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'They wanted to live.' Inside a California nursing home as COVID-19 swept through its doors

Sacramento Bee - 7/11/2020

Jul. 11--WOODLAND, Calif. -- Donna Scully said a last goodbye to her mother on March 19, as California closed its doors in hopes of slowing the spread of the new coronavirus. Scully didn't know that at her mother's funeral that day she would also say a final farewell to her father.

Scully's mother, Gerry Warren, spent three years living in Stollwood Convalescent Hospital, a small nursing home amid the 14-acre campus of St. John's Retirement Village in Woodland.

Gerry's husband of 71 years, Don Warren, moved in with her at the end of February. They shared a room at the 48-bed facility until Gerry died on March 8 of complications from Alzheimer's disease.

After Gerry died, Don and his children gathered at a small, tree-lined cemetery in rural Yolo County for the funeral. He arrived "all masked up," Scully said. They didn't have much time for visiting because the employees rushed him away as soon as the ceremony ended.

"We didn't really get to spend time with my dad because he had to get right back," Scully said. "And that was the last time I saw him."

Within days, the disease that ricocheted around the world began its terrifying march through Stollwood. A housekeeping employee tested positive April 2 and was the first confirmed to have the virus there. Three days later, a resident developed a fever. And then, a rash of residents tested positive but did not show signs of the virus.

Don tested positive for COVID-19 about two weeks after his wife's funeral. His family tried to keep in touch as he struggled to fend it off, his lungs filling with fluid that hindered his every breath.

He died April 16, the fifth person at Stollwood known to have died from COVID-19 complications.

All told, the outbreak at Stollwood has killed at least 17 people, including a certified nursing assistant who worked there for nearly 20 years. It is the deadliest nursing home outbreak in Northern California and among the worst COVID-19 clusters in the state, where about 2,700 nursing home residents have died -- roughly 40 percent of the state's total.

Stollwood provides a vivid glimpse into how a catastrophe unfolded inside nursing homes in the early weeks of an outbreak for which nobody had a tried-and-tested response. Now, as California toggles on reopening bars and allowing sporting events, thousands of nursing home residents who have been locked down since March, and the front-line employees who care for them, remain trapped in a fatalistic limbo.

California health officials tried to allay public unease, but nursing home and county health officials struggled behind the scenes with the grim reality of a disease they could not control, interviews and emails reviewed by The Sacramento Bee show.

The documents detail a frantic, sometimes slapdash effort to ramp up testing at the nursing home and roll out ever-changing rules from California's health department. New bureaucratic edicts spawned by California officials left health leaders confused.

And employees at nearby facilities who might have been exposed to people leaving Stollwood expressed their concerns to others with the county, who in turn criticized the response.

"We need clearer guidance and clear oversight with a complaint line to the health department," Dr. Michael S. Wilkes, a member of the Yolo County Health Council, wrote in a May 5 email to the county's top health officials.

"Not only are employees (and their families) at risk, but so too are the residents," he added. "We should not be cheap or restrictive with testing."

High marks, but still not prepared

The speed at which the coronavirus spread throughout Stollwood illustrates the difficulty even highly rated nursing homes face in curbing the virus.

Stollwood, a nonprofit facility, was not prepared to combat the coronavirus when it arrived, even with a track record of high marks from nursing home inspectors, accolades from a national accreditation bureau and a high rating on the federal government's comparison website. A state inspection at the height of the outbreak found no quality-control problems.

Sean Beloud, the facility's CEO, said in an interview that he struggles to understand how the situation spiraled out of control. He took the top job in August after working as a physical therapy assistant at the campus for 24 years.

When he learned of the first case, he set up a cot in his office. He didn't sleep at home for eight weeks, he said.

"I've looked and I've searched for answers. I'm a caregiver at heart. And to be honest, this whole transition has broken my heart with what could have, or what should have," Beloud said.

"I ask myself, I've asked the county, I've asked medical professionals, I've asked other administrators," he added. "And I know we had the policies in place, procedures in place following every guideline that was put forth in front of us. And I know that for a fact because I was there. And so I don't know if I've been able to come up with that answer. But I know I ask myself that every day. Was there something there?"

