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Boston Globe Spotlight Team

A home to die in

They were the most vulnerable to COVID — thousands of elders in nursing homes across the state. Yet for the Baker administration, praised for its overall pandemic response, they were for too long a secondary priority. The result was calamity — 1 in 7 dead, among the highest rates in the land.

Second in a three-part series

The discovery in Washington state was so remarkable that US health authorities posted it online immediately: Thirteen nursing home residents who tested positive for COVID-19 in one of the nation’s first outbreaks showed absolutely no symptoms, but they might have unknowingly infected others.

It was an ominous warning on March 27 that the deadly virus may have the ability to spread rapidly and invisibly among the most vulnerable. But it was a warning not heeded here: That very day, Massachusetts leaders unveiled a hastily arranged plan to shuffle hundreds of symptom-free — and untested — residents from one nursing home to others to clear room for older COVID-19 patients discharged from hospitals.

There was still time to hit the pause button. No one did.

And so it began. Over the next three cold and gloomy days, medical workers moved 137 elderly women and men, many with dementia, out of their familiar rooms at Beaumont Rehabilitation and Skilled Nursing Center in Worcester, loaded them into ambulances, and scattered them among 18 facilities. They were people like 92-year-old Frannie Trotto, who never recovered from the sudden and disorienting uprooting. Neither she nor the others were tested for COVID-19 because state guidelines at the time called for swabbing only those with a fever or cough. And some may have brought the virus to their new homes.

It was an unaccountable move by the state, one with dire consequences. In that critical moment, and for far too long, the population at gravest risk of COVID seemed a comparative afterthought for Governor Charlie Baker’s administration. The governor and his public health team deserve credit for the intense state response that helped bring about an impressive overall reduction in COVID sickness and deaths since summer; one of the hardest hit states now has one of the lowest infection rates in the land.

But the state’s early response to the predictable crisis in the nursing home population was halting, chaotic, and in the end, disastrous, a Globe Spotlight Team review has found. It showed a striking lack of foresight and urgency as the virus, in the critical period between mid-March and early April, infiltrated nursing homes, eventually killing thousands of senior citizens.

Controlling the COVID-19 outbreak in housing for elders proved to be a daunting challenge across the nation. But the staggering tally of coronavirus deaths in Massachusetts long-term care facilities, which last week topped 6,000, is among the worst in the United States. Only two states — New York and New Jersey, both with far larger populations — surpass Massachusetts in total nursing home deaths.

Massachusetts has one of the highest nursing home death rates

While New York and New Jersey surpass Massachusetts in total number of deaths among nursing home residents, Massachusetts is second in COVID-19 deaths per 100,000 population.

NOTES: Data for four states (Hawaii, Montana, South Dakota, and Alaska) are not available. States are inconsistent in how they count nursing home deaths, so comparisons may not be exact.

SOURCE: Kaiser Family Foundation, US Census. Data updated as of Sept. 4, 2020.

Daigo Fujiwara, Tood Wallack/Globe Staff

By percentage, the losses have been similarly staggering, and have triggered a state attorney general probe of some homes, including criminal charges filed in one case already.

Long-term care facilities account for nearly 66 percent of COVID-19 deaths here. Adjusted for population size, Massachusetts’ nursing home death rate during the pandemic is the second-highest in the nation. The state’s publicly reported long-term care figures do not include deaths in assisted-living facilities; health officials told the Globe last week that those facilities have reported an additional 457 coronavirus fatalities.

To put it even more starkly: About one in seven Massachusetts long-term care residents died from COVID-19.

This tragic fallout is especially glaring in a state that boasts of its world-class health care system. But lift the hood, and you will find a large but less visible swath of that system, so weakened by a lack of funding, staff, rigorous infection control, and protective gear, that it was unprepared for a pandemic.

It’s not as if there weren’t alarm bells sounding.

The startling news from Washington state should have been catalyzing. And closer to home, MIT researchers warned the governor and his health and human services secretary, Marylou Sudders, during an evening meeting at the institute president’s home in mid-March that nursing homes — where 40 percent of residents are over 85 — were dangerously exposed to COVID-19. “We said 'here are the facilities, you need to protect them,’” said Retsef Levi, a Massachusetts Institute of Technology management professor, who had mapped out the number of elderly residents in each location.

