Nursing homes in Nevada and across the nation have found themselves at the epicenter of the coronavirus pandemic, with elderly and sick residents at particular risk for contracting the illness.

Since March, more than 1,000 nursing home residents and staff across Nevada have contracted the virus and nearly 100 have died. Some nursing homes have had just one or a handful of positive cases, while nine facilities have had more than 50 cases each. 

Two nursing homes have been particularly hard hit by the virus, responsible for roughly half of the deaths in nursing homes across the state. The Heights of Summerlin nursing home in Las Vegas has had 26 deaths, while Lakeside Health and Wellness in Reno has seen another 20.

The state has blamed outbreaks of the coronavirus in nursing homes on three specific violations of best practices for infection control: improperly worn personal protective equipment, a lack of isolation of patients who were infected and improper hand washing. 

But Brett Salmon, president and CEO of the Nevada Health Care Association, which represents about 80 skilled nursing and assisted living facilities across the state, believes it’s still too early to tell why some nursing homes have been harder hit than others. He said that nursing homes’ own understandings of the outbreaks in their own facilities are still evolving.

“I spoke with an assisted living facility last week where they were guessing — and I'm not going to give you their guesses — as to how they think it started and how they think it spread, and when I followed up with them, I think they were wrong,” Salmon said. “I mean, they thought it was one way, and I think they found out recently as they've been digging even deeper that it's not the way they thought.”

Salmon spoke to The Nevada Independent this week about how nursing homes have been coping with the coronavirus pandemic, what best practices they have been implementing and how they’ve been working to provide the most vulnerable residents with some social interaction even as they’re required to remain isolated.

“It’s hard on the residents and we understand that because they’re having to be isolated. There’s no communal dining anymore which was obviously a very social event in the building. There’s no activities anymore in the building, because they can’t do that,” Salmon said. “They do intercom bingo and things like that where they’re still trying to do fun things through their TVs, or they’re trying to connect them with their families. But it would never be enough.”

The below interview has been edited for length and clarity.

I want to start at a 30,000-foot level. What have the biggest challenges for skilled nursing facilities been during the pandemic?

There have been lots of challenges, and I think probably the largest challenge is dealing with the most vulnerable population you could possibly deal with during a pandemic and struggling to make sure that you're abiding by the most recent regulatory guidance, whether that be from the Centers for Medicare and Medicaid Services or the [Centers for Disease Control and Prevention] or county-driven updates, as well as state updates. Everything has moved really, really fast, and I think that has been probably the hardest thing on the skilled nursing facilities, particularly in long term care, is just keeping up with how quickly the guidance has changed.

What has been the most confusing thing for skilled nursing facilities to adapt to as they are processing all of this guidance?

I don't know if confusing is the right word, per se. The difficulty has been just the amount. If you go on the [Department of Health and Human Services’] website on their technical bulletins, they have 14, and they have some [subheads] under that, so over 14 technical bulletins that have come out since January 24 in regards to COVID, how you should be protecting your facilities from admission, how you should be protecting your facilities from visitors to your facility, how you should be testing your staff coming into the facility and logging that, and then also how you handle PPE.

So I wouldn't say that it's been confusing as much as it's just been a lot of stuff that people have had to incorporate into their policies and procedures, and I think that anybody who's in health care right now, they've had to be very nimble and very quick, and I think they've done a really good job being nimble and quick to it.

What right now is the best practice in terms of who should be wearing PPE and when? Is it just when you’re treating a patient that has COVID, or is it now recommended that everyone wears it? What are the best practices facilities should be following?

I’m not a clinical person, so I’ll tell it to you as best as I understand it. But my understanding is the way they've been directed now is they’re to treat basically every resident who hasn't been in their building before as COVID positive. So they will quarantine them for 14 days when they come into the building, and then they're also to have a COVID wing in their building set aside so that they can handle that kind of quarantining.

In some facilities, because they're so tiny, that's really hard to do. You have buildings that have 38 beds, and so — cohorting, it's called — to cohort can be a struggle. But that's the guidance they've been given thus far, and when the next guidance comes out, obviously, they'll adapt and make sure that they're doing it the correct way. 

