As the coronavirus pandemic barreled through New Jersey’s nursing homes this spring, 524 residents of the six New Jersey facilities that Sidney Greenberger’s company owns tested positive. More than a quarter of the people — 137 — died.

“It was the most harrowing experience in my professional lifetime, and I’ve been in this for almost 30 years,” said Greenberger, who is CEO of AristaCare Health Services. He contracted the disease himself in April after a family gathering that led to 17 other cases.

“We can’t go through this again.”

Sidney Greenberger is CEO of AristaCare Health Services, which operates 14 nursing homes in Pennsylvania and New Jersey.
Courtesy of Sidney Greenberger
Sidney Greenberger is CEO of AristaCare Health Services, which operates 14 nursing homes in Pennsylvania and New Jersey.

For weeks, nursing homes and other long-term care settings were COVID-19 battlegrounds in the region, accounting for 68% of deaths in Pennsylvania and 49% in New Jersey. Access to better testing for the virus and more personal protective equipment (PPE) for staff has now brought cases in long-term care way down.

In Pennsylvania, deaths associated with long-term care settings have fallen from about 110 a day in early May to fewer than 10. In Philadelphia, deaths increased by 308 between April 22 and May 22, but just 35 between June 7 and July 7. Bucks saw a similar change with new deaths during the earlier time period at 293 and 28 during the more recent month. In South Jersey, cases in long-term care facilities have fallen by 85% to 95%, according to its state Health Department.

“The first wave is over,” said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, a trade group for nursing and personal-care homes.

Pennsylvania Secretary of Health Rachel Levine said cases in long-term care settings have “stabilized” throughout the state, even in Allegheny County, where they are rising among young people.

No one thinks the virus has been vanquished, but long-term care leaders are using the lull to evaluate what they have learned as well as to stock up on supplies they’ll need for a future onslaught.

“We’re anticipating and assuming that there’s going to be a second wave,” Greenberger said.

He and other nursing-home leaders said they know much more about the virus now and may be able to fight it more effectively. “We believe that, even if COVID comes into a building again, we are better prepared … to keep it from spreading as rapidly as it did the first time,” said Jim Bernardo, CEO of York County-based Presbyterian Senior Living.

What about surges in other states?

Administrators are watching warily as cases surge in Southern and Western states. Those increases mean more competition for PPE and lab capacity. There already are reports of new shortages and mounting turnaround times for test results. Getting quick results is essential in senior facilities, where the insidious virus often spreads easily and invisibly.

“If we’ve learning anything through our experience, it’s that it’s very difficult to keep the virus completely out of a nursing facility,” said JoAnne Reifsnyder, chief nursing officer for Genesis HealthCare. The goal then becomes reducing spread.

JoAnne Reifsnyder is chief nursing officer for Genesis HealthCare.
Courtesy of Genesis HealthCare
JoAnne Reifsnyder is chief nursing officer for Genesis HealthCare.

Levine said health authorities had expected to use this time to prepare for a fall resurgence. “The plan nationally was that we were going to have a quieter summer,” she said. “As you well know, it has not worked out like that.”

It remains to be seen whether nursing homes and assisted-living facilities in states now getting hit will be able to keep cases down. They’ve had many more months to prepare than facilities in states like New York, New Jersey, and Pennsylvania, which not only faced equipment and testing shortages, but had to learn about the virus on the fly. When the coronavirus arrived here, many facilities thought they could keep it at bay by taking temperatures and looking for symptoms, not realizing how often it can spread without either.

Throughout the pandemic, long-term care leaders have complained bitterly that state and national officials did not make their centers a high enough priority, given that it was always obvious that nursing-home residents were in special danger. Data from China, where the virus emerged late last year, made it clear that older people are at high risk for serious illness and death.

“I’ve spent my entire career dedicated to the service of seniors in multiple locations,” Bernardo said. “I am angry and I am frustrated because the system failed the most vulnerable people.” He said that only about half of the PPE his nursing homes received in a federal shipment was usable. Masks had broken straps. Gowns were flimsy painters’ tarps with holes cut in them. “It was garbage. Garbage.”

Jim Bernardo is CEO of York County-based Presbyterian Senior Living.
Courtesy of Presbyterian Senior Living
Jim Bernardo is CEO of York County-based Presbyterian Senior Living.

Now, it’s even more clear that one way to reduce death rates is to keep the coronavirus away from people in care homes. Area long-term care leaders said government support and understanding of their predicament have improved, but Vincent Mor, a Brown University health services expert, said nursing homes are still not a high priority.

“They should be, but I don’t think they are,” he said. “People are still more worried about hospitals and hospital capacity.”

Levine said that nursing homes are a state priority and that they have gotten PPE shipments “almost exclusively” in recent weeks. Pennsylvania has mandated one round of universal testing, and she said they’ll need to do more. The state is also creating regional programs that pair nursing homes with academic medical centers.

Community ties

Many are eager to blame COVID-19 deaths in care homes on poor quality care. But research by Mor and others has found that the factors that correlate best with coronavirus cases are the amount of COVID-19 in the surrounding community and how large a facility is. Larger buildings have more staff, and staff members, especially those without symptoms, often bring the virus to work.

“It’s really a social and societal issue,” he said. ”It’s not about a couple bad apples.”

That profile could change now that the virus is exploding in regions where nursing homes and governments have had more time to prepare, Mor said. Better-run or better-funded facilities might get better results during this go-round.

Mor, who has analyzed state and federal data along with detailed information from Kennett Square-based Genesis Healthcare, said the most important factor for preventing large numbers of nursing-home cases is early warning. That requires testing staff at least weekly when the virus is in their community. Using current nasal swab kits, that level of diagnostic testing would quickly overwhelm processing labs. “We need to have better, more rapid, point-of-care testing,” he said. Such tests, which can yield reports in less than an hour, are not widely available.

