Finalist: Staff of The Wall Street Journal

Menlo Park veterans site discouraged masks, mixed patients as 101 died

By Christopher Weaver and Nora Eckert

EDISON, N.J. -- At the beginning of the outbreak that would eventually make the Menlo Park Veterans Memorial Home one of the deadliest Covid-19 sites in the country, workers tried to contain the virus by hanging a piece of plastic across a hall.

The sheet separating virus patients from dementia sufferers soon sagged, according to interviews and photographs. Somebody taped up its opening, leaving a gap in the makeshift fortifications.

Administrators discouraged the use of masks, conserving them in a storage closet as more residents and workers sickened, employees said.

The nursing home's chief executive waited more than a week after one resident tested positive to alert families, according to interviews of family members, medical records and documents. The short-staffed facility placed visibly ill residents in the same rooms as healthy ones.

As deaths soared in April, administrators tallied them in a way that minimized the coronavirus toll.

Menlo became an uncommonly deadly place in the midst of a stubbornly infectious virus. A Wall Street Journal analysis of available official data suggests Menlo suffered more Covid deaths than any other nursing home in the country.

The dangers shouldn't have been a surprise. Covid-19 tore through the Life Care Center of Kirkland, in Washington state, more than a month before Menlo's first case in late March. Other nursing homes, including Menlo's sister facility, New Jersey's Paramus Veterans Memorial Home, also were racking up cases and deaths.

"No one took that lesson to heart," said Joan McAndrew, whose 93-year-old father, Joseph Cavalieri, died of Covid-19 in late April at Menlo.

Kryn Westhoven, a spokesman for Menlo's operator, the New Jersey Department of Military and Veterans Affairs, said every nursing home was vulnerable, not just Menlo. The veterans agency "made every effort to provide all resident families with the status of Covid-19 within the facility as soon as possible," he said.

Seven months into the pandemic, problems persist in the nation's senior-care system.

Nearly 25,000 nursing-home residents have died of Covid since June 1, an analysis of federal data shows -- well after the pandemic's first national peak in April.

State-run veterans homes, where men far outnumber women, have been particularly hard-hit.

Menlo, a modern, two-story complex in central New Jersey's industrial heart, stands out for its leaders' early denial of how serious its Covid problem was and their efforts to play down the consequences.

Mr. Cavalieri's daughter didn't learn the virus had entered the building until after his roommate had died of it. Mr. Cavalieri tested Covid-positive before his own death, but a Menlo doctor initially listed pneumonia as the cause. His daughter demanded a revision.

Menlo reported only 62 deaths linked to the virus to state officials. But 112 residents died of all reported causes from March 31, when it registered its first fatality, to the end of May, records reviewed by the Journal show.

Mr. Westhoven said the official death tally reflected only residents with death certificates listing coronavirus.

He declined comment on many of the Journal's questions, citing expected litigation. Menlo's chief executive, Elizabeth Schiff-Heedles, and her boss, Sean Van Lew, didn't respond to requests for comment.

Brig. Gen. Mark Piterski, the state official overseeing veterans affairs until he resigned in late April, defended his agency's handling of the crisis. He blamed a tight state budget and slow federal response, but acknowledged there were problems, including delays in reporting the outbreak to families.

"The communication piece was absolutely an abomination," said Gen. Piterski. He said the reason for the delays was, "It was all hands on deck."

Emails obtained by the Journal in a public-records request show the agency didn't have a plan early on to communicate about the virus with families.

"Not sure what people expect," Mr. Van Lew emailed administrators of veterans homes the day before Menlo's first confirmed Covid-19 death. "Do we blanket notify everyone, every time we get a case of the flu?"

To document the toll at Menlo, the Journal turned to hundreds of emails between administrators and internal records of the facility showing deaths, hospitalizations and internal transfers. The Journal attempted to contact the families of every resident who died from March until May, interviewing dozens of family members, staff members and surviving residents.

As the threat of the new virus mounted, Mr. Van Lew, the state veterans agency official, ordered Menlo and Paramus to shut down to outsiders on March 12, according to a letter sent to residents' families.

Around that time, Ms. Schiff-Heedles gathered workers in one of the facility's dining rooms to discuss the virus.

Several nurses and other workers asked her why they weren't given masks to wear when working with patients, four employees who were present said.

Ms. Schiff-Heedles said the agency was following state and federal guidelines, said Shirley Suddoth-Lewis, a licensed practical nurse working at the facility at the time.

"We don't want to frighten the residents," Ms. Schiff-Heedles added, according to Ms. Lewis, who retired in August.

By several accounts, masks were in short supply. When a worker brought in a note from his doctor recommending he wear a mask, his manager advised Ms. Schiff-Heedles to permit him, but she balked at the request.

"If I do that then every employee will come to work with a doctors note," she wrote to Mr. Van Lew on March 30. "Not sure if this is good advise [sic]."

At the time, the federal Centers for Disease Control and Prevention recommended that facilities only "consider" providing masks to all health-care workers. By March 30, the state Department of Health had recommended universal mask-wearing at health facilities, a document shows.

Rose Dente, a 99-year-old widow of a Newark police officer and Army veteran, looked sick in a FaceTime call on March 29, her daughter, Donna Lourenco said, adding that nurses attending her weren't wearing gloves or masks. A Menlo worker called Ms. Lourenco later that day saying Ms. Dente should be hospitalized.

Two days later, on March 31, Ms. Dente tested positive for coronavirus at Hackensack Meridian Health JFK Medical Center, making her the first known Covid case among Menlo residents. She died that same day.

That night, Ms. Schiff-Heedles emailed Mr. Van Lew saying, "2 positive in hospital." A report indicating Ms. Dente had tested positive was attached to the email.

Ms. Lourenco repeatedly texted Ms. Schiff-Heedles in the days that followed, urging her to notify other families. The manager never replied, the texts show.

Ms. Lourenco formally began the process to sue the state over her mother's death in June, said her attorney, Paul da Costa, who represents more than 35 families of deceased Menlo residents.

Meanwhile, maintenance workers erected the plastic curtain spanning a hallway in the dementia unit, known as "Stars and Stripes," separating six rooms for potential Covid cases, according to people involved and photographs. Dementia patients in those rooms were moved to the "clean" side of the curtain, the people said.

One of the displaced patients was John Faranda, an 89-year-old from North Bergen who served as an Army cook in postwar Germany and went on to roast coffee beans in Hoboken.

Mr. Faranda had been living in room 749 since January when his dementia worsened to the point that he no longer recognized his son. In an April 1 transfer order reviewed by the Journal, Mr. Faranda was moved to room 711, on the Covid-free side of the plastic sheet.

"There is no Covid-19 at their site," one of the facility's social workers, Robin Schneider, told Mr. Faranda's son, also named John, in a March 31 phone call, according to an email the son sent his two brothers that day.

Mr. Schneider himself ultimately contracted Covid, but later recovered, according to people who know him. He didn't respond to requests for comment.

In the days that followed, Menlo administrators didn't disclose the Covid case to families. Word of the outbreak began to leak out from residents.

"I think Alex has got it, and I'm going to get it, too," Donald Wylde, a resident in the Liberty unit, told his daughter in an April 1 phone call, describing his roommate Alexander Sena's coughing fits.

The April 1 call was "the last time I ever talked to him," said Donna Schautz, Mr. Wylde's daughter. After the call, she began a spree of phone calls to social workers and administrators that weren't returned for days, she said. Mr. Sena was moved to the hospital only on April 7, and by that time, Mr. Wylde was sick, too, records show.

The virus would take the lives of both roommates. Mr. Sena, a 93-year-old Navy medic at the Battle of Iwo Jima, died April 8, and Mr. Wylde, 92-year-old Army veteran who later worked for a plumbing supplier, died April 20.

On April 3, Howard Conyack, an 81-year-old Marine veteran and retired advertising executive residing in the Eagle unit, left a panicked voice message for his daughter, Tanya Montuore.

