COVID-19 and Long Term Care

Collection of articles on COVID and LTC is available here

COVID-19 and Resident Care

Rapid review of the evidence on impacts of visiting policies in care homes during the COVID-19 pandemic [Pre-Print, Not peer-reviewed]

Comas-Herrera A, Salcher-Konrad M, Baumbusch J, Farina N, Goodman C, Lorenz-Dant K, Low L-F (2020) Pre-print published in
Most countries have restricted visits to care homes to prevent COVID-19 infections, however, concern is increasing about the negative impact of these restrictions on the health and wellbeing of care home residents and their families.

We carried out a rapid review of evidence to address three questions:

What is the evidence on the impact of visitors in terms of infections in care homes?
We found no scientific evidence that visitors to care homes introduced COVID-19 infections, however during the peak of the pandemic most countries did not allow visiting and there are some anecdotal reports attributing infections to visitors before restrictions.
What is the evidence on the impact of closing care homes to visitors on the wellbeing of residents?
There is increasing evidence that care home residents experienced greater depression and loneliness and demonstrated more behavioural disturbance during the period that included visitor bans.
What has been the impact of restricting visits on quality of care?
There is evidence of substantial care provision by unpaid carers and volunteers in care homes prior to the pandemic, hence visiting restrictions may have resulted in reductions in quality of care or additional tasks for care home staff.
Given that there were already low rates of social interactions among residents and loneliness before the COVID-19 pandemic, the evidence reviewed suggests that visiting restrictions are likely to have exacerbated this further. While there is no scientific evidence identifying visitors as the source of infections this is likely to reflect that most care homes did not allow visitors during the initial peaks of the pandemic. A pilot re-opening homes to visits under strict guidelines did not result in any infections.

Allowing visitors in facilities where there are no COVID-19 cases is important to support resident wellbeing. Safeguards to reduce risk of COVID-19 infection have been described, including visits through windows/glass, outdoor visits, and well-ventilated indoor spaces, screening of visitors, use of masks and other PPE and hand hygiene and cleaning.

In addition, it is important to recognize and support the provision of unpaid care, particularly for people who pre-COVID had a history of regular visiting to provide care (e.g. feeding, grooming, emotional support). They should be classified as essential workers, provided training and PPE, and be allowed to visit regularly and provide care, interacting as closely with residents as staff.

“It’s Pure Panic”: The Portrayal of Residential Care in American Newspapers During COVID-19.
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L. D. Allen and L. Ayalon.
Gerontologist 2020 Oct 26
This study examines the discursive construction of residential care during the COVID-19 pandemic in three leading American newspapers: The New York Times, USA Today, and The New York Post. RESEARCH DESIGN AND METHODS: A total of 54 news articles between 21 January and 8 May 2020 were identified from the LexisNexis academic database for analysis. The articles were analyzed using both a critical discourse analysis approach and a thematic analytical framework. RESULTS: Findings indicate that residents’ voices are excluded and superseded by others, namely their family members. Literary elements were used to portray residential care as shockingly dangerous, deceptive, and problematic. Blame was often assigned to an individual or group according to the political tendency of the newspaper. DISCUSSION AND IMPLICATIONS: A cultural model of panic and dishonesty begins to take shape through the COVID-19 pandemic. Fearmongering and the portrayal of residential care as lacking transparency will likely create future mistrust of the industry. The depiction of vulnerability and the illusion of resident inclusion in the news coverage enable paternalistic decision-making and care practices in the name of supposed protection.

