The New York Times tracked the outbreak, the struggle to contain it and the fallout, interviewing residents' families and listening to their conference calls as they sought answers from the facility's leaders.
Betty LaBombard, a longtime waitress at Woolworth's, celebrated her 95th birthday March 1 at the Vermont nursing home where she had been a fixture for eight years, often perched in her wheelchair near the fourth-floor nurses' station. Her niece brought her a chocolate cupcake.
Down the hall, Frances McKenna, a social force on their floor, looked forward to getting her hair done in the home's salon. One flight up, Joseph Metallo, who had moderate dementia, chatted with his son, Mike, while making a construction paper lamb for Easter. He wore his new glasses and kept his large-print Bible nearby.
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It was one of the last routine days at the Burlington Health & Rehab Center, before anyone knew just how badly the coronavirus would savage nursing homes, killing more than 44,000 residents and staff members nationwide. When the Burlington home shut its doors to the outside March 12, only two people in Vermont had tested positive. But it was too late. The virus was already inside.
"I feel like I murdered him by putting him in there," Mike Metallo said of his father.
Even though the number of new deaths from the coronavirus has been decreasing, the legacy of the pandemic in this country is already bound up in nursing homes. More than 40% of the coronavirus fatalities in the US have been tied to nursing homes and long-term care facilities. After such a toll, the nation faces a reckoning over its care of the elderly, regardless of what happens in coming months.
The senior Metallo, 89, became not just the first coronavirus case for the Burlington center but the first for Genesis HealthCare, a for-profit chain with a spotty record and almost 400 nursing homes and long-term care facilities in 25 states.
The New York Times tracked the outbreak at Burlington, following who lived and who died, interviewing family members and listening to their conference calls with the facility's administrators. What emerged is an intimate account of how the virus moved through a nursing home, how operators struggled to subdue it and how residents' families split over their performance and the outcome.
Burlington Health, ranked by regulators last year as one of the state's worst nursing homes, did some things right: It eventually tested all residents and staff members and isolated positive cases. It moved out a floor of healthy patients. Administrators updated families on Zoom conference calls, initially twice a day, an unusual level of transparency. A nearby nursing home, rated one of the state's better facilities, had a higher death toll.
Still, 11 Burlington residents died after contracting Covid-19, the disease caused by the virus. Relatives said they saw lapses in the home's infection control practices. The facility was pilloried in the press. In this lakeside community of about 43,000, people shouted "Murderers!" as they drove past. Families of three residents who died said they hoped to sue.
"Covid didn't kill her; neglect did," said John Reynolds, the son-in-law of a resident who had the disease yet died from a urinary tract infection that spread throughout her body. He said the family had told the home repeatedly about her history of such infections. He and his wife have since talked to state investigators about what happened, he said.
Dr. Richard Feifer, chief medical officer at Genesis, said the company had met or exceeded guidelines from the Centers for Disease Control and Prevention in responding to the coronavirus. But those guidelines, he contended, were slow to catch up with what was happening on the ground.
There usually weren't enough tests available; when there were tests, getting results took up to 11 days, Feifer said. Until late March, no one realized how many asymptomatic people could be spreading the virus.
Early on, Genesis decided any home with a positive case would hold regular calls with family members. In many other facilities, relatives have struggled to get even basic information.
The Burlington calls started March 18, two days after Metallo's diagnosis, and echoed national debates. When should coronavirus-positive staff be allowed to work? Why do some people with no symptoms test positive for weeks? How long are they contagious?
"It is frustrating because we would love definitive answers," Amanda Nagell, the home's nursing director, told families April 15. "We just don't know. And that's the scary part."
Home of last resort
Around town, the Burlington center, bought by Genesis in 2016, was known as the nursing home of last resort.
Nationally, the for-profit chain had a reputation for cutting costs and maximising profits. In 2017, Genesis agreed to pay the federal government almost $54 million, in part for providing "grossly substandard nursing home care" at several homes, none in Vermont. The company, based in Kennett Square, Pennsylvania, denied the allegations; some issues had happened at facilities before Genesis acquired them.
