As the second surge of the coronavirus sweeps through the D.C. region, a group residents at one local long-term care facility will be spending the upcoming holidays alone and isolated in their rooms. At the Little Sisters of the Poor’s Jeanne Jugan Residence, which serves low-income seniors in Northeast D.C., a staff member tested positive for COVID-19 — and now the facility is isolating people who might have been exposed.

“Despite all of your best efforts, [the virus] can still sneak in,” says Sister Constance, the communications director for the residence.

The Jeanne Jugan Residence hadn’t reported a staff or resident death related to the coronavirus for more than seven months. The home saw an outbreak in the early days of the pandemic, Constance says. After that, new weekly cases among residents and staff dwindled to zero for several weeks in the summer and fall. Four of the home’s residents in total have passed away from COVID-19 per DC Health data, and Constance says the home has reported a total of 18 deaths in 2020, more than an average year.

Dozens of nursing homes and assisted living residences across the D.C. region are still wrestling with the pandemic, which has now entered its deadliest days — even as the hope of vaccine distribution rounds the corner. One cause is increased transmission within the wider community, outside a home’s walls.

“We’re definitely in the middle of another surge right now,” says Enrico Lachica, a clinical nurse administrator who oversees the pandemic response in long-term care facilities for the Montgomery County Department of Health. Almost 50 facilities in the county have current outbreaks, according to Lachica, and case counts are at an all-time high.

Nursing home industry leaders around the region say they’re better prepared to fight the virus this time: they’re armed with a far better scientific understanding of how COVID-19 spreads and how to treat it; access to personal protective gear supplies is much improved now, and so is testing capacity and efficiency (nursing home staff are now required to be tested for the coronavirus once or sometimes even twice per week, depending on the surrounding community’s positivity rate). And they’re preparing their residents and staff to receive a first round of vaccinations in the immediate future.

But the second surge in cases in the community is still taking a toll on the congregate settings that bore the brunt of the pandemic in its early days — with staff members facing exhaustion, the threat of infection forcing residents into months of isolation, and the financial toll of nine months of the pandemic response becoming deeper and deeper.

The darkest days of the pandemic

Across D.C., Maryland and Virginia, 806 residents and 681 staff members in nursing homes had new confirmed cases of COVID-19 in the week ending December 6, according to data from the Centers for Medicare and Medicaid (CMS data is reported on a two-week lag). That’s the highest number of new resident cases and the second-highest number of new staff cases since CMS began tracking the metric from week-to-week.

The number of current cases in area facilities is higher. Across Maryland, 11,733 nursing home and assisted living facility residents have COVID-19, along with 8,733 staff, according to Maryland’s Department of Health. Montgomery County alone has nearly 3,900 cases among residents and staff. Case and death numbers are removed from state totals when the facility is clear of the virus for 14 days.

In Virginia, outbreaks in the state’s long-term care facilities have been increasing steadily over the past three months, reaching and surpassing the weekly numbers seen in the spring. Out of the state’s 1,079 outbreaks recorded during the pandemic, more than 600 have occurred in nursing homes.

The record-breaking number of infections in local nursing homes closely tracks the region’s biggest outbreak yet.

“What we’ve learned from experience and from some research, is that the biggest connector between COVID entering a healthcare setting is directly related to the positivity rate of the virus in the community at large,” says Joseph DeMattos, the president and CEO of the Health Facilities Association of Maryland.

“So because there is that undeniable correlation between the positivity rate in a community at large and the positivity rate in a healthcare setting, hospital, nursing home, we are seeing more cases today in healthcare settings than we did, let’s say, six weeks ago,” DeMattos says.

For that reason, Keith Hare, the president of the industry group Virginia Health Care Association, implores the public to adhere to public health guidance.

“The best thing you can do to protect a resident in a nursing facility is to do all the things that we’ve been asking for nine months now, which is: wear a mask, really limit your exposure to the individuals that you haven’t been in contact with, particularly if you are indoors, stay at least six feet away from some others. And if you don’t feel well please don’t go out,” he says.

“We have a better handle on the scope of the community transmission, whereas at the beginning of the pandemic, we really just didn’t know how significant that was,” Hare says.

While case counts are higher in long-term care facilities now than during the spring, death rates have overall declined, Montgomery County’s Lachica says. He attributes that to more effective treatments for the illness.

Long-term care facilities continue to account for significant numbers of deaths across the region, however.

Cases linked to D.C.’s long-term care and assisted living facilities throughout the pandemic make up only 6% of the city’s total infections, but 26% of deaths, according to data as of December 15. That gap is even greater in Maryland and Virginia. In Maryland, nearly 10% of the state’s total cases are linked to nursing, group homes, and assisted living facilities, but deaths from those settings account for half of the state’s total count. In Virginia, long-term care facilities make up almost 6% of cases, while they constitute nearly 48% of deaths.

An ‘Invisible Enemy’

Despite the recent positive case that’s led a small group residents to quarantine, Sister Constance says that Jeanne Jugan Residence managed to limit outbreaks over the past several months thanks to a combination of factors: learning more about the virus and how symptoms develop in the elderly, weekly testing and plenty of PPE supplies.

“There’s definitely a learning curve,” Constance says. “You kind of master it to some degree, as much as you can master something that’s an invisible enemy.”

