Before the COVID-19 outbreak was over, almost every resident of a small nursing home in the Shenandoah Valley would contract the virus. The facility’s administrator would get it, so many staff would quit it would become a struggle to keep the facility functioning, and 22 people -- about a fifth of the residents -- would die.
Meanwhile, at a nursing home for adults with physical disabilities just hours away in Richmond, COVID-19 patients would be kept to a single floor with dedicated staff, isolated from the rest of the population. Only 13 residents and four staff members would get the virus, and none would die.
This is the story of two coronavirus outbreaks. The story of how rigorous infection control measures, rapid emergency response, and adequate staffing can make the difference between living and dying.
Skyview Springs
The local health department director called the outbreak at Skyview Springs Rehab and Nursing Center the worst-case scenario: a combination of catching the outbreak too late and not having enough staff to respond.
About a hundred residents live at the for-profit nursing home, just off the small main street of Luray, Virginia. Officials say there’s no way to know how the virus snuck in, but once it did it spread rapidly.
RADIOIQ and VPM pieced together the story of how that happened through a 40-page inspection report detailing the facility’s response to the outbreak and an interview with the director of the local health district. After canceling earlier interviews, someone with the facility eventually answered questions over email.
It was late April when the first resident tested positive at Skyview Springs. The Lord Fairfax Health District worked with the nearby hospital system to mobilize quickly and test everyone. The testing revealed an outbreak that was already well underway.
“The biggest thing fighting against us was by the time we realized there was an outbreak more than half the residents were already sick and enough of the staff was sick that it was a struggle just to keep the facility functioning,” said Colin Greene, director of the Lord Fairfax Health District.
So they made a tough call. Federal standards dictate that positive and negative patients should be separated. But Skyview Springs, in partnership with the local health district, decided not to do that. Greene said they didn’t have the manpower to move people around, and the fact that residents shared rooms made things more difficult.
“If you’ve got two roommates, this one’s positive and this one’s negative and you say, ‘Gee let’s move this guy, or lady.’ This person may already be infected,” he explained. “So you’re going to take this person and move them over here with the uninfected people? And they turn positive and infect all these folks over here? It’s not that simple.”
Instead, the goal became to isolate in place. But as state regulators would soon find out during an unannounced visit that didn’t happen. In one instance regulators saw a positive and negative resident sitting together in a common area, without masks on. The facility said they would separate residents of shared rooms with a closed curtain. But inspectors noted several instances of the curtains between residents not fully shut.
On the same day, state investigators observed a COVID-19 positive patient with dementia wandering the hallways without a mask. They watched the director of nursing, not wearing gloves or a gown, put an arm around the resident and help them back to their room. Then, still without gloves or a gown, the director of nursing went over to help a COVID-19 negative resident.
“I mean those aren’t good things. Shouldn’t have been happening,” Greene said. “Having seen that I can understand why the investigators reacted the way they did.”
The way they reacted was with the strongest rebuke possible, a citation of immediate jeopardy.
Immediate Jeopardy at Skyview
More than half of Virginians who have died from COVID-19 were long-term care residents. With the elderly and disabled living in close quarters, nursing homes have been struck hard by the virus.
That doesn’t come as a surprise to experts. Infection control and emergency response have been a struggle for many nursing homes, even before the pandemic. According to ProPublica’sNursing Home Inspect tool, 85-percent of Medicare-certified nursing homes in Virginia have been cited for at least one infection-related deficiency in the past three years.
"The real kind of coordinated response that you want to see in a pandemic was just not in place here."
But even still, what happened at Skyview Springs is exceptional. A citation of “immediate jeopardy” is given when regulators see a mistake that is so egregious it could, or already has, seriously injured or even killed a resident. In the past three years, only one in 10 Medicare-certified nursing homes in Virginia have been given such a citation.
This spring and summer, state regulators have been rapidly inspecting nursing homes across the state in response to the pandemic. According to our analysis of the more than 240 inspections done so far, two facilities have been given an “immediate jeopardy” citation. And only one, Skyview Springs, had the citation extended after a second unannounced inspection.
Regulators immediately directed the facility to separate positive and negative patients and, when possible, they said staff should only work with one group or the other. It took the facility several attempts to write a corrective action plan that regulators approved of.
Mary Helen McSweeney-Feld, an expert on nursing home administration at Towson University, reviewed the inspection report. She says what happened at Skyview Springs is a tragic example of how the system for responding to emergencies like this failed.
“There were so many mixed messages that were sent here,” she said. “Was it the nursing homes fault? Was it the Department of Health’s fault? Was it the state survey team fault? The real kind of coordinated response that you want to see in a pandemic was just not in place here.”
McSweeney-Feld says it’s not realistic to expect all nursing home staff to be sufficiently trained for a disaster of this scope. Instead, she says, the burden should be on local, state and federal officials to have an emergency plan and a team of experts in place, ready to swoop in and triage immediately.
“If they had had a team like that that came in in April, maybe the result would have been better,” she said.
Amy Dean is vice president of clinical services for the management company Excelerate Healthcare Services. Dean declined to give details about the relationship between that company and Skyview Springs, but she did say she served as the interim administrator during the outbreak after the facility’s regular administrator tested positive.
Dean says more resources would have absolutely helped, describing the situation as a “staffing crisis.” She added that she didn’t think the outbreak was preventable. Local health director Colin Greene wouldn’t speculate on whether things could have turned out differently.
“It was a very difficult time. And it’s most tragic obviously for the people and their families, but for the folks taking care of them it’s heart wrenching,” he said.
By late July, the outbreak had mostly passed. According to Dean, the facility is now back to normal operating status. Outside, signs reading “Heroes Work Here” dot the grass.
