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By Hannah Critchfield and Thomas Goldsmith
The calls from Cherry Springs Village came at night.
Assisted-living roommates Alicia Rodgers, 50, and Margaret Osteen, 66, were getting results on April 4 from a test for the novel coronavirus that had been taken two days earlier.
The disease had infected both women, family members learned. And they weren’t the only ones.
“They called us and told us she had tested positive,” said Hendersonville resident Laura Moore, Rodgers’s sister. “They mentioned that several others had tested positive as well.”
Cherry Springs Village, a 60-bed Hendersonville assisted living center, had an outbreak on its hands and suddenly needed rapid help.
That became the mission of the Henderson County “strike team,” a locally organized effort that brought together county emergency management, county health officials, nurses and doctors, a hospice group, and additional players.
Such teams apply a disaster-response model, more suited to natural disasters such as hurricanes and wildfires, to combating COVID-19 outbreaks in long-term care facilities. North Carolina Health News retraced the strike team’s formation and work during the two-month-long outbreak at the facility.
Thanks to the county’s preparation and a rapid response from a variety of actors across government agencies and private industries, outside help would flood into Cherry Springs. About 50 people there recovered, but 10 residents would die of COVID-19 during the two-month outbreak. Many others died in nearby nursing homes.
The strike team would help mitigate the spread of COVID-19 and work to protect the lives of vulnerable people such as Rodgers and Osteen. It eventually became a model for preventing or tranquilizing COVID-19 outbreaks in assisted living facilities throughout western North Carolina.
April 3: Henderson County Rescue Squad arrives on site, delivering PPE to the facility staff.
Rodgers had moved into Cherry Springs in 2018 for help dealing with disabilities caused by a car wreck on her 17th birthday. Osteen has been living with dementia for five years after a lifetime of working in restaurants such as the diner-style Hasty Tasty.
“She said she wasn’t feeling good,” said Tammy Summey, Osteen’s daughter, recalling a conversation with Osteen the day after she tested positive. “But it was already affecting her dementia pretty bad — she didn’t even realize what she had, what was going on.”
April 6: Hospice chaplains and grief counselors from Four Seasons Hospice come to Cherry Springs as several residents’ conditions worsen.
Some bread-and-butter elements typify the care that strike teams provide. Early on, for instance, staff members have to be taught the proper use of personal protective equipment — the masks, gloves, biohazard clothes and other equipment that prevent the spread of infection further.
Especially the equipment prevents the spread to other staff. At Cherry Springs Village, a large percentage of employees who typically cared for residents were suddenly out sick.
Beyond education, there was another immediate, practical, need: Beefing up staffing.
“Almost everybody in the building got it,” said Dr. Ann Hicks, a local geriatrician who treats patients at Cherry Springs and helped shape the strike team, noting that there were ultimately 59 COVID-19 cases out of about 75 residents and staff.
The sick residents had far greater needs than usual.
April 8: A person in hospice care becomes the first Cherry Springs resident to die of COVID-19.
Despite a somewhat pugnacious name, strike teams are designed to adapt to existing systems, Hicks said, acting more as partners than as special agents doing an overhaul.
“It’s not like this SWAT team that comes in and dominates,” Hicks said. “It’s not prescriptive – it’s an extra set of hands that works with the facility to respond.”
April 8: Staff education on PPE use continues as the Henderson County Rescue Squad remains on site.
“What we know from Ebola and other infectious diseases, is that the time that you’re most likely to get contaminated as the health care worker is actually when you’re taking your PPE off,” said Mark Shepherd, head of the county rescue team and a physician assistant specializing in trauma and critical care.
“We actually set up a decontamination tent outside, so at the end of their shift, they could actually take their clothes off,” said Shepherd. “We had a really rigid way of how they would exit the building, the order in which they would take their PPE off. I had volunteers at every shift change for 72 hours, instructing on how to take off the PPE correctly”
Staff was only required to remove dirty PPE, according to Hicks, but some staff wanted and were able to change out of their work clothes fully “for their own peace of mind.”
Within a week of her diagnosis, Osteen was able to stand at the closed window of her room to see Summey, who wanted to make contact with her mother however she could.
Just days later, Osteen was “bedridden,” Summey said.
“She got to where she couldn’t eat, she couldn’t talk,” Summey said. “It was really heartbreaking because you can’t advocate for anybody if you’re not around.”
Rodgers, for her part, was having trouble breathing, and Moore worried when she heard talk of a ventilator and learned of more frequent checkups on her condition.
April 8: Nurses from a local rehab center and other Affinity Living Group facilities arrive from as far as three hours away to provide medical care at Cherry Springs.
Unlike many hospitals, congregate care facilities are not always robustly staffed with medical providers. This is especially true of assisted living facilities, which unlike their skilled nursing home counterparts, are residential living settings for people who need basic assistance with daily activities. Under normal circumstances, residents don’t need routine medical care, and thus medical staff isn’t required.
Cherry Springs doesn’t have full-time nursing staff – a Licensed Health Professional Support (LHPS) nurse typically visits the facility once a week. But suddenly and imminently, residents there needed far more intensive medical care.
