By Jason Pohl, The Sacramento Bee, October 29 2020
The virus seemed to find a way in no matter what Dawn Calkins did. As the director of nursing, she’d spent months in masks sterilizing, scrubbing and worrying. She needed her own quarantine plan, just in case.
“I’m trying to plan ahead and was wondering,” she asked her friends on Facebook, “… would anybody lend or rent me an RV/something similar that could house me near work/home? Any leads? Much appreciated.”
This was in April, a lifetime ago in pandemic time. Calkins, who is 46 and lives in Rocklin, was getting anxious about her Sacramento nursing home.
“It looks like this time will be coming for me sooner than later,” she wrote.
Calkins and the head of housekeeping at Saint Claire’s Nursing Center, Lina Young, together took every step possible to keep the virus away. The best offense was a good, sterilized defense. When Young described her work, it was almost like a mantra: “Every doorknob. Every light switch. Every bed. Every call-light button.”
Their efforts would prevail against a virus that ricocheted from city centers to rural outposts, top-tier eldercare facilities to low-ranked nursing homes. Spring turned to summer without a single case. Saint Claire’s survived the pandemic’s opening months unscathed, a remarkable achievement. Dr. Olivia Kasirye, Sacramento County’s public health officer, in late-August told a reporter the success at Saint Claire’s had given her “hope.”
As other facilities scrambled, Calkins was painfully aware that her months of prevailing amounted in part to luck. She watched as elderly residents in nursing homes across the country died by the tens of thousands.
And then the dam broke at Saint Claire’s.
The Sacramento nursing home is now part of a tragic national story as cases of the new coronavirus are again surging. Nursing homes, largely corporately owned and many of them chronically mismanaged, have borne the brunt of the pandemic, home to some 38% of more than 220,000 coronavirus deaths in the U.S. Front-line employees working in facilities like Saint Claire’s have had to confront state-level edicts intended to address the country’s failure to control this public health crisis.
Calkins and Young have spoken with The Sacramento Bee since early May about how they kept COVID-19 away from their nursing home, which had been all-but-written off early in the pandemic. The picture that emerged through hours of interviews and late-night text messages is a mosaic of front-line employees struggling against a remorseless virus and navigating confusing state mandates with little support from the outside world. It was a lonely fight.
When California shut down, Calkins scrambled. When state and federal health care technology faltered and information came in confusing bursts, she stumbled but generally succeeded in meeting the moment. When California rushed to re-open, she waited skeptically, anxiously.
And when a South Sacramento neighborhood experienced one of the highest rates of spread in the county, Saint Claire’s luck ran out. Like the wildfires choking the air outside Saint Claire’s at the time, the virus found a foothold, burned through resident rooms and spread down the halls.
After months of watching COVID-19 batter other facilities, Calkins found herself working 15-hour shifts, living out of a hotel room, missing her family. Batches of test results soon came back positive, including her own.
All the preparations couldn’t prepare her for the cruelty that would accompany the outbreak that would ultimately cost Calkins her job.
“You see all these signs. Nurses, healthcare heroes and all this,” Calkins said earlier this month. “But when it came down to it, we were like Public Enemy Number One. And it was a horrible, horrible feeling.”
CLEANING A STAINED REPUTATION
Saint Claire’s Nursing Center is a tan-colored one-floor building off Florin Road and Stockton Boulevard in South Sacramento. Single-family homes and apartment complexes surround much of the rectangular complex, with a dried-up field of weeds on the fourth. Years of deferred maintenance left paint faded and a parking lot in disrepair.
The facility’s age shows in the long, beige-colored hallways occasionally adorned with patterned wallpaper, faux-wood flooring and dated decor. With 53 rooms for up to 99 residents, Saint Claire’s is one of Sacramento’s larger nursing homes.
It is in one of the city’s lowest-income brackets, according to census data. About 25% of residents in Saint Claire’s ZIP code live below the poverty line and median household incomes are about $45,000 annually, making it one of the more economically depressed areas in Sacramento County. It’s also one of the most diverse. One-third of the people living there are Hispanic, a quarter are Asian and one-in-five are Black.
Saint Claire’s has long been a microcosm of its surrounding community, home to some 88 residents in March who were Black, white, Asian and Latino. Many had resided at Saint Claire’s for years and spoke all manner of languages, from Spanish and Greek to Cantonese and Punjabi.
