What 2 Very Different Nursing Homes Learned From Fighting COVID-19

The bonds created during the 75-day lock-in remain strong and motivate compliance with rules. “We built a forever bond,” Williams says. “You cannot hurt someone you care about. You cannot take a shortcut with someone you care about. We are family."

But Moore knows that they must stay vigilant and that their story could have unfolded differently. They planned well, but sheer luck may have helped spare them, too. Also, if not for the ample space and the support of owners who fed everyone and paid overtime and a bonus stipend to workers during the lock-in, they couldn't have pulled this off.

Because Park Springs is a private organization, Moore cannot share financial information, but says: “I can tell you that we were not focused on the cost throughout the lock-in.” When it comes to ordering supplies or equipment to keep everyone safe, “we are going to do the right thing regardless of cost."

Her heart aches for facilities that were hit with COVID-19 outbreaks. “They love their residents, too,” she says. “It's like a wave that knocks you over in the ocean, and you never saw it coming."

Doing everything possible to keep the virus from returning

David Ross sobbed as he drove home from work. It was mid-July, and the 300-bed nursing home that he runs in New Hampshire, the one that once registered 30 new cases of coronavirus per week, had just reached an important milestone: a week of no new positives.

These tears were driven as much from relief and joy as they were from the accumulation of two months of sadness, pain and frustration.

Ross, the administrator of the nursing home, remembers that state representatives wanted to know how a major outbreak could have happened at Hillsborough County Nursing Home, a nonprofit facility in Goffstown. In May, when the first residents came down with symptoms, the staff administered coronavirus tests to all residents in one 50-bed unit and rushed samples to the state lab. About half the residents in the unit were positive, most of the rest soon joined them, and the virus later spread to three more units, infecting 209 people in all, including 57 staff members. Forty-two residents died, but no staff members did.

Employees and residents were being tested each week, although because of an increase in cases in the community, the facility was gearing up for the possibility of twice-weekly tests. When the nursing home is in “outbreak status,” meaning at least one positive case in the building, about 20 members of the National Guard come in weekly to test everyone, Dubois says. She and other nurses scramble to take over the testing of residents who are war veterans, not wanting the military uniforms to trigger PTSD.

Staff also use a rapid-test machine whenever anyone has sniffles, a headache or other minor symptoms. The federal government, through the Centers for Medicare & Medicaid Services (CMS), supplied the machine without cost, but the nursing home still must cover the expense of testing materials. One test runs about $23, Ross says, already costing the nursing home $50,000.

Ross understood why the state officials asked their questions, but the answer was simple: His staff had done what they could with the information and testing protocols available. And while other institutions, like schools and churches, could go virtual, his residents had no place else to go. “It's not like you could shut us down,” he says.

A staff member (in blue) with a team from the National Guard (in white) who were at the Hillsborough facility to help with testing.

Courtesy Hillsborough County Nursing Home

Before COVID-19, signs asking visitors with flu-like symptoms to stay out were about the only restrictions on outsiders, Ross says. That was when 50 visitors a day might stream in, residents gathered in common spaces, and college-student volunteers flitted in and out. Nurses concerned themselves with preventing falls, aspiration control, managing common contagious infections and keeping surgical wounds clean, says Tonya Dubois, the director of nursing. And even before the pandemic, they followed strict protocols for handwashing, sanitizing equipment, and proper disposal of needles and other medical gear.

While all those priorities remain in place today, “the water has been muddied with this pandemic,” Dubois says. “It's taken over a large portion of what we do in our building now and how we do things."

Employees put on surgical masks when they enter the building. Anyone within 6 feet of a resident must add a face shield. Ross says the nursing home has spent close to $300,000 on PPE, contributing to more than $500,000 in unbudgeted expenses since March. All of this has forced a reallocation of funds, a search for coronavirus-relief reimbursement sources and delays in projects, such as a planned renovation of a nursing unit and the expansion of a behavioral health unit.

Test results dictate response, including whether the nursing home is cleared to enter the next stage of reopening. Phase zero was shutdown. Phase 1 — which started after two weeks of no positive cases — allowed the facility to crack the doors open a bit. Residents began seeing family members at a distance outside. Then, once the home kept cases at zero for another two weeks and the county rate of cases dropped to less than 50 per 100,000 people, the doors opened wider — allowing for occasional nonessential appointments inside, like visits from a hairdresser or routine dental or eye exams.

Coordinating 20-minute supervised visits outside took 80 hours of work a week but was a “labor of love,” Ross says. “When you saw families and residents connecting again, it was breathtaking, absolutely the best part of the day."

But that joy was fleeting. Come fall, a resident who had previously been infected tested positive again, forcing the facility to roll back to phase zero. Eleven positive cases were found, Ross says, though public health officials believed they were recurring positives, likely not contagious. Only one person showed short-lived, minor symptoms. Still, Ross worked with the public health officials to add a temporary wall in one unit to create an 18-bed isolation area. Employees working there have gone back to wearing full PPE. “We had to err on the side of caution,” Ross says. The facility remained in phase zero as of mid-December.

Going backward was a blow to residents, who had started to leave their rooms again for socially distant meals in the dining room and spread-out group activities, such as bingo, exercises and crafts. “You just felt like you let air out of a balloon,” Ross says. “Folks were deflated” thinking about the residents’ return to isolation, the need for extra PPE, the potential loss of more lives. Some employees who had stepped away from their jobs at the nursing home when the initial outbreak hit had just come back — only to leave once more, this time questioning if the health care field would ever be right for them.

Dubois cries when she talks about residents separated from their loved ones and says the need to be their support system keeps her and others coming back. “The people that are here really, really, really just care about them,” she says. “Even when you're scared — you don't want to catch COVID and bring it home to your family — you come in because who else is going to help take care of them?"

Long-term care in the time of COVID, Ross says, means never getting too comfortable. Anxiety hovers over the nursing home. Each time he reviews test results, Ross has to stop to remind himself to breathe. “It's kind of like playing with a jack-in-the-box when you're a kid. You know it's going to jump out and scare your pants off,” he says. “That's the feeling when you're looking through those reports. You're waiting for something bad to happen."

Ross clings to the guidance touted by public health professionals to “avoid the three C's,” which he describes as “close contact, closed spaces, crowded places.” But no matter how strictly he and others in the long-term care industry adhere to these rules, he fears outbreaks will continue. All it takes is one asymptomatic employee being COVID-positive — between tests, so not yet aware — to bring it into a building. And as people outside grow tired of taking precautions and start letting their defenses down, community spread will grow, as evidenced by surging numbers this fall, he says. That, in turn, increases the risk for nursing home employees and the residents they want to protect.

"Even the best of facilities are at risk for this because of the nature of what we do and the closeness of people,” Ross says. “We're forever changed. We'll never be the same."

Jessica Ravitz is a former senior writer for CNN Digital whose work has also been published in Smithsonian magazine, The Washington Post and The Atlanta Journal-Constitution.