In late March, staff at Canterbury Rehabilitation & Healthcare in Henrico turned to Genetworx, a private diagnostic lab in nearby Glen Allen, to begin testing residents for COVID-19 — the disease caused by a new strain of coronavirus.
The Henrico County Health Department urged them to be cautious. In a March 25 letter to Dr. Jim Wright, medical director of the long-term care facility, Henrico Health District Director Dr. Danny Avula pointed out that the company hadn’t yet been cleared by the U.S. Food and Drug Administration to run tests for COVID-19.
“[Emergency use authorization] and [Clinical Laboratory Improvement Amendments] status is still pending for their COVID-19 assay,” Avula wrote, referring to federal designations designed to ensure the tests deliver accurate results. “We understand the need to utilize this capability in the setting of an outbreak to attempt proper cohorting. In particular, a negative should be cautiously interpreted if the clinical signs and symptoms are consistent with COVID.”
Wright said the facility had no choice. Canterbury had reported its first suspected case of coronavirus two weeks before Avula sent the letter — a follow-up to two onsite visits by the Virginia Department of Health. By late March, nine residents had confirmed cases, two had died, and three health care workers were sick.
While the first few residents began displaying symptoms on March 11, VDH didn’t begin testing patients at the state lab until March 17, Wright said. Even then, residents had to meet onerous requirements to qualify for the state’s rapid-turnaround testing.
Wright said that included first testing negative for influenza and other viral respiratory diseases, a process which could take up to a week. The deal with Genetworx wouldn’t be finalized until March 23. So, for the first crucial days of the outbreak at Canterbury — among the most deadly wave of COVID-19 cases known at any long-term care facility in the U.S., The New York Times reported last week — staff were sending samples to a lab in California to try to learn whether the virus was spreading among its intensely vulnerable population.
“That was a time when Virginia simply did not have access to rapid testing,” Wright said. By the time the facility received those initial results, on March 22, its first resident had died from the disease.
It would take another eight days for Gov. Ralph Northam to declare a full stay-at-home order for Virginia, and more than two weeks for him to announce a long-term care task force to direct resources to the state’s nursing homes and assisted living facilities.
Between the start of the outbreak at Canterbury and the task force’s first meeting on Thursday, more than 40 residents at the facility would die (the death toll was approaching 50 as of Sunday) and at least 63 other long-term care facilities would report their own outbreaks, according to data on the VDH public surveillance dashboard, which often lags behind other reports.
‘I really believe there was nothing we could have done’
The outbreak at Canterbury was one of the first in Virginia, and by far the most deadly. But health experts and insiders say that existing vulnerabilities within the long-term care industry, coupled with critical gaps in knowledge and delays on the part of state health officials, compounded the spread of disease in ways that likely led to similar outbreaks in other facilities.
“It was just our horrible luck to get this infection at a time the state was not ready for it,” Wright said. “I really believe there was nothing we could have done.”
Even before the start of the COVID-19 pandemic, the Henrico facility had a mixed reputation and long history of violations with the state’s licensing requirements for nursing homes. One survey in October 2019 — when the center, then called Lexington Court Rehabilitation, was under different ownership — found more than a dozen citable offenses, from patients with bedsores to lapses in infection control protocols.
At the start of 2020, the facility was purchased by Marquis Health Services, a New Jersey-based corporation with nursing and rehabilitation centers up and down the East Coast. The transfer in ownership bolstered Canterbury’s resources, said Wright, who’s been with the facility since 2010. A follow-up survey on Feb. 6 found no deficiencies, according to documents provided by VDH.
Joani Latimer, the state’s long-term care ombudsmen, said it’s unclear how quickly the change in ownership could have resolved long-standing problems at the facility before Virginia’s first confirmed case of COVID-19 on March 7. But she pointed out that Canterbury was far from the only nursing home with reported lapses in care.
A recent analysis by The Virginian-Pilot found that at least 77 percent of the state’s nursing homes had been cited for failing to meet infection prevention and control regulations over the last three years. Canterbury currently has an overall Medicare rating of two stars — meaning that it’s “below average” based on the agency’s most recent three inspections. But of the 29 other long-term care facilities within the same 25-mile radius, 16 are rated the same or below Canterbury.
“I think it’s fair to say that it could happen in many facilities in the state because many facilities struggle with the same issues,” Latimer said. “Canterbury’s not alone. And I think that any facility with a lot of turnover, that lacks adequate staffing, is liable for this kind of breakdown.”
Many of the conditions that led to widespread transmission at Canterbury are endemic to publicly funded nursing homes across the state, Avula said. According to Wright, more than 90 percent of the facility’s long-term care residents pay through Medicaid, which offers limited reimbursement rates to facilities. The vast majority share rooms. And staff — frequently among the lowest paid workers in the health care industry — regularly work second jobs at other long-term care facilities in the area.
“It’s very, very common within the industry,” said Dana Parsons, vice president and legislative counsel for LeadingAge Virginia, an association of nonprofit senior living centers. It also became a major weakness in Canterbury’s efforts to control the spread of the disease.
Avula said it started with the slow rollout of a mandatory stay-at-home order for Virginians. While Northam issued a ban against large gatherings on March 15 — and closed schools, entertainment, and personal care businesses on March 23 — it took him (and other regional leaders) another week to emphasize that residents should remain home for all but the most essential errands.
“A lot of health care workers and individuals everywhere were not necessarily avoiding the grocery store or not going out in public,” Avula said. “It was a very different behavioral, societal context. But now, I think it’s pretty clear that health care workers have been a big contributor to spreading the virus prior to the development of symptoms.”