"I think I have one of the symptoms," he said between gasps for breath. Naming her husband, Mr. Conyack told his daughter: "If anything happens to me, I miss you so much, and Bobby and the dog." He died 13 days later.

Emails flowed in from distressed family members reporting residents' positive tests at the local hospital or inquiring about rumors the virus had penetrated the facility.

In the Freedom unit, Joan Williams, a well-known member of the residents' elected council, stopped answering phone calls on about April 4, her daughter, Shari Davis said.

Down the hall, resident Isabella Kovacs, an Irish woman who moved to California as a teenager and served in both the U.S. Army and Air Force, called her own daughter, Julie Diaz, around that time saying Joan had been moved into her room.

"She told me Joan was sick and she thought she had Covid," said Ms. Diaz.

Ms. Williams died of Covid at the hospital on April 21. Ms. Diaz visited her mother at the same hospital the next day and found Reese's peanut butter cups, a favorite treat, she'd asked a nurse to bring her when she'd stopped eating untouched on her bedside table. She died of Covid on April 23.

Around the time Ms. Williams was moved into Ms. Kovacs's room, Ms. Schiff-Heedles wrote to Mr. Van Lew: "I think we really need to call all the families (sic) let them know we have an outbreak."

On April 7, more than a week after Ms. Dente became Menlo's first Covid death, Ms. Schiff-Heedles sent a letter to families to inform them the virus had struck.

"During this global Covid-19 pandemic, no facility is immune," she wrote. "I can confirm that we do have positive cases of Covid-19 in our home at this time."

Six residents died the next day.

On that day, Vipul Mody, a Menlo medical director, sent Ms. Schiff-Heedles an updated policy on how to handle Covid. The facility would provide masks to all workers, the policy, reviewed by the Journal, said, and "in the event of an outbreak of Covid-19," would notify family members. Dr. Mody didn't respond to requests for comment.

Even before the pandemic, the Menlo facility was short-handed, current and former officials said. The staff had shrunk about 5% in the first quarter, state payroll data shows.

Gen. Piterski said the shortfall was caused by attrition, low state-government pay rates and a state hiring freeze that added bureaucratic obstacles to filling jobs.

The virus outbreak made staffing problems worse when workers started getting sick, too -- including one who later died. Gen. Piterski said at one point more than 100 out of about 250 workers on a single shift at Menlo and its Paramus sister facility called out sick, forcing administrative workers -- including himself, he said -- to help change beds and feed residents.

Gen. Piterski said he asked for federal help with protective gear, more nurses and tests. None came for more than two weeks, he said.

Within the Stars and Stripes unit, the virus had overtaken the facility's precautions, flooding the unit with far more sick patients than managers had prepared for.

Staff members assigned to the unit said in interviews that workers in full hazmat gear from the Covid side of the curtain shared a nurses' station with their counterparts on the "clean" side.

Mr. Faranda, the resident with dementia who was transferred on April 1 to the clean side of Stars and Stripes to make room for Covid patients, struck a 103-degree fever on April 15, his son, John Faranda, said.

A National Guard medic told Mr. Faranda's son that workers had attempted to put him on oxygen, but he repeatedly pulled the mask off, the son said in an email to his brothers. The former Army cook died the next day. His death certificate listed sepsis as the cause of death. Fever and low oxygen saturation are classic signs of Covid.

In all of April, Menlo's deadliest month, 98 residents died in total. The Journal reviewed photographs of a memorial wall outside Menlo's chapel showing monthly deaths going back to December 2018. A review of the postings indicate that in a typical month an average of just over 8 residents died.

Mr. Westhoven, the veterans-agency spokesman, said "all resident deaths were reported according to the findings of qualified medical professionals."

The state Department of Health last week confirmed the Journal's findings that the facility underreported Covid-linked deaths, asserting that an additional 39 Menlo residents probably died of Covid, in addition to the 62 the agency has acknowledged. Based on a Journal review of state and federal data, that total, 101, is the highest in the country.

By May 18, the facility was down to 186 residents, from just over 300 in early March, a state report shows.

Beverly Epstein, an 89-year-old from the Brownsville neighborhood of Brooklyn, N.Y., spent much of the pandemic isolated in a private room following a hospital visit, separated from her boyfriend and roommate, Stanley Agines.

She found out Mr. Agines, Menlo's librarian, had died from the virus when she returned to their room and found a stranger in his bed, she said.

Mr. Agines's wheelchair wound up stacked among dozens of abandoned devices in a Menlo dining room, a May photograph shows.

"I'm one of the lucky ones, I guess," said Ms. Epstein, who tested negative.

Lisa Schwartz contributed to this article.

State cites urgent need to expand hospital capacity; doctors group says decision ‘represents a clear and present danger to all of the residents of a nursing home.’

By Anna Wilde Mathews

New York told nursing-home operators that they will be required to accept patients infected with the new coronavirus who are discharged from hospitals but may be still convalescing, amid more cases in the state that are straining the health-care system .

The decision will draw pushback from some nursing-home officials, who have warned that such moves endanger residents who aren't infected by the virus, because discharged patients may still be contagious. A group representing doctors who work in nursing homes, known as AMDA, the Society for Post-Acute and Long-Term Care Medicine, said in a recent resolution that "admitting patients with suspected or documented Covid-19 infection represents a clear and present danger to all of the residents of a nursing home."

"We've got an extraordinarily vulnerable population on our hands," said Christopher Laxton, executive director of the group. Nursing homes' older, often frail residents are particularly susceptible to the virus. Many nursing homes have also long struggled with infection control, according to federal inspection records and researchers.

Covid-19, the respiratory illness caused by the new coronavirus, has been spreading rapidly in nursing homes, resulting in large outbreaks and more deaths across the U.S. The federal government has said there are cases in at least 147 nursing homes, with clusters and deaths reported in elder-living facilities from Louisiana to Vermont to Florida.

At least 37 deaths have been tied to an outbreak in one Seattle-area nursing home, Life Care Center of Kirkland.

In the directive sent Wednesday to nursing homes, which was viewed by The Wall Street Journal, the New York State Department of Health said, "No resident shall be denied readmission or admission to the [nursing home] solely based on a confirmed or suspected diagnosis of Covid-19." In addition, the document said, nursing homes "are prohibited from requiring a hospitalized resident who is determined medically stable to be tested for Covid-19 prior to admission or readmission."

The document noted that there is an "urgent need to expand hospital capacity in New York State to be able to meet the demand for patients with Covid-19 requiring acute care."

A spokesman for the state's Department of Health said that "protecting New York's most vulnerable nursing-home population is a priority for addressing the current Covid-19 outbreak and containing the virus." The department continues to issue guidance to nursing homes regarding testing, visitation and other matters during the outbreak, he said.

Like other health-care sectors, nursing homes have said they are struggling with a lack of personal protective equipment for their workers, and that in some cases they aren't able to get prompt coronavirus tests for all of their residents and employees who might need them.

The state reversed its policy after mounting criticism and deaths. The mandate is part of broader scrutiny of weaknesses at long-term care facilities that have made them hot spots for Covid-19.

By Anna Wilde Mathews

In late March, Dottie Hickey got a call from Luxor Nursing & Rehabilitation at Mills Pond, the nursing home where her sister lived. The 79-year-old was being moved to make space for incoming hospital patients recovering from coronavirus. Ms. Hickey was told the St. James, N.Y., facility had no choice but to take in these patients under a new state policy.

Ms. Hickey said that after a few days she struggled to reach staff for updates on her sister, and after repeated calls, one employee told her why. The nursing home was overwhelmed with cases of Covid-19, the illness caused by the virus.

Luxor Nursing & Rehabilitation had no confirmed coronavirus cases before the patients moved in, and can't say if any arrived while still infectious, a spokesman said. But he added: Luxor "would not have accepted [the patients] without this directive."

