BISMARCK — The extent of COVID-19's devastation on North Dakota nursing homes is hard to fathom for those living outside the facilities' walls.

Long-term care residents account for about 10% of the state's COVID-19 cases but nearly 60% of its virus-related deaths. The residents who survived the last 16 months found themselves in isolation most of the time as disease control measures put the clamps on family visitation, socializing with neighbors and group activities.

So when the COVID-19 vaccine arrived late last year, no other segment of North Dakota society embraced the shot like nursing home residents: Nearly 92% are fully immunized, according to state data from June 17. That's one of the top vaccination rates for nursing home residents in the nation, said Shelly Peterson, director of the North Dakota Long Term Care Association.

"It has been a very, very difficult year, and more than anything, (nursing home residents) want life as they knew it to come back," Peterson said.

The high vaccination rate has translated into remarkably low COVID-19 case counts and reopened indoor visitation, communal dining and group activities for most facilities, Peterson said. Just two long-term care residents in the state were considered active COVID-19 cases as of Thursday, June 24.

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But nursing home workers haven't kept pace on vaccinations with the residents for whom they care. Despite becoming eligible for the shot before almost anyone else, about 35% of staff statewide remain completely unvaccinated against the virus, per data from June 17.

Even though only a handful of nursing home employees across the state are considered active COVID-19 cases, the lower rates of vaccine-generated immunity could endanger vulnerable residents, strain staffing levels and pause family visitation in facilities where many workers have not accepted the shot, said state epidemiologist Grace Njau and disease control chief Kirby Kruger.

Earlier this month, the U.S. Centers for Medicare and Medicaid Services, known as CMS, began releasing the resident and staff vaccination rates for skilled nursing homes, giving the first public look at the progress — or lack thereof — made by North Dakota's 79 facilities.

The rates, reported to CMS during the first week of June, reveal wide variances between the facilities with highly effective vaccination efforts and those struggling to get staff to take the jab.

However, the database does not include basic care or assisted living facilities, which serve similar clientele but do not fall under CMS's jurisdiction. The North Dakota Department of Health denied a records request from Forum News Service seeking the facilities' vaccination rates in February, and the agency has not responded to a second request for the records following the CMS data release.

'We need to protect our residents'

St. Gerard's Community of Care in Hankinson has emerged as a clear vaccine leader among North Dakota nursing homes. More than 93% of health care staff and all 30 residents are fully vaccinated at the facility southwest of Wahpeton, according to the CMS data.

Administrator Jill Foertsch and vaccination coordinator Lori Gulan said the facility's leadership threw its weight behind a strong and persistent vaccine campaign as soon as the shot became available. For them, it was a simple matter of shielding susceptible residents from the virus that has killed 902 North Dakotans in long-term care.

"Most likely, if there is COVID coming into the facility and infecting our residents, it's coming from our staff," Foertsch said. "We need to protect our residents. They're the most vulnerable, the weakest, get hit the hardest ... so that's why it's so critical that our direct caregivers and supplementary caregivers are vaccinated and educated in proper protocols for infection control."

Gulan made promotional videos and posters about the shot and spoke one-on-one to skeptical staff members, many of whom "were listening to myths," she said.

Foertsch said she's thankful residents and staff kept an open mind about the vaccine because everyone in the facility "can breathe a little bit easier" now with the threat of the virus somewhat suppressed. The facility hasn't seen an active case of COVID-19 since January, and staff plan to keep it that way, Foertsch said.

A screenshot from St. Gerard's Community of Care's website shows an employee promoting the COVID-19 vaccine. The nursing home in Hankinson has the highest resident and staff vaccination rates of any skilled nursing facility in North Dakota. Screenshot via St. Gerard's Community of Care
A screenshot from St. Gerard's Community of Care's website shows an employee promoting the COVID-19 vaccine. The nursing home in Hankinson has the highest resident and staff vaccination rates of any skilled nursing facility in North Dakota. Screenshot via St. Gerard's Community of Care

Florence Mitzel, an 80-year-old resident at St. Gerard's, said the high rate of vaccination in the facility gives her peace of mind, noting that more people across the country need to get on board with the vaccine since it's "not a political issue but one of life and death." Mitzel noted that her vaccination status allows her to leave the facility on occasion, but she's not ready to completely shed her mask and stop taking precautions.

"I think (COVID-19) is in the past for the present, but I do realize it could come back and slap us," Mitzel said.

Most facilities in Fargo also sit near the top of the staff vaccination leaderboard, with six of the top eight homes located in and around the state's biggest city. Bethany on University and Bethany on 42nd, where more than 88% of staff are fully vaccinated, ranked second and third on the list.

Grant Richardson, a senior executive at Bethany Retirement Living, told Forum News Service the facilities offered education to staff that emphasized the difficulties of the past year and brought in immunologists from North Dakota State University to speak with hesitant workers. He noted that the company offered a small financial reward to vaccinated staff and allowed those who took the shot to stop testing regularly for COVID-19 and swap N95 masks for surgical masks.

On the other end of the spectrum, Mountrail Bethel Home in Stanley reported that only 31% of its health care personnel are vaccinated. An administrator from the facility in northwest North Dakota did not respond to a request for comment.

Leaders at two facilities in the south-central part of the state said they have experienced similar difficulties in getting staff to accept the jab.

Rick Regner, an administrator at Napoleon Care Center, said many young female staff members have declined the shot at his facility where just 32% of staff are fully vaccinated. He speculated that the workers may be concerned that the vaccine could cause fertility issues — worries without merit, according to immunization experts.

Only a third of health care workers at nearby Strasburg Nursing Home are fully vaccinated. Administrator Brian Schumacher said some local groups have pushed anti-vaccination messages, which could be reaching his staff.

Both facilities have been forced to shut down indoor visitation for several days this month because staff members tested positive for the virus.

Regner and Schumacher said administrators at their facilities southeast of Bismarck continue to provide educational materials and encourage vaccination to staff, but they noted that unvaccinated staff are not much of a risk to residents, most of whom are vaccinated. Schumacher added that staff continue to wear masks around residents, further lowering the risk the virus will spread within the facility.

Njau, the state epidemiologist, said the vaccines have shown to be very effective, but do not provide absolute protection from the virus to everyone who gets the shot. North Dakota has seen at least 443 "breakthrough" COVID-19 cases and 11 deaths in vaccinated people.

Though breakthrough cases are fairly uncommon, Njau said unvaccinated nursing home staff still imperil vaccinated residents at their facilities. Older people are likely more vulnerable to breakthrough infections because of their weaker immune systems, Njau said.

Kirby Kruger (right), director of the North Dakota Division of Disease Control, speaks about COVID-19 at a press conference in Bismarck on March 3. Former State Health Officer Mylynn Tufte stands behind Kruger. (Forum News Service file photo)
Kirby Kruger (right), director of the North Dakota Division of Disease Control, speaks about COVID-19 at a press conference in Bismarck on March 3. Former State Health Officer Mylynn Tufte stands behind Kruger. (Forum News Service file photo)

Kruger, the disease control director, noted that the emergence of the COVID-19 Delta variant in North Dakota adds another layer of complexity to the situation. The new variant is more contagious and thought to cause more severe illness, especially in unvaccinated people, Kruger said.

Njau added that CMS still requires facilities with a positive case in a staff member to shut down indoor visitation, so workers should want to get vaccinated for the sake of their residents' access to family and mental well-being.

"We've lived in this very sad state of isolation and just being away from family and loved ones for a very long time," Njau said. "I can't imagine having to be isolated from people for 10 days or so just because we had someone who was not vaccinated bring it into a facility. There's a social cost."