The early onset of COVID-19 at Canterbury also worked against the facility, Avula added. By the time the virus hit, the Life Care Center in Kirkland, Washington had recorded more than a dozen resident deaths, and there was widespread understanding that older Americans — especially those with preexisting conditions — were most at risk of dying from the disease.
What many health experts still didn’t understand were the mechanisms behind the spread. Avula said it wasn’t until March 27, when the New England Journal of Medicine published a report on transmission within nursing homes in the Seattle area, that he and other state officials understood how extensively the virus could be transmitted by asymptomatic patients. At the end of March, the Centers for Disease Control and Prevention warned that as many as a quarter of people infected with the virus might not show symptoms.
That became a period of reckoning for Canterbury and long-term care facilities across the state, Avula said. Epidemiologists already suspected that the disease entered Canterbury through an infected visitor or staff member. “Statistically speaking, we have many more employees who work here than visitors, so that’s probably how it spread,” Wright added.
With the sudden realization that asymptomatic health care workers could be spreading the disease to other facilities, Avula said he asked Virginia’s Health Commissioner, Dr. Norman Oliver, to prohibit health care workers from working at more than one long-term care facility. Oliver declined, later explaining that “health care workers are not an infinite resource.”
Oliver — and many health officials — worried that mandated restrictions would further exacerbate staffing shortages at long-term care facilities across the state, Avula said. It remains a contentious debate, especially given VDH’s ongoing guidance to test only symptomatic health care workers.
Canterbury asked staff members to sign voluntary waivers promising to limit their work to that facility. But Avula said there was no way to enforce it. Staffing agencies are also reluctant to send workers to facilities demanding those restrictions, Wright said, especially given the low pay and high risk of exposure.
“I think that requirement is completely untenable,” he added. But Latimer said the alternative was just as risky.
“It opens such a wide portal for introducing infections, to have staff crossing between multiple facilities,” she added. “You have to find a way to restrict that. And you can’t fault staff, because they’re just trying to eke out a living.”
On April 15 — nearly a month after the first lab-confirmed case of COVID-19 at Canterbury, and more than two weeks after the release of the Life Care Center study — Northam called for additional volunteers to enlist in the state’s Medical Reserve Corps, estimating that “up to 30,000 volunteers are needed to provide support for the expected surge in hospitals and long-term care facilities throughout the commonwealth.”
For some facilities, it was a step in the right direction, if a step too late. After a critical staffing shortage between March 25 and April 1, Wright said Canterbury was able to recruit new workers through a third-party staffing agency and with help from Marquis, which sent additional employees from other nursing centers along the East Coast.
Other facilities have implemented their own plans for reducing the risk of transmission by health care workers. David Abraham, the CEO of Beth Shalom Village in Virginia Beach, said he’s asked all health care workers with jobs at more than one facility to choose between his site and their other workplaces.
“If they choose us, we’ve guaranteed to make up their wages at the other facility,” Abraham added. Beth Shalom Village has also established an isolation ward for all new admissions and relegated some staff to working in that area alone for an additional $4 an hour. That’s in addition to an across-the-board pay increase of $1 an hour for any staff member with five years or less of experience, and $1.50 for anyone who’s worked there between five to ten years.
“I will certainly tell you that through June, without even factoring in the $4 an hour increase for the isolation ward, our staff expenses are expected to increase by $75,000,” Abraham said.
For Beth Shalom Village, the increase in staff spending is tacked onto the roughly $100,000 it’s taken to increase the facility’s supply of personal protective equipment for frontline workers — another major challenge in containing the spread of COVID-19 at Canterbury and other long-term care facilities, Avula said.
In the early days of the epidemic, multiple long-term care facilities reported receiving little to no supplies from Virginia’s six regional health care coalitions, the agencies in charge of distributing the state’s allotment of supplies from the national Strategic National Stockpile. Documents from FEMA later showed that the state was receiving a fraction of the equipment it requested from the federal government.
In early April, Northam announced that the state signed a $27 million contract with Northfield Medical Manufacturing, a logistics company based in Norfolk, to supply more protective gear for health workers. But his office has yet to provide more details on the order, and it’s still unclear how much of the equipment will be allocated to long-term care facilities.
Latimer said that the state’s latest steps, including the long-term care task force and promise of additional Medicaid payments to struggling facilities, are encouraging signs of progress. But Abraham said that many long-term care facilities are also growing more financially vulnerable as their number of short-term stays decrease, driven by a ban on elective surgeries at hospitals.
The same patients who receive services such as joint-replacement surgeries frequently book limited stays at long-term care facilities for rehabilitation before returning home, he added. Those patients — who often pay independently or through Medicare, which offers better reimbursement rates — are profit-drivers for many senior living centers.
“So, not only do you have increased expenses now, but those kinds of stays are continuing to go down,” he said. At Beth Shalom Village, they’ve decreased by 20 percent since the start of the pandemic. As it continues, Abraham said the volume will only get lower.
The uncertainty has led to rising anxiety among long-term care centers, their residents, and families who depend on their care. Since the start of the pandemic, Latimer said she’s received complaints from families who said they’ve been left in the dark about outbreaks at certain facilities — or unable to contact their loved ones who live there. But the extent of the issue is difficult to track, she added.
“I don’t know if we’re getting as many of these complaints as we ordinarily would,” she said. “Most of these facilities are closed to outside visitors, as they should be, to reduce the risk of transmission. But if no one is getting in, it’s not as likely that they’re going to reach out to us.”
State health officials have repeatedly declined to publicly release the names of long-term care facilities with COVID-19 outbreaks. The Mercury requested a list of facilities that have been investigated between March 15 and April 15, but was told that VDH would require an extension to provide the information, pushing the release to the end of April, according to an email from Virginia Pierce, an analyst with the department’s Office of Licensure and Certification.