“That was one of the things that we noticed early on — specifically in the assisted living facilities,” said Jimmy Brissie, the county emergency management director, who helped put together the strike team. “They typically don’t have as much in-house medical support as a skilled nursing facility.”
The team tried not to send residents unnecessarily to a hospital, where they risked further exposure and might take up beds other community members needed. So the strike team reached out and coordinated with other properties in the same corporate ownership throughout western North Carolina.
“We had to bring in staff just to help people eat,” Hicks recalled.
Many outside employees came in to help fatigued residents hold up iPads for telemedicine or do rapid assessments of patient vitals.
April 8: Communications specialist D.J. Buff arrives at Cherry Springs.
Rodgers was cared for by a nurse from a few hours down the road in Winston-Salem, according to Moore.
Dr. Kevin O’Neil is chief medical officer for Affinity Living Group, the private company that owns Cherry Springs and operates other assisted living facilities in eight states.
He said that for the first time, strike team members set up intravenous fluid drips and oxygen concentrators within the facility for patients like Osteen.
April 9: Henderson County Rescue Squad erects “decontamination tents” outside the facility.
In any disaster, responders must account for the emotional toll on survivors.
Emergency response is fast — but that doesn’t mean it’s done without recognition of the people who are hit the hardest by the tragedy.
The strike team realized it could be no different now — someone would have to head up communication about the Cherry Hill outbreak to family, who were forced to worry about — and mourn — their loved ones from a distance.
“When it all first hit, it was very frustrating because I couldn’t get through to anyone,” Summey said. “That was very stressful and very aggravating. But then they got a wonderful person out there, D.J. And he turned it all around, he did a wonderful job.”
April 27: The death toll at Cherry Springs rises to seven people.
There were times when several residents died in one day, Hicks said.
Cherry Springs and its corporate owners have not released the identities or other details about those who died.
The team brought in chaplains and music therapists from Four Seasons Hospice to provide trauma care to both family members and the staff, who watched residents that had become friends over the years pass away.
“The staff get very close to their residents,” Michael Wermuth, a chaplain from the palliative care facility, said. “And when you have a lot of loss like that, you have what our grief counselors call ‘complicated grief,’ because there’s so much loss so quickly. It’s hard for us to process sometimes.”
The counselors came twice a week to meet with the staff when they were on break.
One family watched through an outside window as their loved one died from the virus inside a room, Wermuth recalled. The chaplain remained sitting at a six-foot distance.
“Cherry Springs did a wonderful job of placing the patient’s bed next to the window, so they could be very close to their loved one,” Wermuth said. “But obviously they couldn’t touch them, and that was difficult.
“So we provide active listening, and help people to verbally process the challenges of not being able to be at their bedside.”
May 9: The last outside staffers, the remnants of the strike team, leave Cherry Springs as numbers of active COVID-19 cases drop.
By mid-May, the strike team members and outside staff had gone home – they were taking down the decontamination tents as COVID-19 cases within Cherry Springs fell to a handful, according to James Harvey, a spokesman for Affinity Living Group.
Meanwhile, the work of the strike team continues.
After the Cherry Springs outbreak, Henderson County officials started to use the strike team concept in other facilities. Two skilled nursing facilities in the county have used it to respond to outbreaks since.
Notably, the officials now want to use it to prevent COVID-19 outbreaks in residential adult care centers, not just respond once tragedy looms.
“After dealing with one outbreak in one facility, we started a conversation with Dr. Hicks and Dr. Russell, the doctors for Cherry Springs,” Brissie said. “We kind of brainstormed: In a perfect world, when this happens again, what’s the best model to bring some additional resources in place early on, to get them through that initial phase of an outbreak?”
May 30: NC DHHS removes Cherry Springs Village from its list of congregate living settings with an ongoing outbreak.
Members of the strike time have since visited every long-term care facility in Henderson County – educating them on proper PPE use, taking stock of the needs they’d have if an outbreak were to hit (Would it be staffing? Medical supplies?), and simply letting them know the strike team exists and will be able to step in.
The idea is catching on in other western North Carolina counties: McDowell, Rutherford, Haywood, and Buncombe County have all begun to use strike teams of their own, according to Brissie.
“With this level of outbreak, no facility can stand alone,” said Hicks. “Really facilities, they need to be looking for partnerships in the community.”
Relatives such as Tammy Summey saw and appreciated the effects of the strike team’s work to fend off more deaths.
Nonetheless, she lived with stress that seemed never-ending through those days of fearing for her mother’s life. Like so many other relatives in this situation, Summey couldn’t shake the thought that someone who had brought her to life might face a solitary end.
“Unless you’ve been through it, you just don’t know, because your loved one can pass and you’re not going to be there,” Summey said. “They’re not going to have anybody there. They’re alone.”
June 8: DHHS releases daily count of COVID-19 cases and deaths in North Carolina’s long-term care facilities — 4,528 people have contracted the disease and 611 have died.
Correction: This story has been changed to reflect that Mark Shepherd is a critical care physician assistant.