Jamie Smith, a staffing agency nurse who loves hospice, said she was warmly welcomed by Frontier Health & Rehabilitation staff and residents in this conservative St. Louis suburb.

Even if she wasn’t vaccinated against COVID-19.

But until a vaccine is available, the leader of a nursing home where 22 residents have died from the coronavirus likely won’t be able to hire an unvaccinated person like Smith. The U.S. Supreme Court on Jan. 13 upheld a federal mandate that requires health care workers in Medicaid- or Medicare-funded facilities to be fully vaccinated. If all staff — excluding those with approved religious or medical exemptions — are not fully vaccinated, the facility will lose the money.

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Health care facilities in Missouri and other states challenging the federal requirement must fully vaccinate their employees by March 15, according to the Centers for Medicare and Medicaid Services, without filing a lawsuit to block health care in the authorized state Institutions must have a February 28 deadline.

This poses a challenge for Frontier and its residents, as the nursing home has run out of staff. As of Jan. 9, the state had the lowest percentage of nursing home health care workers fully vaccinated, at 67 percent, according to CMS data. Frontier reported an employee vaccination rate of just 30% at the beginning of the year.

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

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While the task ensures that unvaccinated workers don’t care for some of the most vulnerable to the virus, there aren’t enough workers willing to take on low-paying, challenging jobs. Nursing home residents may not be safer if they quit their jobs to avoid being shot, or get fired for not being shot — because of a lack of care.

“Obviously, we need great staff to care for residents, but residents also need safety,” said Marjorie Moore, executive director of Voyce, a St. Louis nonprofit that advocates for nursing home residents, who supports the mission. and their families.

“People who live in their own homes have the opportunity to say, ‘I don’t want anyone in the family who isn’t vaccinated,'” she added. “In nursing homes, they don’t have the opportunity to say, ‘I don’t want people who aren’t vaccinated to come and feed me.'”

The problem of understaffed nursing homes existed long before the pandemic, and it has gotten worse.

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According to the U.S. Bureau of Labor Statistics, in March 2020, 3.3 million people worked in nursing and nursing homes in the United States. By December 2021, that number had fallen to 2.9 million, a loss of 400,000 workers.

Nursing home operators can’t find enough staff because they usually don’t pay much. According to the Bureau of Statistics, the average hourly wage for a nursing assistant in Missouri in 2020 is $13.33. Nursing homes require staff to take on a range of responsibilities, including feeding residents, changing adult diapers, and caring for residents who have dementia and may become aggressive.

Nursing assistants “can often find jobs that pay better and are less physically and emotionally demanding,” said Brian McGarry, a professor at the University of Rochester who studies long-term care. “It’s a huge responsibility that someone’s life and dignity is in your hands, and you’re not being paid commensurate with that responsibility.”

These shortcomings of jobs often lead to significant turnover. In 2017-18, Missouri’s nursing home employee turnover rate was 138 percent, the fourth highest in the nation, according to a study in the journal Health Affairs. Yu Huizi, one of the authors of the study, said Frontier’s rate was over 300 percent.

Nursing home management declined to comment.

Smith, a nurse who works at a health care facility, said she hadn’t had a COVID vaccine because she developed a rare form of cancer in 2017 and was “very picky about what I put in my body.”

“I’m not sure I’ll be able to get it just to keep my job,” she said.

But, she noted in a text message, “I’m still practicing safely.”

In fact, according to federal data, no border resident has died from COVID since the pandemic began. But the center reported 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.

According to a recent analysis in the New England Journal of Medicine, low levels of staff vaccinations put residents at greater risk. The analysis found that in facilities in high-COVID counties, where the average employee vaccination rate was about 30%, the number of COVID deaths among residents was almost three times higher than in facilities where about 82% of employees were vaccinated.

“I think it is clear that unvaccinated or unvaccinated workers put residents at risk — even if they are vaccinated,” said McGarry, one of the authors of the analysis.

Vaccination rates have jumped from less than half of Missouri nursing home workers to about two-thirds now, when President Joe Biden announced nursing home authorization on Aug. 18, according to federal data.

Like Frontier, Northview Village doesn’t have enough staff, and most of those who work there are not vaccinated. The nursing home — located in a low-income, predominantly black community in northern St. Louis — held a vaccination campaign in December to boost its staff vaccination rate by about 20%, but the numbers haven’t risen, according to federal data. Only half of the residents were fully vaccinated.

Northview management declined to comment.

Kimberly Watkins, a techie working to keep Northview residents active, was reluctant to take any photos, in part because she had heard conspiracy theories that they contained tracking chips. But she said she decided to keep getting the vaccine because she suffers from asthma and high blood pressure. Colleagues told her that their doctor said they didn’t need the vaccine, or that they might be allergic to it.

Now, with the mandate in effect, Moore of Voyce, a nonprofit, believes most local nursing home workers will comply.

She highlighted the Mary, Queen and Mother Center, a Catholic nonprofit nursing home in St. Louis County, which announced its mission in August. By the Sept. 30 deadline, the nursing home’s staff had increased vaccination rates from 67 percent to 92 percent, with the remainder being medical or religiously exempt, according to the group. The facility retains nearly all employees.

Not everyone is concerned about nursing home workers getting vaccinated, which is partly a reflection of the community around them. Only 55% of Missourians are fully vaccinated.

“I don’t like to impose,” said St. Louis firefighter Antuan Diltz, whose mother is a 64-year-old retired nurse with dementia and diabetes who lives in Frontier. She was vaccinated; Dilts didn’t.

But others, like Bill Tarleton, have families at Frontier and wish more employees would get the chance. Tarleton, a 77-year-old retired computer programmer, said he was happy with the care his brother, who has dementia, received, although he was sometimes unable to visit him during the COVID-related lockdown.

“It’s a little late in the game,” said Tarleton, who has been fully vaccinated and given a booster. “They’ll get it done – I hope.”

Kaiser Health News is a national health policy news service. It is an independent editorial project of the Henry J. Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.