At Burlington, a resident choked to death after being mistakenly fed a grape; last year, the federal government flagged it as one of Vermont's worst homes. In February, the state settled with Genesis for $740,000 over claims of neglect in three homes, including Burlington.
"The facility was the last place to put people when there was nowhere else to put them," said Mike Metallo, whose father was sent there in October from the hospital after a bout of pneumonia. He said he had complained repeatedly about the care at Burlington. The home lost his father's glasses and hearing aids. When he visited, he said, he heard people calling for help; nobody answered.
Still, some people did not want to leave. LaBombard adopted newcomers, called her room "home" and refused her family's attempts to move her.
She often played bingo with her friend McKenna, who was paralysed on one side from a stroke. Now a widow, she had supported her four children and sick husband in the 1980s by wiring weapons for military aircraft at the General Electric plant.
Jeff McKenna, her son, said he and other family members visited frequently to tend to her because the home was understaffed.
No one knows for certain how the virus entered. Metallo went to the eye doctor in a crowded wing of the hospital March 9. Around that time, his neighbour on the fifth floor, a Vietnam veteran with severe dementia, returned from a 10-day stay at a psychiatric facility in Massachusetts, then a virus hot spot.
"This is something that still keeps me up at night," said Dr. Mark Pitcher, an internist and the home's medical director of 25 years, who knew all the residents by their first names.
On March 15, three days after the home closed to visitors, Metallo seemed fine. But the next morning, he was sent to the hospital with a fever and breathing problems. By 7pm the home knew he had the virus.
Others on the fourth floor had fallen sick. Maybe they contracted it at bingo, or through a staff member, or from one of the residents with dementia who wandered the halls. But that night, March 16, the nursing home called LaBombard's nieces. Their aunt, one recalled, was described as "under the weather."
LaBombard cratered. Two days later, her niece Holly Willard said, a doctor called about a fever and low oxygen. The next morning, another call: Her aunt was dying.
Willard rushed over. She said her aunt's roommate was still there; the curtain between the two beds was open; the room door was open. She said she was given a mask and gown, but staff members were walking around without masks or gloves.
"Some in street clothes going right to work," she recalled. "Nurses with no masks, going between floors." Asked later about safety practices, Pitcher said workers might have been changing protective gear between rooms. He said there was "a very small chance that someone might not be fully compliant" about gear.
On March 19, LaBombard died. That evening, the center's executive director, Ross Farnsworth, phoned Willard with test results: Her aunt had had the virus.
The calls
Farnsworth started twice-daily Zoom calls that week, opening up the home to a battering ram of questions.
Day 5: On March 20, one relative asked, did the home send coronavirus-positive patients to the hospital?
Not necessarily, Farnsworth responded. It depended on residents' wishes, and the home could treat most residents.
Might it be better to move them to the hospital so they didn't infect others?
No. The home had to assume others in the building already had the virus, the director said. And the state did not have enough tests to screen all residents.
Farnsworth did "the numbers," the grim tally he would do on every call. Six more residents with symptoms had tested positive; 17 were awaiting results.
Never had so many residents lost their lives so quickly. Seven more died before the end of March. At one point Pitcher told a colleague, "They're all going to die."
Metallo was cremated with his Bible and glasses. His neighbour, the veteran, also died. So did the single mother who had become a computer programmer at IBM; the former roofing contractor; two school janitors with diabetes; and a homemaker named Irene Santulli, whose grandchildren and children sang "My Way" and "Let It Go" over the phone during her final days.
Diane Santulli, her daughter, said the family had nothing but praise for the home's staff. "We just thought they were angels," she said.
But many city residents blamed the home. Pitcher said he witnessed people verbally abuse a hospice nurse. Anonymous callers threatened nurses. Police put a marked car out front so employees could enter safely. Staff members were also getting sick: Fourteen had tested positive.