Staffers also need good PPE, including masks and face shields, but that will never completely contain the virus, he said. Imagine what happens when two nursing assistants have to work together to move a 170-pound resident, who may not tolerate wearing a mask, from bed to chair. Their faces are inches apart, and they are breathing heavily from exertion. “Having PPE reduces the problem,” he said. “It doesn’t make it go away entirely.”

In the early days of the pandemic, nursing homes in the eastern U.S. struggled to get tests or PPE. Tests were rationed and there were only enough for staff and residents with fevers, coughs, or shortness of breath. We now know that there are many other symptoms.

“The game changer was when there were adequate tests to test everybody, because we discovered there was a significant number of asymptomatic staff and asymptomatic residents,” Bernardo said. Before that, he said, “we were running blind.”

Area nursing homes are now routinely screening staff with tests every one to four weeks, depending on what’s happening in their facilities and communities.

Tests are much more available than they were in April, but turnaround times are slowing from one to two days to as many as five. “That’s too long. That’s a meaningless test,” Reifsnyder told Seema Verma, administrator for the Centers for Medicare and Medicaid Services, at a meeting in Philadelphia earlier this month.

When test results take too long, nursing homes have to rely on screening staff for fevers and exposure to others with the disease. They’ve become vigilant about small changes in temperatures and blood oxygen levels among residents. For backup, four Kendal-Crosslands communities in Kennett Square have started testing waste water for the virus. So far, they have had cases among staff, but not residents.

A new effort to prepare for incursions of coronavirus is this wastewater testing project at Kendal-Crosslands, a group of four senior facilities in Kennett Square. Here, Seth Beaver, left, director of facilities and capitol projects for Kendal-Crosslands, works with Heath Edelman, president of Locus Technologies. Edelman is taking samples at the intake area of Kendal-Crosslands' wastewater treatment plant.
Courtesy of Kendal-Crosslands
A new effort to prepare for incursions of coronavirus is this wastewater testing project at Kendal-Crosslands, a group of four senior facilities in Kennett Square. Here, Seth Beaver, left, director of facilities and capitol projects for Kendal-Crosslands, works with Heath Edelman, president of Locus Technologies. Edelman is taking samples at the intake area of Kendal-Crosslands' wastewater treatment plant.

Supplies are now easier to buy in this area, people say, although some items, like gowns and gloves, are still scarce. Greenberger now has about a 90-day supply. Bernardo’s company has 30 days, enough for an outbreak like this spring’s. Reifsnyder said Genesis is on the verge of emerging from crisis mode. Several other facilities with multiple COVID-19 cases said their supplies are now ample.

Brian Holloway, who with his wife, Patricia, owns Seacrest Village and the Terraces at Seacrest Village in Little Egg Harbor Township, started stocking up in February after a staff member’s family in China asked for PPE. While four staffers caught the virus, none of his residents did. He’s now renting a climate-controlled storage facility to store a six-month supply. “Not only do we have enough. We have a lot. I mean a lot,” he said.

Brian Holloway, co-owner of Seacrest Village in Little Egg Harbor Township, rented a storage shed and filled it to the top with protective equipment for his staff. He wants to be prepared for a new onslaught from the coronavirus.
Courtesy of Seacrest Village
Brian Holloway, co-owner of Seacrest Village in Little Egg Harbor Township, rented a storage shed and filled it to the top with protective equipment for his staff. He wants to be prepared for a new onslaught from the coronavirus.

Nursing homes have also physically reorganized. Many now quarantine new residents for 14 days before sending them to other units. Some are being extra careful with dialysis patients, who must leave the building for care and have brought the virus into some buildings. They’ve become more adept at grouping patients with the same testing status. Staff members are now less likely to work in multiple units.

Through all of this, they have to balance the misery isolation has caused for residents and family. States have given the go-ahead for some activities to resume in small groups once facilities are coronavirus-free. Kendal-Crosslands last week arranged a small parade of cars driven by residents’ family members. Greenberger is talking with an architect about creating safe places to meet inside once the weather turns cold. They would have sound systems, extra ventilation, and glass partitions between residents and visitors.

Employees at Kendal-Crosslands in Kennett Square organized a car parade by family members for residents of the nursing center earlier this month. Facilities are trying to find creative ways to keep families connected while coronavirus makes visitation dangerous.
Courtesy of Kendal-Crosslands
Employees at Kendal-Crosslands in Kennett Square organized a car parade by family members for residents of the nursing center earlier this month. Facilities are trying to find creative ways to keep families connected while coronavirus makes visitation dangerous.

Coronavirus is adding financial stress to an industry that was already poorly funded. While Medicare and Medicaid pay for many resident tests, care homes are generally on the hook for screening tests for staff. Reifsnyder said that one testing sweep of staff in its 37 Pennsylvania facilities costs $600,000. (Private insurance pays for tests when people have symptoms.) The extra PPE and cleaning supplies cost money, too. Jon Dolan, president and CEO of the Health Care Association of New Jersey, estimates that the extra costs will add up to $150,000 to $200,000 a month for an average nursing home. On top of that, he said the population is down 20% in facilities that had COVID-19 and 10% in others.

Holloway is now doing his fifth round of testing of staff. “I’m worried about it every day,” he said “Every day. It’s not just testing.” He’s worried about vacationers who might not be careful enough, visitors who could bring the virus back in from other states. “I pray every day.”

The many precautions are here to stay. “I’m treating it as though I’m living in a COVID world,” he said. He figures that will last till we reach herd immunity through sickness or a vaccine. “I’m letting our people know that we’re looking at a year.”