Older people are at higher risk for COVID-19. So are people with chronic medical conditions, such as heart disease, diabetes, kidney disease and respiratory illness. Both groups are heavily represented among the nation's 1.3 million nursing home residents.
That concentration is a key reason why 35 percent of U.S. deaths from COVID-19 have occurred in nursing homes and other long-term care facilities, according to tracking by the Kaiser Family Foundation. But it's not the only one. A number of conditions at nursing homes can exacerbate the spread of the disease:
- shortages of personal protective equipment (PPE) such as masks and gowns
- frequent physical contact between residents and staff
- employees who work in multiple facilities, increasing chances for exposure
- residents sharing rooms
- transfers of residents from hospitals and other settings
These factors make nursing homes potential breeding grounds for viral and bacterial diseases, especially given chronic problems with infection control that predate the pandemic. A May 2020 report from U.S. Government Accountability Office found that 4 in 5 nursing homes surveyed between 2013 and 2017 were cited for deficiencies in infection prevention and control, leading the Centers for Medicare & Medicaid Services (CMS) to announce tougher rules for infection-control inspections and enforcement.
What's being done about it?
Residents and staff at nursing homes were in the first priority group to get vaccinated as COVID-19 shots rolled out in December and January. Health protocols such as masking, social distancing and hand hygiene have been in place at long-term care facilities throughout the crisis, and federal guidelines direct them to test staff for COVID-19 regularly and test residents whenever there's an outbreak on-site.
Early in the pandemic, as the scale of the toll in nursing homes became clear, facilities essentially shut their doors in an effort to curb coronavirus entry and spread, instituting strict limits on visitation, suspending group activities like communal dining and requiring PPE for staff.
In September 2020, the CMS recommended that nursing homes ease some restrictions if a facility or its surrounding community is not experiencing a COVID outbreak. In March, it issued new guidance to further ease limits, urging the resumption of indoor visits in most circumstances.
How are nursing home residents getting COVID-19 vaccines?
The federal government contracted with CVS and Walgreens to vaccinate residents and staff at nursing homes and other long-term care facilities nationwide. Regional pharmacy chains are also taking part in several states.
The participating companies started administering the two-dose Pfizer or Moderna vaccines at free clinics at long-term care sites in late December. Nationally, almost all nursing homes have completed their vaccination clinics, as have most assisted living and other long-term care facilities. The program is projected to wrap up by late March.
Can I visit my loved one in a nursing home?
Possibly. The CMS issued revised guidelines March 10 that call on states to allow indoor visits at long-term care facilities with only a few exceptions — for example, if the resident you want to see has COVID-19 or is unvaccinated and his or her facility is located in county with a high coronavirus transmission rate.
Pending state adoption of the new recommendations, long-term care facilities have generally continued to follow the prior federal guidance to restrict indoor visits unless the facility has been COVID-free for at least 14 days or is in a county with a coronavirus-test positive rate under 10 percent. When COVID cases and deaths surged nationally in the fall and early winter, many nursing homes effectively went back into lockdown.
Where visits are happening, they are often tightly controlled. Facilities may require advance scheduling, set time limits on visits, perform temperature checks and other health screening of visitors, and enforce rules on masking and physical distancing. Some may want visitors to get a coronavirus test for indoor visits, especially in communities with high transmission rates. Restrictions may be looser for outdoor visits, since the risk of viral spread is considerably lower outside. The CMS continues to recommend these steps in its new guidance.
If your loved one needs help with daily activities such as eating and grooming, or is showing signs of physical decline or emotional distress from extended isolation, you may be able to arrange longer or more frequent "compassionate care” or “essential caregiver” visits, even if their facility is in outbreak status. Under the new guidance, the CMS says that compassionate care visits “should be allowed at all times for any resident (vaccinated or unvaccinated).” Contact the facility or your local long-term care ombudsman for information on these options.
What can I do to support my loved one?
Stay connected. It's crucial for your loved one's well-being — physically and emotionally. Isolation “can have very real and serious health impacts” for nursing home residents, says Megan O'Reilly, AARP's vice president of health and family.
Where in-person visiting is difficult, try virtual visits using video-chat or videoconferencing platforms like Zoom, FaceTime and Skype to stay in touch. Ask the nursing home what it can do to facilitate communication. Does it have tablets residents can use for televisits? Can staff help those who have mobile devices but aren't familiar with video-chat apps?
Use tech to do more than just check in. With smartphone cameras and video apps, you can take a locked-down loved one for a walk, share a virtual meal or watch a movie together. Also think about non-digital ways to boost morale, like sending handwritten cards or arranging a delivery from their favorite restaurant. (Not all facilities allow this, so check first.)
