Inside the nursing home with the most COVID-19 deaths in the Prince William Health District, as recently as June 24 nurses were complaining about a lack of personal protective equipment when treating COVID-positive residents.

That’s according to a Virginia Department of Health report from earlier this month about the situation at Birmingham Green in Manassas, where as of Wednesday there had been 132 confirmed cases of COVID-19 and 33 related deaths. That’s the third most coronavirus-related deaths at any long-term care facility Northern Virginia, and the fourth most in the state.

Required by federal certification rules, the inspection led by the health department’s Office of Licensure and Certification followed two COVID-positive residents and those who treated them. At the time, the facility had 97 COVID-positive residents, 59 of whom had recovered. In addition, 43 staff cases had been detected, indicating that the facility may have been short-staffed at the time.

State inspectors logged one nursing assistant who was caring for two COVID-positive patients wearing an isolation gown, gloves and a surgical mask. When asked whether she also wore a face shield when caring for positive residents, she told the inspector that a doctor from a nearby hospital told the nurses they needed only a surgical mask.

She said nurses were given a new mask every three days, but an equipment sign-out sheet showed she had last been given one June 16 — a little more than a week earlier. According to the sheet, no N95 masks — which need to be individually fitted — or face shields had been recently distributed.

“I was fit-tested for an N95 and also had a face shield, but was told they were costly and didn’t need them,” the report quotes the nurse as saying. “I don’t feel comfortable being in such close contact with the COVID residents, but I pray I remain COVID-free.”

According to health department and CDC guidelines, the preferred COVID-19 personal protective equipment (PPE) is an N95 or higher respirator with a face shield or goggles, but the “acceptable alternative” is a facemask with face shield or goggles.

During the inspection, two other nurses volunteered that they were also told that N95s and face shields weren’t necessary for treating COVID-positive patients.

In the Prince William Health District, which encompasses the county and the cities of Manassas and Manassas Park, 14 of 17 COVID-19 outbreaks have occurred at long-term care facilities, according to health department data.

Kent Brockwell, communications director for Madison+Main, a marketing and public relations firm that represents Birmingham Green, told InsideNoVa that the outside doctor had delivered the message “during the peak of the outbreak and nationwide PPE shortages. … Since then, we have received numerous updates and continuing education regarding the preferred donning and doffing of PPE from state and federal health organizations.”

The facility’s interim administrator, Joyce Raphael, told investigators June 26 that there was some kind of “disconnect” and that after being short on certain protective equipment early in the pandemic, the facility “was fully equipped with the necessary PPE to include N95s and face shields,” according to the report.

Raphael and other Birmingham Green administrative staff members also said N95 masks and face shields were being stored and distributed by the facility and that nursing staff was expected to at least wear a face shield and surgical mask when assisting a COVID-positive resident.

Raphael ultimately put the onus on the nursing staff.

“If the staff is not getting what they need, they were not telling us because the equipment is available,” she told investigators.

According to the report, VaOuida Magee, the facility’s interim nursing director, said the outside doctor had actually told nursing staff to wear a surgical mask and face shield when treating COVID-positive residents and that N95 masks were needed when delivering aerosol treatments. She said the equipment sign-out sheet may have mislabeled the N95s as simply “masks.”

“They can have one anytime they needed one, especially if it got wet inside,” Magee told inspectors, according to the report.

The on-site inspection followed a shake-up of the facility’s management. On June 1, Raphael took over the interim administrator role from Pam Clark, who was administrator for nine years. According to Birmingham Green’s June newsletter, Clark was going into “semi-retirement.” Magee, meanwhile, took over for Sibyl Goodwin, who “resigned in April,” according to the newsletter.

On July 20, the facility submitted its mandated “Plan of Correction,” which stipulated that it did not constitute agreement with the deficiencies cited in the report. In it, the facility pointed out that the two residents followed by inspectors “had no negative outcomes from staff not using preferred PPE” and ultimately recovered from the virus. And it said that on June 24, “all units were stocked with needed PPE supplies.”

State health department data indicated Wednesday that Birmingham Green had no active COVID-19 cases and the outbreak was considered “pending closure.”

Going forward, the facility’s plan said that leadership will conduct rounds to observe “and reinforce compliance with appropriate PPE utilization and resident equipment storage.”

Jared Foretek covers the Manassas area and regional news across Northern Virginia. Reach him at


Jared Foretek covers the Manassas area and regional news across Northern Virginia. Reach him at

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