Dr. Jim Wright knew that COVID-19 would come to Canterbury Rehabilitation & Healthcare Center, a nursing home in western Henrico County that he oversaw as medical director last year as the global pandemic reached the United States.
Wright and his staff had tried to prepare for the mysterious disease that had leapt from China to the West Coast and swept through a nursing home outside of Seattle, resulting in the first U.S. death from COVID-19 on Feb. 29, 2020. Ultimately, 46 people who lived or worked at the Life Care Center of Kirkland died in the first major outbreak of the coronavirus disease in the United States.
But he had no idea that within weeks Canterbury would surpass the death toll at the Kirkland nursing home, even after the first case was confirmed in a 55-year-old resident on March 19, 2020. She would survive, but more than 50 residents would not.
“That’s when I knew we had an outbreak,” Wright recalled in an interview. “Little did I know what was in store for us over the next five to six weeks … It was just a tidal wave that swept all our preparations away.”
The deaths began a year ago, on March 22, 2020, when a Canterbury resident was the first person to die in the Richmond area from a pandemic that would kill more than 10,000 Virginians over the next year, including almost 4,000 people in nursing homes and assisted living facilities across the state.
Canterbury began a desperate battle against a highly communicable disease that no one could see because it often spread without showing symptoms in the people who carried it.
During the outbreak, 51 people died of COVID-19 at the privately owned nursing home, which relied on shared rooms and public funding through Medicaid for most of the 166 residents living there when the outbreak began. During the pandemic, the facility at least temporarily lost 69 employees who either left in fear or became sick and were forced to quarantine.
“It was a horrible experience,” said Wright, who is medical director at three other long-term care facilities, but no longer at Canterbury. “Every day, I grieve for the patients I lost.”
“My mark of success in long-term care – even though all of my patients die, of course – is to give them a good death,” he said, with care that allows them to “survive as long as possible and with the best quality of life possible.”
“And I had failed miserably for six weeks at Canterbury.”
Consequently, Wright has become a forceful public advocate for changes in Virginia’s long-term care industry, especially at underfunded, understaffed, for-profit nursing homes that rely on public funding for more than two-thirds of their residents.
“I want to make sure people understand, it’s not ‘that terrible nursing home’ that caused those deaths,” Wright said. “It’s what society has determined is the appropriate level of care for our elders.”
Nichelle Jones, the new administrator at Canterbury, said the home “was among the first skilled nursing facilities in the country to experience a major COVID-19 outbreak.”
“Unfortunately, we did not stay unique for long,” Jones said.
The outbreak at Canterbury exposed every flaw in the public health system in the U.S. and Virginia. That began with the lack of testing supplies and laboratory capacity to quickly identify cases of the disease and isolate the people carrying it, or an understanding of how it spread. Employees didn’t have enough protective equipment – gowns, masks, gloves – to prevent contamination by the virus, which has infected more than 25,000 health care workers across the state.
“That was kind of a sentinel event for us in Virginia,” said Dr. Laurie Forlano, deputy commissioner at the Virginia Department of Health and the chair of a long-term care task force that Gov. Ralph Northam appointed less than three weeks after the first deaths at Canterbury.
Long-term care facilities, filled with vulnerable residents living in close quarters, were “just a ripe environment” for the novel coronavirus, Forlano said. “The speed with which the disease moved through these facilities was really remarkable – and very tragic.”
Henrico’s dire challenge
Canterbury’s ordeal also posed a potentially catastrophic challenge to Henrico, which is home to more than 60 long-term care facilities. The county, with more than 330,000 residents, had experienced 568 deaths from COVID-19 through Thursday, second only to Fairfax County, the state’s most heavily populated locality, with more than 1.1 million people.
“It’s just because there is such a huge concentration of long-term care facilities in our county,” said Rebecca Lewis, senior epidemiologist at the Henrico Health District, which Wright praised for the critical role it played in responding to the crisis at Canterbury.
Lewis was the first to offer help to a facility that found itself so isolated from the fearful community that surrounds it that it couldn’t get trash picked up or grass mowed, Wright said. “From that point on, they were our lifeline.”
The medical director and his staff “were truly doing their best with the knowledge we had at the time, which was very little,” said Lewis at the health department.
“Although it’s unfortunate that it had to be Canterbury and they had to be the first to go through this, we really learned from them,” she said.
Led by Dr. Danny Avula, whom Northam appointed this year to coordinate COVID-19 vaccinations throughout Virginia, the Henrico health district – operated jointly with Richmond – pioneered mass testing of all residents and employees at Canterbury, which the state ultimately extended to all long-term care facilities.