Adverse Events in Italian Nursing Homes During the COVID-19 Epidemic: A National Survey.
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F. L. Lombardo, E. Salvi, E. Lacorte, et al.
Front Psychiatry 2020 Sep 30;11:578465
Older people living in nursing homes (NHs) are particularly vulnerable in the ongoing COVID-19 pandemic, due to the high prevalence of chronic diseases and disabilities (e.g., dementia). The phenomenon of adverse events (AEs), intended as any harm or injury resulting from medical care or to the failure to provide care, has not yet been investigated in NHs during the pandemic. We performed a national survey on 3,292 NHs, either public or providing services both privately and within the national health system, out of the 3,417 NHs covering the whole Italian territory. An online questionnaire was addressed to the directors of each facility between March 24 and April 27, 2020. The list of NHs was provided by the Dementia Observatory, an online map of Italian services for people with dementia, which was one of the objectives of the implementation of the Italian National Dementia Plan. About 26% of residents in the Italian NHs for older people listed within the Dementia Observatory site had dementia. The objective of our study was to report the frequency of AEs that occurred during the months when SARS-CoV-2 spreading rate was at its highest in the Italian NHs and to identify which conditions and attributes were most associated with the occurrence of AEs by means of multivariate regression logistic analysis. Data are referred to 1,356 NHs that participated in the survey. The overall response rate was 41.2% over a time-period of six weeks (from March 24 to May 5). About one third of the facilities (444 out of 1,334) (33.3%) reported at least 1 adverse event, with a total of 2,000 events. Among the included NHs, having a bed capacity higher than the median of 60 beds (OR=1.57, CI95% 1.17-2.09; p=0.002), an observed increased in the use of psychiatric drugs (OR=1.80, CI95% 1.05-3.07; p=0.032), adopting physical restraint measures (OR=1.97, CI95% 1.47-2.64; p<0.001), residents hospitalized due to flu-like symptoms (OR =1.73, CI95% 1.28-2.32; p<0.001), and being located in specific geographic areas (OR=3.59, CI95% 1.81-7.08; OR = 2.90, CI95% 1.45-5.81 and OR = 4.02, CI05% 2.01-8.04 for, respectively, North-West, North-East and Centre vs South, p<0.001) were all factors positively associated to the occurrence of adverse events in the facility. Future recommendations for the management and care of residents in NHs during the COVID-19 pandemic should include specific statements for the most vulnerable populations, such as people with dementia.

Neuropsychiatric Symptoms in Elderly With Dementia During COVID-19 Pandemic: Definition, Treatment, and Future Directions.
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A. Simonetti, C. Pais, M. Jones, et al.
Front Psychiatry 2020 Sep 29;11:579842
Neuropsychiatric symptoms (NPS) of dementia, such as anxiety, depression, agitation, and apathy, are complex, stressful, and costly aspects of care, and are associated to poor health outcomes and caregiver burden. A steep worsening of such symptoms has been reported during Coronavirus Disease 2019 (COVID-19) pandemic. However, their causes, their impact on everyday life, and treatment strategies have not been systematically assessed. Therefore, the aim of this review is to provide a detailed description of behavioral and psychopathological alterations in subjects with dementia during COVID-19 pandemic and the associated management challenges. METHODS: A PubMed search was performed focusing on studies reporting alterations in behavior and mood and treatment strategies for elderly patients with dementia, in accordance with PRISMA guidelines. The following search strategy was utilized: (COVID* OR coronavirus OR “corona vir*” OR SARS-CoV-2) AND (dementia OR demented OR dement* OR alzheimer* OR “pick’s disease” OR “lewy body” OR “mild cognitive” OR mild cognitive impairment OR MCI). RESULTS: Apathy, anxiety and agitation are the most frequently NPS during the COVID-19 pandemic and are mainly triggered by protracted isolation. Most treatment strategies rely on pharmacotherapy; technology is increasingly utilized with mixed results. CONCLUSIONS: NPS of dementia during COVID-19 appear to arise from social restrictions occurring as a consequence of the pandemic. Implementation of caregiver support and the presence of skilled nursing home staff are required to restore social interaction and adjust technological support to the patients’ needs.

