After year of fighting COVID-19, nursing homes see hope in relaxed visitation rules

After a difficult spring and an even more difficult fall, long-term care facility administrators were thrilled to see their vulnerable populations among the first offered COVID-19 vaccines in December.

By the end of February, nearly every resident and staff was inoculated against the virus.

It meant fewer cases, fewer deaths from the coronavirus - and, maybe most importantly, allowing residents to see their loved ones in person.

The federal Centers for Medicare and Medicaid Services released new recommendations on Wednesday, revising its previous stance and allowing indoor visits 'for all residents, regardless of vaccination status of the resident or visitor.”

Certain scenarios still would limit visits, such as a high positivity rate for the county, but the new guidance was a long-awaited move after a year of separation between older Iowans and their loved ones.

'We need to consider that everyone is vaccinated. It makes me nervous, but if you look at the science, we're as protected as we're going to be,” said Kim Bergen-Jackson, administrator at Oaknoll Retirement Residence in Iowa City.

'It's been a year. It's unethical not to allow visitors,” she said.

Nursing home administrators welcomed the positive news after a year that has taken a huge toll on the staff and residents of long-term care facilities across the state.

Less than 1 percent of the U.S. population lives in a long-term care facility, but they accounted for 34 percent of all COVID-19 deaths in the United States, according to The Atlantic's COVID Tracking Project.

As of March 4, long-term care residents accounted for more than 2,100 of the total 5,600 Iowans who have died. More than 6,000 cases have been reported among residents - just a fraction of the more than 369,000 cases statewide.

'The past year, it's almost been like they've been at war with COVID-19,” said Lori Ristau, Iowa Health Care Association senior vice president of strategic communications. 'After going through that traumatic event, it's definitely going to have long-term impacts.”

‘An invisible wolf at the door'

As nursing home administrators look back at one year of COVID-19 in Iowa, they remember long hours for employees, sickness and death of residents, and the constant adjustments to try to beat back the deadly virus.

'We were fighting a fricking invisible wolf at the door,” recalled Kris Hansen, CEO of Western Home Communities in Cedar Falls.

Hansen gets goose bumps just thinking about March 2020. Lisa Gates, president and CEO of Friendship Village in Waterloo, remembers a chaplain returning from an overseas trip with a sinus infection, freaking out residents.

And Millisa Tierney, CEO at New Aldaya Lifescapes in Cedar Falls, remembers the calm before the storm.

'Two weeks prior, we were watching what was happening across the ocean, trying to prepare for what we could,” she said. 'The following week, all of a sudden we were getting guidances and alerts from both the Centers for Medicare (and Medicaid) Services and the Centers for Disease Control and Prevention that we had to enact immediately.

'It really did feel like the entire country was writing a plan on the fly. It was new to everyone.”

The worst part of it all, Hansen said, was employees who had the virus but no symptoms. They wouldn't know they were inadvertently putting their high-risk populations in harm's way until they lost their sense of smell.

'This was the perfect killing machine for the folks that we take care of,” he said.

Working off their own internal plans first, then from CMS and CDC guidance that changed frequently as more information became known about the new virus, nursing home administrators worked hard to keep their elderly residents from falling victim to COVID-19.

Many made the decision to stop all visitations before federal guidance mandated it, which was hard on both residents and their families.

'It was kind of surreal for them - ‘What are you talking about, that I can't visit my wife or my mother?'” Tierney said. 'I think everyone was still kind of in that state of shock.”

Hansen said he made some 'very unpopular calls” at Western Home to prevent introducing the virus.

'It was one of those deals where we've got to do what we've got to do, and we'll beg forgiveness later,” Hansen said.

Gates said one family member was so desperate to see his loved one that he dressed up as an oxygen delivery person just to get in the door.

'We've seen what the isolation has done,” Gates said. 'It's been brutal.”

Roberta Maas, though not as desperate, has been among the family members eager to see their relatives.

Her mother, Unita Schliemann, is a resident at Heritage Specialty Care in Cedar Rapids, the first long-term care facility in Iowa to report an outbreak. Within a month of the first employees testing positive, more than 100 residents and staff were infected with COVID-19.

Eighty-six-year-old Schliemann tested positive in early April. She recovered and has remained healthy since, but as the months have progressed, loneliness has taken its toll.

Schliemann, who has 10 children and is used to having family around her, said Maas, her oldest daughter. The past several months have been isolating as lockdown kept interactions with her family restricted to window visits and phone calls.

'That is so hard to see your mom, and she's actually just a few feet away, but you're not able to give her a hug,” said Maas, 68, of Watkins. 'We have to get back to life.

'By locking our elderly up behind closed doors, it's not good for them. It's very lonely.”

