As States Reopen, Nursing Home Operators Can’t Assume They’ll ‘Be in the Clear Forever’

As COVID-19 initially swept through nursing homes across the country in March and April, operators and staffers had a key advantage: Just about every state implemented stay-at-home orders that kept public spaces clear for the essential health care workers, reducing the risk of infection.

But as spring turns to summer, states around the country have implemented varying degrees of “reopening” plans, setting off increases in case counts in certain states — and underscoring the growing realization that COVID-19 in long-term care will be a marathon, not a three-month sprint.

This dynamic, with nursing homes in states that were spared from the initial spikes facing the prospect of community spread, makes a new study on the early response in New York required reading for operators around the country.


Written by a quartet of clinicians and published in the Journal of the American Medical Directors Association (JAMDA) in May, the paper dives into the the top lessons that operators learned during the early days of the outbreaks in New York, which bore the brunt of COVID-19 infections both in long-term care and among the general population.

SNN invited study co-author Dr. Paula Lester, an associate professor of medicine at the NYU Long Island School of Medicine and a geriatrician at NYU Winthrop Hospital in Mineola, N.Y., to join an episode of our “Rethink” podcast.

Lester walked through the group’s top conclusions, and offered her professional advice for leaders that may be watching case counts rise in their communities, with a particular warning about the unique severity and difficulties of COVID-19.


“As a geriatrician, I still count on my history and my physical exam and my clinical judgment,” Lester said. “COVID has basically wiped out any perception of my ability to have a similar judgment on diagnosis of COVID. I’ve seen too many people who have absolutely no symptoms at all test positive.”

Selections from Lester’s conversation with SNN, recorded June 8, are below; the full episode is available on Apple Podcasts, Google Play, and Soundcloud.

What kind of work went into this research?

I am a member and a board member of the New York Medical Directors Association. In March, soon after it was evident that COVID was traveling throughout the nursing homes and having a large impact, the organization organized a meeting for members — and it was very informative and interesting, because it’s membership from throughout the state. There were people in Manhattan, people in Queens, people in Nassau/Suffolk, people in Rochester — people all over the state, and it was very informative because we were all in different stages of the pandemic. As we met, we learned from each other’s experiences.

We had to make our own adjustments in the nursing home as more changes were evident. At a certain point, I was talking with one of the co-authors, and I said: It’s really, honestly, pretty traumatic, what we went through, but we learned a lot through it. We really should try to help other facilities and areas who have not had this experience — fortunately have not had this experience — learn from our experience, so that they could be better prepared, and then we decided that we should identify two other people who were heavily involved and have a lot of input. Then the four of us, we had various meetings — we had a lot sharing of documents. We edited, we had some phone calls and Zoom meetings.

It was all cordial — there are a few things that we had differences of opinion about, but for the most part, it was all cordial, and for the most part we agreed on the recommendations.

Let’s get into those recommendations. There are plenty of nursing homes in the country that did not report any cases, and as we move into a new phase of the pandemic, how can they avoid the problems that we saw in New York and other hotspots?

Number one would be to not assume that you’re in the clear, and you’re going to be in the clear forever. In the nursing home generally everyone was so worried about keeping it out that we didn’t realize it was already in. One is to not rest on your laurels and think that you’re magically somehow immune or better — everyone is at risk, and once it happens, it can spread quickly.

So the way to do that, if you’re not in the midst of an outbreak, I would say: Work very hard on getting the sufficient and appropriate PPE. You need a lot of equipment. The face shields, the N95 or similar masks, surgical masks, the gowns — and also to kind of strategize. Do I have a unit or a wing for people who test positive? Do I have the ability to test? Do I have the ability to do antibodies? Can my laboratory help with that? Do they have enough swabs to do that testing?

I would also work on infection control training. The hospitals don’t often have TB patients, but everyone knows there’s a special isolation room, and everyone wears a gown and an N95.

But they’re aware of that. The nursing homes, they’re not used to that; they’re not used to having to do contact and droplet isolation. So I think that it’s a good time to make sure that you have enough hand sanitizer, make sure you have enough training for staff on how to put on and take off the masks and the gowns and the gloves.

How should operators start to reassess their testing strategies as more communities start to return to “normal”? Even a CDC official has noted that repeated testing of residents may not necessarily always be useful after a baseline has been established, since it won’t really change the way a nursing home is reacting to the pandemic in terms of PPE and cohorting.

Yeah, that’s a very good question. Unfortunately, I don’t think we’ve lived enough of it yet to have an opinion. Maybe in six months, we’ll have another paper or recommendations about that.

I think in principle, it does make sense to test staff because they’re not living in a bubble. They are not only going to the nursing home, and not going anyplace else. They’re living their lives, and going to the supermarket and wherever else they need to go. That’s more true now, as non-essential workers are now going out and about more as well. So you can’t assume that your staff is fine.

I do think that we were behind the eight-ball because we didn’t realize that it was being spread, so we weren’t using the PPE. I think now that we’re aware they could spread it asymptomatically, and staff is wearing PPE, I think even if staff is sick, I think they are less likely to spread it. But you don’t want to count just on that.

I would say that my personal feeling is ideally, testing for staff should be non-traumatic, and with a rapid turnaround time. In New York State, staff — if they work more than three days a week — have to get swabbed for PCR twice a week, and if they work less than three days a week, they get swabbed once a week. Many facilities are using the nasal test for that instead of the nasopharyngeal swab. I think that for prolonged, repeated testing, the nasal swab is far less traumatic for staff. Only time will tell if it is as effective in diagnosis, but personally, my opinion: I think to subject staff to twice-a-week nasopharyngeal swab has the potential for injury and trauma.