Quality Improvement

Position paper of the Austrian Alzheimer Association (Österreichische Alzheimer Gesellschaft, ÖAG) : Effects of the COVID-19 pandemic in Austria on people with dementia and their care environment-problem areas, recommendations, and strategies.
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M. Defrancesco, C. Bancher, P. Dal-Bianco, et al.
Neuropsychiatr 2020 Oct 29
Older adults are particularly affected by the current COVID-19 (SARS-CoV-2) pandemic. The risk of dying from COVID-19 increases with age and is often associated with pre-existing health conditions. Globally, more than 50 million-in Austria currently approximately 140,000 people-suffer from dementia. The co-occurrence of dementia as a “pandemic of old age” together with the COVID-19 pandemic has a double impact on persons living with dementia and their caregivers. The COVID-19 pandemic poses major challenges for individuals with dementia and their caregivers: (1) People with dementia have limited access to information on COVID-19, may have difficulties with protective measures such as wearing masks and in remembering safety regulations. (2) People with dementia live alone or with their family, or are institutionalized. To reduce the chance of infection among older people in nursing homes, Austrian local authorities have banned visitors to nursing homes and long-term care facilities and implemented strict social-distancing measures. As a result, older people lost face-to-face contact with their family members, became isolated and social activities stopped. Consequently, anxiety, stress and serious concerns about infections among staff in nursing homes increased and they developed signs of exhaustion and burnout during the full lockdown of the facilities. Thus, due to the emerging COVID-19 crisis, the Austrian Alzheimer Association (Österreichische Alzheimer Gesellschaft, ÖAG) and international societies developed recommendations to support people living with dementia and their caregivers on various issues of physical and mental health.

The Japan Geriatrics Society consensus statement “recommendations for older persons to receive the best medical and long-term care during the COVID-19 outbreak-considering the timing of advance care planning implementation”.
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Japan Geriatrics Society Subcommittee on End-of-Life Issues and New Coronavirus Countermeasure Team, M. Kuzuya, K. Aita, et al.
Geriatr Gerontol Int 2020 Nov 2
Since the end of 2019, a life-threatening infectious disease (coronavirus disease 2019: COVID-19) has spread globally, and numerous victims have been reported. In particular, older persons tend to suffer more severely when infected with a novel coronavirus (SARS-CoV-2) and have higher case mortality rates; additionally, outbreaks frequently occur in hospitals and long-term care facilities where most of the residents are older persons. Unfortunately, it has been stated that the COVID-19 pandemic has caused a medical collapse in some countries, resulting in the depletion of medical resources, such as ventilators, and triage based on chronological age. Furthermore, as some COVID-19 cases show a rapid deterioration of clinical symptoms and accordingly, the medical and long-term care staff cannot always confirm the patient’s values and wishes in time, we are very concerned as to whether older patients are receiving the medical and long-term care services that they wish for. It was once again recognized that it is vital to implement advance care planning as early as possible before suffering from COVID-19. To this end, in August 2020, the Japan Geriatrics Society announced ethical recommendations for medical and long-term care for older persons and emphasized the importance of conducting advance care planning at earlier stages. Geriatr Gerontol Int 2020

Dealing with COVID-19 Outbreaks in Long-term Care Homes: A Protocol for Room Moving and Cohorting.
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D. Kain, L. McCreight and J. Johnstone.
Infect Control Hosp Epidemiol 2020 Oct 28:1-4
As we prepare for a second wave of disease in many countries, having clear guidance for homes on ways to safely move residents is critical to prevent such large scale outbreaks. We hope this guidance will serve as a template for long-term care homes moving forward.

COVID-19 outbreak in long-term care facilities from Spain. Many lessons to learn.
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M. Mas Romero, A. Avendaño Céspedes, M. T. Tabernero Sahuquillo, et al.
PLoS One 2020 Oct 27;15(10):e0241030
To analyze mortality, costs, residents and personnel characteristics, in six long-term care facilities (LTCF) during the outbreak of COVID-19 in Spain. DESIGN: Epidemiological study. SETTING: Six open LTCFs in Albacete (Spain). PARTICIPANTS: 198 residents and 190 workers from LTCF A were included, between 2020 March 6 and April 5. Epidemiological data were also collected from six LTCFs of Albacete for the same period of time, including 1,084 residents. MEASUREMENTS: Baseline demographic, clinical, functional, cognitive and nutritional variables were collected. 1-month and 3-month mortality was determined, excess mortality was calculated, and costs associated with the pandemics were analyzed. RESULTS: The pooled mortality rate for the first month and first three months of the outbreak were 15.3% and 28.0%, and the pooled excess mortality for these periods were 564% and 315% respectively. In facility A, the percentage of probable COVID-19 infected residents were 33.6%. Probable infected patients were older, frail, and with a worse functional situation than those without COVID-19. The most common symptoms were fever, cough and dyspnea. 25 residents were transferred to the emergency department, 21 were hospitalized, and 54 were moved to the facility medical unit. Mortality was higher upon male older residents, with worse functionality, and higher comorbidity. During the first month of the outbreak, 65 (24.6%) workers leaved, mainly with COVID-19 symptoms, and 69 new workers were contracted. The mean number of days of leave was 19.2. Costs associated with the COVID-19 in facility A were estimated at € 276,281/month, mostly caused by resident hospitalizations, leaves of workers, staff replacement, and interventions of healthcare professionals. CONCLUSION: The COVID-19 pandemic posed residents at high mortality risk, mainly in those older, frail and with worse functional status. Personal and economic costs were high.

