The leaders of three Camden County retirement communities — places that offer independent living, assisted living, and memory and nursing-home care — say they were doing everything they could to keep the coronavirus away from their residents.

They followed federal and state guidelines and more, they said. They stopped allowing visitors, activities and communal dining. Residents were largely quarantined in their rooms. Facilities screened staff members for exposure. They took temperatures. Staff wore masks everywhere.

And yet the virus got in anyway, with markedly different results. Allegria at the Fountains in Atco has had five cases among residents and four among staff. One resident died, having tested positive five days after entering the hospital for something else. At United Methodist Communities at Collingswood, 33 residents and 13 staff members have tested positive. Thirteen residents have died. At Lions Gate in Voorhees, 54 residents and 19 employees have tested positive. Twelve have died.

There may be lessons among them about preparedness, especially in the value of efficient testing. But even Avi Satt, the owner of Allegria at the Fountains, which held off the respiratory virus longer than many, said he sees no way to keep it out. On April 24, his community had its first positive case, in an assisted-living staff member.

“The weakest link when you’re trying to shut down a building like this is the staff, because they’re going home” after each shift, Satt said.

Satt thought infection with the virus, which can spread without symptoms, was inevitable. “You dream about having zero cases, but the reality of how this travels, it was a matter of when, not if …,” he said. “When it gets into your building, it hits hard. It doesn’t matter if you’re the nicest or the ugliest. It’s a vicious disease. It doesn’t give up for a second.”

The retirement community in the county with the most cases, Premier Cadbury of Cherry Hill, did not make an official available for an interview. According to the state, which lumps residents and staff cases together, that facility has had 93 cases and 20 deaths. It separately lists 13 more cases in Premier Cadbury assisted living.

Two assessments of Premier conducted for the county in April found that it was understaffed and did not have enough personal protective equipment (PPE).

Earlier this month, the county Board of Freeholders asked the state to assign a monitor to Premier Cadbury, United Methodist Communities and Lions Gate, along with two freestanding nursing facilities, Avista Healthcare in Cherry Hill (60 cases, 18 deaths) and Voorhees Center (160 cases, 30 deaths). It has since withdrawn that request for Lions Gate and Methodist because of improvements.

In a letter to freeholders, Premier Cadbury’s executive director, Meredith Becker, said the community is following all “state-mandated protocols.” Its first case was on April 6. By May 8, there were just eight positive cases remaining and 40 residents had recovered. The staff, she said, was “working day and night through this crisis to ensure we have proper staffing and adequate protective supplies.”

Community cases add to the risk

Coronavirus is especially deadly for the oldest adults and those with chronic health conditions. While those in assisted living usually have their own apartments and need limited hands-on care, people in nursing homes often have roommates and need close, personal attention, such as help with brushing teeth and bathing. Social distancing is not an option. People in independent living typically have less contact with medical staff. Resident leaders in two facilities said they had little contact with people in medical units.

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Coronavirus has raged in nursing homes across the nation, accounting for a high percentage of deaths, including in both Pennsylvania and New Jersey. Pennsylvania has not released information detailing the virus’ course through specific long-term care providers. Although officials and experts acknowledge that some facilities had staffing, training and infection-control problems long before COVID-19, they also often agree with Satt’s assessment that high-quality nursing homes also are vulnerable.

Two recent studies tied cases in nursing homes to larger size, urban location and cases in their surrounding communities. One study found that the number of cases in a nursing home correlated with community cases, possibly because staff members were infected outside work.

A facility’s government quality rating, whether it was a for-profit business, and how much of its budget came from Medicaid, did not predict whether it had cases, said David Grabowski, a health-care policy professor at Harvard University whose study looked at whether nursing homes had any cases, not how many. He said facilities with more staff, PPE and ability to group patients with similar disease status together might have better odds of avoiding major outbreaks.

Cases in nursing homes, he said, are “kind of an across-the-board crisis.”

According to the government website Nursing Home Compare, which rates homes on a scale of one to five stars, nursing homes at Allegria and Methodist had overall ratings of five stars, Lions Gate had four, and Premier Cadbury had two. Allegria and Methodist have about half as many beds as Lions Gate and Premier Cadbury.

As for payer mix, Medicaid covered 27% of patient-days at Allegria, 30 percent at Methodist, 39% at Lions Gate, and 56% at Premier Cadbury. Medicaid is less generous than other payers.

The virus arrived in many nursing homes before testing was readily available. Testing was usually restricted to people with serious symptoms and it could take days to get results — days in which the virus could spread.

