During the overnight shift at a Bellingham nursing home, residents have started dropping by the nurses station again.

Some are in pain from a recent procedure, or “sundowning,” a common symptom of dementia marked by confusion and restlessness as night falls. Others are night owls, or anxious from not seeing family members for so long. Still more stop by for no reason at all — everyone eventually has a sleepless night.

Shelly Hughes, a certified nursing assistant at North Cascades Health and Rehab, has vitals to take and supply closets to stock. But she is happy to see people start to come out from their rooms. She must guide them back — but this is progress. For nearly a year, the station has been quiet, as COVID-19 shuttered so much of life inside the facility and out.

Nursing homes have absorbed so many of the cruel blows of the pandemic. Long-term care facilities, which include nursing homes, assisted-living facilities and adult family homes, account for half the state’s now-almost 5,000 deaths, since the very first outbreaks in the U.S., in the Seattle area. Those rightly stoked fears about the virulent spread of the new disease and the vulnerability of so many seniors, often frail, living so close together.

“A year ago, being at work, it was scary and you never knew what you were coming into,” Hughes said. “You came in, and thought ‘OK, is this the day I find out we have an outbreak? Am I going to show up and be the only person here?’”

“A year ago, being at work, it was scary and you never knew what you were coming into,” says certified nursing assistant Shelly Hughes, who works at North Cascades Health and Rehab.  (Courtesy of Shelly Hughes)

Some of the fear has diminished. Nearly all residents in Bellingham have received both doses of the COVID-19 vaccine, and a good majority of staff have as well. They have the masks and gloves they need.

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Hughes has more time now to focus on taking vitals and stocking cabinets, and more to talk to residents who might not have anyone else to speak with. But in the dead of night, she also has more time to reflect on a crisis that began a year ago at another nursing home, 88 miles away.

On Feb. 29, 2020, health officials reported the first deaths in the U.S. attributed to COVID-19, which at the time had killed about 2,900 people worldwide. Those deaths were connected to Life Care Center of Kirkland, a nursing home where dozens of people were sickened and more than 40 died.

Life Care wasn’t an outlier. The nursing home was an omen of how devastating the virus would be in these facilities, in Washington and throughout the U.S.

A year since the first death at Life Care, nearly 200 nursing homes have experienced at least one outbreak, and some have had multiple, according to the Washington State Department of Social and Health Services. Only a handful of buildings have gone without a single infection.

In King County, 455 people connected to nursing homes have died, accounting for a third of the county’s total deaths.

Nursing homes were prioritized for vaccinations, and received doses in December and earlier this year. The number of facilities with active cases continues to decrease from its highest points last year, when as many as three-fourths of all such facilities had at least one resident or staff member with an active infection.

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Dr. Sabine von Preyss-Friedman, former medical director of Issaquah Nursing, receives the COVID-19 vaccine. Von Preyss-Friedman is now chief medical officer for Avalon Health Care. (Courtesy of Dr. Sabine von Preyss-Friedman)

For the first time in a year, there wasn’t a single new COVID-19 case last week at any long-term care facility in King County, according to Dr. Jeffrey Duchin, health officer for Public Health — Seattle & King County. Duchin called this “tremendous news.”

The direct and indirect impacts of the pandemic remain. At one nursing home, a worker walks in for her shift with no one she knows well — many of the staff members she worked with before quit. At another, a woman no longer recognizes her daughter — a year of isolation accelerated her dementia decline. A longtime nurse struggles with survivor’s guilt — she recovered from the virus, while so many of her residents didn’t.

And in Issaquah, Michelle Bennett will occasionally drive by the nursing home where her mom used to live and think about stopping by to say hello, or almost stop at a McDonald’s drive-thru to grab french fries to take to her for a late-night treat. Then she remembers.

“Hardest thing to watch”

It still doesn’t seem real: Bennett’s mother becoming ill with COVID-19, saying goodbye to her through a nurse’s cellphone, overhearing a man at a park blabbing about the pandemic being a ploy of the government. Bennett and her siblings still haven’t had a funeral for Carolann Christine Gann, who died March 26 at age 75.

Gann was a resident of Issaquah Nursing and Rehabilitation Center, which shared staff members with Life Care and reported cases just days after the Kirkland facility.

Michelle Bennett says goodbye to her mother, Carolann Gann, 75, who was hospitalized with COVID-19 at Swedish Issaquah. Gann died March 26.  (Courtesy of Michelle Bennett )

At the time, no one knew how the virus was spread, or about asymptomatic spreading, so even when Issaquah went into lockdown and screened the staff, someone still brought the infection inside, recalled Dr. Sabine von Preyss-Friedman, then-medical director of Issaquah Nursing, which had about 100 residents.

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There wasn’t enough personal protective equipment, she said. Von Preyss-Friedman bought goggles from Home Depot, gowns were fashioned from raincoats, no one was even talking about N95 masks yet.

“You saw staff going in and risking their lives on an everyday basis, and I couldn’t provide them what they needed, not for all the money in the world,” von Preyss-Friedman said. “That was the hardest thing to watch.”

Even harder: Residents were dying and there was nothing to be done. As the virus spread around the building, Gann left a spotty voicemail for her daughter that she had tested positive. With no visitors allowed at the hospital, Bennett said goodbye to her mom, a former Harborview nurse, over FaceTime.

Gann was one of 19 people connected to Issaquah who died, according to Public Health — Seattle & King County. Her belongings remain at Bennett’s house, because her siblings haven’t been able to pick them up.