After mounting criticism and thousands of deaths in New York nursing homes—including several individual facilities that have lost more than 50 residents—the state on Sunday reversed the mandate , which said nursing homes couldn't refuse to accept patients from hospitals who had been diagnosed with Covid-19. New York now says hospitals can send patients to nursing homes only if they have tested negative for the virus.

The policy before the U-turn is one of several decisions the state made that are now coming under fire , as New York's death toll tied to nursing homes rises, to 5,398 presumed and confirmed fatalities as of May 12, more than any other state and a significant part of New York's total deaths.

"The state has failed to protect the lives of the most vulnerable members of our community," said Ron Kim, a Democratic member of the state Assembly whose Queens district has seen many nursing-home deaths. "The fact we maintained and pushed Covid-positive patients into facilities that were not equipped to handle them, it was a fatal error."

New York Gov. Andrew Cuomo in a news conference Sunday said the new policy on hospital transfers would reduce the burden on nursing homes. The original policy, issued from the department of New York Health Commissioner Howard Zucker, had come amid a "scramble to provide more hospital beds."

Mr. Cuomo said the change didn't reflect a view that the original directive was flawed, and that nursing homes should not have accepted patients they weren't able to care for.

New York also said Sunday that it would require nursing homes to test their employees twice a week.

The state quietly surveyed nursing homes about the impact of the original hospital admissions policy last week. A state health official declined to reveal the results but said they hadn't affected the recent change. "The state has greatly increased testing capacity in a short amount of time and the anticipated strain on the hospital system didn't happen, making the new health and safety standards possible," he said.

The transfer of recovering coronavirus patients to nursing homes compounded broader vulnerabilities at the facilities, including low levels of staffing and limited access to protective gear and testing, which made them weak spots in New York's fight against the pandemic. Despite the homes' elderly, frail populations, the state long put its major focus on the safety, staffing and supplies of hospitals, according to researchers, consumer groups and nursing-home executives.

Richard Gottfried, a Democrat who chairs the state Assembly's health committee, said he wants an independent investigation of the state's handling of nursing-home issues. "A tough look at nursing homes and how we regulate them has been needed for decades," he said. "The Covid-19 situation has made it much more obvious and much more deadly."

In a written statement, Rich Azzopardi, a senior adviser to Mr. Cuomo, said the New York policy was similar to those of other states, and that if a nursing home didn't have the resources to care for a resident, it "must transfer them to a place that can—period."

Researchers who study long-term care facilities said the extent of coronavirus infections in the state's nursing homes reflects the virus's widespread presence in the community, particularly around New York City.

Nationwide, more than 28,000 coronavirus deaths have been tied to long-term care facilities, according to a Wall Street Journal tally of data reported by states. Nursing-home residents, who are typically frail and live in close quarters, are particularly vulnerable to the virus.

In New York, decisions at the state level show that officials didn't always make nursing homes a priority. For weeks, even as their residents were dying, some facilities couldn't access testing and protective equipment for staff, industry officials said. Mr. Kim, the New York Assembly member, said his office was scrambling to procure gear for short-handed nursing homes in his district.

New York has stopped short of steps taken by other states weeks ago, such as sending National Guard teams into nursing homes to help with decontamination, testing, staffing and other tasks.

The state has struggled at times to even offer an accurate count of coronavirus deaths in nursing homes. In March and early April, a survey it relied on for such data was asking the facilities only about a slice of resident fatalities, those that took place in hospitals, and not deaths at the homes themselves.

"Our main concern was dampening the spread to our patients. The state had a different concern," said Bill Pascocello, administrator at New York City's Amsterdam Nursing Home. "They were looking at the total system, and the hospitals."

The original order on hospital transfers to nursing homes came on March 25 and was first reported in The Wall Street Journal.

The day the policy was issued, Mr. Cuomo was closely focused on an expected huge shortfall in hospital capacity amid surging coronavirus cases. He said in a press conference that day the state was looking at options such as hotels and former nursing homes.

Mr. Cuomo didn't mention the nursing-home directive, which said patients referred from a hospital couldn't be denied admission or readmission to a nursing home "based on a confirmed or suspected diagnosis of Covid-19," and that nursing homes couldn't require incoming patients to be tested.

The governor over the following weeks defended the March 25 policy and said repeatedly that nursing homes shouldn't accept patients if they believed they couldn't care for them. The directive was meant to protect those infected with coronavirus from discrimination, a state official said.

Nursing-home groups and physicians warned about the order's potential effects. AMDA, the Society for Post-Acute and Long-Term Care Medicine, said that admitting infected patients represented a "clear and present danger" to nursing-home residents.

Christopher Laxton, executive director of the group, said that he is "completely convinced there has been a higher level of spread in nursing homes, and both acute illness and death, because of" the New York directive.

On April 7, Tamara Burrell, a federal auditor who lives in Pasadena, Calif., got a call from Amsterdam Nursing Home, where her 92-year-old mother lives. Her mom was being relocated from her 12th-floor room to make space for an influx of recovering coronavirus hospital patients.

"I was speechless," she said, at the idea of bringing coronavirus patients into a nursing home. "I'm thinking, this cannot be happening…how can they do this?" Her mother remains well, she said.

Mr. Pascocello, the administrator at the Amsterdam home, said the facility preferred to accept Covid-19 patients from hospitals only after they tested negative for the virus but couldn't require that under the original state policy. The hospital patients were a mix of new arrivals and Amsterdam's own residents who had gone to the hospital and were confirmed to have the viral infection, he said.

Mr. Pascocello said he was relieved by the state's announcement that it will change the policy. Amsterdam, with 409 beds, now has 11 confirmed and 45 presumed deaths among residents due to Covid-19, according to the state.

New York has many facilities that house large numbers of residents and were in some cases already stretched thin before the pandemic. The average staffing level in New York nursing homes ranks in the lowest third of states, according to a Wall Street Journal analysis of federal data from the fourth quarter of 2019, which focused on a widely used measure of nursing staff levels.

On March 21, as the infection spread, the state told nursing homes in areas with high prevalence of Covid-19, mostly around New York City, that they didn't need to test symptomatic residents, and should assume they were positive. The state had previously said that infected residents should be kept separate from those who weren't.

"Some facilities took it to mean you should stop testing altogether, and they did," said Elaine Healy, vice president of the New York Medical Directors Association. But, she said, nursing homes aren't supposed to house people with positive tests in the same parts of the facility as those who haven't yet been tested, in case the virus spreads to residents who aren't infected. The lack of test results made it difficult to separate residents properly, she said. "It was confusing."

Even as testing capacity has grown, she said, "there has been no focus by the state on assuring that nursing homes have consistent and reliable access to testing."

Limited testing made it difficult for some nursing-home operators to get a full sense of the virus's impact as it began to spread. Donny Tuchman, chief executive of Cobble Hill Health Center, a Brooklyn nursing home where the state currently lists four confirmed and 50 presumed deaths from Covid-19, said that only one of the 50 deaths he originally reported was a lab-confirmed case. He said access has gotten better recently.

Nursing homes said they have struggled to get personal protective equipment such as gowns and masks. Stuart Almer, chief executive of Gurwin Healthcare System in Commack, N.Y., which includes a 460-bed nursing home, said the state still supplies little help. "It's been very minimal in terms of amounts and nowhere near what we need in this crisis," he said. A spokesman said Gurwin had 49 Covid-19 deaths, including confirmed and presumed; the state currently lists 41.

State health officials said that they are moving rapidly to increase the availability of protective equipment and testing for nursing homes, with about 110,000 testing kits sent this week. Nursing homes have access to the state's volunteer health-care staffing portal, they said.

A spokeswoman for the state's Department of Health said the March 21 guidance was meant to ensure that infection control and other responses could "be implemented quickly without having to wait for the results of a diagnostic test."

