The omicron wave is hitting nursing homes hard, with infections among residents and staff reaching record highs in recent weeks.

There were more than 40,000 residents who tested positive last week, according to data from the Centers for Disease Control and Prevention, almost a 10-fold rise since November. Cases for staff hit a record high of more than 67,000 cases the first week of January, but started to decline last week.

"What we've learned with the pandemic is that when there are large [numbers] of COVID cases in the general population, COVID finds its way into skilled nursing facilities," says Mark Parkinson, President and CEO of the industry group American Health Care Association.

Deaths have also risen but nowhere near the months before Covid vaccines became available when nursing homes suffered terrible losses. Last week, there were 988 reported deaths among nursing home residents, only a fraction of the peak in deaths – over 6,000 – back in December, 2020.

"Largely because our resident population is so heavily vaccinated, we aren't seeing large numbers of deaths as we did much earlier during the pandemic," says Katy Smith Sloan, president and CEO of Leading Age, a group representing non-profit providers of long-term care for seniors.

That said, those numbers could still rise in the coming weeks.

"Older adults who live in nursing homes have underlying health conditions," says Smith Sloan. "They tend to be frail. They live in a nursing home because they need 24-7 nursing care. And we know from the beginning of this pandemic that that's the population that was most at risk and that hasn't changed."

But unlike the early waves of the pandemic, it's not the deaths among residents that have nursing homes most concerned. It's staff outages due to infection that is worsening the historic worker shortage that facilities were already grappling with.

Slow uptake of Covid-19 vaccines among staff has added another layer to this problem. Staff vaccination at nursing homes and long-term care facilities was slow to begin with, but has caught up somewhat to that of residents – nearly 84% of staff are now fully vaccinated compared to 87% of residents.

However, staff are still far behind in receiving boosters. Only 30% have received their boosters – that's less than half the number of residents who are boosted.

And the staffing situation is affecting the care residents are receiving.

"We are certainly seeing a huge increase in the number of calls from residents who are saying that they are not being changed, they're not receiving their meals on time," says Laurie Facciarossa Brewer, the Long-Term Care Ombudsman in New Jersey. "That happens when you don't have enough staff."

In recent days, Brewer's office has received complaints that facilities have one nursing assistant taking care of more than 50 residents.

"The state mandated staffing ratio in New Jersey is one certified nursing assistant for eight residents on the day shift," says Brewer. "So clearly, people are not going to be getting the care they need under those types of conditions where you have double-digit numbers of residents per certified nursing assistant. That's just an impossible job for that nurse aide."

She says things aren't that dire in every long-term care facility, but it's happening in more places than she's seen since the early days of the pandemic.

New Jersey is one of several states that has teams from the National Guard helping nursing homes and other long-term care facilities due to the dire worker shortage.

Workers are feeling "moral distress," says Susan Reinhard, executive director of the AARP's Public Policy Institute.

"If you have too many people to care for, you're going to feel moral distress," she says. "Like 'I'm not doing my best.' 'I can't do the best job I've been trained to do, that I want to do.' 'I'm not meeting the needs of those that I'm supposed to be caring for.' That is really devastating personally, just day after day."

These conditions are fueling more burnout. And many nursing homes are shutting down under the pressure.

Smith Sloan says she heard of two of her organization's members closing the first week of January. "I think there were five (closures) the week before," she says. "And I think we're going to see more of that."

Many facilities are responding by closing wings and reducing the number of new patients they accept. That in turn is having an impact on hospitals and family caregivers.

For one, hospitals are getting backed up because they can't discharge patients that need to go to a skilled nursing facility or a nursing home. \

"It starts backing up all along the chain," says Dr. David Kim, who leads the Physician Enterprise at Providence, a health system based in Renton, Wa. "And then you start seeing it come out with long wait times, E.R. patients in hallways, waiting rooms, because they're not ready to go home, but they can't get a bed."

Data from Careport, a company that connects patients in over 1000 hospitals to long-term care facilities shows that the average length of stay at hospitals for patients getting discharged to skilled nursing facilities is up 21% in the last four weeks compared to 2019.

And the average hospital stay for patients getting discharged to home health is up 14% during the same period of time. "That's not an insignificant trend," says Dr. Lissy Hu, founder and CEO of Careport.

"We're also starting to see more families start to pull patients out of nursing homes."

And it's putting enormous pressures on families who are now the primary caregiver for their elderly loved ones, she adds, especially because home health agencies are also grappling with dire worker shortage.

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