On Thursday, March 12, Kenneth Green complained to his brother about some pain in his back.

The 85-year-old had dementia and lived on a special floor at Plantation Manor Nursing Home in McCalla but enjoyed good physical health and frequent visits from family. He still recognized his grandkids and great-grandchildren, laughing and joking with them during a visit in early March.

His health took a sharp turn on Monday. That morning, he choked on his juice, said his granddaughter, Dena Marshall. The nursing home said he appeared to be struggling to breathe. That afternoon, they transferred him to the hospital, where he was admitted to the ICU.

Marshall said by then he had pneumonia and kidney failure. Marshall worked as a nurse in the hospital where he was admitted. She donned a mask and gown for protection and held Green’s hand as he died on Tuesday.

It took several days for a COVID-19 test to come back positive. Green may be one of the earliest people in Alabama to die after contracting COVID-19, which has now taken the lives of 16 people living in nursing homes and assisted living facilities, according to the Alabama Department of Public Health. Due to privacy concerns, it’s difficult to verify cases of coronavirus, and Plantation Manor did not respond to requests for comment.

For Green, the end came quickly. Marshall said the home should have seen it coming.

“You don’t get double pneumonia and kidney failure in 24 hours,” Marshall said. “Why didn’t they contact the family when he started having breathing problems earlier in the day?”

Early warnings

It didn’t take long for COVID-19 to show up in nursing homes after the first positive U.S. case. A rash of influenza-like illness swept across a suburban Seattle nursing home in early February. By the time the first tests came back positive for COVID-19, dozens had been infected.

That first outbreak of COVID-19 infected almost 200 people and killed more than three dozen, according to health officials. Investigators later found that staff members unwittingly spread coronavirus from one patient to the next, and into other facilities where they worked.

“It hit first in the nursing homes and it will last longer in the nursing homes,” said Joe Perkins, a spokesman for nursing home operator NHS Management.

Brandon Farmer, president of the Alabama Nursing Home Association, said his members have watched this play out in other states. Hundreds of residents in New York nursing homes have died from the virus. Investigators found 17 bodies in a New Jersey nursing home overwhelmed by illness. And in California, staff members refused to work, forcing the evacuation of a nursing home hit with an outbreak.

“We certainly are making preparations to try to prevent what has happened nationally,” Farmer said.

Nonetheless, COVID-19 has continued to spread in Alabama, from two cases in two Jefferson County nursing homes in mid-March to hundreds of cases in 54 different homes in 30 counties, almost a quarter of the state’s total. The Alabama Department of Public Health said 469 residents of nursing homes and assisted living facilities have tested positive for the virus.

Read more about COVID-19 in Alabama

Perkins said it’s extremely difficult to keep the virus out. One of their nursing homes, South Haven Health and Rehabilitation in Hoover, found 27 COVID-19 positive residents and 19 staff members when it tested everyone inside the building. More than a dozen had no symptoms.

“This virus is insidious,” Perkins said. “As long as it exists outside the nursing home, there is a chance it will come in with a visitor, with a staff member, with a delivery person, and it will spread.”

“This is a battle”

Containing it once it gets inside can be difficult. Nursing homes have struggled to obtain protective masks and gowns needed by staff.

“A resident that tests positive and remains in the building, they are immediately on full isolation,” Farmer said. “Any person who enters that room must have the full PPE on, the masks, gloves and isolation gowns. On average, a caregiver interacts with them 22 times over 24-hour timeframe. Multiply that and you can see how quickly they can go through it.”

Unlike large hospitals, nursing homes usually have little ability to sterilize and reuse equipment. Perkins said nursing homes have had to pay a premium to obtain masks and gowns that are in short supply all across the country.

“You end up finding whatever vendor wherever you can and you are at their mercy for their prices,” Perkins said.

During the first few weeks of the outbreak, nursing homes struggled to get test results from backlogged laboratories. That left them blindfolded as they tried to isolate and contain outbreaks.

“For the longest time, skilled nursing patients and skilled nursing employees were not considered priority one,” Farmer said.

Perkins said it absolutely critical to determine which staff and residents have the virus.

“Here’s the biggest obstacle any of the facilities face, and this is a battle, this is an absolute war,” Perkins said. “25 percent of people who contract this virus show no symptoms, but they can spread it.”

Families in the dark

Alabama only publishes the total number of positive cases and deaths for all nursing homes and assisted living facilities. Some facilities announce cases publicly, but others don’t – leaving families frightened and bewildered as information trickles out.

Family members have reported hearing about outbreaks from the media before the nursing home reached out. Or not hearing anything at all.

Jewell Emerson, pictured here with her grandson, lives in a nursing home battling an outbreak of COVID-19

Rick Emerson’s mother, Jewell, lives at the Marion Regional Nursing Home in Hamilton. Several nurses there have reportedly tested positive for COVID-19, including one who died. A few residents recently died and Emerson said he was told 12 tested positive. But administrators at North Mississippi Health Services, which runs the home, have made few public statements about the situation.

Emerson said he has heard that many residents might be infected, and that nurses worked while they were sick. So far, he said the owners have not been up front with families.

“I can’t verify the information I receive,” Emerson said. “I don’t have the confidence to believe what they are telling me is true.”

A letter from North Mississippi Medical Center-Hamilton acknowledged COVID-19 cases but didn’t provide a number of positive tests or deaths.

“We have had employees, patients and nursing home residents test positive for COVID-19,” it read. “We have mourned those who lost the battle with this disease in our community.”

After Jewell Emerson tested positive for COVID-19, her son consulted a lawyer who helped him draft a letter requesting specific information about her care. The 93-year-old has several underlying health conditions and is susceptible to complications from the virus. Emerson said the nursing home never replied.

Teams from the Alabama Department of Public Health investigate positive cases at nursing homes, but they have not published any findings about how the illness is spread inside facilities.

National Guard deployed

Members of the Alabama National Guard have been deployed to disinfect nursing homes and assist with staff training. In addition, nursing homes and hospitals have been working together on a plan to create alternative sites where COVID-19 positive residents could recover.

The nursing home association objected to a March request to send patients back to nursing homes after they were discharged from hospitals, arguing the plan endangered residents who hadn’t been infected.

The arrival of COVID-19 also exposed some of the struggles nursing homes already had with staffing. Many nursing assistant jobs have low pay and can be difficult to fill. As staff members become sick and unable to work, care can suffer.

Farmer said nursing homes have been able to fill the gaps with nurses furloughed from hospitals and medical centers. When elective medical surgeries resume, those positions may become more difficult to fill.

“The workforce shortage is a primary concern within a nursing home facility,” Farmer said. “When they start showing symptoms, we immediately send them home and isolate them for testing. It can create staffing concerns.”

Farmer said the growth of coronavirus cases has not slowed in Alabama nursing homes. The association is encouraging all facilities to test as many staff members and residents as possible to determine which ones carry the virus.

“The virus, as reported, is extraordinarily contagious,” Farmer said. “Our residents are the most vulnerable of our population as a whole. It’s a crisis on day one for us as far as trying to isolate those residents.”

Nursing homes have taken different approaches to testing. Some require all staff members and residents to be tested, while others only require it for those who were directly exposed.

Before the state ended visitation, Emerson said nurses and Marion Regional Nursing Home didn’t wear masks and gloves. He said he understands how overwhelming it must be to deal with such an aggressive virus, but says the home should have done more.

“It’s a disease that people weren’t prepared for,” Emerson said, “but that doesn’t excuse them from not handling it properly.”