But the paramount aim of the Baker team during the initial weeks of the pandemic was preparing hospitals for an expected onslaught of patients — a vital goal amid an epic crisis. At the same time, state leaders, who are ultimately responsible for protecting 42,000 elderly people unable to care for themselves, were so inattentive to the elders’ plight that they thought it appropriate to claim nursing home beds as reserve space for the predicted flood of recovering hospital patients.

Long-term care residents account for more than six out of 10 coronavirus deaths

Total COVID deaths in Massachusetts
COVID deaths among long-term care residents

NOTES: State long-term care data do not include deaths at assisted-living facilities and some other senior sites. The state’s methodology for counting deaths also changed over time.

SOURCE: Mass. Department of Public Health.

Daigo Fujiwara/Globe Staff

This transfer of nursing home residents, which ended after some Beaumont residents tested positive for the virus right before their planned move, was one devastating early stumble. And interviews with more than 80 nursing home owners and staff, families, researchers, and health care leaders, and an extensive review of state records and data revealed more:

State officials, the Globe found, failed to give priority in March to front-line nursing home workers for protective masks and gowns. Instead, they sent more of the limited supply to hospitals, which were in a far better position than nursing homes to acquire the gear on their own.

Five nursing home workers, including three who became infected, told the Globe they were discouraged from wearing masks and gowns in March, either because managers didn’t want to scare patients or because they were conserving limited supplies.

“I called infection control and she said, ‘I already provided the limit of gowns to that unit that day,’’' said a former worker at Charlwell House Health & Rehabilitation Center in Norwood, where an outbreak killed 22 residents. Christopher Roberts, vice president of operations, said the facility followed all public health guidance on when to provide protective equipment to staff.

State leaders also did not quickly authorize widespread testing for nursing home staff, allowing them to potentially spread the virus to one another and to residents for weeks, even as the state lab performed thousands of tests for hospitals. And the state promoted a poorly conceived plan to have nursing home employees test their elderly charges themselves, with little extra training, only to abandon it after widespread failures. The state now prioritizes testing for staff and residents though results are sometimes delayed, and there is reason to fear that the system will again be overwhelmed if the virus roars back.

Nursing home workers — underpaid, undertrained, and under-protected — for weeks didn’t even rate their own separate mortality count among the statistics the state publishes daily. At least 28 elder care employees have died of COVID-19 and that is likely an undercount. Those include Maria Krier, a 59-year-old nurse who complained publicly that her employer, Life Care Center of Nashoba Valley, was violating infection control rules. Days later, she died of the coronavirus, her family said.

The lack of urgency in addressing the nursing homes’ needs was also reflected in the people the administration turned to for advice in the early weeks of the pandemic. Leaders of the state’s prestigious hospitals were invited into the governor’s inner advisory circle, their concerns about the need for “surge capacity” echoed at his press briefings. Operators of nursing homes, who braced for their own emergency, remained largely on the sidelines.

“Nursing homes needed the attention sooner, and more aggressively,” said Richard Bane, owner of 12 nursing homes and assisted-living facilities in Massachusetts. “Hospitals had the administration’s ear.”

Bane said the fear of hospitals being overwhelmed was legitimate even though it did not come to pass. But, he said, the threat to nursing homes was the more critical problem from the start. Bane used a sports analogy: State leaders initially were “guarding the wrong man.”

The governor, through his communications director, declined repeated Globe requests to discuss his response to the virus in nursing homes.

Baker’s trusted adviser, Sudders, whom he tapped to run the Massachusetts COVID-19 Response Command Center, spoke to Globe reporters twice. Sudders said that bolstering hospital resources was vital but that leaders in no way neglected nursing homes. She said that nursing homes were on her mind frequently and that she attended daily meetings in the early months in which they were discussed.

“You need to make the very best decisions, sometimes with incomplete information, as quickly as possible,” she said. “You don’t have the luxury of time in a pandemic.”

Secretary of Health and Human Services Marylou Sudders speaks at a daily press conference. Behind her is Governor Charlie Baker and a row of flags.

Sudders acknowledged that Massachusetts officials, like their counterparts elsewhere, were slow to recognize the danger of contagion spreading from nursing home staffers and residents without symptoms. But she said her team grasped this problem earlier than most. And once they understood the danger of asymptomatic spread, she said, they stopped moving residents and accelerated testing, making Massachusetts one of the first states to deploy National Guard units to swab residents.

