"COVID is not pretty in a nursing home," said Deb Wityk, a 70-year-old retired massage therapist who lives in one called Spurgeon Manor, in rural Iowa. She has contracted the disease twice and is eager to get the newly approved vaccine because she has chronic leukemia, which weakens her immune system.

The Centers for Disease Control and Prevention approved the latest vaccine two weeks ago, and the new shots became available to the general public within the last week or so. But many nursing homes will not begin inoculations until well into October or even November, though infections among this vulnerable population are rising, to nearly 1%, or 9.7 per 1,000 residents, in mid-September from a low of 2.2 per 1,000 residents in mid-June.

"The distribution of the new COVID-19 vaccine is not going well," said Chad Worz, the CEO of the American Society of Consultant Pharmacists. "Older adults in those settings are certainly the most vulnerable and should have been prioritized."

With the end of the formal public health emergency in May, the federal government stopped purchasing and distributing COVID vaccines. That has added new complications for operators of nursing homes, who have encountered resistance throughout the pandemic in persuading people, especially employees, to receive yet another round of shots.

The coronavirus decimated nursing homes during the first two years of the pandemic, killing more than 200,000 residents and staff members. Elizabeth Sobczyk, the project director of Moving Needles, a CDC-funded initiative to improve adult immunization rates in long-term care facilities, said that without a government agreement to purchase the shots, vaccine manufacturers would make large quantities only once CDC experts recommended approval.

"Then they need to be FDA-inspected — we want safe vaccines — then there is contracting and rollout," Sobczyk said. "So I completely understand the frustration, but also why the availability wasn't immediate."

Even once the shots are available, nursing homes face continuing resistance to the vaccines among nurses and aides. Without state mandates for workers to be vaccinated, most nursing homes are relying on persuasion, and that is often proving difficult.

"People want COVID-19 to be in the rearview mirror," said Leslie Eber, medical director of Orchard Park Health Care Center in Centennial, Colorado. "We're going to have to remind people more this year that COVID-19 is not benign. Maybe it's a cold for some people, but it's not going to be a cold for the folks I care for."

Only 62% of nursing home residents are up to date on their vaccines, meaning they have received the last booster available before this month's new shot, according to federal data from mid-September. That's an improvement over the 38% rate at the start of October 2022.

But only 25% of nursing home employees are up to date, which is close to last October's rate.

In a written statement, the Department of Health and Human Services said that it would be identifying long-term care facilities with low vaccination rates and reaching out to ensure "proven infection prevention and control measures are being implemented to protect seniors."

This year, more nurses and aides will have to obtain shots at drugstores or health centers on their personal time, rather than at work. Many homes are running clinics, with their long-term care pharmacies supplying the vaccine as they did before, but they face extra bureaucratic hassles in billing insurers for the vaccine for residents and employees.

On top of that, homes are rolling out a new vaccine for another dangerous virus — respiratory syncytial virus, or RSV — which will be a third shot for many residents, along with vaccines for COVID and the flu.

The trio of vaccines will create more administrative complexity for nursing homes because now they must bill Medicare to be reimbursed for the shots. The COVID vaccine is charged to Medicare Part B, which covers outpatient and physicians' services, but the RSV vaccine must be billed to Medicare Part D, the prescription drug benefit.

"The United States has been phenomenal in screwing up vaccinations," said David Nace, chief medical officer of UPMC Senior Communities in Pittsburgh. "This idea that some are under Part B and some are under Part D and some can be billed by a pharmacy — who in God's name came up with this?"

While Medicare will pay for vaccines for most nursing home residents, employees may face private insurance red tape and, for a small group, potential out-of-pocket costs.

Leslie Frane, an executive vice president of Service Employees International Union, which represents more than 134,000 workers in 1,465 nursing homes, said that many homes had stopped running clinics in their facilities and had told workers to go to the drugstore to get vaccinated. She said this would lead to more workers skipping their shots.

"There's very little time, given how many nursing home workers work multiple jobs," she said.

