Canterbury Rehabilitation & Health Care Center already had a staffing crisis before Henrico County public health officials tested every resident and employee in the skilled nursing facility for COVID-19 at the end of March.

Staffing agencies pulled temporary nurses from the center after the facility's first positive coronavirus case became public on March 18, Canterbury officials said. Other employees left because of concerns expressed by their day care providers and educational institutions where they were studying to advance their health care careers. Some left to care for ill family members.

By the peak of the crisis in April, Canterbury had lost 69 members of its staff because of what Administrator Jeremiah Davis called "COVID-19 related issues and fears."

The total includes 36 direct-care workers who tested positive for the coronavirus and later returned to work in a facility that briefly represented the deadliest coronavirus outbreak in the United States and has had 51 deaths to date. Now, the center cares primarily for people recuperating for COVID-19.

'Valuable' testing

Canterbury officials say they don't regret the decision to become the first long-term care facility in Virginia to test all residents and staff for COVID-19 so they could identify who was carrying the disease without showing any of its symptoms.

"It was so valuable," said Dr. Jim Wright, the nursing home's medical director. "You need to know the asymptomatic carriers. They're the ones who are going to spread it throughout your facility."

State health officials who previously were reluctant to use scarce testing supplies for people without symptoms now make mass testing a priority for curbing the spread of COVID-19 in facilities responsible for almost 60% of deaths from the disease in Virginia - 774 through Friday morning.

Canterbury did it in partnership with Dr. Danny Avula, director of the Henrico and Richmond health districts, after publication of a study in late March that showed most residents of a Seattle-area nursing home who tested positive for the disease were asymptomatic.

"It's way better for a facility to test all of its staff and all of its residents, and then be able to respond effectively to the data," he said Thursday.

Some facilities reluctant

But Avula said some long-term care facilities remain reluctant to conduct "point prevalence surveys" - testing of people in congregate settings to identify the spread of the virus at a point in time - because they know it's likely to deplete already scarce direct-care staff.

"There's been a fair amount of resistance and hesitation by facilities for that reason: they're already struggling with staff," he said. "I've heard that story many times."

Canterbury faced the same quandary - the potential of losing scarce staff to quarantine for 14 days, before the Centers for Disease Control and Prevention issued new guidelines last month for "mitigating staff shortages."

The new guidelines allow previously infected employees to return to work sooner if they show no symptoms, wear protective masks and work with patients who also have tested positive for COVID-19, which represented about two-thirds of the remaining population at Canterbury.

"There's perhaps more wiggle room now than there used to be," said Wright, who now treats recuperating COVID-19 patients transferred to Canterbury from hospitals.

Staffing shortages are "the flip side of the coin for weekly testing of staff," he said. "It pales in comparison to protecting your patients."

Henrico's push

The day after Canterbury announced its first two COVID-19 deaths in late March, Henrico County began an aggressive push to bring the nursing home the resources it needed to prevent the virus from spreading through a highly vulnerable population who rely overwhelmingly on Medicaid to pay for their long-term care.

The county hired a private ambulance service to transport residents between the center and local hospitals. It offered testing kits and protective gear. Above all, the county tried to connect Canterbury with sources of staff.

"That was the primary need," Avula said.

A new owner, Marquis Health Services, had purchased Canterbury in January. The nursing home had changed owners numerous times over the previous 30 years. The last Medicare inspection, in October, rated the facility at two out of five stars, plagued by serious staffing shortages and nearly twice as many health deficiencies as the average Virginia nursing home.

Under the new owner, Canterbury "launched an aggressive recruiting and retainment plan, and at the time of the outbreak in-house staffing was actually at its highest point in years," said Davis, the nursing home administrator. "In fact, we were just a few weeks away from eliminating the need for supplemental agency staffing.”

COVID-19's chilling effect 

But the arrival of the coronavirus at the facility in mid-March changed everything, he said in an email response to questions.

"When COVID-19 was confirmed at Canterbury, several of the agencies we were working with pulled their nursing staff out of the building," David said. "Other agency staff refused to work in the building with COVID."

"Some [certified nursing assistants] and [licensed practical nurses] who were attending college to advance their education were told by their schools they could not work here and also attend classes," he said. "Day care centers told staff they could not drop off their children if they worked in a COVID building."

"In one case, a team member’s spouse was told to stay home because their wife worked in a COVID building," he said. "Subsequently, we had team members who needed to stay home to care for sick family members or children who were home from school."

Canterbury did not name any of the outside institutions, so Davis' account could not be verified independently.

Henrico officials had a different concern about Canterbury's staff. They didn't want direct-care aides and other low-wage employees working shifts at multiple facilities and potentially spread the virus among long-term care operations in a county with an estimated 50 nursing home and assisted living operations.