It also worked with the nursing home to allow staff who had tested positive for the virus to return after quarantine, if they showed no symptoms, and care for residents infected with the disease.
“Danny Avula is a gift,” Henrico County Manager John Vithoulkas said.
After initially clashing with Canterbury management over access to the stricken center, the county government stepped up its role in responding to the outbreak.
It arranged for private ambulance service and built a shower facility for employees, and reached out to local hospitals to help recruit employees the nursing home desperately needed to bolster its depleted staff. It produced a 56-page manual of COVID-19 resources that it distributed to all long-term care facilities in Henrico and shared testing supplies with them.
“Ground zero of the past year is Canterbury,” Vithoulkas said.
Now, Henrico is supplying hundreds of workers and spending millions of dollars to run a mass vaccination center at the Richmond International Raceway that is administering vaccines against COVID-19 to up to 5,000 people a day.
“The bureaucracy does not know best,” Vithoulkas said. “If you can’t take a chance during a global pandemic, Lord help you!”
A ‘shocking’ revelation
Jim Wright thought COVID-19 had arrived at Canterbury a few days before it did, and he was worried that Virginia wasn’t prepared.
A resident had begun showing alarming symptoms on March 11, 2020 – fever, aches – but tested negative for the flu. Ultimately, COVID-19 wasn’t the cause, but Wright was alarmed at the difficulty of testing for the disease, which showed up a few days later in a 55-year-old woman who shared a room with two other people at the nursing home.
On March 18, 2020, the day before the woman tested positive for the virus, Wright and five other nursing home directors wrote to Northam with a plea for the state to relax restrictions on testing for COVID-19. Faced with a shortage of test supplies and limited laboratory capacity, the state health department required doctors to clear several hurdles, including a negative flu test, a chest x-ray, a test to rule out the common cold.
“You had to test for all these things before the state would agree to test for coronavirus,” Wright said.
Two days earlier, an 80-year-old independent living resident at Westminster Canterbury, a nonprofit continuing care retirement community in Henrico that is not affiliated with Canterbury Rehabilitation, became the first person to test positive for COVID-19 at VCU Medical Center. Carter Fox, the retired CEO of Chesapeake Corp., who had returned from vacationing in Florida when he was stricken by the virus, survived, after being placed on a ventilator to breathe.
But the stealth that marked the spread of COVID-19 already had infected a resident of Canterbury Rehabilitation without Wright knowing it. Henrico health officials traced the outbreak to a 48-year-old resident who had been admitted to a local hospital on March 13, 2020, with sepsis from a bladder infection. The man later was tested and confirmed with COVID-19 at the hospital, even though Wright said his symptoms “did not present like a typical COVID patient.”
The outbreak quickly spread, killing one Canterbury resident on March 22 and another the next day. The health district announced the deaths on March 24, putting a harsh public spotlight on the nursing home for the next six weeks as Canterbury experienced what was then the most deadly COVID-19 outbreak in the U.S., surpassing that at the nursing home in Washington.
Avula, director of the Henrico and Richmond health district, told Canterbury in a letter the next day that its investigation deduced that the original source of the outbreak “may have been an ill visitor or staff member” in one unit of the building.
By then, the nursing home had found a ready source of test kits from GENETWORx, a laboratory in Innsbrook that also supplied the county government. Vithoulkas wanted Canterbury to test everyone, but national and state public health guidance reserved tests for people who showed symptoms of the disease.
That changed after the Centers for Disease Control and Prevention released a study on March 27 about the initial COVID-19 outbreak at the Life Care Center of Kirkland in Washington state. The study showed that more than half the residents who had tested positive for the virus showed no symptoms.
Angela Myrick-West, a regional epidemiologist for the health department who assisted Rebecca Lewis in the Canterbury investigation, quickly shared the study with Avula and Wright. The health department also discussed the results directly with the nursing home in Kirkland and local health officials there.
“It was shocking,” Wright said.
The results were even more shocking after the Henrico health department sent dozens of nurses to Canterbury the next Monday to test every resident and employee in the building. The testing found that 92 residents were infected with COVID-19 and 54, more than half, showed no symptoms of the disease.
“A lot of people were nervous [about the results],” Lewis said. “We thought, ‘If this is true, we’re going to have a huge ordeal on our hands,’ and, of course, we did.”
