BIG STONE GAP, Va. (WJHL) – The ladies inside a local business on this small Appalachian town’s main drag weren’t aware a COVID outbreak at a nearby nursing home had infected more than 200 residents and staff when they spoke to a reporter on a cold December morning.

Two of them were unmasked, having already had the virus. One said COVID was “part of life” and Americans were going to have to learn to live with it.

Not far away, staff at Heritage Hall Nursing Home continued to grapple with an outbreak that has cost 33 lives — so far — and recorded 219 total positive cases. It’s the largest of any outbreak Virginia’s reported since the pandemic began, and one of the deadliest.

The scene outside Heritage Hall nursing home, which has 33 reported COVID deaths, in early December.

Up the street from the one business, Robert Bloomer and Lorenzo Rodriguez are taking masking and social distancing seriously. They’re partners in a bike shop — one a Wise County native who’s on the town council (Bloomer), the other a California transplant who loves the mountains and whose wife teaches at the nearby university.

“There’s a lot of people who don’t take it serious, they think it’s not as bad as it is,” Bloomer said in a Zoom interview after a day spent worrying about his mother – who’s in ICU at Big Stone Gap’s Lonesome Pine Hospital.

“I do see more people with masks on now.”

But not enough, he said. Rodriguez agreed, and while he chatted, masked, with a masked reporter, three customers, a woman paying a bill and a delivery man all came into the store. Only the woman dropping off the bill was masked in a state whose governor has imposed a statewide mandate.

Rodriguez said the outbreak’s “magnitude has not hit.

Bike shop co-owner Lorenzo Rodriguez said he believes there’s a middle way that would involve more mask-wearing and caution without a complete shutdown.

“That’s right here in our community, and I don’t see people reacting to that on a day to day,” he said. “We’re still in that general mentality of ‘it’s been a long year, I’m over it, let’s get on with our lives, we can’t live in fear.’

“I understand that. I’m a business owner, I don’t want to be closed down.”

But Rodriguez said he thinks a middle way is possible — a proactive approach to mask wearing and social distancing that avoids a complete lockdown.

“The feeling I get from too many people is that it’s one or the other. Either I have to be carefree and prove that I’m not gonna let this control me, and do away with all precaution, or I’m gonna be very safe and stay holed up in my house. There’s many more options than that.”

Hit late but hit hard

Few Southwest Virginia long term cares were affected during a wave of outbreaks last spring, when the virus was much more prevalent in northern Virginia and more urban areas.

So by late summer, health officials and nursing homes knew what they were dealing with and the best ways to try and slow COVID down if it did enter facilities. Still, as community spread finally hit the rural mountains of the state’s southwest corner, situations like Heritage Hall’s began cropping up across the region.

It’s a scenario that’s been repeated, albeit not always in numbers quite so high, across the jurisdictions Dr. Sue Cantrell oversees as director of the Lenowisco and Upper Cumberland Health Districts.

With those districts having some of Virginia’s highest community spread rates, the virus is nearly impossible to keep out, Cantrell told News Channel 11 in a statement.

“Community spread is high in southwest Virginia and contributes to the introduction of (COVID-19) into many settings,” Cantrell said, listing workplaces, schools and churches as well.

Cantrell said the biggest tragedy occurs in nursing homes. Just as she prepares to retire at the end of this year, she’s seen multiple nursing homes suffer more than 100 cases.

“It is heartbreaking for healthcare and long term care staff, for me and our staff to consider these lives that survived world wars, the great depression and other national emergencies as well as their own social and physical challenges, succumb to the devastation of this infection and we see it nowhere as much as in our long term care facilities.”

What’s the procedure been?

Local and regional Virginia Department of Health (VDH) staff began visiting area long term care facilities several months ago. They helped fit-test and train staff to wear and dispose of PPE and reviewed general infection control, Cantrell said.

As community spread increased, facilities in the region underwent more and more frequent testing of residents and staff in what’s called “point prevalence screening.”

That screening began to detect positives, with Cantrell saying nearly all long term care facility infections were introduced by staff. Though point prevalence screening positive cases must isolate, the cat’s often out of the bag.

“When staff are working during their infectious period — before symptoms develop or in many cases, where no symptoms ever develop — they expose residents and other staff,” Cantrell said.

Those staff are also out in the community — likely where they’ve contracted the virus in the first place — and a vicious cycle ensues. Once an outbreak occurs, Cantrell said additional cases in staff and residents are often identified over the next 14 days — COVID’s incubation period.

This chart reveals how rapidly COVID spread after entering Heritage Hall nursing home in Big Stone Gap, Va.

That’s what happened at Heritage Hall, which reported 73 cases Nov. 10 and 190 six days later.

“When three and four and five employees are identified at one time who work in various parts of a long-term care, that results in many other of the residents having been exposed before they were aware that they were infected,” Cantrell said.

Once an outbreak is in progress, testing occurs twice a week.