In the middle of it all, they were told to just treat everybody as COVID positive and so with PPE, you were donning it for everybody and you were doffing it when you left the room and going to the next resident, and so a lot of PPE was used during that time, particularly. 

And now it’s more about trying to separate folks and quarantine new individuals who are new to the environment?

Yes, and there's actually been a couple of facilities in Southern Nevada that have actually done that. So Transitional Care Las Vegas and Las Ventanas actually have created COVID positive wings where they actually take active COVID residents. They have separate staff. They have separate entrances. They're the two that are actively doing it. Other ones will take their own residents — if they've gone through and tested and they're discharged back from the hospital — they'll take them back. But a lot of them are obviously very nervous, because of not having adequate staff or having adequate PPE during this time, to take an active COVID positive because PPE is a struggle.

What is happening with people who are still actively COVID positive and they’ve been in the hospital and they need to be released for whatever reason, where do they go? And what is the best practice for people who’ve had COVID but they’re now recovered? Are they allowed to go back to the nursing facility where they were?

I can just give you anecdotal information on that. I can't confirm how every single facility does it. But I surveyed our members several weeks ago, and generally, if it's their resident that they discharged to the hospital for a procedure and they have no symptoms, are asymptomatic, they will take them immediately back. Now, if they have symptoms, they will request for a test, a negative test and then they will take them back if they have adequate staffing, adequate PPE and the ability to cohort, and that's kind of where they run into those issues. But I think generally they're pretty protective about the residents that they've discharged that they want to have come back, and so they will take them on. Now, a person they've never met, a new admission to their facility and they don't have a negative test yet on them, most of them will say, no, we need at least a negative test so that we're not introducing it to our facility if we don't have COVID yet.

How has COVID been getting introduced to these facilities? Is it new patients coming into the facility and introducing the virus, or is it staff who are coming in who are maybe asymptomatic and introducing it?

I really don’t know. I think people make assumptions about things, but until the contact tracing has been from A to Z done and we know when this is all played out, I think there will able to be much more data and analysis of how it really is spreading and how it really is occurring. I just really don’t know. I find it kind of fascinating myself, but I really don’t know.

Why have some facilities been particularly hard hit by the virus? Is it that facilities that have tested widely are identifying more positives? Is it that some facilities have just gotten unlucky? The state has also talked about deficiencies in some of the facilities. They said in some facilities people weren’t wearing PPE properly or there weren’t proper hand washing protocols. Why have we seen some of these particularly bad outbreaks in some facilities?

I've read the same articles. I haven't read the paper behind it, so I can't speak to the actual surveys to know. Until they kind of get the final results in and the contact tracing is done affirmatively where they really know, I just don't know. I mean, I can make assumptions as well. I think at this point there are a lot of assumptions that, well, we think maybe it's this, and we think maybe it's that. 

I spoke with an assisted living facility last week where they were guessing — and I'm not going to give you their guesses — as to how they think it started and how they think it spread, and when I followed up with them, I think they were wrong. I mean, they thought it was one way, and I think they found out recently as they've been digging even deeper that it's not the way they thought. That's why I think there's just a lot of assuming at this point, and as it all plays out, I think that we'll see patterns, but at this point, I don't know.

As you're talking with your members, how are they implementing best practices given that it sounds like they don’t know where exactly the virus is coming from?

The feedback that I've heard, as I've talked to them, is that when they get more updated guidance then immediately they train their staff to it. They do their best, and that’s really what they’ve done. They’ve done their best because it’s gone so fast. When you really think about this in context, what was our first case in Nevada, was it early March? Think about from early March until just about hitting June, how quickly it’s just spread everywhere. You’re dealing with the most vulnerable population without any COVID, and then you’re adding in something where they’re trying to adjust to the best practices that they have at any given moment.

What’s interesting on the data is there are 38 facilities that have now had COVID, but there are seven facilities that have had a 100 percent recovery of people who’ve had it and they no longer have it. We have 64 nursing facilities, so 31 of 64.

When you put it in context nationally, we’ve had outbreaks, absolutely, but we’ve done a really good job in maintaining where we’ve been at, and it’s creeping up, but that’s typical for how the virus spreads too.

The state has said that the issue in some of these facilities was not having not enough PPE but that people didn’t know how to use PPE. What has the PPE situation been like in nursing homes? Has there been a lack of training on how to use it?