She adds that D.C. hasn’t reopened nursing homes for indoor visits — another factor that’s likely blunted the spread. Constance says the isolation has led to cognitive decline for some residents, who have far fewer human interactions available to them — and exhaustion for staff, who provide both medical care and a single human connection to the outside world. This holiday season, family visits came in the form of drive-by caravans, instead of indoor gatherings and conversations over meals.

“I can’t say enough about [the staff], how faithful they’ve been, how careful they are, both for themselves, for the residents, for the elderly that they’re caring for,” Constance says. “And they have families and dependents at home.”

Col. Paul Bricker is a veteran of conflicts in Iraq and Afghanistan and runs the Knollwood Life Plan retirement community in the District. He says his facility has so far weathered the second surge without any residents testing positive, though about 60 staff have tested positive since May). Bricker credits Knollwood’s success to an aggressive testing regimen — which the facility instituted well before local and federal authorities required it — and continued communication with and support of staff.

“We have been much more effective at avoiding catching the virus,” he says. “And I think it’s because our employees are more disciplined.”

Bricker says he emphasizes to staff that they should apply the same public health guidelines at work in their lives at home, too.

“For example, don’t go out to a party, be careful with your personal behavior when you’re not at work,” he says. “But we also test because we have so many living in group and family homes where they might have two or three generations living in the same house.”

Knollwood is investing in retaining its staff, too, even as many industry leaders express concerns over staffing after months of exhaustion. Bricker says Knollwood has sometimes been forced to seek staffing help from healthcare agencies, but he’s mostly trying to retain his own people as much as possible: paying workers overtime, giving them sick leave and holding their positions for them if they get sick.

“We’re very loyal to our employees because they’ve been wonderful here and in protecting our community,” he says.

Preserving staff as much as possible — and finding more people to fill in — is a concern for many long-term care facilities weathering the second surge, says Allison Ciborowski, the executive director of Leading Age Maryland, an industry group for nonprofit elderly care providers.

“It’s just very stressful working conditions. So we need more staff,” she says. “But it’s hard because everyone is kind of competing for the same resource.”

When staying open is ‘just not sustainable’

The pandemic response has been costly for nursing homes. Budgets are stretched to cover new operating expenses like stockpiling personal protective gear. Facilities in Maryland and Virginia are being forced to foot the bill for required regular testing of all staff (the District covers the cost of staff testing in its nursing homes). Plus, the number of people receiving care in nursing homes has dropped, often because fewer people now want to live in congregate settings. Some facilities have reshuffled their floor plans to try to stem the threat of infection.

Knollwood, for instance, reduced its capacity so that all residents have their own private rooms“in order to maintain infection control,” Bricker says

For many facilities, the financial strain is becoming more and more acute, according to Ciborowski.

“I’ve had some conversations with members recently who are just saying this is just not sustainable,” she says.

Survey results from the American Health Care Association and the National Center for Assisted Living indicate the national financial toll. According to the study, 66% of nursing homes say they won’t be able to continue for another year at current operating levels because of increased costs. Currently, 65% of nursing homes are operating at a loss. Maintaining adequate staffing in the pandemic was the costliest line item in most nursing home budgets, with 90% of nursing homes reporting that they’ve had to hire additional staff or pay existing workers overtime. And staffing is just one of the costs.

“I spoke to a member who has cases currently in their building, and they’re spending about $30,000 a week on PPE and $30,000 a week on testing,” Ciborowski says. “That doesn’t include overtime and increased costs of potentially having to bring in agency staff when staff are testing positive and having to leave.”

Preparing for a vaccine

Residents and staff in long-term care facilities will be among the first people in the region and the country to be vaccinated against COVID-19.

Nursing home leaders say they expect most of the logistics of transporting and storing the doses and giving people the shots at each facility will be shouldered by CVS and Walgreens, as part of a partnership with the federal government. Now that both Moderna and Pfizer-BioNTech vaccines have been approved by the Food and Drug Administration, nursing homes expect vaccine clinics to begin in the next week or two.

There’s much to do to prepare, says Donna Epps, the health services administrator at Knollwood, including getting consent forms and other information ready prior to the day of the clinic.

“We are very excited, but it is a lot of work to be done in a short period of time,” she says. “So we have developed a task force with about seven or eight different work groups to handle each of the major areas from communication to education.”

While Sister Constance says she has not been briefed on a timeline for the vaccine rollout to Jeanne Jugan residents, people there have been majorly receptive to flu inoculations and hopes that bodes well for COVID-19 vaccines.

“That’s our next challenge on the horizon — to start trying to educate them and answer their questions and their fears so that they’ll be open to getting it once we have it available,” Constance says.

At Knollwood, Epps and Bricker enlisted a doctor from Walter Reed Military Hospital, where most Knollwood residents get their care, to lead a recorded vaccine informational session for staff and residents.

Bricker says staff may be required to receive a vaccine as a condition of employment, with exceptions for people with serious allergies or other health concerns that would lead a doctor to advise caution.

Once the vaccine does arrive, nursing home leaders are cautiously optimistic about what it’ll mean for restrictions inside and outside of their facilities. Bricker sees the vaccine as one of many ways Knollwood can continue to fight the virus, along with social distancing and infection control measures.

“It’ll be a great day when the Walgreen truck pulls up and Donna leads them in and they start vaccinating our employees,” Bricker says. “It has been a long slog.”