On May 18, relief swept over Cesar Noriega. He got word that his mother — and others in her skilled nursing facility — would be tested for COVID-19.
Testing can detect, and thus help prevent, a virus that has raced through senior homes. Noriega’s mom hasn’t shown symptoms, but everything about her screams vulnerable: 90 years old, Alzheimer’s disease and she shares a room at Reo Vista Healthcare Center in San Diego.
“I’m feeling so relieved she’ll be tested,” Noriega said. “Everybody should be tested in nursing homes.”
But that often doesn’t happen. COVID-19 testing varies widely across San Diego senior facilities. The state and county aim to induce widespread testing in senior homes, but advocates say these efforts are moving too slowly and lack teeth.
Expert after expert agrees: Testing should be at the center of any plan to contain the novel coronavirus, a harbinger of doom in homes for the elderly. Congregate living facilities, which include skilled nursing homes, account for nearly half of the region’s 230 deaths linked to COVID-19.
Fearful of this grim statistic, Noriega urged Reo Vista Healthcare Center to test everyone, after the facility on May 10 confirmed a staff member tested positive.
Initially, the county directed testing of staff in one wing of the building, according to Reo Vista. But on May 18, the facility said UC San Diego Medical Center would test all its residents and staffers later this week, under a contract with San Diego County, which paid for the cost.
The county public health department prioritizes comprehensive testing in this vein at skilled nursing homes with COVID-19 cases.
The next step, the county says, is testing all of the region’s 87 skilled nursing homes, regardless of whether a facility is battling an outbreak. Facilities are urged to spearhead testing, but the county said it will aid test-strapped facilities, including in some instances by sending testing teams.
To reach the goal of broad testing, San Diego County Public Health Officer Wilma Wooten said during a press conference that the county plans to contract with additional health systems.
In response to emailed questions, the county did not say whether widespread testing would be mandatory, or provide a timeline. It’s also unclear whether universal testing plans include assisted living facilities, a different type of senior housing.
Dr. Michael Wasserman, president of the California Association of Long Term Care Medicine, said it’s urgent that San Diego County do more asymptomatic testing in senior facilities. Focusing on homes battling outbreaks doesn’t cut it, he said.
“The horse is out of the barn at that point,” Wasserman said. “We know that this virus is transmitted through asymptomatic spread. If you wait to test in nursing homes until someone is sick, you’re going to have more deaths amongst residents and possibly among staff.”
The county isn’t alone in guiding who gets tested.
Recently, the California Department of Public Health gave skilled nursing facilities until June 1 to submit a plan  for regularly testing residents and staff. Wasserman said the state action came way too late — and falls short of a mandate to test.
“The California Department of Public Health is literally avoiding responsibility to deliver a clear message to what should have been happening since March,” Wasserman said.
Asked whether skilled nursing testing will be required, the department in an emailed statement said a universal testing plan will soon be released after much stakeholder input.
“A process for universal testing must be done right – our vulnerable residents and health care personnel deserve and require a plan that works across all of California in the more than 1,000 skilled nursing facilities,” said the statement.
“The plan must be comprehensive and include statewide requirements, while also allowing the flexibility needed to account for significant regional variations in our nursing homes.”
On May 1, the department called for skilled nursing facilities to test those showing symptoms, or upon admission or re-admission into a facility. The agency also advises testing the asymptomatic if cases are confirmed at a senior home.
Los Angeles and San Francisco counties have gone further by requiring regular testing of staff and residents in all nursing homes. In the absence of such a mandate in San Diego, facilities take different approaches. Some preventatively test, while others do so only after confirmed cases, according to doctors and industry groups.
The lack of uniformity extends to personal protective equipment and facility screening questions, said Dr. Luis Navazo, a geriatrician who treats patients throughout San Diego.
“It feels like the wild, wild west where every township has its own rules,” said Navazo. But, he added, commonalities include temperature checks to enter a building.
Making more senior facility testing possible, San Diego labs have ramped up  their COVID-19 testing capacity — to the point where testing capacity exceeds demand.
“We had more tests than actual demand, so we started outreach to the community,” said Dr. David Pride, an infectious disease specialist with UC San Diego Health. “One of the most obvious places to start was nursing homes.” Pride said some facilities decline testing, citing existing contracts.
The Trump administration has said nursing homes should test all residents and staff of nursing homes, but hasn’t required it. Industry groups say more funding is needed to achieve the goal.
The American Health Care Association, a senior facility trade organization, has advocated that $10 billion in federal funding go to expedited testing, as well as staffing.
In San Diego, the county health department offers up testing kits to senior facilities that cannot otherwise obtain them. While a critical service, some facilities aren’t equipped to administer tests.
Cyndy Minnery, a consultant for the senior care industry, got called to help a San Diego assisted-living facility swiftly test all residents and staff. One staff member had contracted COVID-19, and a resident there showed symptoms.
In search of test kits and unsure where to turn, Minnery phoned various contacts, and finally found a county official who could help. The county offered to provide tests, but it was up to the facility to administer them — a problem because the site doesn’t employ nurses, a common situation in the nonmedical assisted living industry.
So Minnery tapped her daughter, an emergency room nurse, to perform the nasal swab tests on May 8. The county ran the tests. Four residents came back COVID-19 positive. They were isolated to prevent the spread of the virus.
Although testing worked out in this instance, Minnery said it was at best an imperfect solution. “We’ve got to have reliable tests that nonmedical staff can use,” she said.
The county’s public health department pairs testing with infection control support and contact tracers tasked with documenting who the infected may have encountered.
Amid plans for wider senior home testing, the county said key details are forthcoming, such as retesting frequency.
Los Angeles requires monthly testing in nursing homes — far from frequent enough, said Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“What does once a month tell you?” asked Osterholm during a webinar hosted by USC Annenberg Center for Health Journalism.
Osterholm said too much attention is given to testing volumes and not enough on the purpose of a test, how accurate it is and interpreting the data.
He said a test that positively registers 95 percent of COVID-19 cases could be helpful in the wider community. But that same test isn’t as helpful in a senior facility where missing 5 percent of cases could lead to quick spread among a frail population.
“Suddenly, that’s a match in the gas can,” he said.
Jared Whitlock reported this story with support from the 2019 Impact Fund, a program of the USC Annenberg Center for Health Journalism .