(CNN)In the middle of the night, Stefania Silvestri lies in bed remembering her elderly patients' cries.
"Please don't leave me."
"I need my family."
Months of caring for older adults in a Rhode Island nursing home ravaged by Covid-19 have taken a steep toll on Silvestri, 37, a registered nurse.
She can't sleep, as she replays memories of residents who became ill and died. She has gained 45 pounds. "I have anxiety. Some days I don't want to get out of bed," she said.
Now, as the coronavirus surges around the country, Silvestri and hundreds of thousands of workers in nursing homes and assisted living centers are watching cases rise in long-term care facilities with a sense of dread.
Many of these workers struggle with grief over the suffering they've witnessed, both at work and in their communities. Some, like Silvestri, have been infected with Covid-19 and recovered physically -- but not emotionally.
Since the start of the pandemic, more than 616,000 residents and employees at long-term care facilities have been struck by Covid-19, according to the latest data from KFF. Just over 91,000 have died as the coronavirus has invaded nearly 23,000 facilities. (KHN is an editorially independent program of KFF.)
At least 1,000 of those deaths represent certified certified nursing assistants, nurses and other people who work in institutions that care for older adults, according to a recent analysis of government data by Harold Pollack, a professor at the School of Social Service Administration at the University of Chicago. This is almost certainly an undercount, he said, because of incomplete data reporting.
How are long-term care workers affected by the losses they're experiencing, including the deaths of colleagues and residents they've cared for, often for many years?
Edwina Gobewoe, a certified nurse assistant who has worked at Charlesgate Nursing Center in Providence, Rhode Island, for nearly 20 years, acknowledged, "It's been overwhelming for me, personally."
At least 15 residents died of Covid-19 at Charlesgate from April to June, many of them suddenly. "One day, we hear our resident has breathing problems, needs oxygen, and then a few days later they pass," she said. "Families couldn't come in. We were the only people with them, holding their hands. It made me very, very sad."
Every morning, Gobewoe would pray with a close friend at work. "We asked the Lord to give us strength so we could take care of these people who needed us so much." When Kallon was struck by Covid-19, Gobewoe prayed for her recovery and was glad when she returned to work several weeks later.
But sorrow followed in early September: Gobewoe's friend collapsed and died at home while complaining of unusual chest pain. Gobewoe was told that her death was caused by blood clots, which can be a dangerous complication of Covid-19.
She would "do anything for any resident," Gobewoe remembered, sobbing. "It's too much, something you can't even talk about," describing her grief.
I first spoke to Kim Sangrey, 52, of Lancaster, Pennsylvania, in July. She was distraught over the deaths of 36 residents in March and April at the nursing home where she has worked for several decades -- most of them due to Covid-19 and related complications. Sangrey, a recreational therapist, asked me not to name the home, where she continues to be employed.
"You know residents like family -- their likes and dislikes, the food they prefer, their families, their grandchildren," she explained. "They depend on us for everything."
When Covid-19 hit, "it was horrible," she said. "You'd go into residents' rooms and they couldn't breathe. Their families wanted to see them, and we'd set up Zoom wearing full gear, head to toe. Tears are flowing under your mask as you watch this person that you loved dying -- and the family mourning their death through a tablet."
"It was completely devastating. It runs through your memory -- you think about it all the time."
Mostly, Sangrey said, she felt empty and exhausted. "You feel like this is never going to end -- you feel defeated. But you have to continue moving forward," she told me.
Three months later, when we spoke again, Covid-19 cases were rising in Pennsylvania but Sangrey sounded resolute. She'd had six sessions with a grief counselor and said it had become clear that "my purpose at this point is to take every ounce of strength I have and move through this second wave of Covid."
"As human beings, it is our duty to be there for