'Still Far From Normal': How One Nursing Home Is Coming Back From COVID

"B1,” the residents shouted back, as they ran their markers over their playing boards — which only they can handle, to avoid cross contamination of equipment — searching for the lucky number.

"Bingo!” yelled Jo Shackelfurd, 88, collecting the two winner's nickels for herself, then a “neighbor nickel” each for the players to her right and left.

"Thank goodness I'm sitting next to you,” quipped Melva Keever, 89, who hadn't won a game yet, “or I'd be broke.”

Communal activities, which beyond bowling and bingo include gardening, ceramics workshops, manicures and movie nights, have been some of the most celebrated returns of the past couple of months at the Manor.

Beginning in March 2020, when the federal Centers for Medicare & Medicaid Services (CMS) issued its first COVID-19 memorandum, instructing nursing homes to cancel communal dining and all group activities, the Manor's residents were largely confined to their rooms. Meals were eaten bedside. Activities were performed alone. Exercise often fell by the wayside. Loved ones were seen only through windows or phone screens.

In mid-September, the CMS — which regulates the nation's 15,000 nursing homes — recognized that “residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress,” and revised its guidance to allow for communal activities and visitation under certain conditions.

But the Manor identified its first COVID-19 cases of the pandemic shortly afterward. More positive tests followed, with a total of five residents and 15 staff members becoming infected with the virus over the next few months. Two of those residents died from COVID-19.

It wasn't until December, when all of the facility's residents and staff had finally been COVID free for two weeks, that the dining room reopened for the first time in nine months, only to be shuttered again three days later when a staff member tested positive. When communal events finally returned consistently in January, amid the facility's rollout of COVID-19 vaccinations, residents rejoiced.

"It was wonderful,” said Norma Reman, 87, of the first meal with her fellow residents. “You're all together — kind of,” she said, gesturing with her hands that residents are spaced apart, “and you can have different things to eat.”

"And you don't have to eat on paper,” noted Suzanne Steele, an activities aide.

Reman agreed, enthusiastically. “I didn't like that, having to stay in the room,” she said. “I just hoped that [the virus] would finally go or get to where we were able to do everything together.

But not all residents are embracing the Manor's return to communal life. One of the recent challenges for staff here has been persuading residents to come out of their rooms.

Increased rates of depression or worsened physical debilities caused by extended isolation during the lockdown are likely driving decreased engagement, said Carla Perissinotto, M.D., associate chief of clinical programs in geriatrics at the University of California San Francisco. Shifts in routine, particularly for residents with dementia — who can find change disorienting — could also be a cause, as could lingering fears of catching the virus.

But finding ways to reengage residents is critical, Perissinotto said. Isolation and loneliness are associated with a roughly 50 percent increased risk of developing dementia and a nearly fourfold increased risk of death among heart failure patients, according to studies.

"Be aware of who is lonely as a result of all of [the pandemic] and find out from each person what may help them,” Perissinotto said she tells nursing homes. “Open up the discussion … acknowledge that this sucks and we're here and we'll get through it, to try and bring some hope.”

'I'm smiling under this, I swear’

In early March, following vaccinations at nearly every nursing home in the country and plummeting infection and death rates, the federal government revised guidance for facilities again, making it easier for residents to see, hug and hold hands with visiting loved ones, even indoors. “There is no substitute for physical contact, such as the warm embrace between a resident and their loved one,” the recommendations said, while noting that precautions, including masks, time limits and number caps, should continue.

The very next day, the Manor announced that each resident would be allowed two 30-minute or one 60-minute indoor visit per week with two guests at a time.

It was a sunny Sunday morning in April when Frieda Waterson, 95, spotted her granddaughter Keyra Comer and great-grandchildren, Connor, 17, and Kenna, 19, approaching the Manor's entrance. She gasped as she looked out the window of the main lobby. She hadn't seen them in person in 15 months.

Keyra and Connor entered the building first, following the two-guest limit, while Kenna waited outside in the Manor's gazebo. Connor filled his great-grandmother in on his past year and three months: high school classes, another growth spurt, a new girlfriend. After 15 minutes, it was time for the great-grandkids to switch places.

"Oh, this was the most lovely surprise,” said Waterson, as Connor crouched down beside her wheelchair to give her a goodbye hug. Waterson grasped her great-grandson's arm as they posed for a photo. “I'm smiling under this, I swear,” she said, pointing at her cheetah-print mask.

But for some families, masks are obstructing more than smiles.

When Connie Reimer heard she was now allowed to sit next to her 99-year-old mother, Doris “Dode” Voss, during their visits at the Manor, she asked the staff to dust off Voss’ family photo album, planning to help her mother flip through the pages. Reimer thought it might trigger memories for her mother, who has dementia. But Voss, confused and panicked by her mask, wouldn't keep it on.

"I couldn't hold her hand or give her a hug because she wouldn't wear the mask,” said Reimer. “She doesn't understand why that goes together."