“It’s like there’s no closure,” said Bennett, a retired King County Sheriff’s Office major and former Sammamish police chief. “She had prepaid for her ceremony, and all of the things that go with the service, and it’s all done, and it’s all lined out. We just can’t have it yet. I don’t know when we are going to be able to have it.”

She won’t go to the cemetery, she said, until after they have the funeral.

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Restarting inside, but no visitors yet

Colleen Mallory just wants to hug her mom again.

Her mother, 90 and who has dementia, sits each day in her room at Life Care Center of Kirkland, with little stimulation, save for the TV that’s on, though she was never much of a TV person. She preferred interacting with people. She’s alone in her room; her roommate died of COVID-19.

During window visits, sometimes Mallory notices tears in her mom’s eyes, but she won’t look at anyone if something is wrong. 

“I heard she went to group exercise this morning, so that might be a start,” Mallory, who lives in Lake Stevens, said last week. “Get her out of her room.”

In nursing homes across the state, workers, loved ones and advocates say they’ve witnessed a heartbreaking, indirect impact of the pandemic, caused largely by a lack of visits: residents failing to thrive and declining far faster than they would have otherwise.

“They’re dying of broken hearts, and there doesn’t seem to be much we can do, even though we are trying our best to help these people heal and make it out of the pandemic with us,” said Hughes, the Bellingham nursing assistant.

 “When they are cut off from friends and family, they just give up. It’s the loneliness of not being able to see people who keep you going.” Hughes recalled one resident who tried to rip a screen off a window while visiting his wife, to get closer to her.

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Indoor visits, in most cases, have yet to formally resume. A facility has to meet several criteria to open its doors, divided into four phases, with indoor visits in the third and fourth phase. The third phase, for example, requires being in a county with 25 or fewer new cases per 100,000 residents.

Von Preyss-Friedman, who is president of the Washington State Society for Post-Acute and Long-Term Care Medicine and a member of a state COVID-19 advisory group, said she’s advocating for relaxed restrictions, but acknowledged there’s still worry about potentially infecting a resident or staff member when most people haven’t been vaccinated yet.

Some nursing homes are restarting socially distanced group dining and activities. At Stanwood’s Josephine Caring Community, which had two large outbreaks, residents got together for Bible studies and stability ball exercises.

“For a year, we were living the most dangerous part of the world, in a nursing home,” CEO Terry Robertson said. “Now, we are probably the safest. It feels pretty good.”

Longstanding struggles

The pandemic brought nursing homes into the spotlight, but the factors that made them so deadly were reminiscent of longstanding problems: low-paid and overworked staff, funding gaps, those connected to nursing homes feeling like an afterthought because of ageism.

“We want to think about retirement and sitting on a beach in Florida, and nobody wants to think about needing nursing-home services,” said David Grabowski, a health care policy professor at Harvard Medical School who has served on several long-term care expert commissions. “Yet life doesn’t end when you enter a nursing home. I hate that term ‘putting someone in a nursing home.’ It makes it sound like you are ending their life.”

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Some workers and administrators remain bitter that nursing homes and other long-term care facilities were left to bid against big hospitals for the same resources and supplies, and hospitals usually won out. Less attention was paid to the upstream nursing homes, where the infections were originating, von Preyss-Friedman said. A year in, that’s improved, with widespread testing and priority vaccinations.

“But that doesn’t take away from the fact that hundreds of thousands of nursing-home patients died from [COVID-19], and several thousand staff died, too,” she said. “It’s easy to say that it’s dirty nursing homes that didn’t do it right, but that’s not correct.”

The pandemic also revealed the longtime struggles related to staffing and the overarching views of nursing-home jobs. When Sheila Julich, who worked at Life Care Center of Kirkland for decades, first started, people tried to persuade her to work elsewhere, because “you’re not a good nurse if you go to a nursing home.”

No, she would say. I’m going because I’m a good nurse.  

Hughes, who is active in her union, SEIU 775, said she plans to advocate for more state and federal funding for nursing homes. She said she earns about the same wages as her mother earned 20 years ago, working for the same company.

Sheila Julich, a former Life Care Center of Kirkland nurse, fell ill with COVID-19 and still feels guilty that she survived and so many others didn’t. (Erika Schultz / The Seattle Times)

Survivor’s guilt, a nurse’s hope

At noon on Feb. 26, 2020, feverish and pale, Julich, an on-call nurse, walked out of Life Care Center of Kirkland. She hasn’t been back since.

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Julich still wonders why she survived COVID-19 and so many of the residents at the nursing home she dedicated herself to died. At 79, she was about the same age as many of them, and even older than a few.

On her way out the door, she saw another resident sitting nearby, who yelled “Sheila!” and motioned for Julich to come over. Julich waved, but called out that she was sick and needed to keep her distance. The resident later died of COVID-19.

“I was sitting at home and asking, ‘why am I surviving?’” said Julich, who lives in Kirkland. “You see their lives, and their lives were so much more worthy than mine.”

Julich donated plasma six times and took part in University of Washington COVID-19 studies. Once a nurse, always a nurse, she says. It’s helped her survivor’s guilt.

In Bellingham, Hughes remains on the night shift, attending to residents who wake up in the middle of the night.

“This is a calling, this is what I am meant to do,” she said. “I love my job, for all its drawbacks and difficulties and heartbreak. Hopefully soon, we will see some changes.”

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The best day, she says, will be when she can finally take off her mask. When residents can finally see her smile.