Ed Singer’s mobile phone rang at 2 a.m.

Pleasant View Nursing Home was running out of oxygen, a hospital official told Singer, the health officer of rural Carroll County, Md. Without 16 additional tanks, some of the most fragile coronavirus patients might not make it through the night.

The day before, 66 of the 95 residents of the nursing home in Mount Airy, Md., had tested positive for covid-19. One, a man in his 90s, died in his bed. By morning, another resident would be gone.

The nursing home’s medical director was nowhere to be found, according to two government officials, who said the doctor later explained he was self-quarantining because he believed he had been exposed to the virus. Nurses with limited supplies and little supervision were struggling to treat rapidly deteriorating patients. Singer had spent hours the previous day searching for backup, to no avail. A paramedic who responded to a 911 call found the halls eerily quiet, with staff members masked and not talking, and ragged coughing audible from behind closed doors.

The crisis at Pleasant View is an East Coast version of the tragedy at Life Care Center of Kirkland in Kirkland, Wash., where scores of elderly patients were sickened by covid-19, and 40 died. It foreshadows challenges other nursing homes face across the country and in the greater Washington area as the pandemic bears down. As of Sunday, residents and staff at 81 Maryland nursing homes and assisted living facilities have tested positive for covid-19, Gov. Larry Hogan (R) said. Health-care workers are dangerously low on gloves, masks and other protective equipment. At one facility outside Richmond, 133 people have tested positive, and 17 have died.

In the predawn hours of last Sunday morning, Singer was able to secure 14 oxygen tanks from the Carroll County emergency medical services department. Just over 36 hours later, the Maryland National Guard arrived with doctors and supplies.

But the fast-spreading virus had already overwhelmed the nursing home’s staff and filled nearby hospitals to capacity, according to interviews with 18 people directly involved in the crisis. By Friday, 99 residents and staff had tested positive. Forty-two people were hospitalized, and six were dead. Four more people would die over the weekend.

“I was screaming at my boss, saying I needed more resources,” Singer said. “Maybe I should have screamed louder.”

The outbreak

Mount Airy is a bedroom community of 10,000 residents that sits on the border of Carroll and Frederick counties, 45 miles north of Washington, D.C. Most days, said Mayor Pat Rockinberg, it looks like something out of a Hallmark movie — a quiet town, where the most pressing emergencies are water main breaks or roving cows blocking traffic.

The nursing home sits atop a hill, a family-owned facility that has operated for more than four decades. Residents live four to a room, and 76 percent have dementia, according to the Maryland Health Care Commission. The facility received a one-star rating for staffing from Medicare, which bases its rating on nurses per patient and offers from one to five stars.

When the mayor heard on March 27 that two Pleasant View residents had tested positive for the coronavirus, he was concerned, but not alarmed. At the time, there were just nine cases in Carroll County.

“We thought we were doing fine,” said Leslie Simmons, president of Carroll Hospital, who made the 2 a.m. phone call to Singer last Sunday. She has worked at the hospital for nearly 20 years and is the executive vice president of its parent company, LifeBridge Health. “One minute you are fine, and the next minute you are not.”

Singer, a military veteran who has been the county’s top public health official since 2015, visited Pleasant View after he was told about the first two cases. Donning a gown, mask and gloves, he toured the facility.

Generally, he was satisfied. Employees were being screened when they got to work to see if they had elevated temperatures or respiratory symptoms and wearing protective gear while working with all patients. Patients with symptoms were isolated. Few were visibly ill.

Things changed the next day, March 28.

Stephen Wantz, president of the Carroll County Board of Commissioners, said he felt his stomach churn when he heard the numbers: 64 new cases, meaning nearly two-thirds of the elderly residents were ill. In his 30 years as a firefighter in Baltimore, he had run toward burning buildings. But he said he never felt as much dread as he did at that moment.

Wantz and a second county official said no one could locate the nursing home’s medical director, Nandakumar Vellanki, even as officials repeatedly attempted to call him. When they reached him, Wantz added, Vellanki told officials he had been self-quarantining because he was concerned he had been exposed to the infected patients.

In his absence, three nurses were in charge.

“The nurses were attempting to do as much as they could, but they were under no physician’s directions,” Wantz said. “From day one, there was no medical director.”

Singer declined to discuss Vellanki, saying it was for the state health department to determine whether regulations were violated. Fran Phillips, Maryland’s deputy secretary for public health, said the doctor’s conduct is “definitely something to investigate, for another day.”

When contacted by a reporter, Vellanki hung up the phone, saying he needed to see a patient. He could not be reached by a reporter after multiple attempts.

Searching for backup

Singer spent that Saturday in the county health department offices with his staff, calling potential medical volunteers listed in a state database, which has swelled by more than 5,000 names since the outbreak started. They made between 800 and 900 calls for help, Singer said, but few were willing to come, saying the situation appeared to be too dangerous.

Phillips said the state has since hired a network of health-care workers — including nursing and medical students and EMTs licensed in other states — to bolster workers at hard-hit facilities like Pleasant View.

But those resources, intended to prepare for the surge officials say is coming, were not available when Pleasant View was grappling with its response.

“It was an unprecedented situation,” Phillips said.

The county gave gowns, gloves, face shields and masks to the nursing home, and Carroll Hospital sent one of its own nurse practitioners last Saturday, along with oximeters to measure oxygen saturation in the blood, said Sharon McClernan, vice president for clinical integration at LifeBridge Health. She said the 12 intensive care beds in the hospital were filled by the end of the day.

Meanwhile, the state was struggling to set up a triage team, Singer said. With beds full at Carroll Hospital, patients were being sent elsewhere, and those hospitals were complaining about the influx of patients. Singer’s staff members were on the verge of tears.

