronavirus case rate in the state.

As of Friday, 11 San Juan County residents had died, 60 had been hospitalized and 440 had tested positive for the disease. The 15,500-person county, which accounts for less 0.5% of Utah’s population, has seen more than 5% of the state’s 205 total deaths.

But Blanding, the county’s most populous town, had largely been spared the brunt of the pandemic since it began, with the concentration of cases on the Navajo Nation along the Utah-Arizona border.

That changed this week after a 104-bed care facility in Blanding, the Four Corners Regional Care Center, experienced an outbreak that, as of Friday, had spread to 31 of its residents and staff. Meanwhile, geographic data from the San Juan County Public Health Department showed on Friday that the towns of Bluff, Monticello and Blanding had more active cases than the Navajo Nation portion of the county for the first time, partly due to the Blanding outbreak.

The Four Corners Care Center has not allowed visitors since March 13, and staff were screened for symptoms daily, according to a spokesperson. Despite the precautions, a staff member tested positive on June 28, and the facility notified public health officials.

Kirk Benge, the director of the county’s public health department, said he recommended the facility wait five days before testing other staff and residents. Testing too early and receiving negative results, Benge warned, could create a “false sense of security.”

Over the next week, several residents developed symptoms and were tested. On July 6, two positive results came back.

“A quick determination was made to just go over and swab everyone so that could get a jump on this and see how widespread this was,” Benge said.

Derek White, senior vice president of Cascades Healthcare, which provides support to the management of Four Corners Regional Care Center, said a batch of tests shipped to the facility were lost in the mail, and local health care providers Utah Navajo Health Systems and Blue Mountain Hospital in Blanding moved quickly to bring in nurses who tested every resident and staff member at the facility.

The results have been pouring in over the week since, jumping to eight positives on Tuesday and 25 on Wednesday. On Thursday, the facility announced 10 staff and 21 residents had the virus.

Several members of the Utah National Guard’s Covid-19 “strike team” visited the facility Friday, White said, to deliver personal protective equipment “and to continue to help the facility strategize the management of COVID-19.”

Positive residents have been moved to a separate wing and staff members are isolating at home. Two residents were hospitalized this week, though one was expected to be released Friday.

Long-term care centers across the state have been hard hit by the pandemic. The Utah Department of Health says 241 such facilities — about two-thirds of the state’s total — have had at least one resident or staff member test positive for the coronavirus and that those outbreaks have accounted for 86 deaths.

The health department lists 27 nursing homes, rehabilitation centers, assisted-living communities or other types of licensed care centers as currently having two or more positive cases within the last 14 days. Of those, 11 have five or more cases, though the Blanding facility was not yet included in that number on Friday.

When the Utah Department of Health published the list on May 14, only nine facilities were listed.

Because residents of long-term care centers tend to be more susceptible to the coronavirus, the Centers for Disease Control (CDC) guidelines for nursing homes recommend all health care workers wear a face covering “at all times while they are in the facility” and that residents wear a “face mask (if tolerated) whenever they leave their room.”

Before the first case of COVID-19 was identified at the Blanding facility, those recommendations were not always followed. Staff and residents did not routinely wear face coverings as evidenced in photos posted to the facility’s Facebook page and conversations with family members of patients.

One family member of a resident who was hospitalized said she had been concerned about lack of face coverings in the facility for weeks, and when she raised the issue with management she was told Blanding was a “low-risk area.” She described her experience with the facility as “not at all professional” and “rude.”

“CDC makes recommendations but does not mandate,” White said regarding mask usage policy.

Although the Centers for Medicare & Medicaid Services (CMS) impose what White called a “myriad of regulations” on facilities that participate in Medicare, “long-term care and skilled nursing facilities are licensed by the state,” he said. “Four Corners Regional Care Center ultimately does what the Utah State Health Department wants them to do.”

White said state guidelines do not require face coverings in facilities that do not have any confirmed COVID-19 cases. But Joel Hoffman of the Utah Department of Health said the guidelines White referenced were outdated. Updated guidance was released in April and masks have been required for staff in long-term care facilities since then.

Staff were required to wear masks only after the first case was discovered at the Blanding center on June 28, White said.

San Juan County’s northern neighbor, Grand County, which has yet to have any hospitalizations or deaths related to COVID-19, was granted permission by Utah Gov. Gary Herbert earlier in July to require face coverings in indoor settings when social distancing is not feasible.

Benge said that he does not plan to follow Grand’s lead and require masks in San Juan County, adding he would discourage municipalities in the county from seeking their own mask mandates as well.

“Other than this unfortunate facility [outbreak], the county has had a fairly stable, gradual decline in active cases,” he said.

Mask mandates have been controversial throughout the state. Piute County Commissioner Darin Bushman compared Herbert to the Nazis on Twitter when Herbert allowed mask requirements in some urban areas in June.

After Bushman apologized and deleted the tweet, Rep. Phil Lyman, a Republican from Blanding and former San Juan County commissioner, wrote on Twitter, “Hitler didn’t start out killing Jews, Christians, Jehovah’s Witnesses, Hungarians, homosexuals, the disabled, political critics, Poles, Soviets, and Gypsies; that was after he asked politely for people to ‘just wear the dam (sic)’ arm band.” He followed with the hashtag #bushmanforgovernor.

A subsequent Fourth of July gathering in Blanding, which Lyman attended, saw little mask use.

Given the heated debate around mask mandates, Benge said he would attempt to encourage mask use through other means than requirements, including asking businesses to sign pledges.

“The approach that I think actually has the most compliance is to use social pressure to encourage mask use over mandates and enforcement from above,” he said.

The Navajo Nation portion of the county continues to impose some of the strictest coronavirus guidelines in the state, such as nightly curfews, stay-at-home orders and the closure of tribal parks.

— Tribune reporter Nate Carlisle contributed to this story.

Zak Podmore is a Report for America corps member and writes about conflict and change in San Juan County for The Salt Lake Tribune. Your donation to match our RFA grant helps keep him writing stories like this one; please consider making a tax-deductible gift of any amount today by clicking here.

Correction: July 13, 2020, 5:05 p.m.: An earlier version of this article referenced outdated mask guidelines from the Utah Department of Health. Since April, workers at long-term care facilities have been required to wear masks even if no cases of COVID-19 have been confirmed, although that policy was not always followed at the Four Corners Regional Care Center before June 28, according to a spokesperson.