With a Vaccine Mandate Looming, Nursing Homes Face More Staffing Problems

ST. CHARLES, Mo. — Jamie Smith, a staffing agency nurse who loves end-of-life care, said she has been warmly welcomed by staffers and residents at Frontier Health & Rehabilitation in this conservative St. Louis suburb.

That’s even though she has not been vaccinated against covid-19.

But leaders of the nursing home, where 22 residents died from covid before vaccines were available, likely won’t be able to employ unvaccinated people like Smith for much longer. The U.S. Supreme Court on Jan. 13 upheld a federal mandate requiring health care workers at facilities that receive Medicaid or Medicare funding to be fully vaccinated. If all staffers — excluding those with approved religious or medical exemptions — aren’t fully vaccinated, the facility will lose that money.

Health care sites in Missouri and other states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated, according to the Centers for Medicare & Medicaid Services, while facilities in states that didn’t sue to block the mandate have a Feb. 28 deadline.

That poses a challenge for Frontier and its residents because the nursing home already doesn’t have enough staffers. And it is in the state with the lowest rate of fully vaccinated nursing home health care workers, 67% as of Jan. 9, according to CMS data. Frontier’s reported staff vaccination rate was just 30% at the start of the year.

That compares with a national rate of 81%, according to the federal data.

Although the mandate ensures that unvaccinated staff members are not caring for some of the people most vulnerable to the virus, not enough workers are willing to take the low-paying, challenging jobs. If they quit to avoid getting shots or are fired because they won’t get them, nursing home residents might not be any safer — because of lack of care.

“Obviously we need good staff members to take care of residents, but the residents need to be safe as well,” said Marjorie Moore, who supports the mandate and is executive director of Voyce, a St. Louis nonprofit that advocates for nursing home residents and their families.

“A person who lives in their own home has the chance to say, ‘I don’t want somebody in my home who isn’t vaccinated,’” she added. “In a nursing home, they don’t have the opportunity to say, ‘I don’t want somebody who is unvaccinated coming up and feeding me.’”

The problem of inadequate staffing at nursing homes predates the pandemic, and it’s gotten worse.

In March 2020, 3.3 million people were employed at U.S. nursing homes and residential care facilities, according to the Bureau of Labor Statistics. In December 2021, that number had dropped to 2.9 million, a loss of 400,000 workers.

Nursing home operators can’t find enough staffers because they often don’t pay much. The mean hourly wage for nursing assistants in Missouri was $13.33 in 2020, according to the statistics bureau. And the homes require employees to take on a slew of responsibilities, including feeding residents, changing adult diapers, and caring for residents who have dementia and may become combative.

Nursing assistants “can typically find a job with better pay that is less physically and emotionally demanding,” said Brian McGarry, a University of Rochester professor who studies long-term care. “Somebody’s life and dignity is in your hands, and it’s a huge responsibility, and you are not getting paid commensurate with that responsibility.”

Those downsides of the job often lead to significant turnover. In 2017-18, the turnover rate among nursing home employees in Missouri was 138%, the fourth-highest in the country, according to a study in the journal Health Affairs. Frontier had a rate of more than 300%, according to Huizi Yu, one of the study’s authors.

The nursing home’s management declined to comment.

Smith, the nurse who works for a health care staffing agency, said she has not been vaccinated against covid because she had a rare cancer in 2017 and is “very particular about what I put in my body.”

She said, “I’m not sure if I would be able to get it just to keep a job.”

But, she noted in a text message, “I still practice safely.”

And, indeed, no Frontier residents have died from covid since the outbreak at the start of the pandemic, according to the federal data. But the center reported having seven new confirmed cases among its residents and 10 new cases among its staff as of Jan. 9. At the beginning of the year, 89% of residents were fully vaccinated against covid.

Low vaccination levels among staffers place residents at greater risk, according to a recent analysis in The New England Journal of Medicine. Facilities in high-covid counties with an average staff vaccination rate of approximately 30% had nearly three times as many covid deaths among residents as facilities where about 82% of employees were vaccinated, the analysis found.

“An unvaccinated or low-vaccinated staff, I think, pretty clearly puts residents at risk — even if they are vaccinated,” said McGarry, one of the analysis’s authors.

The vaccination rate has increased from fewer than half of Missouri nursing home staff members when President Joe Biden announced the mandate for nursing homes Aug. 18 to about two-thirds of staffers now, according to the federal data.

Like Frontier, Northview Village does not have enough staffers, and most people who work there have not been vaccinated. The facility — a nursing home in a predominantly Black, low-income north St. Louis neighborhood — held a vaccination drive in December to increase its roughly 20% staff vaccination rate, but the numbers did not rise, according to the federal data. And only half of residents were fully vaccinated.

The Northview management declined to comment.

Kimberly Watkins, a technician who works to keep Northview residents active, was reluctant to get any of the shots, in part because she heard the conspiracy theory that they contained a tracking chip. But she said she decided to go ahead and get vaccinated because she has asthma and high blood pressure. Co-workers told her their doctors said that they didn’t need the vaccine or that they may be allergic to it.

Now with the mandate taking effect, Moore, of the nonprofit Voyce, thinks most local nursing home staffers will comply.

She highlighted Mary, Queen and Mother Center, a Catholic nonprofit nursing home in St. Louis County, that announced its own mandate in August. Before its Sept. 30 deadline, the nursing home saw its staff vaccination rate increase from 67% to 92%, with the remainder being those with a medical or religious exemption, according to the organization. The facility retained almost all its staff.

Not everyone is worried about nursing home staffers being vaccinated, in part reflecting the community around them. Just 55% of Missourians are fully vaccinated.

“I’m not into forcing stuff on people,” said Antuan Diltz, a St. Louis firefighter whose mother is a 64-year-old retired nurse with dementia and diabetes living at Frontier. She received the vaccine; Diltz had not.

But others, like Bill Talton, who have family at Frontier hope more staffers will get the shots. Talton, a 77-year-old retired computer programmer, said he is happy with the care his younger brother, who has dementia, has received, although he sometimes couldn’t visit him during covid-related lockdowns.

“It’s kind of late in the game,” said Talton, who is fully vaccinated and received a booster. “They’ll get it done — I hope.”

KHN data editor Holly K. Hacker contributed to this report.