one comorbidity, such as hypertension, obesity, coronary heart disease, lung problems and diabetes are also at an increased risk of severe SARS-COV-2 infection [5]. The resulting COVID-19 pandemic has thus disproportionately affected older and is known to be lethal to adults with underlying health conditions [6]. Adults over 65 years of age represent 80% of COVID-19 hospitalizations and have a 23-fold greater risk of death than those under 65 [6]. In fact, in the United States, 8 out of 10 deaths associated with COVID-19 have been among adults aged 65 years and older [6].

On March 4, 2020, the Federal government recorded the first case of COVID-19 in Tennessee (TN). On March 29, 2020, Tennessee (TN) reported the first COVID-19 case in a rehabilitation center, in which 99 residents and 33 staff tested positive, with one reported death. Following this initial outbreak, several COVID-19 cases were reported in various Long Term Care Facilities, namely Nursing Homes (NHs) and Assisted Care Living Facilities (ALCFs) throughout TN [8]. According to a report by the Centers for Disease Control and Prevention (CDC), four percent of total COVID-19 cases occurred in LTCFs, accounting for approximately 32% of the US’s COVID-19 fatalities [6]. This translates to more than 1,363,000 residents and employees infected in 32,000 facilities and at least 182,000 deaths, as of April 28, 2021. As the deaths in these facilities rose, members of Congress, specifically Senators Warren and Markey, and the House Oversight and Reform Committee, requested a review of 11 of the largest assisted living operators on April 29, 2020 [7]. The report concluded that approximately 4,412 residents in 2,173 communities tested positive for COVID-19, accounting for 2.9% of all residents as of May 2020. The report also indicated that 31% of residents who tested positive died from complications of COVID-19, a fatality rate six times higher than the national average [8].

COVID-19 is an airborne pathogen, thus being in close proximity to other people raises the chances of spreading the disease. Relatedly, because the virus attacks the respiratory system, older adults, who are more likely to have respiratory challenges than their younger counterparts, are at increased risk of severe COVID-19 illness and death [4]. As such, ACLFs and NHs were a primary prevention focus because older adults aged 65 years and older with pre-existing health conditions, living in close quarters, culminated in a potential public health crisis. NHs are special types of LTCFs that provide clinical care including medical and rehabilitation services in addition to the regular daily provision of personal care, hourly supervision, and security that ACLFs provide [9]. NH residents are often post-acute patients who are discharged from intensive care units for continuation of care in skilled nursing facilities, the terminally ill, functionally impaired persons and individuals with several chronic illnesses who may also possess neurocognitive deterioration [10-11]. The current incidence and fatality rate of COVID-19 among LTFCs residents lay bare significant challenges in the face of the more lethal variants and surges in infections. Discussions revolving around resident and staff infectivity and vaccination trends in context of several factors such as laws governing visitation policies and special care accommodations for dementia patients have made overcoming the pandemic an even more complex issue. Hence, inhouse clinical operations may become necessary in conjunction to the adherence to CDC guidelines. Thus, purpose of this study is to describe the incidence of COVID-19 confirmed cases and deaths among residents living in ACLFs and NHs in Tennessee from June 2020 until November 2021 in order to evaluate the efficacy of containment measures recommended by the Center of Disease Control in curbing the spread of the virus and the importance of having clinical standards in LTCFs in decreasing mortality rates from the coronavirus.

Methods

To conduct this non-experimental research project, data collection followed subsequently by correlational data analysis were conducted. The primary data source used was the official TN government website (TN.gov) containing comprehensive weekly data sheets consisting of the number of positive COVID-19 cases and deaths from all LTCFs in TN. The variables examined in this research study were:

1. Type of LTCFs, which were either NH or ACLFs. The number of cases present in Residential Homes for the Aged were comparably minimal and were not included in this study.
2. COVID-19 positivity, which was defined as PCR-positive laboratory results, was reported to the Tennessee Department of Health (TDH).
3. COVID-19 mortality refers to the cumulative number of deceased individuals that were confirmed to be COVID-19 positive and did not become asymptomatic before death either before or after hospital transfer.
4. COVID-19 recovery, preceding September 3 was defined as (1) confirmed asymptomatic cases by local or regional health departments in patients who had concluded necessary quarantine or (2) 21 days post-symptom onset or post-initial positive PCR in asymptomatic individuals. Subsequent definitions of COVID-19 recovery were (1) individuals who were not deceased and (2) at least 14 days post initial onset of symptom or 14 days post initial test confirming infection in asymptomatic cases.
5. Residents - individuals living in facilities and being provided with care and services with ages 65 years or older.
6. Staff - individuals providing care and oversight to residents in the facilities. For NHs, these may include registered nurses (RNs), licensed physical therapists (PTs), and other clinically licensed individuals in addition to administrative and support staff. For ACLFs, personal care aides, certified nursing assistants (CNAs), and medical attendants constitute the staff makeup.
7. Resident census - the count of individuals who are residing in a facility at any given time.

Using Microsoft Excel, the data were aggregated based on each week from June 2020 to November 2021, according to the parameters listed above, and adjusted to account for the duration of illness. The date range approximately coincides with the initial increase of COVID-19 infections across the country and the appearance of omicron variants towards the end. Data collection measures became more standardized and the variables aforementioned were consistently recorded. Heat maps with a red-yellow color scale denoting the proportion of infection and mortality were then plotted showing the distribution of the total number of COVID-19 cases and deaths in the 95 counties across TN. Graphs were plotted showing the trends of infection during the time frame studied and emphasis was placed on the top 5 counties with the highest COVID-19 incidence and mortality and 4 of those counties were coincidentally highest in population and regarded as Metropolitan. The average resident census was calculated for each type of LTCF using the available data provided from TN.gov. Crude incidence, crude fatality rates, county-specific incidence, and county-specific fatality rates were then calculated based on the number of cases and deaths recorded. The significance of having a COVID-19 infection by being a resident in an ACLF versus a nursing home NH was also calculated using odd ratios and summarized in Tables 1-3. The significance of having a COVID-19 infection and either recovering or dying in NHs and ACLFs were calculated and recorded. Staff COVID-19 incidence versus resident COVID-19 incidence was measured and recorded in both NHs and ACLFs and compared.

Results

Analysis of the aggregated data demonstrated that every TN long-term care facility in every county was plagued with COVID-19 from June 2020 amounting to 39,179 cases by midNovember 2021(Figure 1).