In late spring, the 142 nursing homes operated by the Good Samaritan Society hit a milestone that was unthinkable just four months earlier: Zero cases of COVID-19 across the whole company, from 900 at the peak of the pandemic.

The relief was short-lived.

The case count has ticked up again: It is still below 100 among residents and staff, the company said, but includes many breakthrough cases of vaccinated residents testing positive. Then last week, two vaccinated residents died with COVID at the Good Samaritan Society-Deuel County nursing home in Clear Lake, South Dakota.

The company said it had pinpointed the cause of the spread there and at other of its facilities: The breakthroughs had happened in the same homes where unvaccinated staff were testing positive, seemingly carrying the virus into the home from the community.

“We fought this virus, and we were winning with the vaccine,” said Randy Bury, chief executive of the Good Samaritan Society, a nonprofit chain that operates in 24 states.

Late last month, the company became one of the largest long-term care chains in the country to order mandatory vaccines for staff, highlighting turmoil within an industry desperate to avoid a repeat of the devastation that swept through this highly vulnerable population.

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After sharp drops in infections over the past several months, the number of COVID cases among U.S. nursing-home residents and staff roughly tripled from the week of July 4 to the week ending July 25, according to the Centers for Disease Control and Prevention. The agency’s data shows that cases of COVID among residents had risen to 1,312, the highest figure reported since early March.

About 133,000 nursing home residents died of COVID over the course of the pandemic, although the death rate has plummeted in recent months with more than 80% of residents now vaccinated. Overall, COVID deaths among nursing home residents and staff members accounted for nearly one-third of the nation’s pandemic fatalities.

Growing calls for vaccine mandates among health care workers have gained urgency but also met resistance in the nursing home industry, where some homes say it will cost them staff members in an industry already plagued with high turnover. Only about 60% of nursing home staff members are vaccinated, and some states report an even lower rate, with less than half inoculated, according to the most recent government data.

As of the week ending July 25, COVID cases among nursing home staff members nationwide were also climbing, to 2,145, according to the CDC data.

Staff immunization has been an issue in many states, especially as the highly contagious delta variant races through regions with low vaccination rates. On Monday, one of the nation’s largest nursing-home operators, Genesis HealthCare, said it will mandate vaccines for staff by Aug. 23, noting “while we would have greatly preferred a strictly voluntary process, our commitment to health and safety outweighs concerns about imposing a requirement.”

Some states and cities, not waiting for the nursing home industry, are imposing their own mandates for vaccinations on long-term care employees, or operators may face penalties or additional testing requirements for unvaccinated staff. Massachusetts on Wednesday said all nursing home staff must be fully vaccinated by Oct. 1, while California said last week that health care workers must be immunized or be tested weekly for COVID.

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San Francisco and Denver have each announced a vaccine mandate for workers in high-risk settings, including nursing homes.

New outbreaks in some states, including Florida, Colorado, Indiana and Louisiana, have forced some homes to once again limit visitors and impose other restrictions. The Centers for Disease Control and Prevention said Friday that it was monitoring the delta variant’s infections in nursing homes to see if “additional measures are needed.”

“The bottom line is, the vaccine is the No. 1, 2 and 3 thing we have to fight this pandemic, everywhere, but especially in nursing homes,” said Dr. Michael Wasserman, a geriatrician and former president of the California Association of Long Term Care Medicine, who has reluctantly come to believe mandates are necessary.

So far, the nursing home industry has stopped short of endorsing a vaccination mandate, even as major medical organizations have signed on to calls for the requirement among health care workers and as more hospitals are requiring the vaccine for employees.

Last week, the American Health Care Association, the nursing home industry’s main trade group, instead said it supported continued efforts to educate workers.

The vaccination rate is shy of the industry’s goal of having 75% of workers immunized by the end of June, mirroring instead the country’s overall rate for adults.

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“It’s terribly frustrating,” Mark Parkinson, the chief executive of the industry’s main trade group, said of the hesitancy of people to resist vaccines, including in the nursing home industry. “If everybody would get vaccinated, this pandemic would end,” he added.

But, he said, nursing home providers are wary of mandates, worrying that they could lose workers during “one of the worst labor shortages” in the nation’s recent history. Several states appear to be experiencing outbreaks of breakthrough infections among fully vaccinated residents, who number about 1.2 million in skilled nursing homes.

In light of concerns that elderly residents who are vaccinated may be more susceptible to breakthrough infections, especially from the delta variant, West Virginia’s governor last week announced a program to test the antibodies in vaccinated nursing home residents to determine waning immunity to the virus. This test, available on a volunteer basis, will look at how strong their antibody protection remains six months after getting the vaccine as a way to decide whether this population should get booster shots.

