March 4, 2020 — A coronavirus outbreak in a Seattle-area nursing home, identified only late last week, has already led to five deaths, highlighting just how vulnerable people in care facilities can be.

The Life Care Center in Kirkland, WA, has become ground zero of the crisis in the U.S. Fifty other patients and staff are ill with respiratory symptoms or are in the hospital with pneumonia or other respiratory conditions. All are being tested for COVID-19.

The Life Care outbreak served as a wake-up call to nursing homes and other elder-care facilities across the country, which are now using new policies, dusting off old ones, and crossing their fingers that the virus stays away.

Nursing home patients are always potentially at risk for passing viruses, particularly the flu, which kills tens of thousands of older Americans a year. Many facilities have aggressive programs for preventing the flu, including vaccinations, hand-washing stations, and warnings to visitors.

Ripe for Virus’ Spread

Some facilities have already stepped up their seasonal efforts out of concern for coronavirus. Older patients and people with other health conditions are more at risk of having a serious illness, a recent study found.

At Hebrew SeniorLife in the Boston area, signs warning sick visitors to stay away have been changed. They were once a very polite “consider not visiting.” But now, a big red sign says: “If you are sick, please do not enter!” says Helen Chen, MD, chief medical officer of Hebrew SeniorLife, the largest nonprofit provider of senior health care and living communities in New England.

There’s no question, Chen says, that people in nursing homes and rehabilitation facilities are at risk.

“I think every nursing home should have a strong infection control plan and procedure,” she says. “Anytime you have a group of vulnerable people — seniors — living together with shared everything, they’re at risk for also sharing infections. I’m not even talking about COVID-19.”

At Hebrew SeniorLife facilities, staff members who are sick are paid to stay home, Chen says, and routine cleaning of surfaces has been stepped up to prevent the spread of germs. She can order parts of her facilities — say, 3 North — closed to outsiders if illness is found, to stop it from spreading.

She says anyone with a loved one in a long-term care facility should check to make sure it has a vigilant infection control program, extending to housekeeping.

But Chen says that people should think long and hard before taking a family member out of a skilled nursing facility. “I understand why some families might feel more comforted by having eyes on their mom or dad,” she says. “But there are so many things that are provided in a good long-term care setting that I think families would struggle to provide on their own.”

Muriel Gillick, MD, a professor at Harvard Medical School’s Department of Population Medicine, says she doesn’t see any need for a facility to keep out visitors right now. “I don’t think there’s any reason for a lockdown unless there’s a case [at the facility],” she says. “This is too rare an event at this point. … It seems like overkill to exclude everybody just because you never know.”

Industry Offers Guidance

The American Health Care Association, the nation’s largest trade group of senior care facilities, issued new guidelines for its members this week on dealing with coronavirus.

The statement recommends strategies like monitoring staff and visitors for hand-washing; reviewing plans to isolate people or entire wings if an infection is found; and making sure staff know who to contact if they suspect a case.

Like hospitals, many nursing homes are worried about running out of personal protective gear, which they will need if the virus does come — or if a resident falls ill with something else.

Chen says she’s waiting for a new shipment of protective gear. Hebrew SeniorLife’s stock is fine now, and staff members are in daily contact with suppliers, she says. But personal protective equipment is typically made in China, where production has largely stopped since mid-January.

The World Health Organization on Tuesday called on suppliers to boost production by 40% to meet skyrocketing demand.

Return to Basics

Gillick says even more basic measures need to come first.

“Soap and water is a great invention,” she says. “It really makes a difference.”

But in many health care facilities she’s visited, there aren’t sinks in convenient locations, or there’s no hand soap at the sink, or no paper towels, or no trash can for the paper towels. “Somehow, one or the other of those is always missing,” she says. “Real basic stuff that people always forget about because they’re rushing to get these useless masks.”

National Nurses United, the country’s largest union of registered nurses, has been doing a survey to ask its members how prepared their facilities are for an outbreak of coronavirus. Of 6,000 nurses in all sorts of facilities who answered the survey, only 44% report that their employer has given them information about the coronavirus and how to recognize and respond to possible cases. Only 29% say their workplace had a plan for isolating patients with COVID-19.

“That’s kind of scary,” says Jane Thomason, the union’s lead industrial hygienist.

Gillick says that at minimum, nursing homes should be following CDC guidelines.

There are 1.7 million long-term care beds in the United States, she says, with some people in long-stay facilities and others in rehab facilities for shorter stays.

Assisted living facilities are not intended to provide medical services, so they do not have infectious disease consultants on staff. “They’re going to be a classic case of making up the rules and not necessarily rational ones,” she says.

Dementia patients are in another category, Gillick says, because it’s hard to get them to wash their hands appropriately. Like toddlers, she says, dementia patients “drip and they gook and they poop, and there’s not the greatest sanitation.”

It’s crucial, she says, for nursing home workers to stay home when they’re not feeling well, rather than coming in to work, possibly spreading disease.

“It’s so often the case that people in the medical profession work even when they’re sick, because it’s the macho thing to do,” she says.

Many nursing assistants, for example, get paid only when they work, so they can’t afford to stay home, Gillick says. Health care institutions need to step up and keep paying them and make them stay home if they’re sick.

“You’re not doing anybody any favors by having them [come in when they’re sick] — that’s probably always true, but it’s particularly true in an epidemic setting.”

If you have a loved one in a long-term care facility, experts recommend asking administration for their plan to deal with the new coronavirus. Questions to ask include: When would you bar visitors from entering? Can I still take my loved one to lunch, to church or to the doctor? Other tips include:

  • Stay home if you’re sick, at all.
  • If you can’t visit your loved one, try emailing, calling on the phone, FaceTime, or drop off a note.
  • Wash your hands, practice good cough etiquette, and watch facility staff to make sure they do the same.
  • Provide your loved one with hand sanitizer as a backup to hand-washing.


Helen Chen, MD, chief medical officer, Hebrew SeniorLife.

Muriel Gillick, MD, professor, Harvard Medical School Department of Population Medicine.

Jane Thomason, lead industrial hygienist, National Nurses United.

News release, World Health Organization: “Shortage of personal protective equipment endangering health workers worldwide,” March 3, 2020.

CDC: “Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United States.”

American Health Care Association: “COVID-19 — Update #2.”

National Consumer Voice for Quality Long-Term Care: “How to Protect Yourself and Your Loved Ones.”

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