Families and consumer advocates in New York have said individual facilities haven't always disclosed coronavirus infections and other failures. Mr. Cuomo has announced a broad investigation into whether any nursing homes are violating state rules.

New York has passed a law containing a broad liability shield for nursing homes and other health-care providers amid the pandemic, retroactive to March 7.

Total coronavirus deaths in New York as of May 12 were 22,013. The state has said its death totals only include coronavirus cases that were confirmed by a lab test.

The state's nursing home deaths were reported as 2,752 confirmed deaths and 2,646 presumed deaths as of May 12. The counting methodology has changed over time, causing at least one jump in documented cases, and the current total doesn't include nursing-home residents who die in hospitals.

It's been a "confusing, rushed and mixed message on what they're trying to count and not count," said James Clyne, chief executive of LeadingAge New York, which represents nonprofit providers of aging-care services.

A state survey form viewed by the Journal, which a state official confirmed last week was still in use, included a question that ordered nursing homes to report "the total number of Covid-19 positive residents who have died outside your facility since your last report." Then, seemingly contradicting itself, the questionnaire noted that the number "should not include anyone who was NOT physically at your facility at the time of death."

An earlier version of the form viewed by the Journal, which a state health official confirmed was in use from March 9 through April 15, asked nursing homes only about Covid-19 resident deaths in hospitals—not fatalities that occurred in the homes themselves. After that, nursing homes were asked for data going back to the start of March.

A New York state health official said the state sought an accurate accounting. He said the recent jump in the total death count came when the state started separating confirmed from presumed cases, and that previously what was being reported lacked consistency.

At the Luxor nursing home, Ms. Hickey was worried that the incoming hospital patients might still be infected, and she became more alarmed when her sister, Barbara Patton, was moved near them after developing a mild fever. The home confirmed it had a Covid-19 case in a letter to families dated April 6.

Then, on April 10, a nurse warned Ms. Hickey that her sister had become much sicker and was receiving oxygen. During a FaceTime call, Ms. Hickey said, her sister seemed weak, unable to even sit up.

Days later, Ms. Patton died. Ms. Hickey said she was told her death certificate reflected that Covid-19 was the cause, though she was never tested.

The spokesman for Luxor said the facility set up a separate Covid-19 unit and kept families updated about infections. The state tally lists 25 confirmed and presumed Covid-19 deaths for the home.

Ms. Hickey, after her sister's death, remains angry about the state's original policy on recovering coronavirus patients being brought to nursing homes. "How could they do that?" she said. The nursing-home residents "were the most fragile people…It was reckless."

Andrea Fuller, Melanie Grayce West and Jon Kamp contributed to this article.

This account shows how Life Care Center management missed opportunities to launch a more aggressive response

By Elizabeth Koh, Jon Kamp and Dan Frosch

KIRKLAND, Wash.—It seemed a curious day for the Life Care Center to throw a Mardi Gras party.

For one thing, Feb. 26 was actually Ash Wednesday, the day after Mardi Gras.

More crucially, the nursing home was under orders to be in scrub-down mode due to a raft of respiratory problems among its residents. That same day, managers had ordered staff members to close the two dining rooms immediately, wipe down all common spaces and halt group activities.

But the party went ahead. It was one of the facility's biggest events of the year, spokesman Tim Killian later said. Only those residents with concrete respiratory symptoms were kept in their rooms. Meanwhile, dozens of residents, visitors and staff shared cake and clapped as a local band performed songs like "When the Saints Go Marching In."

Within days, nurses were calling in sick, and calls to 911 were spiking for ailing residents. By March 9, 129 people were infected with the new coronavirus, including 81 residents, 34 staff members including health-care personnel, and 14 visitors, testing showed. As of Sunday, 35 deaths were tied to the home, around 7% of the national total.

Even as cases of coronavirus spread nationally, the Life Care Center of Kirkland remains the single deadliest concentration in the outbreak. The unsuspecting facility was hurt by the bustling social calendar meant to enrich residents' days with themed parties, performances and a welcoming attitude toward visitors. It has turned into a deadly example of just how easily and quickly the novel virus can spread, and how it preys on the elderly.

"For us, the 26th is the date everything started escalating," Mr. Killian said in an interview.

This account, pieced together through records and streamed news conferences along with interviews with first responders, public-health officials, family members of residents and comments from the company that runs the Life Care Center, provides the most detailed description yet of what happened on the three days leading up to that Saturday, when the public learned that the facility had contracted the coronavirus.

It reveals that the Life Care Center management missed opportunities. A more aggressive response to the respiratory illnesses in their midst could have made a difference, federal health officials say, even if no one there suspected the much more deadly coronavirus.

Mr. Killian said, "Anybody who thinks they would have known and acted differently simply was not in the situation we were in...and simply does not understand what you can do in a single long-term care facility."

On Monday, the Centers for Medicare and Medicaid Services said there were major violations at the Kirkland home that created imminent danger, including not identifying and managing sick residents. Mr. Killian said the company was disappointed CMS didn't take into account the unprecedented nature of the outbreak.

All day that Wednesday, Feb. 26, the place was abuzz with activity. The facility admitted at least one new resident. A local physical therapy student and professor came by. Visitors came and left. The facility's visitor log was so loosely enforced that it proved insufficient for tracing the disease later on, local officials said.

Throughout the week, firefighters responding to medical calls entered and exited the facility without protection, having had no warning of widespread respiratory problems among the residents. Even after one fire official heard a patient and a staff member were being tested for coronavirus and the facility was supposed to be on self-quarantine that Friday, a nurse told him that day she didn't know anything about it.

Mr. Killian said to his understanding Life Care staff didn't know the patients were being tested for coronavirus at hospitals until they got the results on Saturday.

The Life Care managers' response wasn't out of line with what might be expected at any other long-term care facility in the country, unprepared for a global health emergency without precedent in modern history, public-health experts said in interviews.

"This could happen anywhere," said Dr. Jeffrey Duchin, health officer for Seattle and King County's public-health entity, which monitors communicable disease outbreaks, in a call with reporters.

Seattle-area nursing homes had little reason or direction to be on high alert. Though Washington state on Jan. 19 had its first identified case of Covid-19, the disease caused by the novel coronavirus, the patient had traveled to Wuhan, China, where the disease started. The Kirkland home's vulnerable residents weren't likely to have traveled abroad recently, much less to mainland China, where warnings from federal public-health officials were focused at the time.

"It just think it took them by surprise," said Mike Weatherill, whose mother, Louise Weatherill, was a resident of the facility and died of pneumonia shortly after the first cases were announced. "I'm not going to blame anybody. It's a real tragic and horrible thing that's happened."

First signs

Exactly when or how the virus first arrived at the Kirkland home, a beige and blocky one-story complex surrounded by residential condominiums, is still unclear. The facility had around 120 residents in mid-February, according to Life Care.

It is among more than 200 elder-care facilities spanning 28 states owned by Life Care Centers of America, a privately held company based in Tennessee that is one of the nation's largest nursing-home operators. The Kirkland facility rated five out of five stars on Medicare's Nursing Home Compare quality-ranking site, although it had a three-star health-inspection rating.

Staff members had begun to notice enough respiratory cases by Feb. 10 to take some precautionary measures, Mr. Killian said, including putting up printed-out signs in hallways and by doors to warn of the illness within the facility.

Mr. Killian said in a recent news conference that such respiratory illness symptoms were common. Residents are often near the end of their lives. "We see between three and seven deaths in a normal month," he said.

Pat Herrick, 61, said she suspected nothing at the facility where her mother, Elaine Herrick, had lived for seven years until she came by for her weekly visit on Sunday, Feb. 23.

Ms. Herrick said she noticed some staffers wearing masks in the Baker wing, where her mother lived in room 5. Ms. Herrick had occasionally seen staff members don masks before, when flu cases popped up. She asked a staffer if there was a flu going around.

