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Why Nursing Homes Are Vulnerable to Another Devastating COVID Winter

New risks are 'a recipe for a disaster,' one expert says, threatening much more illness and carnage

Doctor using stethoscope listening to senior patient breathing at her house - using face mask

FG Trade/Getty Images

No period on record has been more deadly for American nursing homes, where more than 158,000 residents have died from COVID-19, than last winter. Roughly 1 in 45 nursing home residents died in a four-week window between early December 2020 and early January 2021; around 24,000 residents perished.

Those months were “so terribly tragic,” says Lori Smetanka, executive director of the nonprofit National Consumer Voice for Quality Long-Term Care. “We can't go back there.” 

But experts warn that an array of new risks for the highly vulnerable nursing home population — including the current record-high community transmission, lagging booster rates, severe staffing shortages, a pause on President Joe Biden’s vaccine mandate for health care workers and even the return of visitors — could result in another major surge of illness and carnage this winter.

Check the vaccination rates of your nursing home  

You can now find vaccination rates of both residents and staff at any Medicare-certified nursing home and compare it with state and national averages on Medicare.gov’s Care Compare website.

  • Find a nursing home’s profile via the home page’s search function
  • Visit the “Details” section of its profile
  • Click the “View COVID-19 Vaccination Rates” button

Even though nursing homes have much more effective tools to tackle the virus today than last winter, including vaccines and boosters, better masking, new treatments and more knowledge of how COVID-19 spreads, there are also signs of more trouble emerging.   

The risks are “a recipe for a disaster,” says Michael Wasserman, a geriatrician and past president of the California Association of Long Term Care Medicine. “And if we all don’t act right now to address them, another disaster is, I’m sorry to say, what’s going to unfold.”

Rapidly rising cases

The spread of COVID-19 in nursing homes tends to follow spread in the surrounding community. “You can do as much as you can to try and keep the virus out of nursing homes, but the more transmission there is in the community, the more chances there are for the virus to sneak in,” Justin Lessler, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, told AARP earlier in the pandemic. 

Cases in the broader U.S. population have skyrocketed in recent weeks, due mostly to the highly transmissible omicron variant. The country is averaging more than 700,000 new infections per day, almost triple the average daily peak of last winter. But deaths have increased only slightly, suggesting that omicron may cause less severe illness than other forms of the virus.

Doctors are saying that the vast majority of hospitalized omicron patients in ICUs are either unvaccinated or have severely compromised immune systems. While 87 percent of nursing home residents are vaccinated, most are immunocompromised, with chronic medical conditions.

Nursing homes remained relatively unscathed during the first few weeks of omicron’s spread. But recent data from the Centers for Disease Control and Prevention (CDC) show that’s changing fast, with weekly cases among residents increasing more than seven-fold between the weeks ending Dec. 19 and Jan. 9 — from 4,300 to 32,000 nationally. The latest weekly infection rate is just shy of the worst infection rate on record, reported last winter.

Infections among nursing home staff are even worse, increasing almost ten-fold — from 6,000 cases to 57,000 nationally — during the same period. The latest weekly staff infection rate is roughly double the worst rate recorded last winter, and the latest weekly number of staff deaths, 67, is the second-highest recorded in the pandemic. That may foretell what’s in store for residents, says Harvard health policy professor David Grabowski, a leading researcher on COVID-19 in nursing homes.

“Staff COVID cases are the canary in the coal mine,” he recently tweeted, adding last week that nursing home cases are going to continue to “increase dramatically in coming weeks.”

For now, resident deaths are up only slightly, according to the CDC data. Whether that changes “hinges on how well full [vaccination] and boosters protect nursing home residents from omicron,” Grabowski writes. “Getting boosters for as many nursing home residents needs to be a national priority.”