The Virginia Home
Some Virginia nursing homes have been able to limit the spread of the virus and prevent deaths. The Virginia Home, a Richmond-based nursing home for adults with physical disabilities, has had a relatively small number of COVID-19 cases: thirteen residents and four staff members, with no deaths. All of the cases were confined to one floor, and staff detected the infections before the virus could spread farther.
The Virginia Home had an organized and coordinated effort, led by full-time medical director Dr. Mary Simmers. She delegated responsibilities, and put in place a methodical process for reusing personal protective equipment, commonly known as PPE. The facility had infection control protocols in place even before the pandemic.
"Their job [housekeeping] is just as important as anybody else's."
“Even a common cold could spread pretty quickly between residents and staff. So we took those situations pretty seriously and acted rapidly to try to prevent spread,” Simmers said.
For example, the Virginia Home would keep residents in their rooms even if they were sick with a cold or the flu. They also always have PPE on hand, which Simmers says should be standard for nursing homes. Hand sanitizer, disinfecting wipes, gloves and masks would all be placed on an “isolation cart” outside a sick resident’s room.
Before the pandemic hit, Andrey Akkerman was a speech and dental assistant at the Virginia Home. But when COVID-19 struck the facility in early April, his job changed overnight. He was quickly trained to be a monitor on the COVID-19 positive floor. Not only did Akkerman help ensure staff had enough PPE, he also helped make sure everyone – including housekeeping employees – were trained to safely put it on and take it off.
“Their job [housekeeping] is just as important as anybody else's within the facility to make sure we contain the spread of the virus, but they've never been trained to put on and take off PPEs,” Akkerman said.
Simmers also limited who could enter the COVID-19 positive floor, and how. There was a specific stairwell, complete with bleach footbaths for staff to clean the bottoms of their shoes. Simmers was frequently on the floor herself doing on-the-spot training.
“I would wear a special white coat and special shoes and then take those off before I went back, like to my office, for example,” Simmers said. “But the remainder of the staff on the affected unit only went in and out of that unit and didn't go anywhere else in the building.”
Simmers says, if anything, the facility was overstaffed. She says that partially explains Virginia Home’s ability to control the outbreak. Of the 200 staff members, she can think of only one who quit because of the virus. The average length of stay for staff is 12 years.
“I think we were able to be maybe a little more nimble and respond faster than nursing homes that had to wait and then get directives from the top down,” Simmers said.
Funding, Leadership and Staffing
The Virginia Home is a non-profit, which is rare. Four out of five nursing homes in the U.S. are corporate-owned, for-profit companies. Charlene Harrington, a national expert who has researched nursing home staffing for over 30 years, has found a correlation between quality of care and low staffing levels at corporate facilities.
Harrington said the U.S. should rethink how it delivers care to its most elderly and frail residents. She points to Norway as an example of greater oversight: localities own long-term care facilities, and contract with non-profit or for-profit organizations to run nursing homes.
“The cities have gotten rid of the contracts that haven't worked out well, and they can do that because they own the building,” Harrington said. “So they can just say, okay, we're not going to contract with you anymore. But in the U.S., almost all of the buildings and property is sold privately.”
Bob Crouse, CEO of the Virginia Home, says their facility did well because of two big factors: Simmers as medical director, and a non-profit model that allowed them to receive philanthropic donations in the form of money and PPE.
The majority of Virginia Home residents are 50 or older although some are younger. Residents often spend decades of their lives here, compared to end-of-life care at more typical nursing homes. The Virginia Home also gets extra Medicaid funding because the majority of residents have one or more of the following diagnoses: quadriplegia, traumatic brain injury, multiple sclerosis, paraplegia, or cerebral palsy. That helps make it possible for residents to have their own rooms, and a full-time medical director.
“Because we don't have to be quite so focused on the bottom line as most nursing homes, we prioritize that which we believe is in the best interests of the care that we're providing and the residents’ lives,” Crouse said.
In a recent study of nursing home outbreaks in California, Harrington found that the number one predictor of having an outbreak was staffing levels, particularly when it came to registered nurses. Facilities that didn’t meet the nationally recommended staffing ratio of four hours of daily direct care per resident, including 45 minutes with a registered nurse, were twice as likely to report an outbreak as facilities that did meet that recommended staffing level.
"As soon as I heard that there was a case there, I was like, okay, well, he's gonna get it. And he didn't."
Experts say not many nursing facilities are staffing at this recommended level. Federal guidelines require one registered nurse onsite from nine to five, seven days a week, and one licensed nurse onsite 24 hours a day, regardless of the number of residents. But Virginia is among the many states that don’t have a minimum staffing requirement for nursing assistants, who provide the bulk of one-on-one care.
Experts also say the leadership at the nursing homes is another important element when it comes to infection control. At Skyview Springs, interim administrator Amy Dean said their medical director only visits once a month. The majority of nursing homes don’t have a full-time medical director, even though it’s required by law that nursing homes employ a medical director.
“What that usually means is that they pay someone for about two hours of care of work a week just to oversee policies and be there for questions and things,” Harrington said. “So the nursing homes that have half time or full time directors are in much better shape. They have a much better quality of care.”
Rob Thompkins knew there was a difference in the quality of care at the Virginia Home before his father moved there in 2016 after seven years on a waiting list. But, Thompkins was still worried about COVID-19.
“As soon as I heard that there was a case there, I was like, okay, well, he's gonna get it,” Thompkins said. “And he didn't. And that in itself is wholly remarkable.”
***Editor's Note: Additional demographic information about The Virginia Home was added to this story after it was originally published.
This story was part of a COVID-19 reporting collaboration between VPM and RADIOIQ. It was co-reported by Megan Pauly and Mallory Noe-Payne.