Sudders agreed that the testing program was “not perfect in execution and implementation in the first couple of weeks” but said that is the very nature of a pilot program, of an approach untried and conceived under pressure. “There’s no playbook to a pandemic.”

There is also no ready way — no way at all, in fact — for Ralph Trotto to make sense of, and peace with, the state’s treatment of his mother, Frannie.

Trotto was infuriated when Beaumont management told his family that Frannie was being uprooted from her home of three years. Frannie was a retired dress shop manager whose love of clothes and music was undiminished by Alzheimer’s.

Ralph Trotto, wearing a blue shirt and shorts, sits on the edge of a bed at his home in Holden, Massachusetts. The room is filled with photographs and memories of his mother, including a cabinet full of cardinal figurines.

She did not want to be at the strange new Westborough facility where she landed, and a nurse told the family that Frannie wandered the halls there, disoriented. Ralph found it excruciating that he was not allowed inside to help her with her confusion.

Bad news came quickly. Within three days of arriving, she tested positive for COVID-19. Her family believes she must have contracted the virus before the move and brought it to her new home.

It wasn’t her home for long. On Easter Sunday, her grown children waved through an open window and Ralph Trotto sang her favorite Frank Sinatra song, “Summer Wind.”

“Mama! We’re here!” they shouted.

She died the next day.

A history of neglect

Nursing homes have long been the problem children in the state’s vaunted health care system.

Hospitals are community anchors that offer care to all ages, delivering babies, sponsoring blood drives, replacing hips. Nursing homes — roughly 380 in Massachusetts — are uncomfortable reminders of infirmity and mortality, often tucked away on side streets.

Their regulatory structure is a patchwork; one agency licenses them, another provides most of their funding, and a third dispatches volunteers to monitor residents’ care. The Office of Elder Affairs, the only agency dedicated solely to older residents, has steadily lost power and influence over two decades under Baker and two previous governors.

The agency’s chief once enjoyed a direct line to the governor and a say over the multibillion-dollar budget that pays the bills for most nursing home residents. Now, Elder Affairs is folded into the massive $23 billion Executive Office of Health and Human Services bureaucracy, led by Sudders.

Meanwhile, the nursing home industry has become financially weaker as high-end assisted-living and independent-living facilities have exploded in popularity, siphoning off wealthier seniors who might have otherwise gone to nursing homes. At the same time, a small, elite group of highly rated homes are marketing themselves to residents who can afford to pay $350 to $450 a day, leaving other nursing homes to care for lower income residents insured by MassHealth, the government program for the poor, which pays roughly half as much.

Frank Romano stands on a brick walkway in front of a bench outside the Blaire House of Tewksbury.

MassHealth rates have largely remained stagnant for years, making it increasingly difficult for nursing home managers to pay their workers competitively. Frank Romano, who owns six nursing homes in Massachusetts, said the low pay for nursing assistants — averaging $14.25 an hour, according to the Bureau of Labor Statistics — directly affects the quality of care. He and other owners have lost workers to higher-paying jobs at an Amazon warehouse, the Encore casino, and even fast-food outlets. Front-line nursing assistants committed to working at nursing homes “have had to take multiple jobs to get by, and we know that’s how COVID got into our buildings,” he said.

Sudders assembled a nursing home task force to study the industry’s growing problems last year. Industry and labor representatives pushed for higher MassHealth payments, but the Baker administration was more interested in improving care and closing poor performers, both elusive goals.

At the end of January, just as Massachusetts was seeing its first cases of COVID-19, the group raised the possibility of shutting down 18 “low quality and low occupancy” homes, many with high rates of indigent residents. The task force proposed more generous MassHealth payments for the surviving homes, payments linked to better quality and infection control.

Before any changes could be carried out, the pandemic was sweeping through nursing homes across the Commonwealth.

The virus afflicted an elder-care sector poorly defended against it. The state’s nursing homes have a weak record of practicing good infection control. Over the past three years, nearly two-thirds of Massachusetts nursing homes were cited for lapses such as poor hand washing practices and failure to manage outbreaks of influenza, the closest pre-pandemic proxy for coronavirus. It was a troubling track record on the eve of the COVID-19 contagion.

After the first US outbreak was reported in late February at the Life Care Center in Kirkland, Wash., near Seattle, killing the first of what would be 46 residents, staff, and visitors, state Senator Pat Jehlen of Somerville issued a dire alert for the older people in Massachusetts senior housing.

