The COVID-19 pandemic has swept the nation and its impact has been especially deadly for residents and staff of nursing homes and other long-term care facilities. The AARP Public Policy Institute, in collaboration with the Scripps Gerontology Center at Miami University in Ohio, created the AARP Nursing Home COVID-19 Dashboard to provide four-week snapshots of the virus’ infiltration into nursing homes and impact on nursing home residents and staff, with the goal of identifying specific areas of concern at national and state levels in a timely manner. AARP’s Nursing Home COVID-19 dashboard has tracked five categories of impact since summer 2020, as well as vaccination rates of nursing home residents and health care staff, updated every three months to track trends over time.
- Rates of COVID-19 cases and deaths in nursing homes have risen considerably since the summer.
- During the four weeks ending 11/19/2023, the rate of COVID-19 resident deaths was approximately 140 percent higher than three months earlier as reported in the last quarterly Dashboard, the rate of COVID-19 resident cases doubled, and the rate of staff cases increased by two-thirds.
- During the four weeks ending 11/19/2023, about one out of every 24 residents contracted COVID-19, and approximately one staff for every 37 residents tested positive.
- More than one-third of facilities (37%) had at least one resident case, and nearly half (47%) had at least one staff case.
- Compared to the four weeks ending 6/25/2023, rates of resident deaths, resident cases, and staff cases have all more than quadrupled.
- This increase occurred in nearly every state in the country. Only Hawaii and Florida had fewer deaths and cases in the four weeks ending 11/19/2023.
- These rates are only through mid-November. In each of the previous three years, the most severe COVID-19 impacts happened in late fall and early winter following the Thanksgiving, Christmas, and New Year’s holidays. We expect to see an additional surge over the next several months.
Vaccination Rates are Lagging Behind Previous Years
- Take-up of the most recent COVID-19 vaccine is much lower than previous vaccines and boosters, leaving most residents and staff without adequate protection from severe outcomes.
- As of mid-November, only about one quarter (27%) of nursing home residents were up-date with the most recent vaccine, and less than one tenth of staff (only 7%).
- In November 2021, 87% of residents were vaccinated and 39% were boosted. 78% of staff were vaccinated and 15% were boosted.
- In November 2022, 45% of residents and 22% of staff were up-to-date.
- Compared to mid-October, the resident vaccination rate increased ten percentage points from 17% to 27%, while the staff rate moved only one percentage point from 6% to 7%.
- There is considerable variation between states.
- The rate of resident vaccination ranged from a low of 10% in Arizona to high of 55% in South Dakota. Only North Dakota (53%) and South Dakota had more than half of residents up-to-date on vaccination.
- The rate of staff vaccination ranged from a low of 2% in Arkansas to a high of 18% in New Mexico. Only six states exceeded a 10% rate.
Since the pandemic started, scant data has been available consistently to help gain a better understanding of the crisis in nursing homes and other long-term care facilities. The country counted mainly on the reporting of news media to glimpse the devastation caused by COVID-19. Organizations such as Kaiser Family Foundation and the COVID Tracking Project also began collecting and publishing vital information from the states. It is important to note that each source collected data differently, so similar information may appear at odds due to variation in precise definitions, types of people and settings included in the measure, and the timeliness and completeness of data collection. Specific to nursing homes:
- Many states have required self-reporting by nursing homes and/or other long-term care facilities, but the requirements vary widely. Some states combine data for nursing homes and other long-term care facilities such as assisted living; others combine resident and staff cases and deaths, while others provide limited or no data at all.
- In May 2020, the Centers for Medicare & Medicaid Services (CMS) required nursing homes to self-report COVID-19 cases and deaths on at least a weekly basis; these data are reported directly from nursing homes to the federal government and are consistent across all states. However, the required reporting was not retroactive. As a result, there is a significant undercounting of cases and deaths before June 2020 in this data source.
- Beginning in June 2020, the data reported by CMS and by individual states appear to be roughly comparable, though exact comparisons are difficult because of the inconsistency in state reporting.
- In May 2021, CMS issued an interim final rule and guidance requiring the reporting of nursing home resident and staff vaccination status. Vaccination data were first reported for the week ending May 30, 2021, and were mandated as of the week ending June 13, 2021. CMS made booster data publicly available on December 10, 2021. Vaccination data are also available on Care Compare for individual nursing homes, including the percentage of residents and staff up to date.
- The CDC publishes a Nursing Home COVID-19 Data Dashboard and Nursing Home COVID-19 Vaccination Data Dashboard that are updated weekly and include several key data points at the state and national level.
Residents and staff in nursing homes were hit hard by the first year of the pandemic. Yet federal policymakers were slow to respond to this crisis, and no state has done a good enough job to stem the loss of life.
AARP has called for the enactment of a 5-point plan to protect nursing home and long-term care facility residents—and save lives—at the federal and state levels:
- Prioritize regular and ongoing testing and adequate personal protective equipment (PPE) for residents and staff—as well as inspectors and any visitors.