When we have more accurate point-of-care testing, I think nursing home staff should be prioritized for that — because, if you get tested on Monday, and you don’t get the results until Wednesday, you could have been sick on Tuesday and working and not knowing it. Now again, you’re wearing equipment, but you really want to [put in] maximal effort to protect patients and staff.

That’s a point raised in your paper that I really haven’t seen discussed elsewhere in terms of nursing home tests — that the process itself is painful and can be traumatic, especially for people who may have cognitive issues and other comorbidities.

I have a lot of physician friends who had the nasopharyngeal swab, and they were very clear that it was beyond unpleasant. My friend had a nosebleed for a while. It’s not a benign test. Obviously, when it needs to be done, it should be done, and if the data in the future shows that it is much more reliable than a nasal swab, that needs to be re-evaluated. If you maybe want to do one of each each week — I don’t know. Ideally, it’d be best if you could have either finger-stick or some other rapid response test.

But you need to find that balance between keeping the staff and the patient safe and also not causing harm to them in the process. People who have had the tests are very clear — I have not had the nasopharyngeal myself, but my colleagues have been very clear about the discomfort.

I can’t imagine what it is like for a patient in the nursing home with mild to moderate dementia, who has been in their room for now months — not having the usual programming that they’re accustomed to, not seeing their family live, staff coming in wearing a gown and a face shield and a mask. Maybe they have an ID now that shows their picture and a big smile. And then this person is something at you with a big Q-tip up your nose.

I think that there is an unrecognized psychological impact for lots of people with it — but certainly for patients with dementia who can’t fully get it.

That does play into the evolving understanding of testing strategies.

I think that there is still value in knowing. I think that when we’ve tested people who are completely asymptomatic, and then they were positive — honestly, it was mind-blowing. As physicians, I think we have a strong belief in our clinical skills, and maybe that’s less so nowadays, maybe people just are used to ordering CAT scans and X-rays and whatnot. But as a geriatrician, I still count on my my history and my physical exam and my clinical judgment.

COVID has basically wiped out any perception of my ability to have a similar judgment on diagnosis of COVID. I’ve seen too many people who have absolutely no symptoms at all test positive.

I think that, yes, depending on your prevalence, you will need to be protective for everybody. But now we’re reaching the point, at least in Nassau County, where we’re kind of over that peak. And now we’re like: “Yes, fine. We’ve tested everybody. We know who’s positive. We know when they get negative, we know that everyone else was negative.”

But then when we start letting visitors in, then when people start going up for tests again, then if we start to have programs, there could be false negatives. There’s still that risk of recurrence, and so I think there is value in having that testing — not on a daily basis, but I think at some level just to really know what you’re dealing with, and to kind of respect COVID.

What do you think needs to be done in terms of infection control, both to beef it up right now to protect people during the pandemic, and then improve it into the future — to make sure that if we ever get struck by another virus like this, we don’t have the same results?

I think that there should be consideration to having nursing staff and CNAs, direct patient care staff, fit-tested in the nursing home world. I know many facilities have tried to get that done, and you just can’t get the equipment to do the fit testing.

Fit testing is basically where they put you in a helmet that looks like you’re an astronaut, kind of airtight, and you wear the mask and then they spray aerosol that’s a certain micron size that wouldn’t fit through the mask filter, but can fit through any sort of edges of the mask where it’s not fitting. Then with that, they decide what size mask you wear. That’s standard when you join a hospital. They make you get fit-tested for that one random TB patient you have every five years — but now, everyone’s fit-tested because of COVID.

I think that the government should help nursing homes procure the ability to do fit testing, and I think the government should focus less on fines and punishments and more on helping, and figuring out what the needs are and how to help those needs be met.

This hit everybody, took everybody by surprise. There should be support and guidance and assistance — as opposed to criticism and blame and fines and citations. I’m sure there will be places that do merit fines or citations. But that’s the exception, and I think the goal should be to help rectify and correct and prevent. That should be their focus.

What are some of the top considerations that operators should consider before opening their doors or to visitors, or trying to come up with a firm plan for reopening to visitations and other kinds of non-emergency visits to the nursing home?

I’m actually very embarrassed to say that I had a dream last night about the nursing homes reopening. And in my dream, the nursing home became bombarded with family members, and people weren’t wearing their masks, and they were just walking around all over the place, and it was chaos.

It’s something that’s important. I cannot express fully, or without crying, how hard it was for families, and still is. Their loved ones are in this facility, dying from an acute, new respiratory infection and they couldn’t visit — and when they were allowed to visit because it was end-of-life, they were afraid to visit. We were their lifeline and their connection, but it was emotionally very difficult for the families to not be there when this is the time when — in our society — we most want to be there.

The desire for families to visit is very, very strong, and the desire for the residents and patients to see their families is also strong. The video visits are nice, but it’s not the same.

Contrary to my dream, I think the idea of outdoor visits makes sense. I think you need a schedule. The patient and the staff need to wear the appropriate masks. They should still social-distance on the visit.

I do think outdoor visit is better; we do have nicer weather now, and that will last. Whether or not family members should get tested before they come? Probably a good idea. I don’t know that it’s feasible to do on a long-standing basis in terms of insurance coverage, and again, you can get tested one day and then the next day be exposed.

I think that operators should work on it. I think that you do need government support for it to happen. But I think that people can be creative and careful in doing that.

I have one family member who literally looked into renting a cherry-picker from Home Depot so that she could drive up and bring herself up to the third floor and see her mom. It does reflect that need, that deep-seated need to see your loved one and to be with them, and how desperate people are for that connection.

This interview has been condensed and edited for clarity.