On Oct. 9, an employee in the business office at Tieszen Memorial Home in Marion, South Dakota, tested positive for the coronavirus. She was sent home immediately, but three days later, a nursing aide and a housekeeper both tested positive.
Marion, a town of fewer than 1,000 residents, was experiencing a sharp uptick in cases — what scientists call community spread. It became more and more likely that the nursing home’s employees had become infected while, for example, grocery shopping.
On Oct. 16, COVID-19 killed its first Tieszen resident. At that point, about 13 of the home’s 55 residents had tested positive.
Nursing home administrator Laura Wilson called the days that followed the worst of her career.
“You almost feel like a battle zone,” she said. “We said, ‘You know, right now, we just need to survive.’”
South Dakota Gov. Kristi Noem, a Republican, has taken a notably relaxed approach to the pandemic. This fall, nursing homes there saw a larger share of their residents die than in any other state.
At Jenkins Living Center in Watertown, 24 residents have died from COVID-19 since the last week of October, according to data submitted to the federal government ― about a fifth of the residents there. Thirteen patients at Weskota Manor in Wessington Springs, or more than a third of its patients, died from COVID-19 this autumn, most of them in one week.
Walworth County Care Center in Selby, a 50-bed facility, saw COVID-19 kill 12 patients this autumn, an administrator said. Overall, more than 40% of South Dakota nursing homes have lost a tenth or more of their patients to the coronavirus, according to a Center for Public Integrity analysis of data from the federal Centers for Medicare and Medicaid Services.
Nationwide, more than 100,000 residents of long-term care facilities have died of COVID-19, according to The Atlantic’s COVID Tracking Project. That figure represents 38% of the nation’s virus deaths in a group that makes up less than 1% of the population.
The federal government has made protecting the elderly a priority, shipping millions of rapid tests to nursing homes across the country. Public health experts spent the first nine months of the pandemic perfecting strategies to keep the virus from spreading in close quarters. But, as researchers have learned, whether nursing home residents die from COVID-19 depends less on what happens inside than outside. Once COVID-19 permeates a town, there’s a limit to what nursing homes alone can do.
And that has made South Dakota an especially deadly place.
A long string of deaths
During Tieszen’s outbreak, the nursing home was eerily quiet. On a normal day, “The Price Is Right” might blare from a room, echoing down the hallways. But when the coronavirus hit, all the residents’ doors had to be closed to try to control the spread.
Before October, Tieszen had pandemic challenges but not mass tragedy. Wilson was forced to hunt for N95 masks on eBay, even though South Dakota is home to a 3M factory that makes them. She relied on her son, who works at Sam’s Club, to buy one pack of disinfecting wipes every day for the nursing home’s stockpile. Back when she was using lab-confirmed tests to screen her staff, she had trouble getting test results back within the time recommended by federal guidelines, as the Sioux Falls lab she had contracted with was swamped. And she says, like always, staffing was a problem: Tieszen told the federal government it was short on nurses and aides every week in October and November.
“You almost feel like a battle zone. ... We said, ‘You know, right now, we just need to survive.’”
Wilson, who has worked at the nursing home for 42 years, said her staff did everything it could during the outbreak. Indeed, Tieszen, a small nonprofit that has earned five stars in the federal government’s nursing home quality rankings, passed three state inspections of its infection-control program between May and November, records show. It received roughly $70,000 in CARES Act incentive payments from the federal government in September based on good performance.
When the coronavirus hit, the nursing home dedicated two of its wings to COVID-19 patients, isolating them from other residents, until so many contracted the virus that they had to stay in their rooms. The entire nursing home, essentially, became a COVID-19 ward. Wilson’s own 85-year-old father tested positive. Nurses worked overtime; Wilson put in 80-hour weeks and hired temporary help.
Staff served residents’ meals on paper plates instead of dishes that might retain the virus. They conducted weekly audits of how often staff were washing their hands. They tested workers and residents at any sign of a sniffle, as well as regularly regardless of symptoms, using equipment shipped to the nursing home from the federal government. They followed up positive rapid test results with lab-confirmed PCR tests.
Despite all of these measures, the virus spread quickly.
The week after Tieszen’s first death on Oct. 16, five more residents died, Wilson said. Among them was 89-year-old Maxine Ortman, a former teacher suffering from dementia whose husband would visit often, before the pandemic, from his home across the street.
The following week, seven more died.
In November, another seven died. They included 68-year-old Larry Johnson, a diabetic and former mechanic whose sense of humor and work ethic drew customers from all over northeastern South Dakota, his family wrote in his obituary.
And they included Randy Wieman, 64. He had Down syndrome, and died a week after testing positive for the virus, said his older sister, Carol Husby. He loved music, dancing and his many nieces and nephews. A normal December would find them celebrating Wieman’s birthday with chocolate cake.
“He would call me every morning to ask if I was up,” Husby said. “Randy was an amazing individual.”
In total, 20 residents died of the coronavirus — more than a third of those living at the Tieszen nursing home — in the space of five weeks.
Tamara Konetzka, a health researcher at the University of Chicago, has been studying the fate of nursing homes in the pandemic since the spring.
Her conclusion: “Nothing much has changed.”