“The situation in Seattle is extraordinarily scary,” said Jehlen, co-chair of the Joint Committee on Elder Affairs. “Nursing homes are not good places to be when viruses and infections are going around.”

Baker confronts a pandemic

Governor Baker was on a skiing vacation with his family in Utah in early March when he realized he had a crisis on his hands. Just before he left, dozens of Biogen employees at a Boston conference had come down with fevers and coughs, early symptoms of COVID-19. By the time Baker reached his time-share, he was getting constant phone updates about the worsening picture. Baker cut the trip short and flew to Boston on March 9.

He quickly reached out to hospitals as they braced to treat patients sickened by the new virus. As former chief of a health insurance company, Harvard Pilgrim Health Care, the governor had long established relationships with leaders of Boston’s prestigious academic medical centers.

Nursing home leaders lacked the same access. A meeting of 11 “front-line leaders” Baker convened on March 4 had representatives of hospitals, higher education, and even the MBTA. The one delegate from long-term care was the president of Hebrew SeniorLife, a nonprofit that runs mostly assisted-living and independent senior housing.

A smaller advisory board the governor established soon after included three hospital representatives but none from nursing homes. A group of academic medical center presidents had conference calls several times a week with the governor, while nursing home operators did not enjoy similar access.

Governor Charlie Baker, Lt. Governor Karyn Polito and members of the Massachusetts National Guard tour a field medical station wearing facemasks. Laptop computers sit open on a row of wheeled tables behind them.
Governor Charlie Baker and Lieutenant Governor Karyn Polito joined the Mass. National Guard to tour a field medical station at Joint Base Cape Cod in April. (Jim Davis/Globe Staff)
Three cleaners wearing white ppe suits and blue rubber gloves unwrap their protective gear outside the Soldiers’ Home in Holyoke.
Cleaners in protective gear in March left the Soldiers' Home in Holyoke, site of one of the state’s deadliest COVID-19 outbreaks. (Stan Grossfeld/Globe Staff)

For the Baker team, hospitals always appeared to be top of mind. A Spotlight analysis of transcripts from the governor’s public briefings, starting March 13, show that Baker and his top advisers mentioned hospitals 246 times during the first month, more than three times as often as nursing homes or long-term care facilities were mentioned.

Baker’s choice of words was also telling. The state’s renowned hospitals were “world-class,” he said at one point, their front-line staffers “brave.” He had scant praise for the tens of thousands of nursing home workers who bathe, feed, and administer medicine to the elderly. They labored in a mostly unsung corner of the health care system.

“No one recognized the bravery of the people who stayed by the bedsides and made sure these people were cared for,” said Dr. Larissa Lucas, of North Shore Physicians Group and the medical director for nursing homes in Peabody, Lynn, and Marblehead.

Key words at Governor Baker's press conferences

Baker and his top staff mentioned hospitals far more often than nursing homes during the early critical period from March 13 to April 12.

Hospital

246

Nursing Home

56

Long-term Care

19

Seniors or elderly

10

SOURCE: Press conference transcripts, except for two dates that were unavailable.

John Hancock/Globe Staff

“Nursing home residents were given low priority, as were employees,” she said. “We were treating the same COVID illness as the hospitals, without the technology, without the onsite labs, without the staffing ratios they have.”

The only references to nursing homes in Baker’s early press briefings came as he spoke of the state plan to restrict visitors to the homes, a step deemed necessary if unpopular with families. Baker and Sudders have frequently claimed Massachusetts was out front in banning visitors. “We were two days before the CDC put out the guidance,’' Sudders told the Globe. But the record shows they were more cautious than that.

While state health officials called on nursing homes to ban high-risk visitors, such as those with symptoms of respiratory illness, starting March 11, they didn’t issue an outright prohibition on visits until March 16, three days after the federal government recommended a ban.

Baker picked Sudders on March 14 to run the pandemic command center. She is known as a competent and politically savvy insider, but her background was in mental health and child welfare, not public health. Some officials in the state bureaucracy bristled at the centralized structure of the command center, which bypassed traditional lines of communication and left some health experts feeling marginalized.

Sudders conceded in an interview with the Spotlight Team that the centralized structure “ruffle[d] some feathers,” but she said it allowed her to move rapidly and draw expertise from outside her agencies during the crisis.

