MINNEAPOLIS — At the Ebenezer Care Center on Portland Avenue in Minneapolis, residents remain on lockdown. Family visitors are not allowed in, and the 80 to 90 seniors are not allowed out except for essential services such as kidney dialysis.

Nurses and aides enter resident rooms almost astronaut-like, wearing surgical masks and plastic face shields that vaguely resemble transparent welding helmets. In an effort to socially distance, most residents stick to their rooms or keep to themselves in the hallway.

Despite those precautions, Ebenezer has not been able to avoid COVID-19.

In mid-May, nurses said at least 14 residents have become infected since the beginning of the pandemic, and at least three workers also tested positive, including one who was hospitalized. Numbers have increased since then.

Frustrated by limited on-site testing, some workers have gone elsewhere for virus tests, including at least one who tested positive. Shortages of disinfectant wipes are common.

With roughly 30 sites across Minnesota, the Ebenezer care system is the largest senior living provider in the state, offering assisted living, memory care, independent living and skilled nursing residences. The network is the senior living arm of Fairview Health Services.

‘One of the hardest parts is the fear’

Despite its size, or perhaps because of it, Ebenezer — like dozens of other senior living providers across the state — remains susceptible to the deadly contagion that has preyed especially hard upon seniors and infirm. It’s also attacking those who care for them.

Some have questioned why more hasn’t been done to safeguard senior living and long-term care sites, the epicenter of virus deaths in Minnesota. Until at least mid-May, widespread virus testing had been largely limited to care centers with known outbreaks.

As of Wednesday, the state Department of Health reported that more than 80 percent, or 635 of the 777 known COVID deaths in Minnesota have involved residents of nursing home, assisted living or other long-term care facilities.

Of the 17,670 confirmed cases of the virus statewide, more than 2,000 — or more than 1 in 10 — are healthcare workers.

“One of the hardest parts for the pandemic is the fear … and questioning what is happening in the care setting when you hear those death numbers,” said Jodi Boyne, a spokesperson for LeadingAge Minnesota, one of the state’s two largest caregiver associations.

Precautions extensive

Officials with Care Providers of Minnesota and LeadingAge Minnesota say despite public perception, precautions have been extensive, even before state and federal mandates rolled out in March. A Minnesota Department of Health “COVID-19 Toolkit” for long-term care sites runs to 51 pages.

The state Department of Health has held weekly conference calls with long-term care providers since March 4, which is two days before the first confirmed COVID-19 case was detected. Facilities began restricting visitors around March 10 based on guidance from MDH, the Centers for Medicare and Medicaid Services and the Centers for Disease Control.

Even before then, care centers stepped up facility cleanings and began screening staff for temperatures and other symptoms. “You now have universal masking, so every staff member wears a mask on every shift,” Boyne said.

At some sites, staff screenings more recently began to include pulse oximeters, or finger-based oxygen detectors, to test for low oxygen levels, which could be an indication of the virus in workers who might otherwise show no symptoms. That’s science that wasn’t known back in March.

“Some homes will ask have you had any loss of taste or smell,” said Casey Block, a phlebotomist who visits care sites to conduct nasal swabs. “Things are changing rapidly.”

Testing has also picked up as state access to test kits and lab services has improved. “We are in the process of testing every resident and staff member in our communities,” said Jon Lundberg, president of Ebenezer and Fairview Senior Services, in an email.

After all these precautions, why do so many COVID-19 deaths still take place in care facilities?

Difficult comparisons

Some counts put Minnesota firmly on top of the nation when it comes to death in care settings, and not in a good way. But it’s difficult to truly assess how the state’s numbers compare to other states.

Some states have only compiled and reported deaths at nursing homes, as opposed to other types of senior housing, assisted living and long-term care settings such as rehab centers.

Minnesota, in contrast, began publicly reporting results from a wide variety of care sites early on.

“We suspect other states may have been under-reporting their cases and deaths in long-term care,” said Scott Smith, a spokesman for the Minnesota Department of Health.

Providers point out that overall, across all age groups, Minnesota has recorded fewer deaths than many states — about one-tenth as many as Massachusetts, to date — and a very limited number are under age 60. That leaves long-term care deaths accounting for a larger percentage of a relatively smaller pie.