"Some people are just being cautious," she recalls being told.

At 1:34 a.m. on Feb. 24, Baboucarr Lowe, a Life Care nurse, called 911 about a 73-year-old woman in room 26 who had been on antibiotics for pneumonia.

"She's just having bad oxygen levels?" the 911 operator asked, according to recordings reviewed by The Wall Street Journal. "Difficulty breathing," the nurse said. Her heart rate fluttered at nearly 200, he relayed. "She's shaking too…she's shivering."

A woman matching that description was then rushed to the hospital, according to a subsequent report from the Centers for Disease Control and Prevention, where she registered a fever of 103.3 and needed intubation and mechanical ventilation the following day.

Again that Monday, the facility called 911—this time about a 54-year-old man with a traumatic brain injury. He, too, had a fever and was increasingly restless.

The next day, Fat Tuesday, a resident who would later test positive for coronavirus and die, transferred from the Life Care Center of Kirkland to the nearby Madison House assisted-living facility, another elder-care facility in Kirkland, a spokesman for Madison House confirmed. Some employees at the Life Care home in Kirkland also worked shifts inside several other facilities in the region before the outbreak was known, including Madison House, those facilities confirmed.

A resident who left the Life Care Center of Kirkland even earlier, on Feb. 19, was also found later to have had the disease.

Ash Wednesday

A memo signed by two Life Care Center of Kirkland managers, dated Feb. 26, spelled out the precautions staff members were to immediately implement "due to [the] increased number of Respiratory Symptoms."

The Baker and Olympic dining rooms on opposite corners of the facility would be closed. Each patient would have meals served in their rooms instead, unless they needed feeding assistance. Group activities were to be put on hold.

A family member who shared a photo of the memo with the Journal recalled seeing it around noon on Ash Wednesday on the counter by the receptionist's window in the lobby. At the bottom of the memo, wrapped in several asterisks, the memo said: "Let's be Safe and Help Protect Our Patients."

Mr. Killian described the memo as "business as usual, normal operating procedures" that the facility would take with any influenza-like outbreak.

A few hours later, at 2 p.m., the Mardi Gras party started up in the Baker dining room.

Several residents, seated in their wheelchairs next to each other, listened to the swing band, which played regularly at senior facilities in the area. Residents and guests drank Sprite or other soft drinks as they sang and clapped, said Patricia McCauley, who attended with her husband, Bob McCauley, and a friend they were visiting at the facility.

Though some staffers in the hallways were wearing masks, the only mask worn inside the party was a glittery masquerade-style one, Ms. McCauley remembered.

"My parents were touching tables, chairs, pushing wheelchairs. It was a big germ fest," said Cheri Chandler, the McCauleys' daughter, who wasn't at the party that day.

"We have the same questions of how prudent that was in hindsight," Mr. Killian, the nursing home spokesman, said, but he stressed that the facility still believed it was dealing with a run-of-the-mill flu outbreak. "We did not have a Covid positive test at that point."

While the party was still going on, around 3 p.m., Lori Spencer brought her mother, Judie Shape, to be admitted to the facility. Mrs. Shape, 81, was recovering from a recent surgery for a blood clot at a nearby hospital and needed additional care after developing an infection, Ms. Spencer said.

No one at the facility informed the two women of a possible respiratory outbreak, Ms. Spencer said. She recalled no signs on the walls and said she wouldn't have proceeded with enrolling her mother there if she had.

Mr. Killian said he could not speak to individual memories of signs at the facility, but said that signs noting respiratory illnesses were posted throughout the month.

A student training to be a physical therapist assistant and a professor from Lake Washington Institute of Technology were also in the halls that day. Sixteen more students in the school's nursing program and two additional faculty members would visit during the rest of the week. A fourth faculty member visited a relative at the nursing home. All would subsequently be self-quarantined.

Also on that Wednesday, for the first time, Life Care reached out to state and county public-health officials to alert them to a respiratory outbreak, Mr. Killian said.

There were two deaths tied to Life Care that day, which officials would later trace to the coronavirus: a female resident in her 80s who was never hospitalized and the 54-year-old brain-injury patient who was taken to Harborview Medical Center in Seattle two days earlier. The facility wouldn't learn about those coronavirus cases until early March.

On the other side of the continental U.S. that day, a man from Wake County, N.C., began to show Covid-19 symptoms, which state health officials later linked to his visit to Life Care. On March 3, he would become North Carolina's first presumptive case.

Just before midnight on that busy Wednesday, Life Care had to call 911 again. Another woman was struggling with respiratory problems. She was 92 years old and had pneumonia. She was transported to EvergreenHealth Medical Center.

Feb. 27

On Thursday morning, the public-health office for Seattle and King County received a message from the Kirkland facility, notifying them of the respiratory illnesses.

The notification felt routine and without urgency, a spokesman for the health agency said.

It wasn't until the regional health unit's communicable disease program received a similar call from EvergreenHealth later that day—about two patients with unexplained pneumonia—that suspicion stirred, according to a timeline later provided by the health unit.

The regional health staff member who took the message noticed that one of those two patients had come from Life Care, hospitalized since Feb. 24. Public-health staffers asked the hospital for specimens as quickly as possible for coronavirus testing.

That evening, Lt. Dick Hughes of the Kirkland Fire Department responded to two calls from Life Care that had troublingly similar symptoms: a 74-year-old woman with "labored breathing," around 5:30 p.m., and a woman in her late 80s, just shy of 8 p.m., who was "sweating, clammy, having a hard time breathing," 911 recordings show.

Nurses seemed more worried than usual, Lt. Hughes recalled, as they frantically asked for help.

He and his team fitted patients with oxygen masks, giving them nebulizer treatments to help them breathe. He recalled the patients coughing up fluid that would splatter on the firefighters.

"Something is not right here," Lt. Hughes said he and his crew agreed at one point that night. They decided to don masks, gowns and protective glasses the next time they were called into the facility.

Feb. 28

Lt. Hughes's next call from Life Care came just after 4 a.m. Friday, for an 84-year-old woman who an employee said was diagnosed with pneumonia a couple of days earlier. A 911 log for the call included the language: "FLU SYMPTOMS—PPE FOR RESPONDERS ADVISED," meaning protective gear such as masks and gowns.

After he returned to the firehouse from the trip to Life Care, Lt. Hughes typed up an email to the city's Emergency Medical Services Captain Joel Bodenman, noting the three distress calls for respiratory problems at the facility during his shift. "They don't meet any of the King County public health criteria of reporting potential COVID-19 but all had similar symptoms and it's an anomaly to have that many resp. distress calls in a day."

Also that morning, the county's public-health offices received word of another suspicious case, from a second nearby hospital. The patient was a Life Care employee.

When a county public-health employee called the nursing home to follow up on the facility's report of a respiratory outbreak, Life Care said about 20 residents were ill—six with pneumonia. Eighteen employees also were sick. And though about 30 residents had been tested for the flu, going back two weeks, tests were returning negative.

Visitors to the Life Care Center, including Mr. and Mrs. McCauley, who had attended the Mardi Gras party just days earlier, discovered by midday that they could visit residents only if they wore masks. Signs were posted on the entrance doors to the facility's lobby, warning prominently of the respiratory outbreak.

The McCauleys subsequently self-quarantined and were eventually tested, but the tests returned negative.

Lt. Hughes, on duty again Friday, heard that afternoon from the local EMS captain that county health officials were having a Life Care patient and staff member tested for coronavirus, and that the facility was self-quarantining.

When Lt. Hughes returned to the facility on a call at 9:20 p.m., he saw no sign of a quarantine. Nurses were moving from room to room with no extra protective equipment that he could see.

When he asked the charge nurse on duty, he recalls her saying that she didn't know anything about a quarantine.

Lt. Hughes, unnerved, called his EMS captain to confirm Life Care was supposed to be on quarantine. He said it was.