“We were drowning,” said Wantz, the president of the board of commissioners. “Every single day, we said, ‘We need help, we need help, we need help.’ ”

Medic Ron Hewitt said he got a call last Saturday night that the nursing home had “essentially blown up.” When he drove up the long driveway, he saw dozens of flashing lights from other ambulances. There was a stillness once he came through the door.

Hewitt and his partner were escorted into a room and told the name of their patient, whom they transported to Frederick Memorial Hospital. The masked nursing home aide who was assisting them started to cough at one point. Hewitt said he and the woman made eye contact.

“It’s just a cough,” she said.

Hewitt, who was wearing protective gear of his own, was not so sure.

“You could see the doubt in her eyes,” he said. “Like, ‘What am I in the middle of?’ ”

Death, shrouded in uncertainty

Hogan announced the outbreak that Saturday night.

Tracy Shavell had her fears confirmed as she read the news reports. Her father, Gary Holmberg, had been taken from Pleasant View to Carroll Hospital the day before with a suspected case of pneumonia. When she asked staff at the nursing home if there were covid-19 cases at the facility, they told her only that there were no cases in Building A, where her father was living.

Holmberg, a 77-year-old former D.C. firefighter who had dementia, had moved into the facility in February, his daughter said. She lived nearby in Frederick and visited frequently, and sometimes thought there was not enough staff on the weekends.

In the hospital, Holmberg’s condition quickly grew worse. By the time his son, Robert Holmberg, arrived from his home in St. Mary’s County around 1 a.m. last Saturday, their father was gasping for air.

“It was the worst thing I’ve seen,” Robert Holmberg said, his voice breaking.

Gary Holmberg died Sunday at 9:30 a.m. Shavell said staff at Pleasant View told her his covid-19 test came back negative, but the hospital said the cause of death was pneumonia and possible covid-19. The family is awaiting test results from the hospital and an autopsy. “He was not supposed to go this way,” Shavell said.

The next morning, state health officials asked Singer whether the nursing home could wait until Tuesday for help. Singer said his answer was emphatic: No.

The Maryland National Guard arrived that night. Their doctors determined which patients needed to be immediately taken to hospitals, and the Maryland Institute for Emergency Medical Services Systems figured out transportation and routed them among 14 different hospitals. Meanwhile, officials said 11 more nursing home residents had tested positive — raising the tally to 77 out of the 95 people who lived there.

Hewitt’s ambulance again was summoned, along with seven others from Butler Medical Transport.

The situation at the nursing home was wildly different from two nights earlier, Hewitt said. There were triage tags on patients noting who was sick and who needed to be hospitalized.

“It went from, ‘We’re really not sure what we’re doing,’ to complete organized chaos,” he said. “You could tell the military went in there and did their thing.”

On Tuesday, Carroll County family medicine physician Daniel Aukerman arrived. He was the only physician the health department could find who was willing to treat patients at the facility. Before going to Pleasant View, he sat down with his wife and children and discussed the risks and the ramifications, but also the potential for him to help vulnerable patients.

“We talked about that no one is willing to step up,” he said. “Everyone seems to be running from this thing instead of confronting it.”

Aukerman got to the nursing home at 7 a.m. and did not leave until after 8 p.m. He has been back every day since, writing medical orders and providing oxygen support for covid-19 patients who remain at the facility. He said those who remain there have either tested negative or are positive and have signed do-not-resuscitate orders.

When Aukerman is not at Pleasant View, he is at his home in Westminster, Md., separate from his family to ensure that if he is infected with coronavirus, he does not spread it to them.

Unanswered questions

The situation at Pleasant View has stabilized, Singer said. But some of the biggest questions are still unanswered — including how the virus entered the facility and spread so rampantly.

Hogan has said it is possible an asymptomatic employee was a carrier, but Singer said it is not yet clear how the disease spread and that the county health department is just beginning contact tracing.

On Friday, the state health department ordered all staff at nursing homes and assisted living facilities across Maryland to wear protective equipment when they interact with patients. The same day, leaders at more than 30 senior living facilities sent Hogan a letter warning that they are not ready for the projected surge in cases.

They asked for immediate testing of all nursing home residents and staff, requested the state set up isolation centers to treat patients who test positive and asked the county and state to provide protective gear.

Phillips said that because testing and personal protective gear are limited, the state prioritizes testing of symptomatic patients and health-care workers and works with local health departments to get supplies to long-term care facilities.

Hogan issued an emergency order Sunday making it mandatory for staff at nursing homes and assisted living facilities to wear face masks, gloves and gowns. The order also requires nursing homes to designate specific staff members and space to treat coronavirus patients. Violators could face up to a year in jail and a fine of up to $5,000.

Nursing homes are particularly susceptible to epidemics because they serve an immunocompromised population that interacts in close quarters. Yet for years, regulatory bodies at the state and federal level have failed to emphasize infection-control measures at nursing homes, said Lona Mody, a professor of epidemiology at the University of Michigan. In part, she said, such measures can seem out of place, because unlike hospitals, a nursing home is a place of long-term residence.

“Imagine knowing a person for 10 years, maybe even seeing them as family, and having to gown up every time you see them,” Mody said. “It’s not intuitive.”

At Pleasant View, 27 employees had tested positive and 34 had tested negative as of Sunday. Singer said he is focused on ensuring that patients who remain in the facility get the care they need and that the county is prepared for the surge officials say is coming.

On Wednesday, he learned that three residents at a retirement community in the county had tested positive for the coronavirus. By Sunday, that community — Carroll Lutheran Village — had 10 more cases.

A woman in her 90s from Carroll Lutheran Village died Saturday, along with four more Pleasant View residents over the weekend: a man in his 80s, a man in his 60s and two women in their 80s.