The first warning of the devastation that the coronavirus could wreak inside U.S. nursing homes came in late February, when residents of a facility in suburban Seattle perished, one by one, as families waited helplessly outside.

In the ensuing six weeks, large and shockingly lethal outbreaks have continued to ravage nursing homes across the nation, undeterred by urgent new safety requirements. Now a nationwide tally by The New York Times has found the number of people living in or connected to nursing homes who have died of the coronavirus to be at least 7,000, far higher than previously known.

In New Jersey, 17 bodies piled up in a nursing home morgue, and more than one-quarter of a Virginia home’s residents have died. At least 24 people at a facility in Maryland have died; more than 100 residents and workers have been infected at another in Kansas; and people have died in centers for military veterans in Florida, Nevada, New York, Maine, Massachusetts, Oregon and Washington.

More on the coronavirus outbreak

On Friday, New York officials for the first time disclosed the names of 72 long-term-care facilities that have had five or more deaths, including the Cobble Hill Health Center in Brooklyn, where 55 people have died. In New Jersey, officials revealed that infections have broken out in 394 long-term facilities — almost two-thirds of the state’s homes — and that more than 1,500 deaths were tied to nursing facilities.

Overall, about one-fifth of deaths from the virus in the United States have been tied to nursing homes or other long-term care facilities, the Times review of cases shows. And more than 36,000 residents and employees across the nation have contracted it.

In interviews with more than two dozen workers in long-term care facilities as well as family members of residents and health care experts, a portrait emerged of a system unequipped to handle the onslaught and disintegrating further amid the growing crisis.

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“They’re death pits,” said Betsy McCaughey, a former lieutenant governor of New York who founded the Committee to Reduce Infection Deaths, an education campaign aimed at stopping hospital-acquired infections. “These nursing homes are already overwhelmed. They’re crowded and they’re understaffed. One COVID-positive patient in a nursing home produces carnage.”

It is a tragedy that is continuing to unfold, and one that even the dire figures that are known only partially capture. The number of cases at these facilities — which include nursing homes, assisted-living facilities, memory care facilities, retirement and senior communities and long-term rehabilitation facilities — is almost certainly still higher since many facilities, counties and states have not provided detailed information. The virus has hit a wide range of facilities, including some of those most highly rated by federal health authorities as well as those with the lowest ratings.

The virus is known to be more deadly to aging, immune-compromised people; and small, confined settings like nursing homes, where workers frequently move from one room to the next, are particularly vulnerable to spreading infection. But oversights and failures also have contributed to the crisis.

Virus tests and protective gear have been scarce inside many of these facilities, which are among the most overlooked players in the health care system. These homes, with staff members who receive less extensive training than those in hospitals, tend to struggle to slow infectious diseases. Employees are often poorly paid workers who move between multiple jobs and return home to communities at risk of contracting the virus.

All of these factors have allowed the virus to thrive, making its way into at least 4,000 U.S. nursing homes and other long-term care facilities, despite increasingly desperate efforts to stop the spread.

Facilities were late to require workers and residents to wear masks — and some were still not enforcing such policies, workers and family members said. Facing shortages of tests and masks, homes often waited, they said, until residents were showing symptoms of COVID-19 before testing them for the virus and isolating them from others, even if they had contact with people who had been infected.

“The residents and staff are being led to slaughter,” said Judith Regan, an editor and publishing executive whose 91-year-old father, Leo Regan, lives at the Long Island State Veterans Home at Stony Brook University. At least 52 residents and 34 staff members there have tested positive for the virus.

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“He is on the Titanic, but there are no lifeboats,” Regan said of her father, adding that she is hesitant to call him to prevent him from being brought to a common space to use a shared phone. Officials at the veterans home did not respond to requests for comment.

Trouble with staff, supplies

Employees at some facilities have stopped coming to work. In California, 83 patients with the virus had to be evacuated from a nursing facility in Riverside County after only one of 13 scheduled certified nursing assistants appeared at work, public health officials said. Sixteen employees and dozens of patients had tested positive days earlier.

Even now, protective gear is in short supply at many homes. One nursing assistant at a Detroit nursing facility said she had been issued an N95 mask but had to make it last three weeks. With no gowns available, she said she and her co-workers were being told to suit up in the same gowns that patients sleep in.

In Miami, Rosa Mercedes, a certified nursing assistant at a residential facility, waited in line in her car for a coronavirus test Thursday at the Hard Rock Stadium. She said her facility, which she declined to name, provides her with one mask each day as she feeds, bathes and helps multiple patients use the bathroom.

Patients have grown ill, though she has not been told who has the virus, she said, and the number of patients she has been assigned has grown as other workers have become ill or been told to quarantine.

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Now she has a cough and sore throat.

“I don’t know if I have it or don’t have it,” she said. “Everybody’s living in a nightmare.”

‘We don’t have what we need to stop this’

Nursing home industry officials acknowledged this week that many of their facilities were in crisis and said they lacked the protective equipment and testing that hospitals have received.

“We don’t have what we need to stop this,” said Mark Parkinson, president and chief executive of the American Health Care Association and the National Center for Assisted Living, a trade organization that represents skilled nursing facilities and assisted-living homes that house more than 1 million people. “We have got to have masks, and we don’t have masks.”