Halting a SARS-CoV-2 Outbreak in a U.S. Veterans Affairs Nursing Home.
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G. Psevdos, A. Papamanoli, N. Barrett, et al.
Am J Infect Control 2020 Nov 3
A Veterans Affairs long term care facility on Long Island New York was confronted with a COVID-19 outbreak in late March to Mid-April 2020. Faced with a dwindling supply of PPE, the Infection Control team distributed supplies saved for a possible Ebola outbreak; A COVID unit was created within the nursing home facilitating the geographic isolation of cases; universal testing of residents and employees allowed for the implementation of proper quarantine measures. It was a multidisciplinary team approach led by the Infection Control team that successfully contained this outbreak.

Health Care Administration and Organization

Comparative Performance of Private Equity-Owned US Nursing Homes During the COVID-19 Pandemic.
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R. T. Braun, H. Yun, L. P. Casalino, et al.
JAMA Netw Open 2020 Oct 1;3(10):e2026702
It is not known whether nursing homes with private equity (PE) ownership have performed better or worse than other nursing homes during the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To evaluate the comparative performance of PE-owned nursing homes on COVID-19 outcomes. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of 11 470 US nursing homes used the Nursing Home COVID-19 Public File from May 17, 2020, to July 2, 2020, to compare outcomes of PE-owned nursing homes with for-profit, nonprofit, and government-owned homes, adjusting for facility characteristics. EXPOSURE: Nursing home ownership status. MAIN OUTCOMES AND MEASURES: Self-reported number of COVID-19 cases and deaths and deaths by any cause per 1000 residents; possessing 1-week supplies of personal protective equipment (PPE); staffing shortages. RESULTS: Of 11 470 nursing homes, 7793 (67.9%) were for-profit; 2523 (22.0%), nonprofit; 511 (5.3%), government-owned; and 543 (4.7%), PE-owned; with mean (SD) COVID-19 cases per 1000 residents of 88.3 [2.1], 67.0 [3.8], 39.8 [7.6] and 110.8 [8.1], respectively. Mean (SD) COVID-19 deaths per 1000 residents were 61.9 [1.6], 66.4 [3.0], 56.2 [7.3], and 78.9 [5.9], respectively; mean deaths by any cause per 1000 residents were 78.1 [1.3], 91.5 [2.2], 67.6 [4.5], and 87.9 [4.8], respectively. In adjusted analyses, government-owned homes had 35.5 (95% CI, -69.2 to -1.8; P = .03) fewer COVID-19 cases per 1000 residents than PE-owned nursing homes. Cases in PE-owned nursing homes were not statistically different compared with for-profit and nonprofit facilities; nor were there statistically significant differences in COVID-19 deaths or deaths by any cause between PE-owned nursing homes and for-profit, nonprofit, and government-owned facilities. For-profit, nonprofit, and government-owned nursing homes were 10.5% (9.1 percentage points; 95% CI, 1.8 to 16.3 percentage points; P = .006), 15.0% (13.0 percentage points; 95% CI, 5.5 to 20.6 percentage points; P < .001), and 17.0% (14.8 percentage points; 95% CI, 6.5 to 23.0 percentage points; P < .001), respectively, more likely to have at least a 1-week supply of N95 masks than PE-owned nursing homes. They were 24.3% (21.3 percentage points; 95% CI, 11.8 to 30.8 percentage points; P < .001), 30.7% (27.0 percentage points; 95% CI, 17.7 to 36.2 percentage points; P < .001), and 29.2% (25.7 percentage points; 95% CI, 16.1 to 35.3 percentage points; P < .001) more likely to have a 1-week supply of medical gowns than PE-owned nursing homes. Government nursing homes were more likely to have a shortage of nurses (6.9 percentage points; 95% CI, 0.0 to 13.9 percentage points; P = .049) than PE-owned nursing homes. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, PE-owned nursing homes performed comparably on staffing levels, resident cases, and deaths with nursing homes with other types of ownership, although their shortages of PPE may warrant monitoring.