The Centers for Disease Control began collecting weekly data from nursing homes on May 8, but the national reporting requirements still do not include assisted living facilities, of which there are hundreds in Minnesota.

“There isn’t a standard from state to state on the reporting of these deaths so it is hard to know if we are comparing the same statistics,” said Patti Cullen, president and CEO of the Care Providers of Minnesota. “Not all states include both nursing facilities and assisted living/senior housing in their totals, and not all states call senior housing by the same name.”

Challenging environments

In all, the state has identified 668 congregate care facilities where at least one or more residents or staffers has tested positive for the virus.

State officials caution that no amount of protection is likely to prevent residents from leaving their care centers to go out for kidney dialysis and other important services.

Meanwhile, most healthcare workers go home at night. Even if they avoid the virus at work, they can get infected off-site and bring it into a facility, or give it to each other.

Cullen noted that recent research from Harvard Medical School and Brown University has found that larger facilities located in urban areas with large populations — particularly in counties with a higher prevalence of COVID-19 — are more likely to have reported cases.

That’s because there’s more foot traffic and a greater likelihood that someone will come in from the outside carrying COVID-19, often without showing symptoms.

“Once a disease gets introduced into these challenging environments, they are difficult to keep from spreading because the vulnerable population requires such close, constant, daily care,” said the MDH’s Smith.

There are other considerations looming. Residents of long-term care centers say weeks without visitors and limited interaction with staff and residents have hurt their mental health.

Dawn Janes-Bartley used to visit her mother, Jo Bigot, in assisted living in Mound twice a week. These days, she and her four children wave up to her third-floor window from the courtyard.

“I think this is incredibly hard,” Janes-Bartley said. “My mom’s depressed. Sometimes all you have is breakfast, lunch and dinner with people in your facility, and she can’t do that. She hasn’t left her room in 60 days. At some point, there’s got to be a different plan. I don’t know what it is.”

Questions, concerns

From March 30 to May 15, the office of the State Ombudsman for Long-Term Care, which is part of the Minnesota Board on Aging, received nearly 4,500 coronavirus-related concerns, complaints and inquiries from community residents, which is almost as many consults as they had in all of last year.

Cheryl Hennen, the ombudsman, said about 35 to 40 percent of questions and concerns relate to virus testing — why isn’t there more of it? — and infection controls, such as shortages of personal protective equipment.

Even before the pandemic, turnover at many facilities was high. It’s now near crisis, she said.

“We have received reports about staffing being so critical in certain facilities, that people are not able to make it to the restroom in time, concerns about not getting their medication on time,” Hennen said.

And in some cases, residents are “noticing that staff are coming and going without following proper procedures related to hand washing,” she said.

Many of the remaining complaints revolve around isolation and mental health, Hennen said.

At care facilities, workers have complained that it’s difficult to socially distance when staff-to-resident ratios are poor in certain units. Isolating a dementia resident in his or her room, for instance, becomes complicated when impulsive movements present a fall risk.

Battle plan

Department of Health officials acknowledge that until early May, they had been more focused on reacting to outbreaks at particular care centers, as opposed to combating the virus with a statewide plan for long-term care facilities.

Gov. Tim Walz this month stepped up efforts by unveiling a five-part “battle plan” focused on increased testing and PPE. He also called in the Minnesota National Guard. About 20 guard members, all of them medical personnel, were trained May 14 to collect COVID-19 samples with nasal swabs and began testing residents and staff members at long-term care facilities with known virus outbreaks.

The goal is to expand testing to patients and staff at all residential care facilities in coming weeks. The state Department of Health has now completed COVID-specific infection control surveys for all nursing homes and for many assisted living facilities, and continues to do surveys for any reports of suspected abuse.

“The governor’s battle plan has not been focused on new procedures within long-term care facilities,” Cullen said. “The governor’s plan is prioritizing testing, PPE and staff resources to long-term care settings, which have long been identified as our greatest area of need.”

Cullen predicted the more organized statewide plan will allow the industry to identify potential “hot spots,” as well as proper interventions.