Positive residents are “cohorted” into one area and staff assigned to care for them wear full PPE — including face shields, N95 masks, gloves and gowns. Residents with negative initial tests but positive roommates are quarantined as well, with full PPE for staff.

“COVID units” are entered and exited from outside the building, Cantrell reported. Meals are delivered from outside in single serve containers. Trash is picked up directly from rooms, from outside.

Essentially, she said, nothing traverses the rest of the building — no people, no meals, no supplies.

Cantrell said unannounced COVID assessments and nursing site visits from local health departments are standard during outbreaks, including during non-routine business hours.

The goal, she said is “to address any questions, concerns of staff or leadership.” VDH also assesses knowledge of proper PPE use and disposal — as well as determining whether there’s additional PPE needed.

When COVID has largely swept through a facility despite all efforts to contain it, the result is an imbalance of infected to non-infected residents, and a shortage of non-infected staff.

After a source told News Channel 11 Heritage Hall staff who had tested positive and weren’t through quarantine period were working at the facility, we asked Cantrell. She said “based on guidelines for essential workers, it is permissible for positive staff to work in units where the COVID-positive patients are cohorted.”

Those staff wear full PPE throughout their shifts.

In the case of Heritage Hall, some extra measures have been taken by authorities. “Health Quality Innovators” contracted by the federal Centers for Medicare and Medicaid Services made a site visit last week to provide technical assistance.

And VDH is engaging in daily calls to facility leadership, as well as on site infection prevention inspection and education. A week ago, they conducted remotely an “ICAR” — infection control and assessment response.

Back on the main drag — masks optional

Trudy Quiroz talked to News Channel 11 through her tie-dyed mask after a quick shopping excursion. She said she has a son-in-law in Heritage Hall who suffered a stroke and has lived there for a good while.

As far as she knows, he’s doing okay — but she’s concerned about people’s approach to their everyday affairs.

Trudy Quiroz said too few people are wearing masks in public and she believes those who refuse should be fined.

“I was just in Family Dollar,” Quiroz said. “Two people behind me were close to me — no mask on. They’re the ones that’s not taking it seriously, and I think it’s unfair.”

She said she’s looking forward to the arrival of widespread vaccinations — she’s nearly 70 — but is disappointed about people’s decisions in a town that’s been so hard hit.

“I think some people realize about the nursing home, and I think some people just don’t care. I think the people that don’t wear the masks should at least get fined. I do.”

The suffering has hit very close to home for Bloomer. He said the best the town council can do is put up signage on its greenway — which is decorated for Christmas — encouraging folks to mask up and social distance.

When he spoke to News Channel 11 Tuesday, his mom, who owns a formal wear store in town, had been on a ventilator for several days. They had tried to remove her from it but it hadn’t worked out.

He said a friend who works at Heritage Hall told him about the outbreak and that “there was very little recognition of what was going on until it was full blown and probably 30 deaths.”

Bloomer doesn’t cast blame on the nursing home, saying he’s sure they were doing everything they possibly could to prevent it.

“Once it started it was probably impossible to stop it,” he said. “Air handling systems for each room, that’s what it would take to stop it in a situation like that.”

An outdoorsman who played linebacker on his high school’s state championship team in the mid-1980s, Bloomer is no coastal elite. But he said he doesn’t understand the resistance to adopting recommended measures.

“Masks work,” he said. “I don’t understand why there’s any debate on that. They’re not 100 percent but they do help.”

Both Bloomer and Rodriguez — whose kindergarten daughter is attending school virtually at this point — say their community is a tight-knit one where people care for each other. But that cohesion has been frayed as the virus has ripped through the area.

“When it does affect people I’ve seen them get very emotional,” said Rodriguez, who called the community “very caring.”

“When cases happen you get prayer requests and big response and everybody, they come together as a community.

The small Southwest Virginia town of Big Stone Gap is home to Virginia’s largest single-facility long term care COVID outbreak with 219 reported cases among residents and staff.

“But I don’t want it to take that, I don’t want it to get that far before we do show that kindness. Let’s do it ahead of time and not make it a political statement, I guess. It’s just, how do we save our community first. And that’s what I think is important.”

But 15 minutes up the road, a local funeral home director who wouldn’t go on the record said he thought COVID-19 was essentially equivalent to the flu. And Bloomer mentioned a local elected official from a nearby town saying publicly that elected leaders shouldn’t encourage mask-wearing, something he called “crazy nonsense.”

Bloomer said he’s having a hard time wrapping his head around why community members who are so protective of their neighbors in some ways aren’t ready to make a few sacrifices to prevent COVID from spreading more widely.

“You see people go in a store with a gun on their waist to protect you from a robber, but they won’t wear a mask,” he said.

“My mom will be lucky if she survives. So just take it serious, wear a mask, wash your hands, stay apart. There’s no debate. Just be a pillar of the community and help each other out.”