- Improve transparency focused on daily, public reporting of cases and deaths in facilities; communication with families about discharges and transfers; and accountability for state and federal funding that goes to facilities.
- Ensure access to in-person visitation following federal and state guidelines for safety and require continued access to virtual visitation for all residents.
- Ensure quality care for residents through adequate staffing, oversight, and access to in-person formal advocates, called long-term care Ombudsmen.
- Hold long-term care facilities accountable when they fail to provide adequate care to residents.
The federal government has taken some action, such as requiring nursing homes to self-report COVID-19 cases and deaths at the federal level, ordering testing, providing limited PPE and other resources to nursing homes, establishing requirements for education on and offering of COVID-19 vaccines to residents and staff, reporting of nursing home resident and staff vaccination and booster status, requiring nursing home staff vaccinations, and issuing guidance for in-person visitation to resume. AARP continues to urge elected officials to take action to combat this national tragedy, make sure it does not happen again, and ensure that public funds provided to nursing homes and other long-term care facilities are used for testing, PPE, staffing, virtual visits, and for the health and safety of residents.
While high primary vaccination rates for residents and staff have given us hope, and have saved many lives, there remain many nursing home residents who are not vaccinated at all, and more than half are not up to date on COVID-19 boosters. Residents and staff who are not up to date are more susceptible to adverse outcomes from COVID-19 exposure, and staff who are not up to date could place residents at unnecessary risk. Ensuring both residents and staff are up to date with their recommended COVID-19 vaccinations is urgently needed to protect this vulnerable population.
The uptick in COVID-19 cases in August 2021 prompted AARP to call for requiring COVID-19 vaccinations for nursing home residents and workers. AARP is now calling on nursing homes to require COVID-19 booster shots for residents and staff.
AARP continues engaging with CMS to urge the agency to remain vigilant in efforts to protect long-term care facility residents and staff. A July 2021 AARP letter to CMS included recommendations that the federal government commit to working with states, long-term care facilities, and other entities, as needed, to ensure that those facilities can access and administer vaccines for the foreseeable future. Everyone must work together to ensure continued vaccine and booster access and administration. AARP also noted the importance of access to vaccines and COVID-19 tests in a December 2021 letter to CMS supporting COVID-19 vaccination requirements for certain health care workers, including staff of nursing homes participating in Medicare and Medicaid.
AARP will continue to shine a light on what’s happening in nursing homes so that families have the information they need to make decisions, and nursing homes and lawmakers can be held accountable. For more information, visit aarp.org/nursinghomes.
Most data are from analysis of data are from the Centers for Medicare & Medicaid Services (CMS) Nursing Home COVID-19 Public File (downloaded most recently on 12/8/2023). These data are self-reported by facilities to the Centers for Disease Control and Prevention (CDC) weekly.
Vaccine data for Q4 2023 are from the CDC Nursing Home COVID-19 Vaccination Data Dashboard (https://www.cdc.gov/nhsn/covid19/ltc-vaccination-dashboard.html; accessed 12/8/2023).
Several data points in the state fact sheets include general population state data (that is, not limited to nursing homes) as a denominator or stand-alone measure. These data are from CDC (downloaded most recently on 12/6/2023).
Data were analyzed by Scripps Gerontology Center at Miami University in Ohio, additional analysis and preparation of the dashboard by the AARP Public Policy Institute.
- COVID-19 deaths (residents): Total number of residents with suspected COVID-19 or a positive COVID-19 test result who died in the facility or another location as a result of COVID-19 related complications.
- Total deaths (residents): This count includes new COVID-19 related deaths and non-COVID-19 related deaths. Includes residents who died in another location, such as a hospital.
- COVID-19 deaths (staff): The number of deaths for staff and facility personnel with suspected COVID-19 or a positive COVID-19 test result.
- COVID-19 cases: Number of residents, or staff and facility personnel, with new laboratory positive COVID-19 test results, as reported by the facility. Staffing shortage: Identified staffing shortage for each personnel category for at least one week out of the four weeks in the reporting period.
- COVID-19 vaccinations: Count of individuals who have a completed vaccination, meaning that they have received all required shots; in the dashboard, we may refer to these as fully vaccinated. Individuals who are not fully vaccinated include those who are partially vaccinated, medically contraindicated, refused vaccination, or vaccination status unknown.
CDC has issued detailed instructions to nursing homes for reporting these data:
- Resident deaths and cases;
- Staff deaths, cases, and shortage;
- Resident vaccinations;
- Health care staff vaccinations.
For the four-week measures, nursing homes were included only if the facility reported to CDC for all four weeks (nationally, 98% of facilities for the most recent four-week period, for states ranging from 94% to 100%). If a nursing facility reported but had missing data for a specific measure, that facility is excluded from the calculation of that measure for the dashboard.
