The skilled nursing and assisted living beds at SpiriTrust Lutheran, a senior care provider in Pennsylvania, have traditionally been filled almost to capacity. But last year, as COVID-19 ravaged long-term care facilities nationwide, the occupancy rate for those beds plunged from 95 percent to around 70 percent.
It’s only ticked up a few percentage points since then. “Fiscally, it’s been a real challenge,” says Bob Rundle, president and CEO of the nonprofit SpiriTrust Lutheran, which runs six continuing care retirement communities. “Our lost revenue last year was $20 million.”
To save money, SpiriTrust Lutheran shut down many community-based offerings, including its financial counseling, tax assistance and senior companion programs. “I really look at those programs as one of the unsung casualties of COVID,” Rundle says.
Many long-term care operators across the country are in the same position. The median occupancy rate for U.S. nursing homes plummeted during the pandemic, from 85 percent in January 2020 to 68 percent in January of this year, according to an analysis by CliftonLarsonAllen, a professional services firm. While the arrival of vaccines and sharp declines in COVID-19 cases in nursing homes have nudged occupancy back up, it’s still only 74 percent as of September.
A return to pre-pandemic occupancy rates is still far off, given the industry’s battered reputation, ongoing staffing shortages and the spread of the delta variant. Some experts say those rates may never fully rebound in the industry’s current framework, which is dominated by “big-box” for-profit nursing home chains.
In the meanwhile, the vacancies are alarming residents and their advocates, who fear that resident care will suffer, in addition to facility operators. Nursing homes are projected to lose a combined $94 billion between 2020 and 2021, according to a leading industry group, which could affect everything from staffing and activities to food and infection control.
“If you have less money, it’s going to have an effect,” says AARP's Susan Reinhard, senior vice president and director of the AARP Public Policy Institute. “[Facilities] really start tightening down. They have less to spend on residents. Quality tends to suffer.”
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A crash in occupancy rates
Occupancy in U.S. nursing homes has been declining since the late 1970s, when roughly 93 percent of nursing home beds nationally were filled. Home- and community-based services — such as senior centers, home-delivery meal programs, personal care services (help with bathing and dressing) and homemaker services — have grown to cater to older Americans who want to age in place. And alternative long-term care facilities, such as assisted living and continuing care retirement communities, have expanded for those who can afford them.
That helps explain why the national average occupancy rate in nursing homes sat at just 80 percent in June 2019, even though more than 550 of the country’s roughly 16,000 nursing homes had closed during the four years prior.
The pandemic accelerated the drops. The coronavirus ravaged long-term care facilities across the country, killing more than 186,000 residents and staff — almost a third of the U.S.’s total COVID-19 fatalities. Most of those deaths — an estimated 150,000-plus — were among nursing home residents, causing many families to stop admitting loved ones to them.
Some facilities, meanwhile, halted new admissions to help prevent further outbreaks. And hospitals canceled elective surgeries, reducing the volume of Medicare-eligible rehab referrals to nursing homes — short-term stays that are many facilities’ most profitable type of income.
Occupancy rates crashed to record lows. And while 2021 has seen some improvements, the climb back is “excruciatingly slow,” Mark Parkinson, president and CEO of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), told Skilled Nursing News. AHCA/NCAL represents some 14,000 senior care providers.
The nursing home industry’s reputation, hardly glowing pre-pandemic, sunk even lower, says Marjorie Moore, the executive director of Voyce, an advocacy group for people living in long-term care. “There are still a lot of people who are scared of what going into a nursing home could mean,” she says, “even just for a visit.”
Now, after months of low COVID-19 cases following last winter’s high peaks, infections in nursing homes are rising again. In the week ending Aug. 22, cases among residents and staff were at their highest since February, according to an AARP analysis of federal data. Residents died with COVID-19 at a rate three times higher than that of mid-July.
On top of the highly contagious delta variant, vaccine hesitancy among nursing home workers is an ongoing threat, with only 65 percent of the workforce fully vaccinated. In some states, just over half of workers have been vaccinated.
“It’s not exactly safe at this time,” says Charlene Harrington, a nursing home researcher at the University of California, San Francisco (UCSF). Vaccine mandates for nursing home workers — which have recently been handed down from long-term care companies, some state governments and now the federal government for nursing homes participating in Medicare and Medicaid — “are a huge step in the right direction,” she says. But right now, as we wait for many of the mandates’ deadlines to come to pass, “[unvaccinated workers] are still a safety problem.”