You can also support loved ones by staying informed about what's going on at their facility. Identify a point of contact on staff for when you have questions and concerns. AARP has a list of eight key questions to ask about circumstances at your loved one's nursing home.
Will the nursing home tell me if people there are infected?
The CMS requires nursing homes to tell residents and their families or representatives within 12 hours if a COVID-19 case is confirmed on-site. The information must also be reported to the Centers for Disease Control and Prevention (CDC) and is compiled in an online dataset where you can search for week-by-week case numbers at individual facilities.
AARP and other advocates for older adults are calling for greater transparency around nursing homes’ COVID status, including case breakdowns by race and ethnicity and publicly available data on the percentage of residents and staff members who have been vaccinated, by state and by facility.
"If a family member or friend plans to visit their loved one, they should have a clear picture of the relative risk,” Nancy LeaMond, AARP's chief advocacy and engagement office, wrote in a Feb. 23 letter to the CMS.
Don't be shy about contacting the nursing home to ask if it's had cases and deaths and about what protective measures it's taking. If the facility is not forthcoming or if you have a concern or complaint, contact your state's long-term care ombudsman.
How are nursing homes regulated?
They are regulated by the federal government, specifically the Centers for Medicare & Medicaid Services, in collaboration with the states.
State survey agencies conduct inspections of nursing homes on behalf of the CMS to check that they're complying with federal laws and standards in areas such as staffing, hygiene, record keeping, and residents’ care and supervision. Facilities must be deemed compliant to be certified by the CMS and eligible for payments from Medicare and Medicaid. State surveyors also ensure compliance with state laws, which frequently go beyond federal requirements.
In 2019, the CMS proposed rolling back what it deemed “excessively burdensome regulations” on nursing homes. The proposals, which are still pending, include relaxing rules on documenting grievances and investigations; requiring facilities to conduct assessments of staff and resource needs every two years rather than annually; and allowing them to use consultants for infection prevention rather than hiring at least one part-time staff member for that purpose.
AARP and other advocates for seniors have voiced opposition to many of the proposals.
What if I have a complaint or concern?
First, try talking to the nursing home. Learn as much as you can about the situation you want to address, and have specific questions ready. AARP has extensive coverage of the crisis in nursing homes and resources on broader issues concerning long-term care.
If the facility is not responsive, reach out to your state's long-term care ombudsman. Ombudsmen programs were established by the federal Older Americans Act in all 50 states, plus the District of Columbia, Puerto Rico and Guam, to address problems related to the health, safety, welfare and rights of residents of nursing homes and long-term care communities.
Staff and volunteers at ombudsmen offices advocate for residents of long-term care facilities, and investigate and resolve complaints. AARP has a directory where you can find contact information and a website link for your state ombudsman.
If an issue persists, you can file a complaint with your state survey agency, which inspects nursing homes to determine if they're complying with CMS regulations. Keep in mind that infection control is getting priority attention, so other concerns may take longer to resolve.
What are nursing home residents’ rights?
The CMS has a list of residents’ rights and protections under federal and state laws. Broadly speaking, these include the right to:
- be treated with dignity and respect
- be free from abuse, neglect and discrimination
- have friends and family visit and participate in your care
- take part in activities
- make complaints without fear of punishment
- receive proper medical care
- have a doctor, family member or legal representative notified of changes in your condition or treatment
Keep in mind that state statutes on resident rights often go beyond federal rights. But rights related to visitation and activities are being restricted as part of efforts to curb the spread of COVID-19. The National Consumer Voice for Quality Long Term Care, an advocacy group that focuses on care issues, has a fact sheet on how the pandemic is affecting rights and rules in nursing homes.
Do these answers apply to other long-term-care facilities, like assisted living?
Many assisted living facilities and other senior care communities also implemented lockdowns and other restrictions to combat COVID-19. The CDC issued recommendations for assisted living facilities that mirror much of its guidance for nursing homes on controlling the disease, including restrictions on outside visitors and group activities and regular screening of staff for symptoms.
Unlike nursing homes, however, assisted living facilities are generally not subject to federal oversight. For example, the CMS rules on disclosing COVID-19 cases to residents and family members do not apply to assisted living facilities, which are licensed by the states.
If you have a loved one in an assisted living community and have questions or concerns about its COVID-19 caseload and response, contact the facility and ask to speak to an administrator. You can also bring issues to your state's department of health or department of aging.
Editor’s Note: This story has been updated to reflect new information.