An elderly woman visits with a family member wearing a facemask through a window at The Rogerson House.

The responsibility for nursing homes fell to state officials like Lauren Peters, the undersecretary for health policy, and Dan Tsai, assistant secretary for MassHealth. The administration brought in a team of health care consultants from McKinsey & Co., at a price of $10.8 million.

Still, for weeks, the administration had no coordinated strategy for aiding nursing homes.

The state has also been slow to publicly release data about COVID-19′s impact on the elderly. Leaders had failed for months to disclose the precise number of cases and deaths in nursing homes and assisted-living facilities, even though the Legislature passed a law requiring just that. That data, public in New York and Connecticut, is crucial to understanding the extent of the problem, nursing home advocates argue.

Soon after Baker established the command center, worrisome signs emerged that COVID-19 had infiltrated long-term care facilities, raising fears that the Washington state outbreak could repeat itself here.

Residents fell ill at The Branches in North Attleborough and Cape Cod Senior Residences in Bourne. And on March 20, retired factory worker Jose Rivera, 91, who lived in Rogerson House in Jamaica Plain, died after testing positive for the virus at Carney Hospital, becoming the state’s first known senior care fatality.

The loudest wake-up call came the weekend of March 28: COVID-19 was ravaging the state-run Soldiers' Home in Holyoke, an outbreak that ultimately claimed the lives of at least 76 elderly veterans and led to state criminal charges filed against two of the home’s officials this past Friday.

“Holyoke was a microcosm,” said Barbara Anthony, a senior fellow in health care at the Pioneer Institute, a public policy research group, citing sloppy oversight and a lack of supplies. “The same things were happening in a lot of homes.”

After weeks of barely discussing nursing homes in his public briefings, Baker brought them up March 30. But it wasn’t to say how the state planned to help them. It was to explain how the nursing homes could be deployed to help hospitals as the pandemic escalated.

Gene N. Pratillo sits alone in a room full of empty folding chairs before the wake for his wife, Janice Cox Pratillo. A portrait of Janice is surrounded by various floral arrangements at the front of the room.

A botched plan

The plan came together quickly.

On March 20, Sudders hosted an emergency call with state public health officials and nursing home and hospital leaders. She assigned them a mission: Set up a network of recovery centers for COVID-19 patients discharged from hospitals.

A series of calls followed between hospital and nursing home chiefs who suddenly had a lot to talk about. Hospital leaders, fearful of overflowing intensive care units, were eager for back-up space, while nursing home owners were desperate to avoid an order like the one issued by New York Governor Andrew Cuomo, forcing them to admit all coronavirus patients sent from hospitals.

There were several possible approaches, but one idea bubbled up from conference calls between executives at nursing homes and UMass Memorial Health Care in Worcester. UMass Memorial president Dr. Eric Dickson challenged the homes’ operators with a rhetorical question: When the coronavirus surge came to Worcester and the hospital needed beds, were they prepared to admit “Mrs. Jones?”

Two EMS personnel wearing neon green jackets move an elderly woman on a gurney wearing a facemask from Beaumont Rehabilitation and Skilled Nursing Center.

No one could or would make that pledge, until Matt Salmon, chief executive of Salmon Health and Retirement, stepped up. He said he could repurpose his Beaumont nursing home, which had no COVID-19 cases at the time and was a half mile from UMass Memorial Medical Center’s university campus. Before he could take in recovering hospital patients, however, he would have to move the home’s 149 residents to other facilities.

“I knew we were going to have this tidal wave of devastation coming,” Salmon recalled. “How could you sit back and do nothing?”

Similar plans were taking shape from Metro Boston to the Berkshires. Sudders held up the Beaumont plan as a shining example of cooperation in a March 27 letter announcing the initiative. Behind the scenes, her staff was finalizing plans to give these nursing homes millions of dollars in compensation.

“We understand that this is not an easy thing to ask residents, families, and nursing facilities to do,” she wrote.

The letter said nothing about the risk of asymptomatic spread of COVID-19.

Salmon wanted to test all Beaumont residents before the move but said the state would only allow testing of the small number who had symptoms. By the time the first positive result came back on March 31, 137 residents were already in their new homes. A dozen residents awaiting transfers were left in the Worcester home.

None of the 18 homes that accepted Beaumont residents had reported virus cases before the moves. They later reported hundreds, leading to more than 250 deaths. No one knows for sure how the virus entered the homes in part because the residents hadn’t been tested before moving.