The cost of staffing shortages
Staffing shortages, which have long plagued nursing homes and were exacerbated during the pandemic, are also contributing to empty beds. Every month since summer 2020, at least a fifth of nursing homes nationwide have reported a shortage of direct care workers, according to AARP’s analysis. In some states, as many as 60 percent of homes reported such shortages during COVID-19 surges.
“Right now, you can’t go anywhere without seeing a 'Help Wanted' sign,” says SpiriTrust Lutheran’s Rundle. While demand is finally returning at his senior care communities, there are now not enough workers to staff new admissions. “Several of our executive directors have told me they could go to 100-percent occupancy if we had team members available to provide the care.”
Nearly 60 percent of nursing homes are limiting new admissions due to staffing shortages, according to a recent survey by the AHCA/NCAL, with almost 80 percent concerned that workforce challenges might force them to close.
Nursing homes have been calling on the government to quickly release billions more in financial aid — on top of the more than $24.5 billion distributed to them last year — to help amid the empty beds and ongoing coronavirus expenses, including personal protective equipment, COVID-19 testing and overtime pay. This month, the U.S. Department of Health and Human Services made another $25.5 billion available to health care providers, including nursing homes, through the American Rescue Plan and the Provider Relief Fund.
But industry watchdogs are concerned about where the money is going. Only around a quarter of U.S. nursing homes are nonprofit organizations. Roughly 70 percent are for-profit, and most of those are part of corporate chains, with about 11 percent of these owned by private equity firms. Studies show that these types of facilities generally have significantly lower quality of care than nonprofit homes. Their “bottom line is how much money we can make, not what kind of care can we give to the residents,” says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform (CANHR).
Many for-profit facilities operate on complex ownership structures and financial agreements that limit financial transparency. “Nursing homes are using [low occupancy] to get more money out of Congress, but we don’t know if they are really losing money,” says UCSF’s Harrington, who recently coauthored a commentary on the issue in the Journal of the American Geriatrics Society. “We don’t know what nursing homes have been doing with their money,” she says. “Before we feel too sorry for them, we really need to see what’s going on.”
‘They’re getting bedsores, their limbs are atrophying’
There are signs that nursing home care is diminishing along with their revenues. “Just think of any business operating at 70 percent,” says AARP’s Reinhard. “If you can only get 70 percent of the clients you used to have, something has to give.”
Staff cuts often come first, since wages are a huge expense. Telemedicine can provide some degree of care, but most of what residents need is hands-on help: bathing, feeding, lifting and changing. “They’re lying in their own feces and urine, they’re not getting turned, they’re getting bedsores, their limbs are atrophying,” says CANHR’s McGinnis. “We’ve had those kinds of complaints for the past year and a half.”
That’s also true in Connecticut, according to Mairead Painter, the state’s long-term care ombudsman, who says the volume of complaints submitted to her office has surged. “We are having significant issues related to staffing and the ability to meet residents’ needs,” she says. “I would say this is the largest area of concern that we’re currently seeing.”
The state’s nursing homes are now only 74 percent occupied. “Too much supply and not enough demand,” Painter says, are causing operators to “pull back on everything because they don’t have the income coming in. They try to ride each other out so that when one closes the other can absorb their residents and staff.”
Staff that survive cuts are often suffering, too. More qualified staff are often cut first to save money, leaving lower-paid staff — mainly certified nursing assistants (CNAs) — to tend to more residents than usual. CNAs are mostly women, generally make less than $15 per hour and often lack health insurance and benefits.
Nursing homes participating in Medicare and Medicaid must provide a minimum amount of nursing coverage per day, but those federal standards don’t take the number of residents in a facility into consideration. Some states have minimum staffing requirements set by regulation, but they’re commonly below levels recommended by experts to consistently meet each resident’s needs. Also, facilities frequently fail to meet them.
“How am I supposed to be kind and compassionate and person-centered in my care if I have 30 [residents to look after]?” says Lori Porter, cofounder and CEO of the National Association of Health Care Assistants. “It’s like an assembly line: I start at one end of the hall and I go like lightning, yanking people out of bed, dropping them in their wheelchairs, driving as fast as I can to the dining room, so no one’s late for supper.”