Funeral home employees didn't want to go inside, Pitcher said. He said he had cried only once, on March 24, when a nurse told him she had been asked to wheel the virus' latest victim out back near the dumpster. There, she was told to wrap the body in plastic before the funeral home would take it.
That was the IBM programmer.
The numbers
McKenna, mother of four, player of bingo, keeper of Popsicles in her minifridge, spiked a fever a few days after LaBombard died. Then she tested positive. Her family did not tell her, fearing it would dampen her spirits.
McKenna, put on oxygen, counted the days to her 90th birthday April 21. Confined to her room, she didn't always wear the mask she was told to wear.
Day 19: On April 3, the home obtained tests for all residents. Twenty-two were positive, including seven with no symptoms. McKenna tested positive again; so did her asymptomatic sister, Anna Stoll.
The home began isolating positive residents from negative ones, following new CDC guidelines.
Day 20: "This should have been done three weeks ago," a man complained on a Zoom call. "I know the resources were hard to get, but this was an epicentre."
After others chimed in, talking over Farnsworth as he tried to respond, he muted everyone. "So, three weeks ago — what I was trying to say is — the resources were not scarce," he said. "They were not available, period, to test all in-house."
On the calls, family members fell into two camps: those who thanked the home for everything, and those like Pat McKenna, McKenna's daughter-in-law, who asked questions like a prosecutor.
On April 6, Burlington got tests to screen workers. Out of 118 staff members, 17 were positive. They would be allowed to return once they were symptom-free for seven days — in line with CDC guidelines at the time.
To Pat McKenna, this made no sense. Asymptomatic people could pass on the virus. Employees should have to test negative before working, she felt.
Day 26: On April 10, she took a stand. "Stick your parent in there," she said, her voice rising. "Wheel your mother right in the middle of the lobby and have 17 positive patients walk right up to her. You wouldn't do it."
Upset, she hung up, so she didn't hear someone else's relative respond, "If you're that concerned about how they're running the center, why don't you move your family member?"
People gasped.
On April 14, the home's executives changed course: Workers could return only if they tested negative twice.
After that, the families seemed less agitated. The questions became less confrontational, more curious.
Day 31: "Does everybody got to test negative, patients and staff?" one woman asked. "And then we're allowed in to see our family members?"
Day 33: "There are no pending tests for residents, right?"
Day 36: "Are new people going to be introduced to the building?"
Visits were a long way off. No tests were pending. New residents would be accepted, with precautions. Pitcher also talked about the virus' baffling behavior.
"If anybody can give me any insight on why some people get very sick very quickly and other people don't get sick at all, I would be more than happy to listen to your opinion, because I am clueless," he said April 20.
The next day, Frances McKenna celebrated her 90th birthday on video calls with relatives. Pat McKenna sent over a carrot cake and fixings for Shirley Temples — her mother-in-law's favourites. She also sent 15 pies for the staff.
Within days, Frances McKenna tested negative, as did her sister. "It was nothing short of a miracle," her son Jeff McKenna said.
The final numbers: Before the outbreak, the Burlington home had 90 residents. Over two months, 39 tested positive. Eleven of those died. Now 48 people live there.
Day 64: On May 18, Pitcher told families the building was most likely clear of the coronavirus. The only resident still in the building who had been positive for the virus for several weeks had tested positive for antibodies and was probably no longer contagious. (Hours later, she tested negative for the virus.)
But that didn't mean the threat was over. "We need to learn to live with it," Pitcher said. "We can't live to be afraid of it."
Over recent weeks, the phone calls turned more to the uncertain future: new residents to keep the home afloat, a return to some kind of normal. That in itself seemed overwhelmingly sad. Locked in their rooms for almost three months, many residents did not know the toll.
"Can you imagine, all these people coming out of their rooms once this is over, and they see everyone who is gone?" Jeff McKenna asked, his voice breaking. "They have no idea."
Written by: Kim Barker
Photographs by: Jacob Hannah
© 2020 THE NEW YORK TIMES