It might easily have been written off at the start of a pandemic that disproportionately sickens and kills lower-income families and people of color. Saint Claire’s was presumably ripe for disaster for other reasons, even absent the coronavirus pandemic.
State inspectors over the years have repeatedly cited the facility for its failures, earning it a one-star rating on the federal government’s website and a reputation as one of the worst facilities in Sacramento.
Indeed, it was among the most problematic nursing homes in California, according to public inspection reports. In the spring of 2019, a resident was hospitalized with a potentially deadly respiratory infection possibly caused by dirty water. Employees routinely failed to clean blood-pressure cuffs, records show, and an inspector said unsanitized testing machines might have transmitted bloodborne pathogens.
But new operators from Kalesta HealthCare Group took over last fall. They immediately went to work reinventing Saint Claire’s.
The facility was set for a long-overdue $1 million facelift this spring. Its history of deficiencies and its troubled reputation were a “stain” on the facility’s past, the new owners said in a March email to The Bee. Everyone was working to rebrand the troubled facility with a new name: City Creek Post Acute.
Kalesta overhauled the staff and looked to “infuse a culture that breeds a tangible feel where residents, families and hospitals want to send their loved ones and patients to,” said Ryan Williams, Kalesta’s co-founder. Last October, they brought in Calkins and charged her with hiring a new team of nurses and revamping the facility’s clinical work.
The company touted its hiring. “We have already assembled a team that is second to none,” Williams said, adding that personal connections “allowed us to attract and hire some of the best in skilled nursing.”
Calkins relished the challenge. She became interested in nursing when she pulled her grandfather out of a facility about 15 years ago. He’d been covered in feces when she went to visit one day, and she knew she could treat him better. She learned to tend to his feeding tube and handle his insulin. Being a caregiver came naturally, she said, and after he died, she decided it was the kind of work she wanted to do full-time.
About seven years ago, after graduating from nursing school and spending a stint working in the insurance and billing department for Dignity Health, Calkins started working in nursing homes. When the Saint Claire’s job came up she was eager to spearhead new nurse training, ramp up coverage and restore rapport with local hospitals.
Calkins wanted to make the facility one where employees would want to work for the long term.
She planned to lead by example. She described herself as a “hands-on” director of nursing, the kind of boss who works on the floor, hangs IV bags and chats up residents.
“I’m not a good meeting person,” she said in the spring. “I like to be out there being a support system for the nursing staff and just making sure they stay up to date.”
The start of 2020 was on pace to be a banner year at Saint Claire’s.
‘WE NEED TO STOP THE VISITORS’
Calkins remembers March 19 with clarity. The facility’s administrator, Kenneth “Rusty” Blankenfeld, walked out of his office with an announcement: “We need to stop the visitors.”
Sacramento public health officials had issued a stay-at-home order, sending shockwaves across a community that was already adjusting to business closures and empty store shelves. Until then, nursing home regulators had been discouraging visitation. The new orders changed the game.
“Some of these people, you can’t explain to them why they can’t see their loved one because they won’t understand,” Calkins recalled. “They just know that one day their loved ones are there and the next day they’re not.
“For me, it felt traumatic.”
Kalesta’s rebranding projects went on hold. The staff focused on cleaning. Calkins and Young, the housekeeper, went to work preparing a severe break in routines — the bedrock for many nursing home residents. Everything was thrown into disarray.
Before the pandemic, days were punctuated by communal meals in the dining room. A constant stream of visitors came and went, bringing with them special ethnic dishes, clean clothes and other items to make their loved ones feel more at home. Though far from perfect, staff and residents tried to make a sense of community, whether sharing a television or going to art classes. There was almost always a bingo game.
All of that evaporated in the spring. Communal meals were too risky. Visits were restricted to window-separated meetings. Groups had to be masked and physically distant. Bingo would have to wait.
Increasingly, the only constant was Young’s team tripling the number of times in a day they deep-cleaned resident rooms.
“We have this form of respect for them,” said Young, who’s worked at Saint Claire’s for nearly 30 years since moving to Sacramento from Jamaica. “We have to protect them and to help them and to assist them in whatever way we can.”
Calkins and others who work in nursing homes watched in the early days of the pandemic as all eyes focused on hospitals. A limited supply of masks, gloves and ventilators fueled a mad dash for equipment. Hospitals were adjusting surge capacities. Meanwhile, nursing home employees prepared for what they feared would become a grueling, endless response.