Parkinson said that federal health authorities have designated nursing homes and long-term care facilities at a lower priority level than hospitals, meaning a longer turnaround times for test results — a significant problem for slowing spread.

He said that many employees, who don’t have the option of isolating themselves from sick patients who must be fed and bathed, have gone to heroic lengths to continue to care for residents but that best efforts can fall apart once the virus has spread to staff members.

“The cavalry hasn’t arrived,” Parkinson said. “We need the health care world to embrace long-term care facilities the same way they did hospitals. And I don’t see that happening. People will end up blaming nursing homes and talking about how terrible we are, but it is the complete lack of prioritization that has put us in the position that we are in.”

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Nursing home facilities have borne the brunt of a structural shift: Hospitals, seeking to keep costs down, send more patients into a growing industry of nursing homes. Vulnerable residents become hosts for viruses and bacteria, which then get transferred back and forth to hospitals when the residents face acute challenges. Even before the pandemic, 380,000 people died each year from infection at long-term care facilities, according to the Centers for Disease Control and Prevention.

The Centers for Medicare and Medicaid Services, which regulates the nation’s more than 15,000 nursing homes, issued new guidance last month, telling administrators to restrict all visitors, cancel group activities, shut down dining rooms and screen all residents and staff members for fevers and respiratory illnesses.

Families of nursing home residents said some of the new restrictions were enforced unevenly in some homes; unlocked front doors in some places, for instance, have failed to stop visits.

But the measures were not always enough to slow the virus even in places where they were enforced. Nursing home staff members could still unwittingly carry the virus inside facilities, according to David Grabowski, professor of health care policy in the Department of Health Care Policy at Harvard Medical School.

“They have been at the back on the line for protective equipment,” he said. “The infection control expertise that we have in other parts of the health care system is really lacking in nursing homes.”

At Canterbury Rehabilitation and Healthcare Center in Richmond, Virginia, where many residents rely on Medicaid to cover costs, triple rooms are not uncommon. The facility has struggled to hire and retain nursing staff. As recently as October, federal investigators found nearly two dozen deficiencies at the facility, including a lack of appropriate respiratory care for a resident and a lack of appropriate ulcer care.

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When a few cases of the virus cropped up at Canterbury in mid-March, the state had only a few hundred test kits available, limiting officials’ ability to figure out how far it had spread, according to Dr. Danny Avula, the local county’s health official. By the time officials were able to test everyone a few weeks later, more than 60 residents tested positive, including some who did not show symptoms. At least 46 of the facility’s estimated 160 residents have died from the virus, making it one of the deadliest clusters in the country.

“Nursing homes were not designed to deal with this kind of crisis,” Avula said.

Employees at nursing homes often toil at low pay without much recognition, caring for chronically ill patients who are unlikely to recover. Even in the best of times, the facilities struggle to retain staff, and families of residents of some facilities heaped praise on staff members for risking their own lives to keep working.

The situation has led anxious families to agonize about whether to try to bring their loved ones home. But many cannot provide the extensive medical care that is required and fear exposing others to the virus. As they wrestle with what to do, many say that they are being given little information about what is happening inside the homes.

‘Totally horrifying’

“It’s totally horrifying — I can’t even describe the feeling,” said Adam Zimmerman, whose 77-year-old mother lives in an acute-care facility near Los Angeles where cases of the virus have been identified. He said he speaks by phone regularly with his mother, who has a tracheotomy and medical conditions, but has not been able to visit her in weeks.

“My mom is kind of like a sitting duck,” he said. LA County publishes a list of long-term care centers with outbreaks, including the Van Nuys facility where Zimmerman’s mother is being treated, but officials have not said how many cases are in each center. Many states and counties do not publish any information about nursing home outbreaks, and facilities vary widely in how many details they release.

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At a facility in Flushing, New York, there had been no indication of a problem, a grandson of a resident said, until last week when he received a call that his grandfather, who has Alzheimer’s, was gravely ill. He was coughing hard and had a fever.

About 24 hours later, the man had been transferred to a hospital and was sedated and on a ventilator, his grandson said. By Sunday, he was dead. Only later was the family told that the man had tested positive for the coronavirus, according to the grandson, who wanted to be identified only by his first name, Andrew, because his grandmother is still in the nursing home and has yet to be told of her husband’s death. She, too, has tested positive for the virus, he said.

“I know some people would look down on the decision my parents made to put him in the nursing home, but I remember seeing the stress my parents were under,” Andrew said. “It was an impossible situation.”

He said it broke his heart that his grandfather died alone.

“I couldn’t even hold his hand,” he said. “He couldn’t speak English, and he was just surrounded by strangers. I can’t imagine how scared he must have been.”

Some facilities have found creative ways to combat the virus. At the Park Springs Life Plan Community in Stone Mountain, Georgia, four staff members and one resident have tested positive for the virus, but they have fully recovered. The facility decided to take a rare step: It asked staff members to volunteer to live on the campus to avoid inadvertently carrying the virus into the facility from home. Sixty workers volunteered. Ginger Hansborough, the facility’s accounting director, who normally lives with a partner and his octogenarian mother, moved in, not only to protect residents at the facility but also to protect her family.

“I didn’t want to be the reason that anything happened to them,” she said.

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(Anika Varty / The Seattle Times)