The CDC has arranged for 25 million to 30 million people who lack health insurance or whose insurance doesn't cover the complete cost of the vaccine to get free COVID shots at select pharmacies, health centers and medical offices listed on vaccines.gov. Frane said the program was not well-known among workers, and Worz said distribution was favoring the large pharmacy chains, slowing access in rural communities. Of the nation's 19,400 independent pharmacies, federal officials said 627, many in rural areas, were enrolled in the program and 100 more were being added.

A big obstacle, though, continues to be resistance to vaccination among nurses and aides. Like many facility owners, Avalon Health Care Group, which owns or operates more than a dozen nursing homes in western states, is not mandating staff be vaccinated. Dr. Sabine von Preyss-Friedman, Avalon's chief medical officer, said she tries to address the reasons with each worker and won't abandon the push.

"We're not going to just say, 'OK, everyone get vaccinated,' and then forget about it," she said.

Avalon's homes have used modest financial incentives to encourage staff members to get vaccinated. Some have organized contests among different units, with the winner getting prizes like a pizza party or a drawing for a gift certificate from a department store, and those efforts will resume this year.

Jim Wright, the medical director of Our Lady of Hope Health Center and two other nursing homes in Richmond, Virginia, said that rewards and respectful persuasion were not enough to sway his homes' employees. They tend to be in their 20s and 30s, he said, and are not worried about catching COVID, which many have already weathered.

"They most likely will not do it to protect the residents or protect themselves," he said. "I don't know what the answer is."

Sheena Bumpas, a nursing assistant in Duncan, Oklahoma, and vice chair of the National Association of Health Care Assistants, planned to get this season's shot but said some of her colleagues would not.

"Now that the public health emergency has ended, I think people are done with it," she said.

Edenwald Senior Living, a nursing home within a retirement community in Towson, Maryland, is requiring its workers be vaccinated unless they can justify an exemption for medical or religious reasons.

As of Sept. 10, about three-fourths of the home's workers were up to date with their previous COVID vaccines, triple the national rate for nursing home employees, according to federal records.

Edenwald is relying on the Giant supermarket pharmacy to administer the shots in the auditorium of its independent living section. Sign-up sheets have already been distributed for clinics later this month. The home is billing workers' insurance for the shots, but managers at the home said it would pay for employees without health coverage.

"This is our seventh clinic for COVID," said Meghan Curtis, Edenwald's director of care management. "We've kind of got it down pat."

Swati Gaur, the medical director of three nursing homes affiliated with Northeast Georgia Health System, said some homes might offer recalcitrant employees the Novavax vaccine. It relies on more traditional virus-blocking technology than the Moderna or Pfizer shots, which use messenger RNA.

"We are basically saying, 'Why are you not taking the vaccine? Have you thought about Novavax? It's manufactured like the flu vaccine,'" Gaur said.

For the first time, nursing home residents will be offered a vaccine for RSV. The virus causes the hospitalizations of as many as 160,000 people older than 65 each year, killing up to 10,000. Most nursing homes are coupling the flu vaccine with either the COVID vaccine or the RSV vaccine but are not attempting to give all three simultaneously.

Gaur said that the novelty of the vaccine and people's relative unfamiliarity with RSV meant that clinicians would need to spend more time explaining the reason for the shots.

Spurgeon Manor, the nursing home where Wityk lives, is partnering with the pharmacy at a nearby Hy-Vee grocery store to provide the COVID shot, most likely in early October, to 85 residents of the home and an adjoining assisted living center, as well as employees.

Alana Marean, its assistant director of nursing, said that workers would be encouraged to receive the shots, but she guessed that not even half would do so. "There's a lot of stigma out there about it," she said.

Lee Giese, 95, a retired truck driver who lives at the home, said he was looking forward to the latest shot after coming down with COVID last winter. He said he believed his earlier vaccinations helped protect him from more serious symptoms.

He said he expected most residents of his facility would get the shots, but a few would refuse. "Some people have a death wish," he said.

Jordan Rau and Tony Leys are reporters for KFF Health News, a nonprofit news organization. For this story, Leys reported from Dallas Center, Iowa, and Rau reported from Washington, D.C.