Despite more testing and efforts to hone infection control practices, despite nine months of scientific study of the virus, nursing home residents are still at the mercy of their surrounding communities. “If they’re in virus hot spots, they’re going to be at risk,” Konetzka said. “The idea that we have found the secret to preventing nursing home cases and death is a little crazy.”
And this autumn, nearly all of South Dakota has been a hot spot. For months, the state has ranked at or near the top of all 50 states in new coronavirus cases and deaths per capita in reports issued to governors by the White House Coronavirus Task Force. During one week prior to Thanksgiving, South Dakota had 988 new coronavirus cases per 100,000 residents — more than double the national average. It had 19.6 deaths per 100,000 residents — the worst rate in the nation and more than six times the national average.
The state’s governor, Noem, is widely believed to have national political ambitions. She has proudly shunned strict measures to curb the virus.
“If they’re in virus hot spots, they’re going to be at risk. ... The idea that we have found the secret to preventing nursing home cases and death is a little crazy.”
“Rather than following the pack and mandating harsh rules,” she wrote in The Wall Street Journal earlier this month, “we ask all South Dakotans to take personal responsibility for their health. ... The state hasn’t issued lockdowns or mask mandates. We haven’t shut down businesses or closed churches.”
Many South Dakotans have refused to wear masks or socially distance. In September, Wilson spoke at a meeting of local business owners in Marion and urged them to take mask-wearing seriously. She was met with blank stares.
“When I left that meeting I had basically resigned myself to the fact that I am living in a different world, and they don’t get it,” she said. “I’d be the only person in the grocery store with a mask on.”
Though limiting community spread is the best way to protect nursing homes, researchers said, measures like having enough staff can affect the severity of outbreaks. Here is where the federal government failed spectacularly, experts said.
“What they needed — damn it — they needed money for more staffing,” said Larry Polivka, executive director of the aging-focused Claude Pepper Center at Florida State University. “And they needed all of the [personal protective equipment]. They needed massive testing capacity as quickly as possible in the spring — they didn’t get it.”
Wilson said the South Dakota Department of Health was helpful when she called or emailed with questions. The state continued to inspect nursing homes for infection control practices, and just 14 South Dakota nursing homes were cited by inspectors for inadequate infection control between March and October, according to federal data. The state has a program to recruit retired nurses and doctors to help work in health care settings. The federal government sent a “strike team” to South Dakota in October to help nursing homes tackle the coronavirus, a spokesman for CMS said in an email, and federal officials have offered training and guidance.
But it’s unclear what else, if anything, South Dakota did to help nursing homes weather the brutal autumn. For nine weeks in October and November, on average, nearly a quarter of all nursing homes in South Dakota told the federal government they were short on nursing staff, far more than the 16% that did so nationwide. On average, more than 40% of South Dakota nursing homes reported shortages of aides, more than double the nationwide figure. And 13% of South Dakota nursing homes during that time reported shortages of PPE — roughly the same as they did nationwide.
Policymakers of all stripes, even those who embrace a controversial “herd immunity” strategy and wish the virus to run free through the population, stress the need to protect long-term care residents. Noem has not explicitly endorsed a herd immunity approach but has emphasized that the coronavirus is less likely to harm young people. She has acknowledged that the elderly face greater risks from the coronavirus.
Yet the governor’s spokesperson did not answer questions from the Center for Public Integrity regarding nursing homes or respond to requests for comment. Noem’s health secretary did not respond to a request for an interview. The South Dakota Department of Health declined to answer multiple emails sent by Public Integrity over multiple weeks. The state’s long-term care ombudsman refused through an agency spokesman to answer questions. When pressed, the spokesman said he did not know the reason but was given orders to decline the interview.
Even supposed advocates for nursing homes are reluctant to speak about the toll the coronavirus is taking on South Dakota’s elderly. Two trade associations representing nursing homes in the state declined interviews. One of them, the South Dakota Health Care Association, recommended that a reporter speak to the state department of health instead. Another lobbyist, who wished to remain anonymous to avoid angering the Noem administration, said people fear upsetting the governor’s office, known for its guarded approach to dealing with the media.
The state also waited until September to decide how to spend nearly $600 million in CARES Act funding approved by Congress in March. Noem finally set aside $115 million for nursing homes and other local health providers. But nursing homes had to apply for the funding during an 11-day period in October and meet strict qualifications. Tieszen applied but was not granted funds. Documents from the South Dakota Legislature dated Dec. 7 show that 115 health care organizations applied for the funding, and 47 were approved. But just $1.9 million had been handed out as of Dec. 18. The state is now proposing another grant program to distribute the money to health organizations based on bed numbers.
But for many nursing homes, the money is coming too late to save lives. South Dakota may be past the worst of this COVID-19 surge. New coronavirus cases in the state are on the wane; vaccines are perhaps weeks away for nursing home residents at Tieszen and elsewhere.
All told, the state has lost roughly 1 out of every 10 nursing home residents to COVID-19, according to federal data.
“I don’t understand why people didn’t take it seriously right from the beginning,” Husby said. “It just breaks my heart because it didn’t have to be this way.”
Taylor Johnston and Pratheek Rebala contributed to this story.