Some family members said that they don't lay blame on Stollwood, because everyone was struggling to understand how to control the virus.

Patricia Warren, Scully's sister, said she thinks Stollwood "did everything they could...knowing what we knew back then."

Nevertheless, nursing homes and county health officials are increasingly facing tough questions as the virus continues to infect and kill thousands of society's most vulnerable people. On Sunday, Yolo County reported increased testing revealed another outbreak underway at a nursing home less than 1 mile from Stollwood.

Ron Chapman, the Yolo County public health officer who once ran the California Department of Public Health, declined through a spokeswoman to an interview. He announced his resignation during the response to the Stollwood disaster. His last day on the job was June 30.

The county would not make anyone from the health department available for an interview for this story. Jenny Tan, a Yolo County spokeswoman, said in a written statement that the county was working with long-term care facilities as much as possible.

"Preparation, communication and resources are key in this pandemic or any outbreak. Also ensuring that there are enough staff to support these facilities in case staff get sick or are confirmed COVID."

That's hardly enough for Simon Chin, whose father died of COVID-19 at Stollwood. He's among those who have searched for answers but gained little clarity about how the outbreak spiraled so quickly.

He's been bothered by what he said was a lack of information from Stollwood management.

"The fact that virtually all residents got COVID-19 and so many staff members also had it," he said, "that means that something wasn't done properly."

'Thinking he would be safe ... And he wasn't'

As far as nursing homes go, Stollwood ranks among the highest quality in California.

The industry is plagued with disturbing inspection findings. But Stollwood's history stands out because of its lack of infractions.

It has a five-star review on the federal government's Nursing Home Compare website. And it boasts a near-sterling record based on recent inspection reports, with the most-serious infection problems in recent years related to relatively minor things such as handwashing -- among the most frequently noted deficiencies.

As a nonprofit, experts say, Stollwood would tend to have higher quality of care than a for-profit facility. The American Health Care Association in 2019 awarded Stollwood a silver designation, among the top-tier facilities in California.

"We put him there thinking he would be safe," Scully said. "And he wasn't."

Before he moved in, Scully said, Don Warren made daily trips to the campus in central Woodland to eat lunch with his wife, Gerry. The couple met at Winters High School, southwest of Woodland. After graduating in 1948, they moved to Sacramento and, ultimately, Esparto where Don grew alfalfa with his father.

He later started his own hay harvesting business and opened an insurance agency in town.

It meant long hours. Sundays were always special, Scully said. After church, Don made a point to take the kids to brunch or make a day-trip to San Francisco. He would "donate" the day to the family after spending the week working.

He also donated blood every chance he could "just to do something good for other people 'cause he was that kind of guy." Before he went to Stollwood, he was awarded a plaque for having donated 15 gallons.

But at age 89, Don stopped moving around so quickly. After several trips to the emergency room in February, his latest one due to congestive heart failure, the family decided it would be best if he moved into Stollwood. That way, he could also be close to Gerry.

On moving day in late February, Scully and her dad walked into Stollwood. She didn't see staff wearing masks. Scully and her sister, Patricia, said not all employees were wearing masks when she visited the facility again on March 9, the day after their mom died.

Though masking requirements were evolving quickly, and a chaotic effort was underway to acquire protective equipment, Scully said that was the first sign in retrospect that she should have become concerned.

"They should have been masking every employee a little earlier than they did," Scully said.

At the time, state and federal health officials downplayed the need for masks among people who were not showing signs of the virus. Health experts were concerned about supply shortages, and the science was contradictory about whether face-coverings were effective. In late March, even California's senior-home inspectors were told not to wear masks because they might scare residents.

The U.S. Centers for Disease Control and Prevention didn't advise people to use face coverings and masks until April 3 -- the day after the first person at Stollwood tested positive for COVID-19.

Two days later, the first Stollwood resident started showing signs of infection.

An outbreak picks up speed

Stollwood worked with Yolo County to triage a testing plan because supplies were limited, said Beloud, the Stollwood CEO. They were able to test 13 residents who might have been exposed to the virus. Ten came back positive.

Most concerning of all, Beloud said: Eight were not showing any signs of infection at all.

