In the earliest days of the pandemic in March 2020, when even the world's best scientists knew almost nothing about combating it, the new coronavirus killed 35 residents at a nursing home in Washington state.
Robert Mitchell, owner of Mitchell's Nursing Home in Danville, was alarmed.
"That's when we knew this thing had a chance to not be good at all," he said of the virus that was just sneaking into Arkansas. Then came another jolt: "The government tells you that you have to lock the doors and keep the families out. They had us stop visitations."
From his 105-bed nursing home, Mitchell started strategy sessions with doctors and nurses, families and staffers, nursing home groups and hospitals, hoping "to prepare for however bad it was going to be."
In Danville, population 2,365, in Yell County, Mitchell's four-star-Medicare-rated nursing home lost 12 residents, all in the pandemic's first year. That was despite bringing in help from a team of researchers and doctors from the federal Centers for Disease Control and Prevention.
During the worst weeks, Mitchell said, "about every day you wanted to cry, but didn't have time to do it."
Covid-19 has killed 2,328 residents of Arkansas nursing homes and assisted living facilities since March 2020, according to state Department of Health data through Feb. 8. They account for about 23% of Arkansas' total coronavirus death toll that surpassed 10,000 on Feb. 12.
Still, the grim numbers in long-term care facilities have improved significantly in the past year, according to state and federal health agencies.
About 81% of Arkansas' covid-19 deaths in those settings, 1,896, were reported in the pandemic's first 11 months, before the end of January 2021, according to the state Health Department's current numbers.
Far fewer -- about 19%, or 432 -- have been reported since, despite delta and omicron variant surges. Numbers nationally are similar.
The first year of the pandemic, especially between April and December of 2020, was "pretty rough in our state" in long-term care settings, said Dr. Naveen Patil, the Health Department's deputy state health officer.
Long-term care residents were "very, very vulnerable" because of age and ill health. Doctors and hospitals had little to help them fight back.
"We didn't have resources for testing, not only our state but also all over the country. We had no vaccines, few treatment options," Patil said.
Before covid-19, Jonas Schaffer, owner of Greenhurst Nursing Center in Charleston, in Franklin County, kept an emergency operations binder with instructions for how to respond to "every scenario you can think of" -- earthquake, chemical spill, tornado, ice storm and even pandemic.
"But it did not have this scenario: We needed N-95 masks, and we could not get them."
At his Danville nursing home, Mitchell said delays in covid-19 testing results were a big problem.
No rapid tests were available. PCR tests, done through health care workers, backed up in labs waiting to be processed. "We were waiting two, three or four days for results," Mitchell said. That delayed crucial decisions, such as whether to quarantine or isolate residents tested.
Proven treatments, vaccines, rapid tests, and better and more plentiful masks didn't begin to emerge until late 2020.
Schaffer and Mitchell, along with Patil and others who work closely with Arkansas' nursing homes, said long-term care settings have saved lives by embracing new tools to fight the virus.
Some, including covid-19 vaccines, are measures many Arkansans outside nursing homes still resist.
'GAME CHANGER'
Covid-19 vaccinations -- maligned in certain corners of social media and by a few athletes and other public figures -- came along when deaths in long-term care facilities in this state and nationally were soaring in late December 2020.
Despite urging from state and federal public health officials and Gov. Asa Hutchinson, Arkansans didn't sign up wholeheartedly.
Almost 35% of the state's population has yet to receive a first dose of covid-19 vaccine, according to Mayo Clinic tracking numbers. Arkansas ranks 37th among 50 states and Washington, D.C., for percentage of residents getting at least one dose.
But in nursing homes and assisted living facilities, "vaccines were the biggest game changer for employees and, most importantly, our residents," said Rachel Bunch, executive director of the Arkansas Health Care Association, which represents 269 nursing homes and assisted living facilities.
The Arkansas Health Department's Patil agrees: The main reason nursing homes and assisted living facilities had relatively few deaths during the recent delta and omicron variant waves was that "very few residents were unvaccinated."
Studies have shown the vaccines are especially effective at preventing hospitalizations and deaths. Since Feb. 1, 2021, almost 81% of all Arkansas residents who have died from the virus were not fully vaccinated, according to the Health Department.
Patil estimates that almost 90% of long-term care residents across Arkansas are vaccinated. After education campaigns during the past six months, "staff vaccinations are about the same number."
Bunch points to federal data from the Centers for Medicare & Medicaid Services that shows Arkansas nursing home staffers have higher vaccination rates than most Southern states. Almost 84% are fully vaccinated, ahead of 25 other states, including Minnesota, Florida, Texas, Tennessee and Oklahoma, according to the data.
For Mitchell's and Greenhurst nursing homes, vaccination ratios are even higher, according to the owners. That's before a federal mandate for staff vaccinations became effective Monday.
Martha Deaver, president of Arkansas Advocates for Nursing Home Residents, is happy that vaccinations among residents have climbed, but believes it's taken too long to get employees to sign on.
