Nursing Homes are Filled with Empty Beds, Raising More Concerns About Care

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.

Morgan Wilt, an administrative secretary at SpiriTrust Lutheran, helps fold towels and linens. The senior care provider in Pennsylvania is struggling to recruit workers to staff new admissions.

SpiriTrust Lutheran

“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.”