California’s hospital workers became the symbol of heroism during the pandemic. But nursing home employees found themselves fighting just as hard.
As Saint Claire’s staff adjusted to new routines, scenes of overwhelmed nursing homes, sick people and blame unfolded nationwide. Gov. Gavin Newsom’s noon briefings became a fixture — a new routine — with TVs echoing through the hall every day at lunch.
When family members came to visit, the staff would escort them to a window in the lobby. There, they could press their hands to the glass, the closest thing to contact they would have indefinitely.
TENSION AND DREAD
Nervous laughter is Calkins’ way of combating stress. California’s dizzying, slapdash pandemic response and new directives had Calkins laughing more than usual through the spring. Sometimes the health department orders kept her up all night.
One in May required facilities to complete a COVID-19 mitigation plan that revamped existing COVID-19 protocols. Facilities, the order said, needed to work with their own labs and county governments to build a plan to test residents and staff. It was a tall order at a time when testing was still a fraught patchwork for labs in California and across the country.
The same document spelled out a 300-plus word requirement for who had to wear what type of mask in what scenarios, all the while acknowledging supply chain limitations still plagued facilities’ ability to get respirators at all.
Rules about where to isolate residents suspected of having COVID-19 — in their room or in a special ward — were in flux. And in the past, staff needed to take vital signs on every resident once a day. By spring it was twice daily.
Small changes led to a cascade of confusion at nursing homes across the state.
“They word things sometimes where it’s like wait, didn’t they just say this but now they’re saying this? It kind of takes a few times to go over these letters to literally decipher what they want,” Calkins said.
She printed them out and read them until 1 a.m., pausing only occasionally to tend to her son. “It’s never a smooth process when I’m at my house,” Calkins said between anxious laughs.
She deciphered the letter until 1 a.m. and then headed back to work by 7. More vital checks. More questions from employees who might’ve just been getting used to the way things were. And then there were the residents. The state was requiring them to wear face coverings when they left their rooms, a significant challenge for some.
“There’s going to be some that will gladly wear them but there are going to be residents that have COPD that can’t tolerate the masks or dementia residents that don’t even understand what we’re putting on their face,” Calkins said in May.
“I just feel a little overwhelmed.”
At one point, state and local governments tried to integrate its data reporting systems, with daily requirements to update case counts or run the risk of fines. As the nursing director, Calkins was the one to submit the daily report. But technology systems were repeatedly plagued with login errors, dead hyperlinks and crashing websites.
One Saturday, California’s reporting website went down right before the noon deadline.
“I was really panicking,” Calkins said.
She reached out to a former coworker at another nursing home. He had a functioning link to a login page and forwarded it in a text message. It was like a key to a secret passage, only the passage was a government-run data portal.
“He was like, ‘This is to use for today ONLY.’ ”
The link worked, she submitted her information on time, and passed it over to other facilities in her network.
“We are good,” Calkins would write to a reporter in text messages that often included the “nervous” emoticon. On May 12, Calkins’ didn’t hold back about the government’s reactive and at times bumbling response to the crisis afflicting nursing homes like hers.
“I think it did not flow smoothly. I don’t think we were prepared to deal with something like this and that’s why everybody’s flying by the seat of their pants right now,” she said.
“And I think we will be moving forward.”
NURSING HOMES BRACE FOR COMMUNITY SPREAD
Calkins and Young grew used to the start-and-stop directives, technical problems and recrimination that surrounded the battered nursing home industry. By the end of May, the off-balance stride felt normal.
When California changed course on Memorial Day weekend and the state raced ahead with plans to reopen in-person dining, offices and shopping, both women agreed that it was too much too soon, and at a potentially perilous cost.
“We still have to protect these patients here and kinda make that our main goal and concern, of doing what’s best for them,” Young said, describing conversations she’d had with her staff. “So we understand, ‘No, you’re not gonna go party tonight because I’ve gotta come in here and take care of these residents tomorrow.’ ”
In mid-May, when California began easing some pandemic closures, the thought of going anywhere barely crossed Calkins’ mind. The stakes were too high, she said. If she got sick, she’d be unable to lead the team. And if she infected anyone, it might be impossible to stop an out-of-control outbreak at Saint Claire’s.
