Nursing Home Workers Were Underpaid, Overworked, and Denied PPE. And Then COVID Hit.

Before I started working to help nursing home CNAs unionize, my conception of nursing homes was colored by a combination of two things: a general sense that they were all nondescript buildings with wheelchair ramps and names evoking bucolic creeks or villages, and a childhood memory of my grandmother in a place where the hallway smelled of urine. I knew old people went there to die but didn’t see the deep bonds between a resident and a CNA that forms from that, or the trades that a CNA makes out of loyalty.

The first time I spoke to a nursing home worker was last spring. We were in her home, a one-room studio without windows or furniture. She had lived there over a year but didn’t make enough to buy anything. She offered me coffee, asking if I wanted cream, opened an empty fridge, then shut it, apologizing. We stood by her stove and drank Folgers as she told me about her day. That same afternoon, I would visit two other apartments just like that.

“I’d make more flipping burgers,” was a phrase I would hear over and over.

Almost any touch a nursing home resident receives will come from a CNA’s hands. They bathe, toilet, feed, and comfort the residents. Usually starting at a little over minimum wage without adequate sick leave or health insurance, these workers are at the highest risk for injury, infection, and the cascading effects that come from poverty.

I had no concept of what it meant for caregivers to work short-staffed. In restaurants, insufficient staffing means someone doesn’t get their drinks. In nursing homes, it means someone might sit for hours in their own feces or worse.

One CNA told me she regularly has to choose between making sure a resident gets fed, another gets cleaned up, and getting to a serious “fall risk” who’s wandered into the hallway. So she goes to help the fall risk, who is trying to get to the bathroom by herself because she couldn’t wait. She mashes food together into one paste so she can speed-feed the resident who hasn’t eaten, and she puts a chuck pad under the resident who needs a bath so he doesn’t leak onto the furniture. Then she goes home crying, riddled with guilt. Another worker returned from a weekend off to find there had been two broken hips and a broken neck in their facility.

If they were to complain to the state, it’s likely they would get little response. Agencies are underfunded and such complaints are common. On the other hand, if the employer finds out they complained, they might get fired and lose their license. A few dings and they’re out. Any of the choices CNAs are forced to make every day could result in a charge of neglect and strip their ability to work. But the emotional cost for caregivers is brutal. In addition to living in constant anxiety, they live in a state of constant loss. Many keep pictures of their residents on their phones. They use precious vacation time to attend funerals and grieve.

Child care is another ever-present issue. With staffing short, CNAs who have to stay home with a sick child are penalized for calling out. In one nursing home, the rule was no more than three times in nine months or you’re terminated. One CNA told me she had no support from child care and had to start leaving her young children home alone. Another CNA received a note from her boss saying simply, “Find more family.”

When asked, CNAs often counted scheduling as one of their primary concerns. Though it sounds bureaucratic or petty, it is one of the most powerful weapons that can be used against a female workforce. Caregivers depend on their schedules to keep intact the complex and fragile systems they’ve developed to survive. CNAs who don’t hustle enough when working short, or who complain, risk the schedule they rely on to pick up their kids or take a sick parent to dialysis or go to nursing school. A small keystroke can upend a life.

Injuries and pregnancies put workers at risk of termination as well. With so few CNAs on the floor, there is no light duty, even when doctors’ notes require it. Pregnant workers are pushed out for early leave or let go for sham reasons. In a female workforce that’s majority people of color, race also plays a role. Black women’s pain is not treated like the pain of white women. Leave, or risk pregnancies compensating for broken Hoyer lifts, these were often their choices.

Across different chains and in different parts of the country, these stories varied in severity but were basically the same. Short staffing, low pay, no respect. It’s true, they would all be financially better off flipping burgers. But why? It may be true that as a nation we value a well-cooked burger over safe elder care. Still, it’s far easier to find a fast food worker than a CNA. It costs a CNA about $1,500 to get certified and takes roughly three months of school. Turnover in the industry is high. Every staffing coordinator will tell you these workers are in demand, so why do they make so little?

The standard answer is that it’s a poor industry. It’s Medicaid money. There’s no profit margin. Yet there are some seriously rich people running these facilities and private equity money is everywhere. Multimillionaires usually aren’t in the habit of investing in losing propositions, so something in the system is working for them. 

The dirty secret of the nursing home industry is real estate. It is not uncommon for the owner of a nursing home chain to also be the majority owner in the real estate investment trust (REIT) that is the leaseholder. This means that many nursing homeowners, through REITs or shell companies with direct family ties, are also their own landlords. They set the rents that eat the operating costs, which drive the margins that incentivize investment.