When Lt. Hughes returned to the nursing home later that night to check, nothing had changed. This time, the nurse told Lt. Hughes that she had spoken to her supervisor, who told her they were having a flu outbreak and staff were not to call 911 unless the patients were very sick.

"They were running it like it was a normal Friday night a year ago," he said.

After driving away from Life Care, he got a call from his captain. The coronavirus tests had returned positive, and a patient had died.

Lt. Hughes and his crew were being put into quarantine. Lt. Hughes developed symptoms but a coronavirus test came back negative, a city spokeswoman said.

Mr. Killian said management had issued no orders to go into quarantine at Life Care that day because no one there knew the patients were being tested until they received results Saturday.

A man in his 80s who died inside the facility that Friday would posthumously test positive for the coronavirus and not be announced as another of its victims until March 18.

Feb. 29 and beyond

Just minutes after midnight on Saturday, Feb. 29, the facility was told a test on a hospitalized resident was positive for coronavirus. This was the 73-year-old woman rushed to the hospital five days before, the CDC later said.

Later in the morning, local officials held briefings announcing new cases. Life Care said it was closing its doors to new visitors—though some were allowed in regardless.

Mr. Killian said that there was some question about whether the facility had the authority to bar people from seeing their family members, something it later determined only the government had the authority to do.

Last week, the CDC issued a study saying that nursing-home facilities in the Seattle area, including the Kirkland facility, contributed to their vulnerability in many ways, including failing to implement infection controls such as using alcohol-based hand sanitizer and wearing proper gear. Staff members would also work while symptomatic, the CDC said, a practice that was shut down by the Life Care Center on Feb. 29.

Mr. Killian said he didn't read the CDC study "as a condemnation of our practices at all," but rather as a summary "of what we've learned since that happened."

After the Kirkland home received its first positive test, it wouldn't get enough testing kits for the bulk of the residents for another week, Mr. Killian said. Moreover, all employees couldn't be tested for another two weeks due to a lack of tests, he said.

As of Friday, 42 residents remained inside the facility: 11 negative for Covid-19, 31 positive. One of them is Mrs. Shape, who was diagnosed earlier this month.

Her daughter broke the news of her positive test to her over the phone. Mrs. Shape and Ms. Spencer haven't been able to be in the same room since the contagion at the nursing home was announced.

At some point there has to be an apology from the Life Care Center, Ms. Spencer said.

"You can understand a lot about crises, but I will never understand the death count at Life Care," she added.

Anna Wilde Mathews, Lisa Schwartz and Melanie Evans contributed to this article.

Jack Eccles didn’t want to leave his wife, who has Alzheimer’s, on her own

By Anna Wilde Mathews | Photographs by Andrea Bruce for The Wall Street Journal

When nursing homes began barring visitors to keep the coronavirus out, Jack Eccles decided to move in.

Hillcrest Convalescent Center in Durham, N.C., had turned him away on March 12 when he arrived as usual to spend much of the day with his wife, Gerry, who suffers from Alzheimer's disease.

So he returned the next day with a suitcase of clothes, books, medications and his computer. Hillcrest had agreed to rent him a single room in its assisted-living area so that he could care for Gerry, who is 91.

Dr. Eccles, who is 93 and a longtime Baptist pastor, remains under lockdown at Hillcrest. For five months, he hasn't left and has rarely seen the sun—the window in his room faces a brick wall.

He isn't allowed to walk around the 154-bed facility, except to Gerry's room, where he feeds her, and sometimes to the lobby, where he can see family members through the windows. Meals in the facility's spacious dining room and its festive monthly parties remain paused.

Hillcrest sometimes feels like a prison, he says, but he won't move out and leave Gerry until it reopens to visitors.

"We're married. I want to be with her. She took care of me for 70 years, and now it's my turn," he says.

The coronavirus cut a deadly swath through senior-care facilities , with more than 70,000 deaths so far, according to a Wall Street Journal tally of state and federal data. Hillcrest has seen two cases of Covid-19, both in patients who came from a hospital in late April. One died.

A less-obvious toll is the tens of thousands of lonely residents cut off from relatives and other social interaction. In mid-March, in addition to closing to nearly all visitors, nursing homes nationwide ended group activities and largely confined residents to their rooms.

Some states have begun permitting more family visits, generally with strict limitations including bans on physical contact. North Carolina has not.

The impact is particularly acute for residents with memory loss. Federal health officials estimated at least 15,000 more Americans died from Alzheimer's disease and dementia than otherwise would have this spring, many of them in senior-living facilities.

Doctors believe the disruption of routines and disappearance of familiar faces in many cases led to health declines among fragile nursing-home residents.

"There are public-health consequences of loneliness, isolation and loss of connection to a beloved person that may be equally devastating" as Covid-19, said Lisa Gwyther, an associate professor at the Duke University School of Medicine. For those with dementia, "the greatest fear is the fear of abandonment in a world that doesn't make sense."

Jack and the rest of his family say they believed Gerry would fail to eat without one of them nearby. Jack also feared he would never see her again. Though their children were nervous about the risk, they agreed with their father's decision, one nursing homes hardly ever encounter.

"They were never apart," says Genece McChesney, one of their nine children.

Three times a day, Jack arrives at Gerry's room, which is shared with a roommate and decorated with pictures of their family and a big photo of the couple.

She sometimes resists eating or dozes off between bites. Wearing a mask and goggles, Jack spoons cereal and purée from a tiny plastic spoon, meticulously checking that she gets the required 40 ounces of liquid a day, and wiping drips so they don't stain her clothes. He positions her head and neck carefully to be sure she doesn't choke.

Months ago, Gerry stopped saying "I love you" to Jack, or any other words, and she no longer smiles in recognition of him, he says. But "there's some radiance about her….That personality still comes through."

When she refuses to eat, he often sings songs like "Chattanooga Choo Choo," pausing to exhort, "Chew, Gerry!" A meal often takes about 90 minutes.

Hillcrest staffers say his efforts have made a huge difference in his wife's health. "That's something we can't do. We haven't been with her for 70 years," said Olivia Jacobs, a Hillcrest dietitian. She and others working at the facility say Jack never complains, and is unfailingly gentle: "He's always having a good day, he's always happy to see her.…He's with his love, and that's where he wants to be."

Jack, who uses a walker and has a history of heart trouble, says the sessions aren't easy, and he has sometimes struggled to be patient as he accepted what he believes is God's plan. A couple of times, he lay down on the floor during a meal, so frustrated he had to take a break. After the meals, he typically needs a nap. "I just have to flop. I'm exhausted, it's an emotional thing."

A smile

John R. Eccles first spotted Geraldine Knobel in 1949, outside the dining hall at Whitworth College in Spokane, Wash., where they were students. "She smiled, and that was all it took," he says.

Gerry, a serious-minded 19-year-old, wasn't immediately smitten with the 21-year-old Merchant Marine veteran. When he invited her to a basketball game, she replied that she went home on weekends. "For a less persistent person, that would have been the end, but not Jack," she wrote in a wedding album.

He won her over with gestures including the gift of a carton of vanilla ice cream with a heart-shaped strawberry core going down the middle. Soon they were driving around in Jack's black Chevrolet Fleetline. Both were from small Washington towns and were committed to their Christian faith. That spring, when he said he wanted to marry her, she was surprised.

"I told him I didn't feel that way about him, but to wait awhile," she wrote in the album.

The following April, Jack gave her the diamond engagement ring once worn by his mother, and on July 16, 1950, they were married at Gerry's family church. "Unspeakably happy," Gerry later wrote about that day in the wedding album.

After college, Jack went to a Baptist seminary. Gerry soon became pregnant with their first child, a daughter named Susan. She was followed by eight others, a total of six girls and three boys.

The family moved every few years, as Jack went from church to church around Washington and California, sometimes working at radio stations or teaching for extra income. He got two different doctoral degrees from theological institutions, and Gerry painstakingly typed his dissertations.