Most nursing facilities with missing data are only missing the most recent week (ending 11/19/2023). That is, most missing data are due to late responses, not skipped entirely. To have the most current data possible, we must exclude those facilities that were late in reporting the most recent week of data as well as those with one or more weeks of non-response in earlier weeks.
Vaccination data points are based on the most current week of data for each facility, as long as it is within the last four weeks. Facilities do not need to report for all four weeks to be included. The Dashboard’s use of multiple weeks of data and definition of booster rate and “up to date” rate as a percentage of all residents/staff means that rates may be systematically different than what is reported elsewhere.
Aggregate counts of deaths and cases may be an undercount if there are facilities that are not reporting. Percentages or rates might be slightly biased if the average of non-reporting facilities differs significantly from the average of reporting facilities.
For the measures of cases and deaths “since 6/1/2020” and “since January 2020,” all nursing homes reporting at least one week of data are included. The national response rate is typically greater than 99% for both measures.
Comparability to Other Data Sources
The first reporting date for the CMS Nursing Home COVID-19 data was May 24, 2020, and includes all cases and deaths that were reported since the beginning of the year; however, retroactive reporting is not mandatory, and the accuracy of reporting at the state level is unknown. Vaccination data were first reported for the week ending May 30, 2021, and are mandated as of the week ending June 13, 2021.
Data points that go back prior to the first reporting date, including the “since January 2020” counts of resident cases and deaths in the state fact sheets, may significantly undercount the total number of cases and deaths. At the national level, the CMS data source gives a significant undercount of the number of cases and deaths before June 2020, compared to other sources that were reporting in real-time.
Since June 2020, the CMS data are much more reliable and at the national level track well against data reported by the states (comparisons to individual states are difficult because each state categorizes and reports the data differently).
The state fact sheets include several measures of the percentage of total state deaths and cases that occurred among nursing home residents and nursing home staff. Because the denominator data is from a different source, the reported data may result in a percentage less than 0% or greater than 100%, which is impossible. The value of each such measure is capped at 100%, and values of less than 0% are marked as NA. These measures should not be used to compute the number of cases or deaths occurring outside of nursing homes.
- Find vaccination rates of both residents and staff at any Medicare-certified nursing home and compare it to state and national averages on the Medicare.gov Care Compare website. Booster rates for nursing home residents and staff, including facility level data, are available from CMS.
Dashboard Special Report
- COVID Kills Over 12,000 Nursing Home Residents in Weeks Surrounding Thanksgiving
- AARP Nursing Home COVID-19 Dashboard Special Report: Surge Continues Over Thanksgiving
Past Dashboard Coverage
- COVID-19 Cases and Deaths Rise in Nursing Homes as Booster Uptake Halts
- Nursing Home COVID-19 Cases Quadruple as Booster Rates Slow
- COVID-19 Deaths and Cases Continue to Climb in Nursing Homes, Our Analysis Finds
- A Million Nursing Home Workers Remain Unboosted as COVID Cases Climb Again
- COVID-19 Death Rate in Nursing Homes Plummets, but Experts Say It’s Still Too High
- 1 in 3 Nursing Home Residents Still Haven’t Received a COVID-19 Booster, AARP Analysis Finds
- 40% of Nursing Home Residents Haven’t Received COVID-19 Boosters, Analysis Finds
- COVID-19 Booster Rate in Nursing Homes Is Relatively Low, AARP Analysis Shows
- COVID-19 Booster Rate in Nursing Homes Is Relatively Low, AARP Analysis Shows
- Worker Shortages in Nursing Homes Hit Pandemic Peak as COVID-19 Deaths Continue
- COVID Keeps Pounding Nursing Homes, Killing Over 2,000 residents in Just 4 Weeks
- COVID Surges Again in Nursing Homes, Mostly Among Unvaccinated, Analysis Finds
- With COVID Cases in Nursing Homes Rising, AARP Calls for Mandatory Vaccinations
- 4 in 5 U.S. Nursing Homes Behind on Staff Vaccination Goal, Analysis Finds
- COVID-19 Still Killing 800 a Month in Nursing Homes, AARP Analysis Shows
- Nursing Homes Record Lowest Rates of COVID-19 Infection and Death
- COVID-19 Deaths in Nursing Homes Plummet, Staff & PPE Shortages Persist
- Nursing Homes Report Worst COVID-19 Death Rate on Record
- North Dakota Nursing Home Deaths Increase 11-Fold, New COVID-19 Analysis Shows
- Exclusive: Nursing Home Cases Skyrocket in 12 States Where COVID Is Surging
- Arkansas Reports Highest COVID-19 Infection Rate Among U.S. Nursing Home Residents
- South Carolina Reports Highest COVID-19 Death Rate Among U.S. Nursing Home Residents
- Exclusive: Half of U.S. Nursing Homes Have Staff Infected With COVID-19