Every year, the Sarah Community, a nursing home in Bridgeton, hosts its own Oktoberfest. The event usually lasts for five or six hours, with live music, carnival games, a Kona ice truck and loads of barbecue.
Despite COVID, recreation director Kelly Potter wanted to make it happen again this fall for the residents. As in normal years, they brought in performers. They laid out food. They even set up a beanbag toss and a makeshift bowling lane. There were a few differences, of course — everyone wore a mask, and workers wiped down the bean bags between each game — but Potter said it was the “closest to normal we’ve had in a while.”
Throughout the pandemic, nursing homes have scrambled to create a sense of normalcy in a non-normal situation. As of Jan. 17, nursing home residents have accounted for nearly 52% of deaths in Missouri, despite representing just 4.5% of the total COVID cases. The risk forced most nursing homes to lock their doors to outsiders early on, and confined many residents to their own facilities, and sometimes, their own rooms.
So activity staffers are trying to think outside of the box to keep residents entertained. They’re holding happy hour on roving carts instead of the dining room. They’re bringing musical performers to the window instead of the multipurpose room. And they’re interrupting bean bag competitions with a little sanitization.
The hope, said Tara Powell, the activity director at Bethesda Southgate in Oakville, is that residents “still feel like they have some kind of a purpose, and they still have life happening around them. ... We want them to feel like life and fun is still happening, no matter what's going on.”
At the Sarah Community, staff members begin each day with one-on-ones, going room-to-room, reading books with residents, talking with residents and even giving out manicures. At 9:30 a.m., they broadcast exercise class. At 10:30 a.m., they hold rosary and mass. At 2 p.m., they play a movie. Each week, residents receive activity packets stuffed with crossword puzzles, brain teasers, word searches and coloring sheets to fill their free time.
Like many long-term care facilities, Bethesda Southgate has supplemented these everyday activities with special events, ranging from a hippie dress-up day to an indoor light tour to food truck visits. Recently, they organized a “trip” to "Nashville," where the staff dressed in Western attire and pushed a Nashville-themed cart down the hallways.
Some of these activities have moved to online. Vanessa Woods, the owner and founder at Vitality in Motion, teaches dance classes, like ballet and Broadway-style choreography, to seniors on a screen. Woods said dance not only allows residents to work on their balance and strength, it provides a mental “escape” from the pandemic.
But some mainstays remain.
“Oh they wanted their bingo,” said Kristi Gard, the activity director at Oak Hill in Waterloo.
The size, the location, the makeup of the long-term care facility — it doesn’t matter. Bingo is a staple, regardless of the pandemic. Most senior living facilities have shifted to “hallway bingo,” with residents playing from their doors.
But this wide variety of events isn’t possible for many nursing facilities, said Marjorie Moore, executive director at VOYCE, a St. Louis-based nonprofit advocacy organization for long-term care communities. In actuality, most nursing homes are understaffed — 36.9% of Missouri nursing homes at one point during the summer, according to an analysis by AARP — a problem that has only been exacerbated by the pandemic. At Clinton Manor Living Center in New Baden, for example, they’ve had to move multiple activity assistants back to their original jobs in nursing.
“Unfortunately, in a lot of cases,” Moore said, “a lot of the creative things that family members may want to do, or nursing home staff want to do, get kicked to the curb because staffing in nursing homes is so low.”
Throughout the pandemic, this has often left residents cooped up in their rooms, sometimes with up to three other roommates, and sometimes without a whole activity plan.
“We've seen a lot of depression,” Moore said. “We've seen a lot of people, who went into long-term care with mild dementia get much worse because they're not getting the sort of social interaction that they need to be able to maintain their health. ... It seems like a lot of facilities are really trying. But under a lot of the current conditions, it's really hard.”
Nursing homes have found that the best way to combat loneliness isn’t a fancy party or a special dress-up day. It’s pretty simple: Residents want to be connected with their loved ones.
“I think the biggest missing factor, no matter what we did to try to improve quality of life and promote activities, was family,” said Dr. Angela Sanford, an associate professor of geriatric medicine at St. Louis University and the certified medical director at a nursing home, NHC HealthCare Maryland Heights.
Before the pandemic, Teva Shirley of Glen Carbon visited her mother at Clinton Manor five to six days per week. Now, she mostly speaks to her mother through FaceTime calls, greetings at the window and the occasional face-to-face visit — when permitted.
At Oak Hill, staffers have designed their own indoor visiting area, with plexiglass separating the residents and family members.
Marilyn Kilby, 84, is one of the residents who has used the visitation area. One year ago, Kilby, moved from Carbondale to the Oak Hill nursing home so that she could be closer to her daughter. But when the pandemic hit, she had been there for just a few months. She doesn’t know many people in the facility and, for a while, she couldn’t visit with her daughter. Her glasses aren’t working and she can’t get them fixed. Naturally, she has started to feel “lonesome.”