She drove church vans, led women's groups, taught Sunday school, played the piano at services and accompanied church members on accordion when they went Christmas caroling. At home, she kept a hand-drawn grid of church members in a private notebook, checking off the names neatly as she prayed for them each day.

The church was "what their lives rotated around," says Kathy Martin, one of their daughters.

At home, while Jack studied and wrote, Gerry ran the household. She tucked in the children at night and delivered home remedies like baking soda for stomachaches. She hand-squeezed the lemon juice Jack liked to drink and ironed his shirts. At night, she made sure all the kids were quietly gathered around the dinner table before Jack was called from his work to start the meal.

Their children say they don't recall any arguments. But "if she didn't like something, she said [so] very gently, and I took the hint," Jack says.

Jack didn't watch the birth of any of the children. When he tried once, he says, he nearly passed out before he even got to the birthing room. "It was more than I could handle."

He still feels guilty about that—and other things, he says. "There are many times I didn't pay attention enough to Gerry," including her birthdays. "We didn't do anything special. Now I can't talk to her, and I thought, 'Man, I've been missing this all my life.' " Some of his fondest memories are of quiet Monday mornings at McDonald's for breakfast with his wife, he says.

Gerry also handled the family's finances, which were often tight. She darned socks and made rag rugs. She sewed up vacuum cleaner bags and reused them.

In 1971, when Jack left a church in Spokane, Gerry took a job selling products door-to-door. Later that year, Jack got a new position at a California church, and the family moved again.

In the early 1980s, Jack went to a church in San Jose, where he stayed for more than two decades. Later, the couple started yet another congregation.

Fading

By 2015, the family could see signs that Gerry's memory was fading. She groped for words. She burned tea kettles. Her fluid piano playing, which had long been at the center of family gatherings, became more halting.

That March, she lost her new glasses. "Jesus I love you," she wrote in her journal, in jagged fragments unlike her usual perfect cursive. "Please help me. Please help Jack. He is really upset."

The couple's oldest son and his wife began bringing dinner to their house. The family affixed labels with names next to the photos lining the walls.

In October 2015, doctors confirmed a diagnosis of Alzheimer's. During the exam, Gerry couldn't name all of her children or recall her birthday, but was able to write a sentence: "The person I love the most is a few jumps away." Her family was sure she meant Jack.

For the first time in their married life, Jack cooked—simple things like toast and boiled eggs for breakfast.

On Feb. 3, 2017, just a few days before his 90th birthday, Jack broke his pelvis. After the hospital, he needed to go to rehab. The couple's youngest daughter, Roberta Drewry, had offered to have them live with her in North Carolina.

Jack didn't want to leave California, but he finally agreed.

He couldn't seem to get started packing up his thousands of books, mostly religious texts, according to his daughter Kathy. His son-in-law, Steve Martin, says he told him, "Jack, you've got a different job. Your job is to take care of Gerry."

Soon after he arrived in North Carolina, Jack sent his résumé to local churches. He began teaching a Bible class. Gerry continued her decline, and in 2018, she moved into Hillcrest. Roberta and Jack came every day to feed her meals. In the evening, Jack and Gerry would watch old episodes of "M*A*S*H" and "The Andy Griffith Show" in the lobby.

In March, after Roberta saw reports of families cut off from their loved ones in the Kirkland, Wash., nursing home that has been tied to dozens of Covid deaths, she spoke to her father. Jack didn't believe Gerry could return to the house, and when Roberta asked if he would move into Hillcrest, he agreed it was the best option. Hillcrest gave him a room and charged a special rate because he doesn't get staff care.

The Eccles children say they were scared for both parents. Jack says he wasn't afraid of catching the virus. "I could kick the bucket any time. I don't think about it," he says.

Jack says he never expected his stay at Hillcrest to be so long, because he thought the virus threat would subside. He never fully unpacked or decorated his room. "You really miss being outdoors," he says. He misses preaching and he daydreams about a favorite apple pastry with hot chocolate. He has seen his newest great-granddaughter, born about a month ago, only through a FaceTime session.

But he won't leave. He has been studying German and worked on a sermon he has posted on YouTube.

On July 16, eight of the nine Eccles siblings and some of the couple's 20 grandchildren and 24 great-grandchildren gathered in a Zoom session to celebrate Jack and Gerry's 70th wedding anniversary. Roberta and her husband set up an iPad outside the lobby windows and held up an intercom device next to the screen so the family could talk to Jack and Gerry. Each family member spoke briefly.

Jack sat next to Gerry, behind the glass of the Hillcrest front lobby, waving and smiling, their wedding photo beside them. Gerry was quiet, impassive, her hands mostly in her lap. Jack fed her bites of gold-accented cake. He prayed, and led the family in "Amazing Grace," conducting and singing through the intercom.

At one point he told them, "Mommie said something. I'm sure it was, 'I love you guys.' "

After about an hour, nursing-home workers packed up the rest of the cake. Jack put on Gerry's mask and his own. He told his family he loved them, waved good night, and slowly wheeled away Gerry's chair.

Jon Kamp contributed to this article.

The virus killed at least 46 vets at one home in Alabama. Their family members still have questions.

By Elizabeth Koh

During the pandemic, one of the worst places to be was in a nursing home . Among nursing homes, one of the worst places to be was a state-run facility for retired servicemen and women.

Of the nation's 150 such homes, thousands of residents have caught the virus. Hundreds have died. Family and staff members tell of miscommunication and neglect.

At the 150-bed Bill Nichols State Veterans Home, one of Alabama's largest individual hot spots, 96 residents have tested positive for coronavirus and 46 deaths have been attributed to Covid-19.

In New York, a government-run veterans home had the third deadliest reported outbreak in the state, with 72 confirmed and probable Covid deaths. Massachusetts' Holyoke Soldiers' Home was linked to more deaths—at least 76—than any other facility in the state as of late October, leading to criminal charges against two former managers, who both pleaded not guilty.

In New Jersey, the top two nursing homes for Covid deaths were both state-run veterans facilities, including the Menlo Park Veterans Memorial Home, which a Wall Street Journal investigation found is perhaps the deadliest home in the country, with 101 Covid-linked deaths.

At Holyoke Soldiers' Home and Menlo Park, the deaths represent about a third of each home's residents.

The federal Department of Veterans Affairs provides funding to states to manage the facilities, totaling $1.17 billion last year for the care of around 20,000 veterans a day.

Many veterans homes faced staffing shortages and a lack of tests and protective gear early in the pandemic, like other long-term care facilities. Health-care officials say state-run facilities are, in addition, chronically understaffed.

Residents at nursing homes are already at higher risk of Covid due to their age, medical needs and close living quarters. Residents of veterans homes are even more vulnerable to the virus, which is more likely to kill men . While two-thirds of nursing-home residents overall are women, those in veterans homes are predominantly men.

The Covid-19 death toll linked to long-term care facilities overall in the U.S. has surpassed 110,000, representing more than 37% of the nation's known deaths from the virus, according to a Journal tally.

Veterans homes fall into a regulatory crevice where the usual oversight of nursing homes doesn't always apply. Many facilities that faced deadly outbreaks, including Bill Nichols and the Holyoke Soldiers' Home, don't participate in Medicare and therefore aren't overseen by the nation's main nursing-home regulator, the U.S. Centers for Medicare and Medicaid Services, or CMS.

For those homes, the federal Department of Veterans Affairs is effectively the only national regulator charged with ensuring the facilities provide quality care. The VA conducts annual inspections of all state-run homes through contractors. Veterans homes that do receive Medicare are also inspected by CMS.

After the pandemic hit, CMS replaced its routine inspections for ones focused on infection control. Those outside its control were exempt. Those facilities also weren't required to report cases and deaths to the Centers for Disease Control and Prevention, unlike homes overseen by CMS.