"At that point, it really started to roll," Beloud said. "We were trying to do aggressive testing because we knew there was no way to tell. We had heard that there was the possibility of asymptomatic people being carriers but it was like, how do you navigate where these residents are, where these staff are?"

For days, he said, they worked every connection they could to obtain the required testing materials.

On April 13, 11 days after the first confirmed case, Yolo County announced it was responding to an outbreak at an unnamed nursing home. Officials said 23 residents and 12 employees had tested positive for the disease. One person had died. News media and ultimately the state, which began to release information on nursing home outbreaks, confirmed it was Stollwood.

In the dearth of information across California, families and residents were left wondering about outbreaks inside nursing homes and other long-term care facilities that hold about 400,000 residents across the state. Nobody knew just how quickly those residents would come to represent an outsize portion of the pandemic's victims.

Scully said she first heard about a confirmed case at Stollwood when the facility called her brother to say that an employee in housekeeping had tested positive. After that, she said, her family didn't hear about any other cases until they were notified a week later that their father had tested positive.

Not long after that, Don Warren died.

Scully spoke with him on the phone on April 15, the day before he died. His voice was barely audible through thick wheezing. But she could tell he said he just wanted to be kept comfortable.

"They assured us they were with him. They surrounded him. They loved my dad too, loved and praised him because he'd been going in there for three years to see my mom," Scully said.

"They knew him. And they were devastated, too."

Going public as rumors spread

The next week, on April 20, Yolo County went public with a somber update on Stollwood. At least 31 residents and 33 staff had contracted the illness. Six people had died.

On its website, Stollwood posted a link to the county's news release but nothing more about the outbreak. Phone calls to the facility were redirected to county employees, who declined to answer questions. The opacity, county officials said, was so that residents could "get better without worrying about their privacy."

As Scully and her family again prepared an obituary and planned a funeral, others were left waiting and worrying about the fate of their own family members.

Simon Chin's father, George Chin, retired early from General Motors and spent his years before Stollwood traveling. He visited at least 15 countries throughout his lifetime, his son said.

He remembered the facility had called his sister about a housekeeping employee testing positive. He readied himself for regular updates, but they never came, he said.

"We were expecting that if anyone else was tested positive, then we would have been notified, but we were not," Chin said. In the weeks following that phone call, "to our knowledge, none of the residents or the staff tested positive."

Chin said his dad had hearing problems and wouldn't normally call him. The family visited Stollwood every weekend, but the facility was restricting visitors at the time.

On April 15, a nurse called him saying that his father had a high temperature and reduced blood oxygen levels. His father's temperature had shot up by almost 2 degrees within three hours, he said. That was "the moment I first learned about this situation."

The state published COVID-19 data specific to nursing homes on April 18, and Chin saw the extent of the outbreak. Though imperfect, the data helped Chin grasp the reality of his dad's nursing home.

"I saw that there were over 60 positive COVID-19 cases at the facility, which was shocking," he said. By that time, though, Dad had been transferred to Woodland Memorial Hospital and on a ventilator. If he wanted to take measures to help his father, "it was too late."

His father, at 80, died April 22. Chin can't help but think of how much life he had left.

"Without COVID-19, he could have lived another 10 years or more."

Crafting a response to families, public

Like officials across California, Stollwood and the county health department were bombarded with a dizzying amount of information as the pandemic seized the state.

Residents with dementia were refusing to be tested, records show. Some who had previously tested negative were found to have contracted the disease. Health officials tried to convince still-skeptical members of the public about the dangers of COVID-19.

California has since called for a robust baseline testing plan for nursing home residents and employees.

Brian Vaughn, the county's public health director, in a June 25 public meeting said testing was well underway within the county's seven nursing homes. Stollwood, he said, was the only one at the beginning stage of a renewed round of tests that would be helpful in stamping out future outbreaks in other facilities.

"We've picked up a few asymptomatic cases through there," he said. "So the system's working."

Yet delayed results and a "fragmented lab system" continued to plague the county's response, he said.

Wilkes, the doctor who has criticized testing and the county's response to Stollwood, said testing still does not show where the virus is concentrated and which nursing homes and other long-term care facilities are the most at risk. Testing has not yet reached the most rural parts of the county, and barriers remain in lower-income neighborhoods.