Mass testing later became the backbone of Virginia’s response to the pandemic’s spread through nursing homes, assisted living facilities, prisons, group homes – anyplace where vulnerable people live in close, congregate settings. The health department deployed “point prevalence surveys” across the state, with help from the Virginia National Guard and Medical Reserve Corps volunteers.
“Canterbury really was the first one,” Lewis said. “That’s when we realized we needed to start doing this everywhere.”
Forlano, head of the state long-term care task force, said, “It’s hard to remember how much we didn’t know back then, how much we didn’t have in place that we do now.”
‘A skeleton crew’
The arrival of COVID-19 at Canterbury a year ago sparked an exodus of staff the nursing home needed to fight the deadly outbreak.
Staffing agencies pulled their nurses out of the building. Others refused to work there. Some left under outside pressure – from educational institutions that didn’t want them attending classes if they worked at the center, or from day care centers that didn’t want them to drop off their children. Others had to remain home to care for sick members of their families or children who couldn’t go to school.
Three dozen employees were forced to stay home temporarily after testing positive for the virus and quarantining. They later returned after their symptoms disappeared and began working with COVID-19 patients, another first at Canterbury.
Altogether, Canterbury lost 69 members of its staff, either permanently or temporarily, while fighting one of the deadliest coronavirus outbreaks in the U.S.
“It was astonishing,” said Wright, who changed beds while the home’s administrator delivered meal trays. “It was a skeleton crew.”
Canterbury ultimately got outside help, from employees supplied by local hospitals and staffing agencies, to Wright’s wife, a palliative care physician who volunteered at the nursing home for weeks.
Marquis Health Services, which had bought the nursing home the previous December and begun bolstering its staff, temporarily doubled wages for its nursing teams and brought in employees from other states where it operates in order to fill the gaps.
The company says the staffing situation improved after it increased wages and offered options for transportation to and from work, in addition to widespread testing and the greater ability of parents to go back to work as their children return to school.
“Due in part to these factors, we have seen a significant increase in new hires,” said Jones, the home’s administrator.
The staffing quandary
But staffing remains a puzzle for long-term care facilities, which rely on low-wage employees who have to work more than one job to make ends meet. Some were reluctant to test all of their employees for the virus for fear of losing critical staff to quarantine, Avula said last year.
During the outbreak at Canterbury, Avula asked employees to commit to not work at multiple facilities, but health officials recognize that it’s a major sacrifice for many workers.
“I think it’s necessary for them to make a living wage,” said Lewis at the health district, who noted that many long-term care facilities are within walking distance of one another in western Henrico.
However, public health officials say employees often unwittingly bring communicable diseases into long-term care facilities, as someone on Canterbury’s staff might have with COVID-19 a year ago and others did at other facilities after the Thanksgiving and Christmas holidays, when Virginia experienced a major surge in community spread of the virus.
“These facilities are not islands,” said Forlano, head of the long-term care task force. “They are connected inextricably to the communities that surround them.”
Wright says his public candor about the challenges of keeping adequate staff was why Marquis removed him as medical director of Canterbury’s skilled nursing rehabilitation unit in June. That ended his direct supervision of patients and prompted him to leave the facility.
Jones, the new administrator at Canterbury, did not comment on Wright’s departure but said the company supports his advocacy for nursing homes.
“Canterbury’s understanding was – and remains – that Dr. Wright was speaking out on behalf of all nursing home residents, not singling out Canterbury in his comments to the media,” Jones said. ” We share his passion and desire to see more governmental investment in long-term care, and we wish Dr. Wright well in his new endeavors.”
Wright still serves as medical director at Our Lady of Hope, a nursing home in western Henrico, and the Memory Center, an assisted living facility in Midlothian for people with dementia. He also has become medical director at Northern Neck Senior Care in Warsaw on the Northern Neck.
Wright also has become a public advocate, pushing for a greater state commitment to funding of nursing home care for Medicaid patients and requiring those facilities to meet minimum staffing standards, as many other states do. He’s also continuing to plan what he calls Homecoming Village, a project to create a different kind of place outside of Richmond for people with dementia to live.
“Instead of being embittered or broken by the experience, I’m galvanized by the experience,” he said.
The governor’s long-term care task force will continue its work, meeting at least monthly, said Forlano, who acknowledged that “staffing remains a challenge” that the state must address to make nursing homes safer for their residents.
“We’ve learned how these people, a lot of times, are forgotten a little bit,” she said. “We need to focus on the important people in our lives and the people who take care of them.”