Lagging booster rates

When COVID-19 vaccines became available in the U.S. in December 2020, nursing home residents were some of the first to receive the jabs. A federal vaccination campaign, which sent squads from CVS and Walgreens into most of the nation’s nursing homes, had most residents fully vaccinated by the end of March.

But studies last summer showed that vaccination becomes less effective over time, especially in people 65 and older. The CDC soon began recommending boosters for nursing home residents. This time, however, there would be no federal campaign to administer the boosters, leaving states or facilities responsible. 

Omicron, with its ability to swiftly evade the antibodies produced after vaccination or infection, made boosters even more critical for nursing home residents. New CDC data shows that the COVID-19 case rate among residents with a booster is more than 10 times lower than those rates among unvaccinated residents and residents who’ve received only their primary series of shots.

But almost 40 percent of fully vaccinated nursing home residents hadn’t received a booster as of Jan. 9, according to CDC data. That’s in addition to the roughly 13 percent of residents who are unvaccinated or only partially vaccinated and are, therefore, ineligible for a booster. 

More than 70 percent of fully vaccinated nursing home staff, meanwhile, haven’t gotten a booster, CDC data shows. That’s along with the approximately 18 percent of staff who are unvaccinated or only partially vaccinated.

“We’ve got to change that,” said Health and Human Services Secretary Xavier Becerra in a virtual forum with the long-term care industry in late December. Describing omicron as “lightning fast” and “a game changer,” he urged nursing home residents and staff to get boosters as soon as they’re eligible.

Nursing homes report that hesitancy among family members or residents, delays in receiving consent from resident representatives, long waits for pharmacy partners to provide on-site vaccinations, and staffing shortages are all contributing to the lag in boosters. Some facilities are also citing recent COVID-19 outbreaks; once residents or staff are infected with the virus, it’s recommended that they wait until symptoms have resolved before receiving a booster.

Many staff are also confused about the official guidance or fatigued by constantly changing guidance, says Glen Lewis, executive director of the Edgewater senior living community in West Des Moines, Iowa. “That’s causing some to delay or just give up trying to keep up,” he says.

Industry groups such as the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which lobbies on behalf of more than 14,000 nursing homes and long-term care facilities nationwide, and LeadingAge, which advocates on behalf of 5,000-plus nonprofit senior-care providers, are urging facilities to get residents and staff boosted as soon as possible.

Staff vaccination requirement delayed

Nursing home staff vaccinations have lagged resident vaccinations since the shots first became available. A recent study coauthored by Harvard’s Grabowski found that low rates of COVID-19 vaccination among nursing home staff are linked with high rates of coronavirus illness and death among residents, even when residents have been vaccinated. 

The national study revealed that more than 4,770 COVID-19 infections in residents and 700 COVID-related resident deaths might have been prevented in just a two-month period last summer had more nursing home staff been vaccinated. 

In mid-August, Biden announced that all U.S. nursing homes that receive federal Medicare and Medicaid funding — the vast majority of facilities — must require workers to be fully vaccinated against COVID-19. The federal Centers for Medicare and Medicaid Services (CMS), which regulates nursing homes, later announced a Jan. 4 deadline.

But the federal requirement has faced legal challenges, causing enforcement delays. While the mandate has since been allowed by the courts, nursing homes have been granted more time — until March 28 — to fully vaccinate all staff.

“Unfortunately, when courts block these mandates, it means that vaccinations are delayed,” says Lawrence Gostin, a professor of global health law at Georgetown University Law School, “and that could mean people lose their lives unnecessarily.”

AARP “strongly supports” the federal vaccine requirement for nursing home workers, the organization wrote in a recent letter to the CMS, adding that it’s “an important step to protect the health and safety of those working in, and those seeking treatment or care at, Medicare and Medicaid facilities, especially nursing homes.”

But other nursing home stakeholders have pushed back. “We are deeply concerned that the current mandate issued by the CMS will cause nursing homes to lose staff at a time when we are already grappling with a historic labor crisis,” said Mark Parkinson, president and CEO of American Health Care Association and National Center for Assisted Living, in a statement.

