The early months of the pandemic highlighted long-standing flaws in the nation's fragmented system of care for frail seniors. Before vaccinations became available last December, nursing home residents accounted for up to 40% of COVID-19 deaths. And while coronavirus-related deaths among seniors have plummeted since that time, the pandemic is not over as infections from the more contagious delta variant surge.

So where does that leave nursing homes?

This news organization reached out to local health leaders to find out the state of nursing homes a year into the pandemic. Many declined to respond, but those who did, say they are much better prepared and optimistic about keeping residents safe.

Should another outbreak occur, it would be "horrendous, but entirely different," said Bethany Murray, administrator at Cedar Crest Nursing and Rehabilitation Center in Sunnyvale, which experienced an outbreak in early 2020 that infected 44 residents and resulted in five deaths.

"We're leaps and bounds ahead of where we were then in terms of process, structures and knowledge," Murray said.

With no uniform response in place for care centers at the start of the crisis, Cedar Crest developed its own protocols and created a walled-off COVID-19 unit. It was later asked to run a unit for other facilities in Santa Clara County that could not manage it on their own, Murray said. No COVID-19 cases have originated in her facility since the March 2020 outbreak, she said.

Brad Heap, administrator of Atherton Park Post-Acute in Menlo Park, which experienced COVID-19 cases early in the pandemic, is also hopeful.

"Obviously the pandemic has been pretty tough on this whole industry, but now I'm feeling optimistic," Heap said. The crisis led to better communication procedures with residents' families, he said.

Though his facility has not had a COVID-19 case for months, Heap said he and other nursing home administrators are required under state law to file daily reports to health agencies, including on weekends, or face fines. In addition to increased reporting requirements, facilities also must have a full-time staff member dedicated to infection prevention and control.

Other precautions that facilities have adopted include the use of surgical masks for anyone entering the building, limited visiting hours and proof of vaccination for family members who wish to take off their masks inside a loved one's room. The precautions are constantly evolving, Heap and Murray said.

On Thursday, the state Department of Public Health issued a new health order requiring workers in health care facilities, including skilled nursing homes, to be fully vaccinated by Sept. 30. A second public health order, also issued Thursday, requires skilled nursing facilities, hospitals and intermediate care facilities to verify that visitors are fully vaccinated or have tested negative for COVID-19 in the prior 72 hours before indoor visits, according to the department's Thursday press release.

The regulation comes amid a recent uptick in COVID-19 cases due to the delta variant.

Statewide, 76.3% of health care workers were fully vaccinated as of June 20, according to a recent AARP analysis of government data. Vaccination rates nationwide among nursing home workers, however, continue to lag, with only 1 in 5 facilities hitting an industry target of getting 75% of their health care staff fully vaccinated.

Locally, rates vary among facilities from 60% to 100% fully vaccinated. The Sequoias and Villa Siena in Mountain View are among local facilities that had the highest employee vaccination rate at 100% as of July 18, according to data from Centers for Medicare and Medicaid Services. Palo Alto Sub-Acute and Rehabilitation Center and Grant-Cuesta Sub-Acute and Rehabilitation Center in Mountain View had the lowest rates at 60% and 79.77%, respectively.

Murray, who last year took over management of Cedar Crest from her mother, Tracie Murray, said 100% of the facility's long-term residents and almost 100% of the staff have been vaccinated.

The March 2020 outbreak at Cedar Crest came after an asymptomatic but infected nursing assistant reported to work. Cases went from zero to 38 residents in 12 days, peaking at 44, Murray said.

The outbreak hit early in the pandemic — even before the Santa Clara County mask mandate — when precautions were not well understood, Tracie Murray said in an interview last year with the insurance risk-management firm Health-Cap. One-third of residents who tested positive were asymptomatic and half of the positive staff members were asymptomatic.

Murray said her mother engaged a construction team to build a temporary wall, creating an isolation unit containing a nursing station, break room and staff bathroom. She rented an RV so staff members could shower before going home. She posted signs inside the building to ensure that food and laundry from the COVID-19 unit did not come into contact with the rest of the floor.

"Mom was very smart to ask the county if COVID-19-positive staff could work in the COVID-19 unit if they didn't have symptoms. They said yes, and later suggested it to other facilities," Murray said.

A single person was tasked with communicating with families so clinical staff could focus on patient care. A simple binder system was established to quickly record and track any and all coronavirus-related events, including test results, communication and guidance.

Seven weeks after the first reported coronavirus case at the center, Cedar Crest was declared coronavirus free.

"(Afterward), we were asked to run a COVID-19 unit for other facilities in the county that had outbreaks but could not manage their own COVID unit," Murray said.

Though still under significant COVID-19 precautions, Murray said things have "relaxed a lot from where we were at the height of the pandemic when we couldn't have visitors and residents couldn't be in the hallways."

The California Department of Public Health issued new guidance in March allowing vaccinated nursing home and long-term care residents to receive indoor and in-room visitors following a yearlong lockdown.

"From a residents' perspective we've definitely come a long way to have activities and communal dining," she said. "Most facilities are even letting residents go out on a pass if their loved ones want to take them to dinner or something."

The lockdown took a particular toll on long-term residents who were not even permitted to leave their rooms to go into the hallway or visit with a neighbor, she said. To try to keep them "oriented to reality and to time passing," Murray said she solicited photos from families and brought them to the residents' rooms along with balloons or flowers.

And while COVID-19 cases in long-term care facilities are at historic lows since the start of the pandemic, many providers are struggling to recover from the economic crisis the pandemic has induced.

According to a national survey released in June by the American Health Care Association, a Washington, D.C., advocacy group for thousands of for-profit and nonprofit facilities, only a quarter of nursing homes said they're confident they'll make it through to next year.

More than half said they're operating at a loss due to fewer residents as well as extra expenses, including additional staff pay because of COVID-19.

Murray and Heap said they will survive. Both said they are now especially focused on helping their staff feel supported after the crisis.

"I know our ability to care for patients is good," Heap said. "Our motto is to uplift, nurture and heal, and we believe if we do that first, success in other ways will follow."