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 almost a quarter of U.S. deaths from COVID-19 have occurred among residents and staff at long-term care facilities, representing more than 200,000 pandemic victims, according to 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
- lagging COVID-19 vaccination and booster rates
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?
As the scale of COVID-19’s toll on nursing homes became clear during the pandemic, heightened infection-control protocols such as testing, masking, social distancing, hand hygiene and proper use of PPE were mandated in facilities. Early on, nursing homes essentially shut their doors in an effort to curb coronavirus entry and spread, instituting strict limits on visitation and suspending communal dining and other resident activities.
Residents and staff at nursing homes were in the first priority group to get vaccinated when America started rolling out its COVID-19 vaccines in late 2020. And residents were prioritized first for boosters in fall 2021 by the the Centers for Disease Control and Prevention (CDC).
As vaccinations increased throughout 2021 and as the rate of COVID-19 deaths in nursing homes declined, restrictions loosened, allowing more visitation and communal activities. But COVID-19 is still a threat to nursing home residents and staff, particularly given the rise of the recent omicron variant. Hundreds of residents continue to die from the virus each month, so some infection control practices remain, such as face coverings and physical distancing.
AARP and others long-term care advocates are working toward major long-term care reforms to ensure another crisis like COVID-19 is avoided. President Joe Biden recently unveiled a slew of proposed changes to how U.S. nursing homes are regulated and run, including a vow to adopt federal minimum staffing requirements for facilities, step up enforcement of regulations and crack down on overcrowded rooms. He touched on the reforms during his March State of the Union address, saying federal officials will “set higher standards for nursing homes and make sure your loved ones get the care they deserve and that they expect."
How are nursing home residents and staff getting COVID-19 vaccines and boosters?
In late 2020 and early 2021, the federal government contracted with CVS, Walgreens and some regional pharmacies to vaccinate residents and staff at most of the nation’s nursing homes and other long-term care facilities. COVID-19 vaccines and boosters, which the CDC recommends for those who live and work in long-term care settings, are now being allocated to pharmacies partnered with long-term care facilities, with facilities responsible for administering them. Facilities that don’t have a pharmacy partner are encouraged to work with local or state health departments or the federal government, if necessary.
A federal mandate now requires all staff of Medicare- and Medicaid-certified health care facilities — which includes almost all nursing homes — to be fully vaccinated against COVID-19 by springtime. Some state governments and nursing home companies, however, have already adopted staff vaccination requirements. Medicare- and Medicaid-certified nursing homes are also required to offer all residents and staff COVID-19 vaccines and to publicly report their vaccination and booster rates. You can find these rates and compare them with state and national averages on Medicare.gov’s Care Compare website.
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Can I visit my loved one in a nursing home?
Yes. Guidance released by the CMS in November 2021 says that nursing homes "must allow indoor visitation at all times and for all residents," regardless of vaccination status. Visitors can only be barred when they are positive for COVID-19, are showing symptoms of COVID-19 or currently meet the criteria for quarantine, or in “very limited and rare” situations. The omicron surge spurred the CMS to allow facilities to regulate visits more, like requiring visitors to be tested prior to entry if the facility provides a rapid antigen test.
CMS guidance reinforces that “visits should be conducted in a manner that adheres to the core principles of COVID-19 infection prevention and does not increase risk to other residents.” Where community level of transmission is high, for example, all residents and visitors should wear face coverings and physically distance during visits to a nursing home, regardless of their vaccination status.
The guidelines "strongly encourage" all visitors to get vaccinated but it's not required as a condition of visitation. If a visitor declines to disclose his or her vaccination status, the visitor should wear a face covering or mask at all times.
What can I do to support my loved one?
Consider getting yourself and your loved one in a nursing home vaccinated and boosted against COVID-19 if you aren’t already. Vaccinations greatly reduce people's risk of contracting the virus and keeps those who do contract it from getting seriously ill, the CDC says. And if you and your loved one in a nursing home are fully vaccinated, fewer infection-control recommendations, such as social distancing and masking, may apply.
Use the newfound visitation liberties to engage and connect with your loved one in a safe way. Socialization is crucial for residents’ well-being — physically and emotionally — particularly now, after pandemic-induced lockdowns. 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 policy.
As restrictions loosen, communal life is returning to 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.
"Be aware of who is lonely as a result of [the pandemic] and find out from each person what may help them," she says.
Where in-person visiting may be unsafe or logistically 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 that residents can use for televisits? Can staff help those who have mobile devices but aren't familiar with video-chat apps? With smartphone cameras and video apps, you can take a loved one for a walk, share a virtual meal or watch a movie together.
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 key questions to ask about circumstances at your loved one's nursing home.
Will the nursing home tell me if it has COVID-19 cases?
It should. 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 CDC and is compiled in an online data set where you can search for week-by-week case numbers.
Don't be shy about contacting a nursing home to ask if it's had COVID-19 cases and deaths or about what protective measures it's taking, including infection-control practices and vaccination rates. 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 (CMS), 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.
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 provides 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 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. The National Consumer Voice for Quality Long-Term Care has 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, such as assisted living?
Unlike nursing homes, assisted living, memory care and other senior care facilities are regulated by the 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 other long-term care facilities. Also, the federal mandate requiring vaccination of employees in health care facilities participating in Medicare and Medicaid applies to nursing homes, but not to all other long-term care facilities. Instead, they are subject to state vaccine mandates, which vary.
But many assisted living facilities and other senior care communities have implemented policies that mirror much of the federal COVID-19 guidance for nursing homes, including infection-prevention practices and vaccination requirements.
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 was updated on March 16, 2022 to reflect new information.