Many families face the same struggle, given that more than a third of nursing home residents have severe cognitive impairment and around another quarter have moderate cognitive impairment, according to a 2015 CMS report.

To keep seeing each other, Reimer and Voss had to move to one of the facility's visitation booths, which use clear plexiglass dividers to keep residents and visitors separated. Voss didn't have to wear her mask, but hearing her daughter through the wall was difficult. Reimer eventually gave up on conversation and instead played her mother soothing music through her phone for the time they had left.

"That was very frustrating,” Reimer said. “And we both are vaccinated now, so it'd be nice if we could just have a nice visit without all of this."

Although the Centers for Disease Control and Prevention (CDC) recently released new guidelines for the general population, giving fully vaccinated people the go-ahead to unmask indoors around other fully vaccinated people, the CMS has not issued the same recommendation to nursing homes. Instead, it continues to list face coverings and masks as a core principle of COVID-19 infection prevention that “should be adhered to at all times."

"Individuals in health care facilities, particularly nursing homes, are generally more susceptible to severe infection from COVID-19,” a CMS spokesperson told AARP, “and therefore more caution is often warranted.”

Reimer hopes those rules loosen up soon. “She's in decline,” she said of her mother, noting that Voss has lost weight and mobility during the lockdowns. Her dementia has also worsened. “The sooner I'm able to be with her, the better.”

Sapped and skeptical

Staff members at Weston County Manor work hard to keep residents’ spirits up, decorating walls and doors with colorful collages and playing nostalgic ‘60s music over the dining room speakers. And they know how to smile with their eyes above their masks.

"We had to stay strong for our residents,” said Tolley, the activities director. “For a year, we were all they had.”

But staff members, like the residents, are eager for relief. COVID-19 sparked heightened infection control measures for the nation's 1.6 million nursing home workers: extra screening, testing, disinfecting, training, reporting, scheduling, caring and more. When outbreaks occurred at homes and infected or exposed staff members were barred from working, it exacerbated staffing shortages. Other staff had to work overtime, in an environment that threatened their own health. Many did so on minimum wage and without benefits like sick leave.

"There were so many times where burnout was so real,” said Tolley, recalling a day in October when all three members of her activity team were out due to a COVID-19 infection or exposure. “It was just me left … and I cried and cried.”

There are still plenty of difficult hours and days.

During Voss and Reimer's failed in-person visit, it was Tolley who had to ask the women to move back into the visitation booth, after she pleaded with Voss to put her mask back on multiple times. “I hate being the bad guy,” she said, “but I have to follow the rules.”

One new infection control challenge: staff inoculations. Although more than 95 percent of the Manor's residents have received a COVID-19 vaccine, less than 50 percent of staff members have opted to get one, mirroring a national trend. As of March 15, roughly half of all long-term care workers offered COVID-19 vaccines through a federal program had declined the shots, according to CDC data provided to the Center for Public Integrity.

National long-term care organizations have launched education campaigns to encourage workers to get vaccinated, but many Manor staffers remain skeptical. That's mainly because of the newness of the shots and the unknowns that come with it, said Angie Phillips, the Manor's infection prevention nurse. Widespread misinformation on vaccine side effects, particularly on social media, is having a “huge, huge effect,” she added.

"I do think little by little it's going to become more routine, like a flu shot,” said Sarah Gregory, the Manor's director of nursing. “But I just feel like it's going to be a very slow transition and possibly even take years to see it where we want to see it."

A great escape

While stuck in her room during the COVID-19 lockdowns, Alice Cunningham, 79, kept herself busy doing diamond art. By positioning hundreds of tiny diamond stickers onto different patterns, she created a bunch of mosaic-like prints and bookmarks that she offered to those who helped her out by bringing her perfume and body lotion, or by exchanging her bingo nickels for notes at the bank.

"Just a small token of my appreciation,” she'd say, as she handed over her masterpiece.

Before COVID-19 lockdowns took hold, when Cunningham was allowed to leave the facility at will, she'd shop and visit the bank herself, venturing to reach her target of 5,000 steps per day. Now, despite the new liberties at nursing homes, residents still can't leave the Manor as they please. “I miss that,” she said, “being able to do my own thing.”

No one knows when that will return. The staff is waiting on community transmission rates to drop and for the federal government to release guidance on the issue.

Still, Cunningham remains optimistic. As the president of the residents’ committee, she's already planning the first big outing for Manor residents for when conditions finally allow it. “We're going to get in our bus and we're going to take a nice drive through Spearfish Canyon, then have a lovely dinner together somewhere, then drive all the way back,” she said one afternoon, peering out her bedroom window in the direction of the Black Hills, which the canyon runs through.

"Now, wouldn't that be somethin'?” she said as she picked up her blue piggy bank off her dresser. “There's about $12 in here, I reckon,” she said. “I can use that for my dinner.”

"Even if we could just go down to the local supermarket,” she said. “That'd be good enough for us."

Emily Paulin is a contributing writer who covers nursing homes, health care, and federal and state policy. Her work has also appeared in Broadsheet, an Australian lifestyle publication.