Attitudes and Experiences of Frontline Nursing Home Staff Towards Coronavirus Testing.

Spencer Hofschulte-Beck, Susan E. Hickman, Justin L. Blackburn, Laramie M. Mack and Kathleen T. Unroe.
Journal of the American Medical Directors Association 2020/11
The Indiana State Department of Health tested nursing home staff for COVID-19 in June 2020. A survey of staff found many felt physical discomfort, some questioned testing the asymptomatic, but a majority agreed testing is important.; The Indiana State Department of Health tested nursing home staff for COVID-19 in June 2020. A survey of staff found many felt physical discomfort, some questioned testing the asymptomatic, but a majority agreed testing is important.

Exploring the N95 and Surgical Mask Supply in U.S. Nursing Homes During COVID-19.
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Y. Li, F. Fang and M. He.
J Appl Gerontol 2020 Oct 26:733464820969015
U.S. health care facilities have been encountering a recurrence of medical supply shortage since COVID-19 exploded in March 2020. There is an urgent need for important Personal Protective Equipment (PPE) such as N95 and surgical masks. This project examined the factors that were associated with nursing homes’ N95 and surgical mask supply. We analyzed data from the Nursing Home COVID-19 Public File and conducted a multivariate logistic regression estimating the association between nursing home characteristics and county-level demographic parameters with mask supply. We found that a high number of resident COVID-19 cases contributed to the supply of N95, but not surgical masks, whereas a high number of staff cases did not lead to an adequate supply of either N95 or surgical masks. Compared with not-for-profit (NFP) facilities, for-profit (FP) nursing homes were less likely to get enough masks. A better supply distribution plan is needed to prepare for future possible PPE shortage.

COVID-19 Test Result Turnaround Time for Residents and Staff in US Nursing Homes.
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B. E. McGarry, G. K. SteelFisher, D. C. Grabowski and M. L. Barnett.
JAMA Intern Med 2020 Oct 30
This cross-sectional study examines trends in test result turnaround rates for COVID-19 testing nursing facility residents and staff in hot spot counties in the US.

Prevalence and Spread

Rapid Review: What risk factors are associated with COVID-19 outbreaks and mortality in long-term care facilities and what strategies mitigate risk?

National Collaborating Centre for Methods and Tools. 2020, October 16
This rapid review was produced to support public health decision makers’ response to the COVID-19 pandemic. This review seeks to identify, appraise, and summarize emerging research evidence to support evidence-informed decision making. This rapid review includes evidence available up to October 5, 2020 to answer the question: What risk factors are associated with COVID-19 outbreaks and mortality in LTC facilities and what strategies mitigate risk?

Time to Stop the Tragedy in Spanish Nursing Homes during the COVID-19 Pandemi
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M. Bernabeu-Wittel, R. Gómez-Huelgas, M. D. Nieto-Martín and SEMI-COVID-19 Network.
J Am Geriatr Soc 2020 Nov 12
This novel disease (COVID-19) is more serious in older persons; those over 65 years make up 45-50% of all hospitalizations and 80% of all deaths. Additionally, one of the most critical settings for its propagation are NH, which are highly vulnerable to COVID-19 outbreaks. Nevertheless, data assessing the impact of COVID-19 in NH populations are scarce. Given this dearth of evidence, we have analyzed patients hospitalized with COVID-19 who live in NH from a multicenter registry sponsored by the Spanish Society of Internal Medicine (Ethics Committee Approval reference SEMI-COVID-19). This consecutive cohort includes patients who were admitted to 132 healthcare centers. Seventy percent of all patients requiring care in Spanish hospitals were attended to by internal medicine departments.