The Government Accountability Office in a July report criticized the federal VA's oversight, charging that it allowed inspectors to cite some failures as "recommendations" over the years and that the agency didn't always track whether nursing homes fixed the problems. The VA said at the time it had taken steps to address the issue.

When asked about the agency's oversight, VA spokeswoman Christina Noel said in a written statement: "Individual states—not the federal Department of Veterans Affairs—are responsible for the operation and management of state-run Veterans homes and any problems that arise within them." She referred questions about the homes to state-level officials.

State officials have said they did everything possible to protect residents with the knowledge and resources they had available at the time. "It's something we've never seen before," said Bob Horton, an assistant commissioner at the Alabama Department of Veterans Affairs.

The VA has recently deployed additional doctors and nurses to state facilities, but the outbreaks continue. Missouri officials have announced that more than 135 residents died of the virus at several of the state's veterans facilities between September and this month.

Bill Nichols in Alabama has been cited by state public-health inspectors for deficiencies in past years, including infection or hygiene issues in 2019, 2017 and 2016. An inspection from August 2019 included two deficiencies: verbal abuse, resulting in an employee fired, and a quality-of-care issue involving an employee who didn't administer medication to a resident. The resident was subsequently hospitalized.

Once the pandemic arrived, family members of residents said Bill Nichols was slow to identify residents who became sick with the coronavirus, with testing delayed by national shortages.

Family members said Bill Nichols didn't sufficiently separate residents who became ill, putting everyone's health at risk. Some family members said the home didn't update them on residents' conditions, despite repeated phone calls, and that when testing results did come in, they weren't notified quickly—or at all.

Clarence John Hill Jr. didn't know his father, a resident at Bill Nichols, had Covid-19 until the bill from the funeral home arrived. The diagnosis came in the form of a line item: an added fee to transport someone positive for the disease.

His father, Clarence John Hill Sr., had died on May 5 at the home, at age 95, and the news came as a shock.

"Why did it have to happen like this?" asked Mr. Hill. "We didn't even have an opportunity to even say, 'I'll take the chance of catching Covid myself. Let me see my father before he passes away.' "

Scott Hurst, a regional vice president for HMR of Alabama, Inc., the private contractor that operates the facility on behalf of the state, said the home promptly reported Covid-19 cases and related deaths to relatives and caregivers, pending a determination from the Alabama Department of Public Health. He said the facility separated residents as best as it could.

"The staff at Bill Nichols State Veterans Home has been working tirelessly and with the support of so many others caring for our country's veterans during this pandemic," he said. "While we are blessed to have helped many recover, we have also had heroes who have succumbed to this illness."

The virus hits

Bill Nichols, one of Alabama's four state-run facilities for former service members, is in Alexander City, known for drawing fishers and tourists. Securing one of the 150 beds in the home, which has two courtyards and widescreen TVs in the dining rooms, often meant waiting for months.

Its usual roster of activities and visiting hours came to a halt when the facility closed down March 12 as the outbreak grew. Administrators monitored the staff and turned away an employee with symptoms on March 30.

The home's first resident tested positive on April 8, said Mr. Hurst.

Cases soon appeared on different floors. On April 18, the governor sent in the Alabama National Guard to spray down rooms, offices and common areas.

Herman Hackworth, 74, died four days later in a memory ward on the fourth floor after exhibiting symptoms of Covid-19, his widow, Annie Kynard-Hackworth, said.

They had met five decades earlier, when the 24-year-old rifle infantry marksman had just returned from his time in Korea along the DMZ. He was the son of family friends, and he cut a tall, handsome figure to the 15-year-old Annie.

They started dating after she turned 18. Marriage and three children followed. Mr. Hackworth worked for decades for General Motors, while Mrs. Kynard-Hackworth became a nurse.

In his later years, Mr. Hackworth's behavior became erratic. One December, Mrs. Kynard-Hackworth prepared Christmas dinner early because she was working through the holidays. She came home from work one day to find he had thrown out all her food in a fit, having forgotten where she was.

"He said, 'The next time you go out and stay out all night, you better not come back home,' " she said. "I just broke down. I just sat in the closet and cried."

The diagnosis came soon after: Lewy body dementia, caused by a buildup of proteins in his brain. He entered Bill Nichols in 2019.

One late April morning, Mrs. Kynard-Hackworth got a call that her husband had been sent to the hospital after having trouble breathing.

She spent a few hours calling the floor repeatedly for more information, she said. She got a call from a nurse that afternoon, when he was back at Bill Nichols, suggesting she come see him.

At Bill Nichols, Mrs. Kynard-Hackworth donned protective gear and went with family members to her husband's floor, where she heard wheezing coughs, she recalled. Zippered partitions divided the floor in two.

"The right side where Herman was, these people were supposed to be asymptomatic. They weren't supposed to have any problems," she said. But as she made a right turn toward her husband's room, she saw he was in respiratory distress. His roommate in the same room was also coughing.

"We knew. We knew it was Covid," said Mrs. Kynard-Hackworth. "I feel like I was deceived until the day I went and saw for myself."

The next day, when Ms. Hackworth angrily called an administrator, the official acknowledged the veteran had tested positive for coronavirus. Mr. Hackworth died later that afternoon.

Mr. Hurst, the company spokesman, said the home "consistently communicated positive cases of the virus with families" during the crisis and had done everything it could to separate Covid patients from other residents.

Some self-identified employees of Bill Nichols complained in Facebook groups of insufficient personal protective equipment and having to wear the same gowns when going from room to room.

Mr. Hurst said the facility gave staff the protective equipment they needed.

Camaraderie

Family members of Clarence Windell Givens said that they learned he had Covid-19 from the workers who took care of him, whom they had gotten to know during their visits, before they officially heard from the home.

A former tank commander for the Army's 9th Infantry Regiment, Mr. Givens often recounted his memories of serving two years in the Korean War during their childhood, his sons said. How days would turn dark with enemy fire. How he was once nearly fatally struck by a mortar round.
Mr. Givens, who had vascular dementia, had moved into Bill Nichols last year. He had a regular checkers buddy and another veteran with whom he'd eat meals and swap stories.

"He loved to talk about military stuff," said son Terence Givens, 61. "We figured with him being in a vet home, he could talk to the other vets that were there."

His sons feared they could catch the virus and spread it to high-risk family members if they came to visit. They tried to talk to him over video calls, but the home wasn't always able to set it up. "They didn't seem to have the time," said Terence Givens. His father died on April 18.

Bill Nichols said it had made "every effort to respond to the concerns of family members and caregivers."

The state's public-health department reviewed how the facility handled the outbreak, said Mr. Horton, the state veterans official. It found the home acted within the broad guidelines provided at the time by the CDC.

A federal VA review done at the same time cautioned the home needed more training on hygiene and use of protective gear.

Alabama's four state veterans homes began using rapid test kits in mid-November to regularly monitor its employees and residents, Mr. Horton said.

Some relatives still have questions about how their loved ones were cared for at Bill Nichols.

Clarence John Hill Sr.'s daughter, Lisa Hill, said that the VA called to give their condolences a few weeks after their father's passing. When she asked why Bill Nichols staff had never called to give their family the diagnosis of Covid, she said, the VA told her its understanding was she had been called but didn't pick up.

Ms. Hill remembers getting a generic voice mail from Bill Nichols not long before her father died. But when she phoned back, no one knew what the call was about.

The VA, Ms. Hill said, was very apologetic, saying Bill Nichols could have made a better effort to let her know of his diagnosis. The VA declined to comment on individual cases.

The funeral home asked the younger Mr. Hill to immediately make a decision about whether to cremate his father. He chose to embalm his father so his children and grandchildren could see him one more time.

"He died alone and the next time we saw him he was in a box," Mr. Hill said. "To fight for this country and you treat them like this. How? How can that be right?"

Christopher Weaver, Lisa Schwartz and Jon Kamp contributed to this article.