The Massachusetts plan at first drew national praise. But Salmon said he now regrets the upheaval it caused. He acknowledged the possibility that transferred residents spread the virus, but he said it was impossible to know.

Massachusetts normally bans involuntary nursing home evictions. But on the day Beaumont began moving residents, public health Commissioner Monica Bharel signed an emergency order allowing the practice during the pandemic.

An exterior of Beaumont Rehabilitation and Skilled Nursing Center.

Nursing home policy experts said no other state approved such a drastic plan to relocate residents — except Connecticut, which encouraged a nursing home chain to move residents out of homes in Bridgeport and the small town of Sharon.

It took the disruption at Beaumont — and another near-crisis north of Boston — before Massachusetts abandoned its plan.

AdviniaCare, a nursing home in Wilmington, also planned to move its 98 elderly residents, but that plan was thrown into turmoil. Doctors at Mass General Brigham, the large health care system, who were advising AdviniaCare on caring for COVID-19 patients, decided to test all the residents on April 1, even though none were sick at the time. It was the largest test of an asymptomatic population at a single site in the United States.

The lab sent the stunning results the following day. Fifty-two residents, more than half, tested positive. A second round of tests four days later brought the total to 83, or 85 percent, infected.

“It was a shocker,’' said Dr. Ryan Thompson, who helped lead the testing effort. “The thought of moving people ended. It was not safe."

After that, “we stopped, we changed, we pivoted,” Sudders told the Globe. The new plan was to reopen closed nursing homes and pay existing ones to create “COVID-positive” wings for infected residents while leaving healthy residents in place.

Families felt betrayed by the moves.

Melinda A. Cox wears a brightly colored facemask.
Melinda Cox pondered family photographs at a wake for her mother, Janice Cox Pratillo, who died after being moved out of her nursing home to make way for recovering coronavirus patients. (Craig F. Walker/Globe Staff)
A collection of photographs of Janice Cox Pratillo displayed at her wake.
Photographs of Janice Cox Pratillo, who died from COVID-19, were displayed during her wake at Mercadante Funeral Home in Worcester. (Craig F. Walker/Globe Staff)

Beaumont Worcester transferred Janice Cox Pratillo, 73, to another Beaumont facility in Westborough.

“Mom’s being moved,” her daughter Faith Shannon, told her sister, Melinda Cox, on the phone. The two sisters pressed Beaumont staff and the governor’s office for details but they didn’t return their calls, they said.

Meanwhile, Janice’s dementia and disorientation worsened in her new residence. She died on April 24. Her death certificate listed COVID-19 as the cause. But her daughters, who don’t know where she contracted the virus, believe the move caused her decline.

Cox stood in the nursing home parking lot and peered through a window cracked open three inches and watched her mother die.

“I stood there sobbing in the pouring rain,” she said.

Some families blame state officials and nursing home operators for failing to do enough to protect their loved ones during the pandemic. (Shelby Lum/Globe Staff)

State stumbles on testing

Sudders took the State House podium on March 31, as she had already done so many times during the pandemic, this time to tackle a crisis that attracted national attention. Veterans were dying in alarming numbers at the Soldiers’ Home in Holyoke amid what would later be revealed as catastrophic errors in infection control.

Calm and professional, the former social worker explained that, starting with the Holyoke home, National Guard teams would fan out to the state’s nursing homes to swab the nasal passages of residents with fevers and coughs. COVID-19 testing, she promised, would be better and faster. “Quick turnaround’' would allow facilities to separate the sick from the well, slowing the virus’s relentless spread.

It sounded encouraging to nursing home managers who had struggled to get their residents tested. Initially, when state officials distributed their testing criteria on March 13 for the state lab, residents of nursing homes, shelters, and prisons were No. 4 on the priority list. And the rules were restrictive. Three or more residents needed to have a fever and respiratory illness for the home to qualify.

But the Holyoke disaster appeared to pull some of the administration’s focus away from the hospitals.

A member of the Massachusetts National Guard stands with his arms spread wide, wearing a grey hazmat suit, blue rubber gloves and face shield outside Alliance Health. Two other guard members, similarly dressed, look on.

On April 2, the state moved nursing home residents to No. 2 on the priority list. Even then, the mobile testing effort, a promising idea that Massachusetts rolled out earlier than other states, was marred by delays and mistakes in execution. The turnaround was anything but quick. Nursing homes reported backups of five days or longer for testing.

