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 30 percent of U.S. deaths from COVID-19 have occurred among residents and staff at 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:
- 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
- shortages of personal protective equipment (PPE) such as masks and gowns
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 the 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 to 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 and then again in April, thanks to high vaccination rates among residents and declining COVID-19 cases, it issued updated guidance to further ease limits, urging the resumption of indoor visits and communal dining and activities 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 long-term care facilities have completed their vaccination clinics.
To ensure long-term care facilities still have access to COVID-19 vaccines — for new residents and staff or for residents and staff who were initially hesitant to receive the shots — the federal government is continuing to allocate vaccines to pharmacies partnered with long-term care facilities.
Can I visit my loved one in a nursing home?
Most likely, yes. With federal vaccination clinics at long-term care facilities nearing completion and their death rates plummeting, 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 a county with a high coronavirus transmission rate. Most states have adopted the new recommendations.
But, where visits are happening, there are often still restriction. 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 for those who are not fully vaccinated.
Federal guidelines do not require nursing home visitors to be vaccinated against COVID-19, although the CMS encourages them to do so when they have the opportunity. Certain privileges may be granted to vaccinated visitors, such as being able to unmask with a vaccinated resident in a private setting, as recommended by the Centers for Disease Control and Prevention (CDC) in late April.
The guidelines also do not require visitors to be tested for COVID-19, although they do suggest that facilities in areas with medium or high coronavirus transmission rates offer tests on-site where feasible or encourage visitors to get tested on their own, so that people who are infected but asymptomatic don't unknowingly infect others.
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?
Consider getting yourself and your loved one in a nursing home vaccinated against COVID-19. Vaccination greatly reduces people’s risk of contracting the virus and keeps those who do contract it from getting seriously ill, the CDC says. Also, once you or your loved one in a nursing home is fully vaccinated, fewer restrictions may apply. For example, you both can unmask in certain settings.
In facilities that are able to loosen visitation restrictions, use these newfound liberties to engage and connect with your loved one in a safe way. Socialization is crucial for residents’ well-being — physically and emotionally — particularly after more than a year of the pandemic. 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.
As restrictions loosen, communal life is also slowly starting to return to these facilities, so encourage your loved one to participate in group dining or activities in a safe manner. One of the recent challenges for nursing homes is reengaging residents who are experiencing increased rates of depression or worsened physical debilities caused by extended isolation during the lockdown, says Carla Perissinotto, M.D., associate chief of clinical programs in geriatrics at the University of California, San Francisco.
But finding ways to reengage residents is critical, she says. Isolation and loneliness are associated with a roughly 50 percent increased risk of developing dementia and a nearly fourfold increased risk of death among heart failure patients, according to studies. "Be aware of who is lonely as a result of [the pandemic] and find out from each person what may help them,” Perissinotto says.
Where in-person visiting is still restricted or limited, 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 that 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 the 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 at 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 information and coverage of the crisis in nursing homes, as well as 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 some helpful resources on the rights of long-term care residents and how the pandemic may be affecting them.
Do these answers apply to other long-term-care facilities, like assisted living?
Unlike nursing homes, assisted living and other senior care facilities are regulated by their state rather than the federal CMS. Therefore, they 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.
But many assisted living facilities and other senior care communities have implemented lockdowns and other restrictions to combat COVID-19 that mirror much of the federal COVID-19 guidance for nursing homes, including restrictions on outside visitors and group activities, and regular screening of staff for symptoms.
CDC guidance for nursing homes generally also applies to other long-term care facilities. 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.