Lessons learned

To date, Henrico has had 14 COVID-19 outbreaks in long-term care facilities, which also have generated the vast majority of the 133 deaths from the disease in the county, the second highest fatality toll in Virginia after Fairfax County.

"From an economic development standpoint or a business standpoint, they are great facilities to have in your county," Henrico County Manager John Vithoulkas said. "What we found out with Canterbury was the fire literally is in the kitchen."

The health department persuaded Canterbury workers to agree voluntarily not to work in multiple facilities. The county connected the nursing home with staffing agencies and local hospitals, including HCA Virginia, which provided professional staff on a stopgap basis during the escalating crisis.

Canterbury temporarily doubled the wages of its nursing teams, "at tremendous cost, and contracted with several third-party staffing agencies to provide supplemental nursing positions as needed," Davis said.

The company also went outside of Virginia to find help. Nurses from Connecticut, Maryland and Florida bolstered the staff at Canterbury, which was so depleted that Wright, the medical director, later said he changed residents' clothes, his wife took leave from a local hospital to help with palliative care and Davis delivered meal trays to residents.

At the same time, however, Henrico pushed hard from the beginning for widespread testing of residents and staff. The county has donated 1,100 testing kits it had procured from GENETWrx, an Innsbrook-based laboratory, for long-term care facilities and health officials to use for mass testing to prevent the coronavirus spread.

Henrico has codified its arsenal of resources in a 56-page manual that it has distributed to every long-term care facility and group home in the county.

"What Canterbury has done for the county is to create a model moving forward to be proactive with these long-term care facilities," said Cari Tretina, chief of staff to the county manager.

State expands testing

Since Canterbury conducted mass testing on March 30, such testing at long-term care facilities has become a priority at the Virginia Department of Health.

The health department has coordinated "point prevalence surveys" at 57 long-term care facilities with help from the Virginia National Guard and Medical Reserve Corps volunteers. In guidance for facilities, the department calls the surveys "a powerful tool that can be used to intervene ​early​ in outbreaks...[and] can help guide decisions regarding cohorting residents and staff."

Currently, long-term care facilities account for almost 60% of COVID-19 outbreaks and deaths in Virginia.

The Centers for Medicare and Medicaid Services, which oversees skilled nursing facilities across the country, also strongly endorses mass testing and issued guidance early this month that recommends weekly testing of staff in facilities that eventually reopen to outside visitation.

"That is going to be a significant challenge for these nursing homes," Avula said.

Testing requires supplies - swabs, chemical reagents and laboratory - but it also means people and time, he said. "It's more who's going to do it?"

Nursing homes and other long-term care facilities also will need adequate supplies of "personal protective equipment" - gear such as gowns, masks, face shields and gloves. Many facilities in Virginia employ elaborate strategies to safely use protective gear that is supposed to be thrown away after one use to avoid potential contamination, said Wright, the medical director.

Canterbury finally secured an adequate PPE supply last week through its parent company, Wright said. "It feels like a luxury to wear a gown and throw it away."

Who will pay?

Resources for testing and gear are particularly concerning for assisted living and memory care facilities, which are not regulated by Medicaid or the health department and have not received any of the aid Congress approved for long-term care facilities.

"Who is going to pay for all this mass testing that [the Centers for Medicare and Medicaid Services] is recommending?" asked Melissa Andrews, president and CEO of LeadingAge Virginia, which represents nonprofit retirement communities that provide a wide range of services to the elderly and disabled.

Still, members of her organizations have asked for point prevalence surveys. Some, such as Brandermill Woods in Chesterfield County, have done the testing themselves at their own expense because the state did not have the capacity to do it. Brandermill Woods has confirmed seven deaths from COVID-19 in its assisted living and memory care units.

Henrico Health & Rehabilitation Center, a skilled nursing facility in Highland Springs, tested 55 employees and 57 residents on April 23. The results showed 29 residents and 11 employees positive for COVID-19.

To date, 17 patients who tested positive for the virus have died and 43 have recovered. Infected employees could not return to work for at least seven days after the test or the onset of symptoms, and three days with no symptoms or fever.

"In some situations, asymptomatic staff with a positive test have volunteered to return earlier and work just with COVID-19 positive patients who were segregated into their own unit," Administrator Adam Harrison said in an email.

The center offered full-time jobs to part-time employees. It paid bonuses and raised pay for uninfected employees to work extra shifts. Many employees offered to work in different roles to support the operation.

"There was not really a silver bullet for us," Harrison wrote. "It was challenging, but I am proud our staff was committed and willing to be flexible."

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