Severe staffing shortages getting worse

Staffing shortages have long plagued U.S. nursing homes, but the pandemic exacerbated them by infecting workers with and exposing them to COVID-19, rendering them unable to work while they quarantine or recover, as well as causing burnout among the labor force. Many nursing home employees — who held one of the deadliest jobs of 2020 — have left the field for other positions with better pay, benefits and working conditions.  

An AARP analysis of federal nursing home data shows that 30 percent of U.S. nursing homes have reported monthly shortages over two four-week periods from mid-September to mid-November, when staff COVID-19 infections were relatively low. That's about 7 percentage points higher than shortages reported to the CMS this summer and just above the worst shortages reached last winter.

The current virus resurgence is likely to make them even worse by pulling infected staff out of facilities, raising concerns that care for residents will suffer, particularly during outbreaks, when it’s needed most.

Even at facilities with high rates of boosters, such as the Jewish Home Family in New Jersey, where 100 percent of residents and 90 percent of staff are boosted, omicron is taking a toll. “The hardest thing is staffing as folks go out with a positive test result,” says Carol Silver Elliott, president and CEO.

Studies from the pandemic have found that low staffing levels translate into higher COVID-19 cases and deaths in nursing homes, particularly once the virus has entered a facility.

“Research tells us that nursing assistants shouldn’t have more than seven patients during a shift to take care of, but I’ve heard of some having 30 patients during the pandemic — that’s insane,” says Charlene Harrington of the University of California, San Francisco, who cowrote a study on the issue in California. “Staff are just running from patient to patient — trying to feed them, take them to the toilet — and basic things like handwashing go out the window.”

The CDC recently updated guidance for health care workers, which shortens their isolation time after a COVID-19 infection in order to get them back to work faster. Some states are training soldiers from the National Guard as certified nursing assistants to support understaffed nursing homes.

Visits return, bringing their own risk

Family caregivers, who have only recently been granted reentry into nursing homes after 20 long months of COVID-induced lockdowns, will also play a stepped-up role in facilities this winter, says the National Consumer Voice for Quality Long-Term Care’s Smetanka.

recent study of pre-pandemic data found that nursing home residents already receive an average of roughly 37 hours of informal care (including help with household activities, mobility needs and self-care) per month, roughly equivalent to an extra full-time shift of care per month. “Family members are an invisible workforce in nursing homes,” the authors wrote.

They also are essential in combating social isolation and loneliness, both of which took a tremendous toll on residents during the extended lockdowns, says Smetanka: “For so many, the isolation and neglect that they experience was just as deadly as COVID.”

In mid-November the CMS released sweeping updates to its visitation guidelines, telling facilities to open their doors and allow visits for “all residents at all times,” barring those who have a positive COVID-19 test or are showing symptoms of COVID-19. The recent resurgence caused the CMS to backpedal slightly, allowing facilities to regulate visits more, but the exceptions are “very limited and rare.”

Many are applauding the relaxed rules, citing the tremendous toll of lockdowns. But reopening to visitors allows another way for the virus to potentially get into facilities, triggering possible outbreaks.

Visitors are not required by the CMS to be vaccinated or to test negative before a visit, which is believed to have led to two unvaccinated, unmasked and infected guests sparking a COVID-19 outbreak in a New Jersey nursing home just before Thanksgiving. One hospice resident who contracted the virus died, and three others were hospitalized.

“The visitors should have been vaccinated or tested prior to the visit,” wrote Ronald G. Nahass, president of ID Care, a New Jersey medical practice. “This situation is simply wrong.”

AARP, the California Association of Long Term Care Medicine and other groups representing long-term care residents are asking the federal government to prioritize nursing homes for COVID-19 tests amid the current shortages. The Biden administration said 500 million rapid COVID-19 tests will be available to the public soon, although no specific date has been announced. 

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