Many facilities have since learned that symptoms can be subtle in the elderly: lethargy, low appetite, mild fevers. Wider testing revealed that many residents and staff members with the disease had no symptoms. Many nursing homes also struggled to buy masks, especially high-quality N95s, along with other protective clothing.

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She thought she was ‘ahead of the curve’

Satt said that he became alarmed in February after seeing reports of double-digit mortality rates from the new coronavirus in the oldest seniors in other countries. “It scared us to no end,” he said.

Before the rush, his company bought three months’ worth of food, PPE and janitorial supplies. By mid-March, he’d contracted with a lab that could give him test results in 24 hours.

Like Lions Gate and Methodist, Allegria stopped allowing visitors. Staff wore masks. They had their temperature taken and so did residents. Satt insisted that employees wear shoe covers and put their cell phones in plastic bags. He warned them about how easily the virus could get on their cigarettes. Cleaning was stepped up.

And still the virus came. Unlike in many facilities, all of Allegria’s cases have been in assisted living, where residents tend to be healthier than those in nursing homes. All residents who tested positive were sent to hospitals, an option often not available in nursing homes. Many nursing-home residents do not want to be hospitalized.

So far, there have been no positive cases in independent living or the nursing home. Allegria has been testing residents only if they had symptoms. A new state mandate will change that.

Lions Gate CEO Susan Love said she thought her community was “ahead of the curve” all along, enacting some restrictions before government recommendations. She said they had enough PPE, including face shields, although she asked for community donations in March to give masks and gloves to all their 330 residents. Love said staffing has been adequate.

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“I’m confident we’ve had everything in place since the beginning,” she said.

Early on, though, their lab limited testing, so Lions Gate could test only people with symptoms. They’d get five test kits every few days. Only in the last two weeks have tests become more available, allowing the community to test everyone in assisted living and skilled nursing. “If we had appropriate testing, it definitely would have helped and slowed things down,” Love said.

Most of Lions Gate’s cases have been in its nursing home, but there have been 18 in assisted living and one in independent living.

Their first case was on March 30, again in a staff member. As the numbers mounted, Lions Gate started testing more widely and found cases among people without symptoms. Love does not know how the first employee got it or how it spread. The community tried to confine sick patients to one floor of the nursing home and to assign specific employees to care only for them. Some assisted-living residents were also seen by outside private aides and hospice workers.

The average age of the 12 residents who died was 93, Love said. Four were on hospice care. Only five residents who tested positive went to the hospital. Most did not want to go.

He needed better testing

Jim Clancy, Methodist’s executive director, bristled last week after reading a news story that compared two facilities in Oregon, one with no cases and one 20 miles away that had many. The article praised the one with no cases for the steps it had taken.

Methodist had taken all those steps and more, Clancy thought. It "really, really jumped on this early and we had so many things in place going back to late February, early March,” he said. Methodist asked staff members who worked at more than one facility — a possible source of viral spread — to work in only one place. Employees were assigned to work in only one level of care to prevent spread within the community. Masks were hard to get, so they saved their N95s for positive cases, but they stocked up on KN95s, which are more effective than standard surgical masks. All employees started wearing surgical masks in mid-March and stepped up protection as the virus spread. The community’s respiratory therapist moved in.

Testing, though, was a problem. Staff members went to outside testing sites that lost samples or took a long time to report back. Methodist used its usual lab for resident testing. In April, it found a lab that could supply more kits and give faster results. That allowed it to test everyone.

“It would have been good if we’d had the ability to do universal testing on everyone to have a baseline,” Clancy said.

Methodist learned of its first case, a nursing-home staffer Clancy said had been diligent about wearing PPE, on April 11. The next day, Easter, brought the first resident case. The average age in the community’s nursing home was 92. Clancy’s mother, who has tested negative, lives there. Four nursing-home residents who tested positive, all in their 90s, never developed symptoms.

Seven of the 13 residents who died were on hospice. None wanted aggressive medical care, Clancy said. He takes comfort in knowing that "we abided by the wishes of every single one of them who passed away.”

Early last week, Love said Lions Gate had not had a case since May 2. “I’m beginning to have my fingers crossed," she said. "I think that we’re seeing a light at the end of the tunnel.”

Clancy was feeling hopeful, too. Methodist hadn’t seen a new positive case since April 29. “I believe we’ve definitely turned a corner, and things are starting to calm down,” he said Thursday morning.

But, after Lions Gate tested everyone in long-term care later in the week, an assisted-living resident without symptoms tested positive Thursday and an employee tested positive on Friday. Clancy, meanwhile, learned Thursday that another Methodist nursing-home resident had tested positive.

Staff writer Harold Brubaker contributed to this article.