That is, until Christmas Eve rolled around and her daughter made a reservation to visit. From across the plexiglass, they talked for 20 minutes. “It was really wonderful,” Kilby said. “It was almost like being with your family.”
As COVID cases have continued to rise in the area, regulations have continued to change, making face-to-face visits tricky and sporadic.
“A lot of people that don't work in a nursing home or health care like this, they don't understand the rules that change on a daily basis,” Potter said. “It's hard to deal with. Because we don't obviously want the residents to have to be in their room so much. We would love for them to be able to interact and get out more and things like that. But we can't — we have rules that we have to follow that, like I said, change daily.”
Nursing homes have seen the negative effects of lessened social interaction in one specific area: Food consumption. Without dining halls full of residents, residents have stopped eating as much. Sanford, who is still finalizing her study results, has found that isolation has caused more weight loss than contracting the virus. “It just isn't the same when you're by yourself in a room eating off of a TV tray and Styrofoam plates,” she said.
The Oak Hill staff has tried to mitigate the weight loss by creating events like “12 days of ice cream,” where residents receive a different flavor of ice cream each day, from “plain old chocolate” to cinnamon crumb cake.
Flashing back with music
Most mornings, recreation director Kelly Potter returns to work at the Sarah Community with a voicemail full of movie reviews from the residents. She has found one constant: “Basically anything that has a little bit of music in it is always popular.”
Especially during COVID, music has become a source of comfort. A source of remembrance. A chance to mentally break away from the pandemic.
“Music is really deeply tied to memory,” Moore said, “...even before the pandemic music is something that's constantly brought up as a great activity because it gets people feeling good. ... Usually it will bring back good memories of when folks were younger, when they were in their prime.”
Some nursing homes have set up courtyard concerts. During the summer, McKnight Place in St. Louis had musicians going window-to-window giving out performances. Clinton Manor has passed around tablets for residents to watch virtual concerts.
When asked about some of the ways she has gotten through isolation, Kilby instantly brought up the Christmas carols that the Oak Hill staff played over the PA system. It was something small, taking place for just a few days and 15 minutes at a time. But, weeks later, Kilby is still talking about the carols. “It was, well, it just raised my spirits. And I think it put us in a mood for a good lunch. ... It added so much to get to hear those familiar tunes.”
Nursing homes have tried to include residents in the musical experience as well. Oak Hill, for instance, has a music therapist that travels among rooms. During residents’ sessions with the therapist, they can sing, dance and even bang on the tambourine.
“Just the act of singing, you take deep breaths and it helps people with respiratory issues,” said Brian Koontz, the administrator at Oak Hill. “Folks who may be battling pneumonia, it helps to expand the lungs to be able to take a breath and sing. There are a lot of physical benefits with that. And then there are a lot of emotional benefits to having a trained music therapist, being able to lift spirits and help people find their joy. A lot of times they're actually doing respiratory therapy through the music and don't even know it.”
On Dec. 28, long-term care facilities in Missouri received more than 120,000 vaccinations. During the first week of January, Oak Hill residents received their first dosage of vaccinations, with the next batch coming three weeks later. Koontz says he doesn’t know what the guidelines will look like in a month. In the meantime, they’ll continue the socially distanced and masked events until they know for certain that it is safe to gather again.
Moore and Chien Hung, program director of the Ombudsman Program at VOYCE, are quick to point out that the problems exemplified during the pandemic — the depression, the isolation, the understaffing — aren’t going anywhere. Even before the pandemic, Moore said, “the loneliness and isolation epidemic in long-term care, and really most all of our elderly, was not something that was new.”
Hung added: “It's not that when residents get vaccines then — done, this isolation is gone, lockdown gone and people start to live their wonderful lives. No, things are never that fabulous. So, I think we have to look at this isolation in a kind of broader kind of context. And that is, that to live in a nursing home itself, with or without COVID, that is actually isolation.”
But Sanford has seen something different come out of the pandemic.
“I think there's a message of hope and resilience,” said Sanford, “that the nursing home communities banded together and really worked as teams, without resources and with the public being so negative about what was happening behind the walls of the nursing home. Every day, we showed up to take care of patients, and tried to think outside the box and how we could best achieve those with very limited resources.”
"We want them to feel like life and fun is still happening, no matter what's going on."
Tara Powell, the activity director at Bethesda Southgate in Oakville
“We've seen a lot of depression. We've seen a lot of people, who went into long-term care with mild dementia get much worse because they're not getting the sort of social interaction that they need to be able to maintain their health. ... It seems like a lot of facilities are really trying. But under a lot of the current conditions, it's really hard.”
Marjorie Moore, executive director at VOYCE