Outbreaks sometimes unavoidable, administrators say

Without family around them, residents at the Iowa City-based Oaknoll turned to each other, forming a solidarity throughout the community as cases increased countywide, always a lingering fear the virus would make its way inside.

But as of March 8, one full year into lockdown, Oaknoll had gone without a single resident of the senior living community becoming infected. Though a handful of employees tested positive throughout the past several months, it's avoided an outbreak.

Earlier this past Monday, residents - all vaccinated and largely unmasked at tables of five - gathered in a communal space for the first time since the pandemic began, for a 'Silver Linings” celebration. They raised glasses of Champagne to Bergen-Jackson's toast to 'what COVID-19 has given to us instead of taken away.”

The residents offered cheers to the staff, thanking them for their commitment to keeping them safe.

Bergen-Jackson only can guess why her facility avoided the virus. Maybe it was early action, she speculated. Maybe it was just luck.

Many were not so lucky.

The state's coronavirus website does not publicly tally how many long-term care facilities reported outbreaks throughout the course of the past year. According to some estimates, the virus still reached dozens of facilities, despite best efforts.

Even with all visits stopped, employees still were coming to work. Friendship Village was one of the first in Black Hawk County to see positive cases in March, from a CNA who tested positive, said Sherry Turner, executive director and vice president of health services.

'It just really gained momentum after that,” Turner said.

New Aldaya managed to stave off its first cases until an employee tested positive at the end of April. Their first positive resident was in the beginning of May.

'Sometimes when you do everything, you can't stop it. And that's a very disheartening feeling for staff,” Tierney said. 'It's another kick in the gut because you know you're doing everything you can, but it's still getting through.”

Others, such as Western Home, saw their first cases from residents who had to travel to and from doctors' visits. Hansen said their first death was a 'direct result” of such a visit.

'We're trying to take care of a tinderbox in the middle of a forest fire,” he said. 'Because if it gets into our buildings, we're going to do the best we can. But it has the opportunity to run rampant.”

In some facilities, that's exactly what happened.

Hansen said managers at Western Home, in Cedar Falls, saw '100 percent” of residents at a primarily dementia facility in Cresco test positive, noting many factors were to blame, including the air-handling system as well as the mostly shared rooms.

At Friendship Village in Waterloo, 26 skilled nursing residents at one time had coronavirus, while another 25 employees caught it this past spring. Ten residents died.

It got so bad so quickly that the facility worked with Black Hawk County Emergency Management to bring in National Guard troops to help provide care during staffing shortages. The Guard ultimately was unable to help.

'We muddled through,” Turner said, noting there already was a nursing staff shortage.

Administrators instituted hazard pay for employees on the front lines, increasing their paychecks if they agreed to work in COVID-19 hot zones. Some even provided off-site housing for those worried they'd take the virus home.

Administrators who hadn't worked the floor in years rolled up their sleeves.

'The horror stories, listening to our nursing staff who stepped up to the plate, was heart-wrenching,” Gates recalled. 'It was heart-wrenching listening to their family members as they FaceTimed with their mom while she was dying.”

Long-term impact

State advocacy groups say recruiting and retaining an adequate workforce will be the greatest challenge facing these facilities. Staffing shortages were an issue that existed long before COVID-19, but the pandemic is likely going to exacerbate it much further, said Anthony Carroll, AARP advocacy director.

By the end of February, about 37 percent of long-term care facilities were reporting staffing shortages, according to the AARP COVID-19 Dashboard.

That's a decrease from December, when nearly 50 percent reported a shortage of nurses and other aides.

A key solution is addressing the low wage direct health care workers receive, Carroll said. He noted many individuals taking these jobs lack insurance coverage because they can't afford it - a detriment to those who were exposing themselves daily to a deadly virus.

'It's not about looking backward, but about looking forward,” Carroll said. 'It all points to needing to have a better plan for staffing issues.”

Now, administrators are figuring out the 'new normal” for caring for people at the end of their lives. For Tierney, at New Aldaya Lifescapes, that includes telehealth, whose availability expanded significantly during the pandemic. It makes sense, at least for some, to avoid transporting out to see a physician, she said.

For Hansen, the pandemic showed him how a wholesale change in nursing home care was necessary, noting that congregate settings - a methodology built in the 1960s and 1970s - looked to be on the way out.

Carroll also noted nursing homes, though necessary in many instances, may become less appealing to families in the future. Instead, many may consider home health care options.

Others said they assume COVID-19 will be a new virus they have to plan for each fall, just like influenza - only deadlier.

'I don't think we'll quickly return to anything that was pre-COVID,” Turner said. 'I think there's always going to be some caution.

'Being how it hit the senior population so very hard, I think it's going to be something that we're going to live with.”

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