I don’t know, on the training side, because when you have N95 masks you have to have a fitting based on the size of the person, and I know that getting fittings was very very difficult through this because the companies that did it were unavailable or wanted to change exorbitant prices for that fitting to occur. I think the PPE situation is a little bit better now in that we’ve gotten a little bit more. Gowns are still a real struggle, and any sort of health care right now gowns is a new issue. They’re doing better on the masks but they’re really struggling with the gowns and being in full gowns is really important when you’re dealing with COVID.

I would say the PPE situation is still tight. We’re appreciative of the PPE we’ve received from the state and we’re getting some FEMA PPE company. Each facility in Nevada is supposed to get a FEMA shipment based on their licensed beds in the next couple of weeks, and so we’re hoping that will really help too. But it’s just based on how much COVID you have in your building, if you have a lot of cases of COVID you’re protecting and dealing with, you really will go through your PPE fast.

The state has also mentioned that in some facilities residents weren’t appropriately isolated when they started showing symptoms. Why is that?

I don’t know the specifics to know why they did what they did, if they did that. On the cohorting side, I’ve just heard generally from some facilities that because of their side cohorting is really really hard so they’ve had to do unique things or they’ve had to discharge, so I don’t know in those situations that you’re referring to how or why it happened that way.

Some family members have been voicing concern over a lack of communication about what’s going on inside these facilities. How do you keep family members and loved ones in the loop when they can’t physically be there with them in person? Is there more nursing homes could be doing?

I have to speak generally on that too because I don’t know specifics. I’ve heard generally that most of them have acquired some sort of technology, multiple iPhones or multiple iPads that allow there to be contact in the building. It’s hard. I think it’s really hard on them. It’s hard on the residents and we understand that because they’re having to be isolated. There’s no communal dining anymore which was obviously a very social event in the building. There’s no activities anymore in the building, because they can’t do that. They’re trying to do activities. They do intercom bingo and things like that where they’re still trying to do fun things through their TVs or they’re trying to connect them with their families. But it would never be enough. They deserve to have access to their family members and I feel so bad for them. 

I’ve asked the state of Nevada if there’s any way we could begin freeing up at least in a building that doesn’t have any COVID or once the residents have all been tested that there would be an opportunity for them to dine together again. But they’re being, and they should be, very cautious, and they’re taking direction from CMS and CDC, and at this point they’re not willing to do that because they’re just concerned so much about a spread happening with asymptomatic people. But I think once we have them tested and there’s a baseline, I think there's hope there that finally you can open it up for the residents and then, hopefully, that then maybe opens up a little bit a window where you could have some sort of better connection with families, but I just don't know. The governor has said those facilities will be the very very last on the list to be wide open for visitation and we support that, but it’s hard.

The head of the state public lab said that there is a plan in place to test all staff and residents in nursing homes by Friday. Is that still happening?

I’m aware of that, and I know that it’s being run through the counties. That was a mandate that came down from the Department of Health and Human Services here, and they requested that it be done by that date. Now, a lot of the testing had already been done in some facilities. Some of them had done it themselves and paid for it themselves. Then others had gone through Washoe County or the Southern Nevada Health District or one of the private labs, however that worked. They’re still actively doing it. It’s still actively being scheduled.

I think the large majority of them will be done by Friday. There’s going to be a few stragglers where just the scheduling with the Southern Nevada Health District just couldn’t get done exactly by the 29th but I think it will be done by Monday, Tuesday, I think at the latest. They’ve done a good job of getting out there.

Initially it was not a mandate, it was just a if you want to have testing done. So there were many facilities that reached out and did that, but there were some who hadn’t done it yet and so those are the ones that now there’s a mandate, they’re following up and saying you need to get it done and so now they’re doing it.

Looking forward, what are the next steps for nursing facilities in the next 30, 60 or 90 days?

Our biggest priority is going to still be PPE and making sure we have everyone’s attention to get the PPE that we need. The COVID virus is going to be around, and we need to make sure that supply lines are opened up and we’re able to really be reassured that we can handle it, particularly if there is another round of this. If we get it in the fall, we want to make sure that we’re ready and that’s going to be a huge priority for all of our members is making sure we have enough PPE.