“Even on [a nursing home’s] best day, if you’re fully staffed, things can still go wrong,” Porter says. “But things will definitely go wrong if you’re staffed at a third of what you need.”
Nursing home staff are often left feeling burnt out. CNAs had one of the deadliest jobs of 2020. But many were villainized for unknowingly introducing COVID-19 to a facility and infecting residents, even as other health care workers were lauded for heroic work. “You don’t want angry people taking care of Grandma,” Porter says. “If I’m angry, I’m not a good caregiver.”
More delta variant lockdowns may add to the stress. In low-occupancy facilities, where staff are overburdened, family members often help out with their loved one’s care, from feeding and grooming to entertaining. But federal guidance recommends locking down an entire unit for at least two weeks after a positive test, which means putting family visits on hold.
“Family members provide an awful lot of care,” the medical director of two U.S. nursing facilities told Human Rights Watch during an investigation into neglect in nursing homes during the pandemic. “When there are no visitors, there is more work for everybody else.”
Reforms get another look
Some see the occupancy crisis as an opportunity to overhaul the long-term care in the U.S. “I’m not sure it’s a bad thing,” says CANHR’s McGinnis of the high vacancies and pending closures, “because we need to change the way we provide care in these kinds of places.”
As a result, long-proposed reforms are getting a fresh look. President Joe Biden has proposed spending $400 billion to expand access to quality, affordable home- and community-based services, which would allow more seniors to age in place.
For those who require a higher degree of care, there is a strong push toward smaller, more self-contained and person-centered congregate settings, such as Green Houses, which have 10 to 12 beds for residents, compared with an average of 109 resident beds in traditional nursing homes.
The Credit for Caring Act, which AARP supports, is calling for tax credits to be distributed to some of the nation’s 48 million family caregivers, who are caring for their loved ones at home as well as in other settings.
But the low-occupancy problem isn’t going away anytime soon. “The homes we need to get rid of, the great big 200 to 300 bed facilities ... are almost too big to fail,” says UCSF’s Harrington. “But the homes we need to keep, the smaller ones ... may have real trouble making it financially. Better homes will go under, while some of the worst homes stay in business.”
Signs of Low Occupancy: What to Watch For
- Staffing cuts. These are the biggest indicator of low occupancy in nursing homes, according to Bei Wu, director of global health and aging research at New York University’s Rory Meyers College of Nursing. Check not only whether the staffing ratios have changed, but also if the distribution of different levels of staff — registered nurses, licensed practical nurses or certified nursing aides — has changed. “We know that the amount of time [registered nurses] spent with each resident has a direct impact on a resident’s quality of care, and even on mortality” Wu says.
- Other quality cuts. Alongside staffing, check to see if other areas of the home, such as the food and cleanliness, have declined in quality, says Mairead Painter, Connecticut’s long-term care ombudsman. “We have started to see a lot of food complaints,” she says. “They’re buying cheaper food: It’s supposed to be baked fish, but it’s fish sticks. Stuff like hot dogs — just really inexpensive food.” If possible, she recommends visiting unannounced at a mealtime to see whether the food is nutritional. While visiting, also check the building, she says. “See the building, smell the building, look at the cleanliness of the building.”
- Consolidating. Sometimes low occupancy rates can lead to a facility closing a section or wing of a facility. That’s not always a bad thing, says Susan Reinhard, AARP senior vice president and director of the Public Policy Institute, because by reducing its number of beds, a facility can save money on things like heating, air-conditioning and electricity, which can instead go back into care. It can, however, be disruptive for residents. “Facilities may move them to another wing of the facility ... or maybe they move them to another facility they own,” says Marjorie Moore, executive director of Voyce, an advocacy group for people living in long-term care. “We’ve seen some really short turnaround times, where facilities announce they’re closing a wing or closing a building — we had one place turn into a different type of facility — very quickly.” Family members should be informed in a timely manner of such changes and understand they have a choice in where their loved one goes, she says.
- Resident signs. A resident’s changing appearance or demeanor can be an indicator of declining resources in a facility, says Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit that advocates for the public on long-term care issues. She recommends looking out for things like weight loss or gain, unwashed hair, untrimmed nails and whether glasses, hearing aids and jewelry are being worn. Also, check to see if a resident's skin has pressure sores, bruises or cuts that aren’t being attended to. Here’s a full list of what to look for, questions to ask and what you can do if you have concerns about a resident’s condition.