"We've got no idea in Yolo County what the prevalence of this virus is," Wilkes said.

Testing failures have plagued the country's response and posed the biggest challenge in nursing homes nationwide. Yet those remain most in need of robust testing regiments, said Patricia Stone, centennial professor of health policy at Columbia University'sSchool of Nursing.

Even facilities with sterling records can experience outbreaks if the virus is in the community. And as the virus is increasingly showing up in communities that might not have experienced previous outbreaks, the stage is set for it to spread -- even if the exact science of transmission remains unsettled.

"We need to be thinking about this disease in a regional manner because it hits people differently," she said, stressing the need for widespread, ongoing testing inside facilities and out. "That's about the best we've got."

'Born to take care of people'

Antonia "Tony" Sisemore, 72, was working as a certified nursing assistant when COVID-19 began roiling nursing homes nationwide. After working at Stollwood for nearly two decades, she refused to retire or take a leave of absence, despite requests from her family, said her daughter, Ruth Edwards.

"That's just what she was born to do, she was born to take care of people," Edwards said.

She had always been that way. Edwards said when she shopped with her mother, she would put something in the basket for one of the residents. Sometimes it was lotion. Other times shampoo. Her heart belonged to the residents of Stollwood, she said.

As the virus began spreading in late March, Edwards, who worked at another nursing home herself, grew more concerned for her mom. Not able to know what the environment within Stollwood looked like, she asked her mom to pay attention to how often the facility was cleaning shared surfaces.

"I would tell her, 'How many people use the microwave? The entire facility shares the microwaves, shares the coffee pot, shares the bathrooms. You guys are always touching doorknobs. Who is wiping those down?' " Edwards said. She constantly reminded her mother that masks by themselves aren't enough to prevent spread, she said.

Sisemore wasn't notified about the first housekeeping employee testing positive as some families said they were, but a few days after, Edwards said. She would have told her mother to stay home and not go to work had she heard about an employee testing positive, she said.

By early April, Sisemore started to cough and stayed home. Labored breathing followed. Edwards' mother eventually was brought to Sutter Medical Center in Sacramento, where they put her on a ventilator.

At first, "we really thought she was going to make it out," Edwards said. She cleaned her mother's house and planned a barbecue for her homecoming.

"But then her body just started declining."

Sisemore died April 30.

'They still wanted to live'

No one has died at Stollwood in more than a month. The storm seems over, but the damage is done. The outbreak accounts for a significant portion of COVID-19 cases and the vast majority of deaths among Yolo County's 220,000 residents.

Beloud moved midway through the response from his office cot to a cottage on campus. He has since returned home to his family and also set up grief counseling for his employees. He said he doesn't know when he will stop racking his brain about what went wrong.

Clearer guidance on masks earlier on could have made a difference he said. But just how much of one is anyone's guess.

As the virus continues to spread into nursing homes across California, Beloud wants to help other administrators prepare. He's said he would be happy to take their calls and talk about the collaboration he needed to navigate the horrors inside. He also has a warning.

"This virus will find its way into the facilities," he said. "No matter what precautions you have."

In May, Stollwood held a virtual memorial ceremony to remember the residents and employees who died of COVID-19. The Davis Enterprise newspaper reported on the tribute, with vignettes of those who died from the outbreak at Stollwood.

They honored Warren, Chin and Sisemore.

They remembered Isabel Bettencourt, the first resident to die, and James V. Testa, Jr., the last.

At 103, Iola Duncan Tandy was the oldest.

And at 68, Ann Davis, was the youngest.

Helen Ehrke was born during the 1918 pandemic.

Frankie McKay and Katie Guerrero died on the same day, April 14.

They paid tribute to Winnie Prewett and Rosemond Davis, Wilma Soares and Lupe Roa. Cruz Palma and Delia Tovar. And they remembered Elaine Albertson.

Scully felt a wave of emotion crash over her as she read the Davis Enterprise's tribute. She had come to know several of those whose names and biographies were spelled out in the story from her time visiting her mom over the years.

She'd wondered for weeks what happened to them, hoping for the best but braced for the worst.

"I think most of the ones I knew are gone. It's sad," Scully said. "They were all really in their older age, but they were lovely people.

"They still wanted to live."

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