She says vaccinations for nursing home staffs should have been mandated earlier and could have saved lives. She also says infection control laws in place for decades "were not followed in too many cases."
Deaver said the stakes were clear from the start of the pandemic, when she was contacted by national media about the dangers facing nursing home residents.
"I told them it's going to be a massacre," she said, "before the massacre hit."
THE TOLL
Deaths from covid-19 have struck some Arkansas nursing homes and assisted living facilities harder than others.
State Health Department data for individual nursing homes through Jan. 18, reviewed by the Arkansas Democrat-Gazette, show 28 had recorded no deaths from the virus. Another 21 facilities lost from 21 to 41 residents.
The average for Arkansas nursing homes that have reported covid-19 deaths was about 11 since the pandemic started, according to the newspaper's review.
The state numbers are self-reported by the facilities, but Health Department staffers review the reports and follow up with those that raise questions, according to agency spokeswoman Danyelle McNeill. The numbers sometimes lag because of delayed reporting.
The newspaper also reviewed federal data for covid-19 deaths and cases in Arkansas nursing homes, also self-reported by the facilities. The state and federal numbers aren't identical for individual nursing homes, but the overall drop in covid-19 deaths in long-term care facilities during the past year is similar for both sets of numbers.
Schaffer's Greenhurst Nursing Center didn't record a single covid-19 death through 2020 and most of 2021, then lost its first resident to the virus a few weeks ago as omicron cases spiked.
That makes Greenhurst different from many Arkansas facilities. The nursing home's long stretch without a single death is an achievement Schaffer credits to his staff and a little luck. Still, the facility has dealt with dozens of virus cases. Thirty residents and 49 staffers have tested positive, he said.
Like Mitchell in Danville, Schaffer also grasped the seriousness of the covid-19 virus with the deaths at the Kirkland, Wash., nursing home.
"We stopped in our tracks," he said. "I was reading about these people, and they were in trouble. But no one knew what to do."
He and his wife and co-owner, Halie, a nurse practitioner, worked with state and national long-term health care associations and the state Health Department to follow their recommendations. She tracked covid-19 contacts and spread inside the nursing home and the community. He tried tactics not used before at the Medicare-rated-five-star home.
At the beginning, he gave cash directly to the staff to purchase scarce N-95 masks, after a local store rationed four per customer.
When most nursing home visitations were shut down, he installed a small building, heated and cooled, on the grounds outside the facility. There a resident could meet with family members face-to-face, behind glass partitions. They called it the Happy House.
When vaccinations came along, most residents wanted the shots as soon as possible. Not so, staffers.
"At one point, it became a group effort," he said. "I asked, 'What will it take? If four more [staff members] agree to get vaccinated, I'll buy everyone Olive Garden.' One said, 'I'll do it.' We cheered.
"Then we got four, and we all got Olive Garden."
It also falls to Schaffer to persuade visitors who are especially resistant to wearing masks or following other covid-19 safety measures. He's come to think of them as "Uncle Eddie."
"We still screen people at the door. We still have people wear masks," he said. "When someone refuses, I tell Uncle Eddie, 'I understand, but you'll have to wear the mask.'"
State Health Department chief epidemiologist Kelley Garner said that in the pandemic's first year, her office was mostly confined to urging long-term care facilities to properly use personal protective equipment (PPE), including masks and gowns, and follow infection control procedures such as quarantine and cleaning.
Garner coordinates teams of nurses and medical workers who have made more than 400 visits to Arkansas long-term care facilities during the pandemic.
"The resources and understanding and best practices have greatly improved" in the past year, she said.
The numbers reflect it.
"We've seen dramatically fewer deaths. That's encouraging," Garner said. "Of course, covid-19 can change, and we will have to change with it."
THE HARDEST DAYS
Residents' lives at Mitchell's Nursing Home in Danville and other Arkansas nursing homes are more normal now than when the pandemic first arrived.
"They see their families as often as they want," Mitchell said. "Friends can come in. We can do activities again."
Principles of infection prevention remain -- masking, hand hygiene, 6-foot distancing. If a resident wants to host a sizable gathering, it takes place in a bigger space such as an activity room or lobby.
Treatment, rapid testing and, primarily, vaccines have made the difference, he said.
Now, fewer residents become ill. If they do, doctors have monoclonal antibodies, antiviral drugs and other tools to treat them.
But better times haven't erased what Mitchell calls the "worst, hardest" days of 2020 that he prays never happen again.
"You've got the facility locked down. Families can't come in. You could communicate through the window, through Facetime. But you can't embrace them in any way," he said. "You have staff who are scared. You have residents who are concerned and you're talking them through it."
Then a positive case is confirmed, he said. Then, a few. Then, a lot.
The nursing home loses one resident.
"Then, you have days where two or three in a row, they pass away," Mitchell said.
To him, they weren't statistics.
"These are people who lived with us a long time," he said. "We loved them. They were part of our family.
"It's hard."