August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19.
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H. Blain, Y. Rolland, J. M. G. A. Schols, et al.
Eur Geriatr Med 2020 Nov 3:1-15
The European Geriatric Medicine Society (EuGMS) is launching a second interim guidance whose aim is to prevent the entrance and spread of COVID-19 into long-term care facilities (LTCFs). METHODS: The EuGMS gathered experts to propose a guide of measures to prevent COVID-19 outbreaks in LTCFs. It is based on the specific features of SARS-CoV-2 transmission in LTCFs, residents’ needs, and on experiences conducted in the field. RESULTS: Asymptomatic COVID-19 residents and staff members contribute substantially to the dissemination of COVID-19 infection in LTCFs. An infection prevention and control focal point should be set up in every LTCF for (1) supervising infection prevention and control measures aimed at keeping COVID-19 out of LTCFs, (2) RT-PCR testing of residents, staff members, and visitors with COVID-19 symptoms, even atypical, and (3) isolating subjects either infected or in contact with infected subjects. When a first LCTF resident or staff member is infected, a facility-wide RT-PCR test-retest strategy should be implemented for detecting all SARS-CoV-2 carriers. Testing should continue until no new COVID-19 cases are identified. The isolation of residents should be limited as much as possible and associated with measures aiming at limiting its negative effects on their mental and somatic health status. CONCLUSIONS: An early recognition of symptoms compatible with COVID-19 may help to diagnose COVID-19 residents and staff more promptly. Subsequently, an earlier testing for SARS-CoV-2 symptomatic and asymptomatic LTCF staff and residents will enable the implementation of appropriate infection prevention and control. The negative effects of social isolation in residents should be limited as much as possible.

Coronavirus disease 2019 (COVID-19) in long-term care facilities: A review of epidemiology, clinical presentations, and containment interventions.
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C. G. Gmehlin and L. S. Munoz-Price.
Infect Control Hosp Epidemiol 2020 Oct 26:1-6
Long-term care facilities (LTCFs) and their populations have been greatly affected by the coronavirus disease 2019 (COVID-19) pandemic. In this review, we summarize the literature to describe the current epidemiology of COVID-19 in LTCFs, clinical presentations and outcomes in the LTCF population with COVID-19, containment interventions, and the role of healthcare workers in SARS-CoV-2 transmission in these facilities.

Nothing much has changed: COVID-19 nursing home cases and deaths follow fall surges.
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R. T. Konetzka and R. J. Gorges.
J Am Geriatr Soc 2020 Nov 12
Our objective in this study was to examine whether the most recent (September/October) surge in community spread was associated with a surge in nursing home cases and deaths; in other words, to assess whether nursing homes have become better equipped to avoid outbreaks.

Unravelling the modes of transmission of SARS-CoV-2 during a nursing home outbreak: looking beyond the church super-spread event.
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H. A. C. M. Voeten, R. S. Sikkema, M. Damen, et al.
Clin Infect Dis 2020 Oct 29
An outbreak of COVID-19 in a nursing home in the Netherlands, following an on-site church service held on March 8 th, 2020, triggered an investigation to unravel sources and chain(s) of transmission. METHODS: Epidemiological data were collected from registries and through a questionnaire among church attendees. Symptomatic residents and healthcare workers (HCWs) were tested for SARS-CoV-2 by RT-PCR and subjected to whole genome sequencing (WGS). Sequences from a selection of people from the same area were included as community reference. RESULTS: After the church service, 30 of 39 attendees (77%) developed symptoms; 14 were tested and were positive for COVID-19 (11 residents and 3 non-residents). In the following five weeks, 62 of 300 residents (21%) and 30 of 640 HCWs (5%) tested positive for COVID-19; 21 of 62 residents (34%) died. The outbreak was controlled through a cascade of measures. WGS of samples from residents and HCWs identified a diversity of sequence types, grouped into eight clusters. Seven resident church attendees all were infected with distinct viruses, four of which belonged to two larger clusters in the nursing home. CONCLUSIONS: Although initial investigation suggested the church service as source of the outbreak, detailed analysis showed a more complex picture, most consistent with widespread regional circulation of the virus in the weeks before the outbreak, and multiple introductions into the nursing home before the visitor ban. The findings underscore the importance of careful outbreak investigations to understand SARS-CoV-2 transmission to develop evidence-based mitigation measures.