To stay within operating costs, administrators have to squeeze the workers by rationing critical supplies and keeping salaries low enough that they don’t have to pay for health care since most staff will qualify for Medicaid. Meanwhile, a CNA making $15 an hour who can’t afford to miss work for the back surgery she needs because her sick time is eaten up by child care, spends all her time trying to save the residents from falls and slips, loneliness, and now, COVID-19.

At the Life Care Center in Kirkland, Washington, a nursing home previously cited for Medicare fraud and since cited with numerous violations that allowed the virus to spread, 101 out of 180 residents had COVID-19. The bodies started to pile up fast as workers got too sick to work or fled to protect their own families and none could be found to replace them.  Someone told me that at the end, they had only two CNAs trying to care for 50 residents on night shift.

It took a long time for officials to start counting the workers in their COVID numbers. You had to sift through reports, scan the fine print of feature stories, or read the obituaries. Nursing home workers and others in long-term care were not considered a priority for PPE.

When the Family First Relief Act passed and gave 80 hours of extra paid time off to American workers, it exempted almost all health-care workers. With staffing already short, and conditions already bad in many facilities, they were afraid that if caregivers had any sick time, they wouldn’t come to work. They were denied the same rights as others because their labor was too essential.

When applied to a workforce that is 90 percent female and majority people of color, this arrangement evokes cotton fields and free child care, sugar cane and convict-leasing partnerships. Furthermore, as caregivers, they are in a double bind, because above all else, they believe that the vulnerable should be safe and treated with dignity, and that no one should have to die alone. That’s why they are not flipping burgers.

Traditionally, caregivers organize when the people they care for are at risk—and at almost no other time. Perhaps this moment is different. I want an America where caregivers demand and can receive the basic dignity they offer without feeling like they are stealing it from someone else. To strike, health-care workers have to send a 10-day notice of warning so that emergency staffing can be arranged with an agency. Yet every nursing home worker who even mumbles about organizing gets grilled on how they could just walk out on their residents. There is no innate sense that staffing safely is the employer’s job; most CNAs think it’s theirs.

Yes, there are decent owners. Yes, the long-term care system is broken and Medicaid needs funding. Multimillionaires also need to stop getting rich off the poorest people in the most vulnerable moments of their lives. Safe staffing is not rocket science. Pay CNAs what you pay workers to stand by a street cone. Stop brokering operating costs on their backs to drive the private equity market and see what happens.

As I write, investors are getting nervous about the future of nursing homes. This will potentially lead to a seismic turnover in ownership as real estate stocks are sold off. The average nursing home can be rough, a failing one is horrifying.

Yet poor people will still get old and sick and need to go somewhere. Investors and owners will be just fine. The equity money will wander with them into the wider field of assisted living facilities (ALFs) where regulations are virtually non-existent, and Memory Care units where business is booming because of Alzheimer’s. In these facilities, COVID numbers are rarely counted, there are no staffing ratios, and workers get paid even less. Nursing homes will not go away, they will just get worse. As an essential over-flow valve for hospitals, they continue to provide post-acute care. But their residents will get sicker, the margins will get slimmer, and caregivers will suffer.

This is an industry where an administrator can not only fire you but strip you of your livelihood by dinging your license with charges of neglect, and where you can work 20 years for the same company and still qualify for Medicaid. Held hostage by their best instincts, caregivers struggle to choose their own financial, physical, and mental health over the residents they love—and these employers know that. In fact, they bank on it.

Recently, at a nursing home in Pennsylvania, facing infection numbers similar to those at the Life Care Center in Kirkland, workers organized in a matter of weeks. They only had to watch one worker die before they acted. Bypassing the usual election process, they sent a 10-day strike notice, demanded union recognition, and won it.

For nursing home workers to organize and take collective action, though, they don’t just have to overcome fear, but a whole racist, sexist, disaggregated system that runs on their labor. They have to come to believe that it might be necessary to step away from one resident, to ensure the safety of all residents. This is why I tell my daughter, if you ever see a health-care worker on strike, show respect and have some humility. You have no idea what choices they’ve had to make that day.

Vanessa Veselka is the author of the novels The Great Offshore Grounds and Zazen, which won the PEN/Robert W. Bingham Prize. Her short stories have appeared in Tin House and ZYZZYVA, and her nonfiction in GQ, The Atlantic, Smithsonian, and The Atavist, and was included in Best American Essays and the anthology Bitchfest: Ten Years of Cultural Criticism. She has been, at various times, a teenage runaway, a sex worker, a union organizer, an independent record label owner, a train hopper, a waitress, and a mother. She lives in Portland, Oregon.