Nationwide, the total cases among all Americans have increased significantly in the last month, averaging over a seven-day period more than 91,500 a day as of Aug. 4, according to the latest data.

Citing rising case numbers, LeadingAge, which represents some 2,000 nonprofit nursing homes, was among the nearly 90 groups that now support mandates for nursing home workers. “As COVID-19 variants emerge and proliferate, we can start saving more lives today by ensuring staff are fully vaccinated,” said Katie Smith Sloan, the chief executive of the group, in a statement. About two-thirds of the staff are already vaccinated and almost 90% of residents, she said.

Bury, the chief executive of Good Samaritan, said the delta variant gave him “tremendous concern” and added he supported widespread mandates. “If you’re a facility that mandates the vaccine, within a short time of the mandate, you’ll be the safest workplace for employees and the safest place to be a resident,” he said.

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“And it’s so much the right thing to do,” he added. “It feels like we’re going back into a clinical crisis, and we should not sit by without taking some action to prevent it.”

Labor and health advocates say the industry’s staffing woes, which they concede have worsened during the pandemic, are the result of paying workers too little. And some argue not enough effort has been spent to educate workers. “If we put a fraction of the money to improve vaccine confidence that we spent on actually developing a vaccine, we’d be further along now,” Wasserman said. “It was neglected from the beginning.”

He emphasized the need to respect the concerns of nursing home workers, mainly women of color. In public opinion polls, Black Americans have expressed skepticism of the new vaccines, citing historical misuse of research in their communities.

The increasing support for a mandate “makes people more comfortable that we are going on the right path,” said Dr. Daniel Roth, the chief clinical officer for Trinity Health, a large Catholic chain of hospitals and nursing homes that was among the first large systems to call for a requirement.

Some nursing homes say they favor mandates but feel they cannot enforce them without full industry backing.

“I would love to mandate the vaccine, and I believe it’s the right thing to do,” said Janet Snipes, executive director of Holly Heights, a nursing home in Denver. “But if the nursing home next door does not, I will lose my employees to it.”

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As it is, Holly Heights is down at least a dozen staff members in the nursing department and last month offered a $2,500 signing bonus to attract employees. Recruiting has become even more difficult because of fears of working in a nursing home. The CDC recently investigated an outbreak at a memory care center in Mesa County, Colorado, where 16 vaccinated residents contracted COVID-19 and four died. The agency is expected to publish its findings shortly.

In saying last Friday that it was monitoring outbreaks at nursing homes related to the delta variant, the CDC said some measures under review would include “testing, quarantine, visitation, use of PPE and source control.”

Underscoring the concern of regulators about unvaccinated workers, Colorado just implemented a new rule that unvaccinated staff members at nursing homes must be tested for the virus, using a rapid test, every time they come to work.

Feelings are raw among nursing home staff and operators.

“I don’t want to lose anyone else,” said Marita Smith, administrator at Saint Anne Nursing and Rehab Center in Seattle. Eight of 32 residents died of COVID early on in the pandemic, including four who were already on hospice. Smith said the losses help explain why all 52 staff members have been vaccinated.

“I question their reason for being in the business if they don’t get it,” Smith said. “You just don’t want to turn your back.”

Some nursing home staff members resisting vaccination argue that they can protect residents without being inoculated. “I go home, stay home as much as possible, do grocery pickup instead of shopping, do a lot of hand-washing. I’m not exposing myself to other people,” said Jessica M., a director of nursing at a home in Grand Junction, Colorado, who is unvaccinated.

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She declined to give her last name because she was not authorized to speak to the media. She added that she wanted to make sure “the side effects aren’t worse than protecting someone from COVID.”

But consumer advocates and others point to the difficulties nursing homes have long had in protecting residents from infection. A government report issued in May found that nursing homes averaged three COVID outbreaks from May 2020 through January 2021, with two-thirds reporting the outbreaks began with an infected staff member testing positive.

At ArchCare, the Catholic group that operates nursing homes and other facilities in New York City, “I think it’s just a matter of time before I have to mandate the vaccine across all the programs,” said Scott LaRue, the chief executive.

While 85% of his staff, including all new employees, are vaccinated, he said a mandate, particularly one ordered by the government, would be helpful. After not having any cases for a couple of months, he is now starting to see employees test positive for the virus — typically a harbinger of future infections among residents.

“This is our ticket out of the pandemic,” he said. “Why are we delaying mandating vaccines?”

Navigating the pandemic
(Jennifer Luxton / The Seattle Times)

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