At St. Chretienne Retirement Residence, a home for Catholic nuns in Marlborough, the National Guard arrived on April 9 to test three ill sisters. The positive results came two days later but the Guard said it would take three more days for them to test the other nuns. City officials intervened, administrator Jackeline Bones said, and they returned immediately, on Easter Sunday. Still, they would not test the staff.

Sickness at St. Chretienne spread — 22 of 31 nuns contracted the coronavirus — and Bones, who is also a nurse, packed a suitcase and moved into the facility to help, along with another nurse. Exhausted, Bones eventually became sick herself with COVID-19. The few healthy nuns, some in their 80s, pitched in to serve meals, wash sheets, and collect trash.

As nursing homes begged for tests, Sudders announced another option: The Broad Institute in Cambridge would put together test kits for nursing homes so their own staff could test residents. The Broad prepared more than 14,000 kits that went to 150 homes.

Once again, however, there were problems with execution. Facilities returned only 4,000 kits and many of those had leaking tubes, incomplete labels, or other problems that required follow-up phone calls that slowed results. Many nursing home employees simply weren’t up to the task of running a testing program, said Simon Johnson, an MIT economist who has advised nursing homes.

Jackeline Bones sits on a small bed at St. Chretienne Retirement Residence. A cross hangs on the wall above the bed.

“Staff were overwhelmed, so expecting people to train themselves to do this was a failure and obviously unrealistic,’' he said.

On April 13, Tara Gregorio, head of the state’s nursing home industry trade group, wrote a strongly worded letter to Baker and legislative leaders demanding “immediate and urgent action.’' The testing program, while “well intentioned, has been inadequate to the scope of the problem,’' she said, her anxiety radiating off the page. The state, she demanded, needed to make nursing homes a higher priority.

If it didn’t, she predicted, 10 percent of nursing home residents would die. As it turned out, her grim prediction was optimistic.

That same day, the state reversed its position on testing, officially allowing testing for asymptomatic nursing home residents and staff. It was a change that predated a similar CDC reversal by a month, Sudders asserted, reflecting one of the first times the state showed an independent streak in handling the nursing home crisis.

But Sudders acknowledged that if she had to do it over, she would have tested nursing home employees, many of whom probably carried the virus into their workplaces, far sooner. “In hindsight, are there things I would have done differently? We would have started to test staff early, much earlier based on what we know now. We would have been testing asymptomatic staff rather than (doing) temperature checks.”

That’s not what happened and, for the first few weeks of the pandemic, senior home employees struggled to cope without meaningful testing — and sometimes an alarming lack of protective equipment.

“Like everyone else, we scrambled,” said Walter Ramos, chief executive of Rogerson Communities in Roslindale, which accepted donations from volunteers and the Boston Public Health Department.

Walter Ramos, wearing a tan suit, blue shirt and blue and yellow striped tie, holds a facemask as he stands outside Rogerson House.

At Mason Wright, an assisted-living facility in Springfield, staff wore clear trash bags as gowns and shower caps to cover their hair during the second week of April. Executive director Eileen Drumm Moore ordered supplies from the state April 15 and got her first delivery a month later.

Ellen Taylor, a nurse practitioner who provided mental health services to nursing home residents, said facilities she visited in Middlesex County didn't appear to be providing protective gear to employees in the critical early weeks.

“One nurse told me he brought in his own mask, but there was no proper gear,” she said. “I told myself, ‘This isn’t right. Something is going to explode here.‘’

State records obtained by the Globe through a public records request only underscore the degree to which hospitals took priority for PPE distributions in March. By the 29th, the administration shipped 15,580 respirator masks to hospitals, compared to 2,965 to nursing facilities.

Sudders said, however, that in time they made up for this discrepancy. Over the spring and summer, the state sent nursing homes more protective gear than hospitals.

But the early weeks were critical.

“As the state stockpiles of these supplies were limited, nursing facilities were not prioritized,’' said Elissa Sherman, president of LeadingAge Massachusetts, which represents nonprofit nursing homes and assisted-living facilities.

State’s weekly distribution of PPE from March 2 through April 19

As the pandemic started, Massachusetts prioritized hospitals for the distributions of masks, gowns, and other personal protective equipment.