“If my family gets sick, then that puts me at risk of bringing something into my facility,” she said. “I get people wanting to be out there and get back to work and they have to. I know that. It’s just, where’s that happy balance of keeping people safe and allowing them to still survive?
“I don’t know that there is a happy balance with this. … I hope there is.”
Calkins’ husband, who works in construction, was largely out of work for several months because of the shutdowns. And their 8-year-old son has been struggling. Springtime homeschooling was difficult. Summer camp eased some of the pressure.
“He’s more of a weekend school kid. And some evenings,” Calkins said. “But there’s just some evenings that I can’t keep up.”
By June 1, the death toll from COVID-19 Sacramento County had reached 58. There were roughly 1,400 confirmed cases. By the end of the month, the death toll would rise toward 70, with case counts in the county surpassing 3,000.
Calkins and Young read the headlines and saw the numbers. They watched as protests demanding the state reopen transitioned to marches about the police killing of George Floyd.
By then, the virus was spreading in the community, increasing the chances that someone would carry it into the facility. At the same time, the California Department of Public Health opened an avenue for in-person visitation in a small number of facilities.
Basically, if a nursing home hadn’t had any positive cases, it could allow a designated visitor for each resident. To Calkins, that seemed backward — if tightly closing the door had kept Saint Claire’s pristine, why open the doors because it had a pristine record?
“It’s so frustrating to me. You just shared these hundreds of thousands of case numbers and then simultaneously you’re like, ‘Have some visitors. Now that we have hundreds, thousands of cases, now you can have one visitor per resident,’ ” Calkins said.
Around that time, an on-call nurse who mainly worked at another facility tested positive for COVID-19. She hadn’t been to Saint Claire’s for days, but the state data needed to reflect the infection nonetheless.
By August a wave of COVID-19 was poised to crash into Saint Claire’s. The facility had held off the disease for six months.
AN OUTBREAK, AND A TEST
There were 644 new COVID-19 cases in Saint Claire’s 95823 ZIP code in August, when the first cases were detected at the facility. The immediate area had one of the highest new-case rates in the county — the one-month tally accounted for nearly half of the ZIP code’s 1,500 cases detected since the pandemic began, a Sacramento Bee review of positive tests found.
One resident went to the hospital for pre-surgical screening and tested positive for COVID-19.
“We’d waited so long,” Blankenfeld, the administrator, said in an interview this month. “It was almost like gosh, maybe we’ll make it out of this.”
Then, a few days later, a dialysis patient came back positive, as did another on-call staff member. The state required weekly tests across the building, so for a while, it was unclear how widespread the infection might be.
The first batch of positive results quickly followed. That was when it got real, Blankenfeld said.
One by one, staff wheeled residents into the COVID-19 unit to begin a 14-day quarantine. The rapid spread quickly overwhelmed the exhausted employees scrambling to keep up. Then the workers began testing positive. Asymptomatic ones could tend to sick residents on the rapidly expanding COVID-19 ward, but many had to stay away altogether. And then, Blankenfeld said, some employees who hadn’t contracted the disease canceled their shifts for fear of being exposed.
Families clamored for information. Calkins knew the pressure was on.
As the person responsible for all clinical decisions, she said she spent 15-hour days at Saint Claire’s and stayed at a nearby hotel so as not to risk exposing her family. She cried a lot.
“You feel helpless,” she said. “My nursing team was scared, a lot of them were so scared and apprehensive. I felt like I didn’t know what to say or do to comfort them.”
Then the headaches started. Stress and lack of sleep, she convinced herself before taking a COVID-19 test and waiting. Calkins remembers lying in bed on Sept. 24, still with those headaches, when the results landed in her inbox: Positive for COVID-19.
First, she felt relief. It meant, as long as she wasn’t too sick, she could work in the COVID-19 ward with people who’d also tested positive and help fill some of the staffing gaps. She could show them that even COVID-19 wouldn’t stop her from leading by example.
That thought quickly faded, though. She was sent home, where she holed up in a separate room, isolated from her family still, and worked remotely on paperwork as much as possible. Her quarantine plan hadn’t gone at all like she’d envisioned when she wrote that Facebook post in April.
Despite the separation, her son developed a sore throat. Headaches and fatigue quickly followed, just like her own. She felt guilty, having likely been the reason he got sick. He developed even more symptoms and at one point lost some of his taste. He didn’t sleep for two nights, she said, and in the mornings he’d complain that his bones hurt.