Nursing homes/Senior living ()

Hospitals ()

Cities and towns* ()

Private Emergency Medical Services ()

State agencies ()

*Includes fire, police, and emergency medical services

SOURCE: Massachusetts state data

John Hancock/Globe Staff

Making matters worse, fewer than normal health inspectors visited homes to witness the chaos first hand. Most state oversight during the beginning of the pandemic was provided by telephone; state epidemiologists called their assigned nursing homes daily.

Meanwhile, inside some nursing homes, the sick were mixing with the well when they should have been quarantined.

At CareOne at Newton, an employee said that during the early days of the pandemic, asymptomatic roommates of sick residents were sometimes moved into rooms with new roommates without being tested.

“This absolutely spread the virus further,’' said the employee, who requested anonymity because she was afraid of losing her job. “We had one patient and then it spread like wildfire.’'

Executives at CareOne, where 32 residents have died, said it began testing all residents exposed to COVID, even those without symptoms, April 5. "CareOne at Newton has not reported any known cases of facility-based transmission since April 2020,'' the company said in a written statement.

Other facilities failed to properly isolate patients. During the 11 inspections the state conducted in April to monitor facilities’ response to the virus, investigators found that two nursing homes had COVID-positive patients sharing rooms with uninfected residents.

Jonathan Gruber, an MIT health economist who has advised the state during the pandemic, said it wasn’t just Massachusetts leaders who missed the dangers to the elderly.

“It was a very crazy, disorganized time,’' he said. “We should have been much more panicked about nursing homes and much more aggressive.’'

Looking forward: “absolutely no excuse”

Sudders was beyond busy, juggling all aspects of the COVID-19 response. But in late April following a series of fumbles in nursing homes, she contacted Lou Woolf, president of Hebrew SeniorLife, to ask for help. The nonprofit organization of rehabilitation and assisted-living facilities is a Harvard affiliate, like Massachusetts General Hospital, which Baker relied on heavily during the pandemic.

By then, COVID-19 had taken the lives of 1,059 elderly nursing home residents — more than half of all those who had died from coronavirus deaths statewide.

A plan to focus on the needs of nursing home residents was finally coming together.

Woolf and Gregorio, president of the senior care group, took over a new nursing home command center that, during the next week, devised a plan centering on infection control. The Baker team provided $130 million for nursing homes, its second large pot of money during the pandemic, but this time it was contingent on facilities testing 90 percent of their residents, properly using protective gear, and isolating infected residents.

They were trying to right the ship.

Still, when state inspectors completed the first audits in mid-May, they found that more than one-third of nursing homes did not meet basic standards, such as separating sick and well residents, training staff to properly use personal protective equipment, and canceling group activities. These slack practices preceded the pandemic but would exacerbate its impact.

While the predictions of overwhelmed hospitals never materialized, nursing home deaths have now reached 6,040 as of Sunday - more than 14 percent of the statewide nursing home population. Katherine Fillo, a nurse who directs quality improvement at the state public health department, recently told her agency’s commissioners that new daily death counts in nursing homes fell to 24 on June 30, down from a high of 96 on May 11.

But the improvement is precarious.

Mourners stand with their arms around each other, their backs to the camera, at Sharon Memorial Park. In front of them is a green canopy on wheels.

Over the summer, COVID cases rose in nursing homes in Florida, Texas, and other states with exploding infection rates.

And experts question whether facilities here will have enough staff and equipment to manage another surge. As August began, 13 percent of Massachusetts nursing homes still did not have even a one-week supply of surgical masks, according to CMS data.

It is a challenge to which the state has begun to respond. On Sept. 10, the state announced more funds for nursing homes and new minimum staffing requirements.

Gruber, of MIT, said it’s understandable that leaders in Massachusetts and other states made mistakes in March and April, because they didn’t fully appreciate the dangers of COVID-19 for the elderly.

“Now,’' he said, “there is no excuse. There is absolutely no excuse.''

Coming tomorrow: Part 3: “Homey, coveted, costly — and crushed by the pandemic”

Lizbeth Kowalczyk can be reached at lizbeth.kowalczyk@globe.com and Robert Weisman can be reached at robert.weisman@globe.com. Any tips and comments can also be sent to the Globe Spotlight Team at spotlight@globe.com or by calling 617-929-7483.

The entire Last Words series can be found at www.bostonglobe.com/lastwords.

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