After a few uncertain days, both began to feel better. “I kind of felt relief,” she said, thankful neither of them had any more serious complications like so many others have. “OK, we’ve had it. And we got through it.”
By Oct. 7, she was ready to return to work.
SEPARATED, RECOVERING, MOVING ON.
Calkins was expecting a call from Blankenfeld the day before she was set to go back to Saint Claire’s.
She just didn’t anticipate how it would go.
As they began talking, Blankenfeld brought up an email Calkins sent to him early in the crisis. “Every morning I wake up, and I have to choose whether I’m going to be a good mom today or a good DON (director of nursing),” she recalled writing.
She said she made it clear that she wasn’t resigning but merely sharing frustrations during a difficult time.
“He never let go of that,” she said.
Their conversation meandered a moment longer. “I finally said, you know, this is not sounding like it’s about me not wanting to come back. This sounds like you not wanting me to come back.”
“I was devastated,” Calkins said. “I mean, I had to hang up at one point with him because I was hyperventilating. I was crying so hard because I just honestly wasn’t really absorbing, is he really saying this right now? He doesn’t want me to come back?
“I relocated my family and my home, and my husband lost his job, and all this sacrifice I felt like I made to work and be part of this team and help develop this building and then just to be like, ‘No, we don’t want you anymore…’
She trailed off, still processing the change.
“He was a friend.”
Blankenfeld declined in an interview to describe the phone call or the terms of Calkins’ “separation.” He did say the work and stress were “burying” her and that her departure “was kind of a mutual understanding, some time away to take care of what’s most important.”
Williams, the Kalesta co-founder, likewise declined to talk specifically about Calkins’ separation from the company, saying only that there were preparations related to infection prevention and control that might have been done differently. “There were things that we would like to have seen preemptively stronger, but we also recognize what this facility was digging out of.”
By mid-October, the outbreak was subsiding. Only a handful of positive cases were detected as October came to a close, according to state data. At least 63 residents tested positive, as did 39 employees.
At least eight residents from Saint Claire’s died after contracting COVID-19, Blankenfeld said. After months of being a success story and watching from the sidelines as residents at Kalesta’s three other nursing homes got sick, the outbreak at Saint Claire’s ended up being the worst by far.
“My license is on the wall,” Blankenfeld said. “At the end of the day, the buck stops with me.”
‘I MISS HUGGING THEM’
The renovations have gradually resumed at the nursing home, which had a name change certified with the state partway through the pandemic — the embattled Saint Claire’s is now called City Creek Post Acute. Outside the facility today, there’s a sign that says, “Heroes work here! With the courage to do whatever it takes to serve our seniors.”
In an interview a week after the tense talk with Blankenfeld, Calkins quipped about how restful it was to get through a night without being awoken by a phone call from Saint Claire’s.
Calkins said she has had more downtime in the past few weeks than she has in years. (She paused midway through an interview to say goodbye to someone at another nursing home where she was helping with paperwork. A week after losing her job, she’d already started working again.)
Her biggest fear is that her nursing team would think she walked out on them. She wants them to know she did not.
“I had a lot of residents that I spent time with,” Calkins said Tuesday from her kitchen table, pausing to wipe tears from her eyes. “A couple of them passed away. And you know, I miss hugging them. I miss holding their hand and comforting them.
“I love the residents, and I loved working with that team. I miss them and I do wish them good things.”
She said a story from midway through the crisis when she was at her lowest point, will remain with her long after she begins full-time work again and the pandemic eventually ends.
One night, when she was working on the floor, she received a call from a resident’s daughter who was upset. The caller had previously used Calkins as a verbal punching bag to vent frustrations about the lockdowns and the pandemic’s toll. Compassionate callers were hard to come by. Calkins was braced for a berating.
The woman took a different tone, Calkins said.
“She prayed with me, and for me, on the phone,” Calkins said, stifling a characteristic nervous laugh. “And I found myself just sitting at the nursing station, just bawling.
“Because I was so touched that someone cared.”
Jason Pohl is an investigative reporter at The Sacramento Bee covering criminal justice and government accountability. He joined The Bee in 2019 and spent the year investigating conditions inside California’s county jails, in collaboration with ProPublica’s Local Reporting Network. He previously reported for newspapers in Colorado and Arizona, and is an avid backpacker and trail runner.