Wave of rural nursing home closures rises amid staffing crisis

WOCON, Iowa. Marjorie Krueger was stunned to learn last fall that she would have to leave the nursing home where she had lived comfortably for six years.

The Good Samaritan Society facility in Postville, Iowa, will close, administrators told Krueger and 38 other residents in September. The facility has joined a growing list of nursing homes closing across the country, especially in rural areas.

“The carpet was kicked out from under me,” said Kruger, 98. “I thought I would stay there for the rest of my life.”

Her son found a room for her at another Good Samaritan center in Waucon, a small town 18 miles north of Postville. Kruger said the new facility is a nice place, but she misses her friends and longtime employees from the old one. “We were so close, like a good family,” she said.

The former residents of the Postville facility are scattered throughout northeastern Iowa. Some have had to move twice, after the first nursing home they moved to also went bankrupt.

The owners say the closure is mainly due to a shortage of workers, including nurses, caregivers and kitchen workers.

The problem could get worse as government aid dries up in the era of the pandemic and caregivers find it hard to compete with rising wages offered by other employers, industry leaders and analysts predict. Many care centers that have managed to stay open are leaving some beds vacant because they don’t have enough workers to care for more residents responsibly.

The pandemic has brought billions of additional federal dollars to the long-term care industry, which has been inundated with covid-19 infections and more than 160,000 deaths of residents. Many businesses have seen a downturn in business due to lockdowns and reports of outbreaks. Employees faced additional danger and stress.

The industry is still feeling the effects.

According to the Federal Bureau of Labor Statistics, from February 2020 to November 2021, the number of workers in nursing homes and other care facilities decreased by 410,000 people nationwide. Since then, the number of staff has increased by only about 103,000 people.

In Iowa, 13 of 15 nursing homes closed in 2022 were in rural areas, according to the Iowa Health Association. “In less populated areas, it is becoming increasingly difficult to staff these facilities,” said Brent Willett, president of the association. He noted that in many rural areas the number of adults of working age is declining.

Due to the lack of open beds in nursing homes, some patients stay in hospitals for several weeks while social workers look for a place to stay. More people are finding themselves in care facilities away from their hometowns, especially if they have dementia, obesity or other conditions that require special attention.

Colorado Executive Director of Health Policy and Financing Kim Bimestefer told a conference in November that the state recognizes the need to help strengthen health care facilities, especially in rural areas. “Last year we had more nursing homes going bankrupt than in the last 10 years combined,” she said.

In Montana, at least 11 nursing homes — 16% of the state’s facilities — closed in 2022, according to the Billings Gazette.

Nationally, the Centers for Medicare and Medicaid Services recently reported that 129 nursing homes closed in 2022. Mark Parkinson, president of the American Health Association, said the actual numbers were much higher, but federal reports tend to lag behind what’s happening on the ground.

For example, a recent KHN survey found that a federal agency counted only one of 11 Montana nursing home closures reported by news outlets in that state in 2022, and only eight of 15 reported in Iowa.

Demand for long-term care is expected to rise over the next decade as the baby boom generation ages. Willett said his industry supports changing immigration laws to allow more workers from other countries. “This should be part of the solution,” he said.

The Postville, Iowa nursing home was one of 10 care centers closed last year by the Good Samaritan Society, a major South Dakota chain.

“For us, as a non-profit organization, this is a last resort that in many cases would have existed in these communities for 50 to 75 years or more,” said Nate Scheme, CEO of the company.

The Evangelical Lutheran Society of the Good Samaritan, the company’s full name, is affiliated with the giant Sanford Health network and serves 12,500 clients, including residents of care facilities and people receiving care at home. According to the Scheme, about 70% of them live in rural areas, mostly in the Plains states and the Midwest.

Shema said many frontline care home workers have found less stressful work after working during the worst days of the coronavirus pandemic, when they had to wear extra protective gear and be regularly screened for infection in the face of constant risk.

Lori Porter, chief executive officer of the National Association of Health Assistants, said staffing problems at nursing homes had been piling up for years. “No one who has been in this business is shocked by the way things are,” she said. “The pandemic has brought this to the attention.”

Porter, who has worked as a certified nurse assistant and nursing home administrator, said the industry needs to highlight how rewarding work can be and how being an assistant can lead to higher paying jobs, including as a registered nurse.

Care industry leaders say they’ve raised wages for frontline workers, but they can’t always keep up with other industries. They say this is mainly because they rely on payments from Medicaid, a government program for low-income Americans that covers the bills of more than 60% of people living in nursing homes.

In recent years, most states have increased the amount their Medicaid programs pay out to nursing homes, but those rates are still less than what institutions get from other insurers or from residents paying their own way. In Iowa, Medicaid pays nursing homes about $215 a day per resident, according to the Iowa Health Association. This compares to about $253 a day for self-paying people. When nursing homes provide short-term rehabilitation to Medicare patients, they receive about $450 a day. However, this federal program does not cover long-term care.

Willett said a recent survey found that 72% of Iowa’s remaining nursing homes are freezing or limiting admissions below their capacity.

Prairie View Nursing Home in Sanborn is one of them. The facility, owned by a local non-profit organization, is licensed for 73 beds. According to administrator Wendy Nelson, recently it can only accommodate about 48 residents.

“We could take on more patients, but we wouldn’t be able to give them the care they deserve,” she said.

Among Prairie View’s painful decisions last year was the closure of its 16-bed dementia care unit.

Nelson has been in the industry for 22 years, including 17 years at Prairie View. It has never been easier to ensure that nursing facilities are fully staffed, she says. But the pandemic has added stress, danger and hassle.

“It pulled the dirt out of some people. They just said, “I’m done with it,” she said.

Prairie View has repeatedly raised pay, Nelson said, with certified nurse assistants now starting at $21 an hour and registered nurses starting at $40 an hour. But she is still looking for more workers.

She understands that other rural employers are also in a difficult position.

“I know we are all struggling,” Nelson said. “The Dairy Queen is also struggling, but the Dairy Queen may change her schedule. We can not”.

David Grabowski, a professor of health policy at Harvard Medical School, said some of the closed medical facilities have a poor safety record. These closures may not seem like a tragedy, he said, especially in urban areas where there are plenty of other options.

“We could say, ‘Maybe that’s how the market works, like closing a bad restaurant or a bad hotel,'” he said. But in rural areas, the closure of even a substandard care facility can leave a hole that is difficult to fill.

For many families, home care would be the preferred alternative, he said, but there are also not enough workers to provide these services.

The result can be long hospital stays for patients who could be cared for in a care facility or with home caregivers instead, if these services were available.

Rachel Olson, a social worker at the Pocahontas Community Hospital in northwest Iowa, said some patients wait a month or more at her hospital while she tries to find a place for them in a nursing home once they are stable enough to transfer.

She said it’s particularly difficult to accommodate certain types of patients, such as those who need extra attention due to dementia or who need intravenous antibiotics.

Olson starts calling nursing homes near the patient’s home and then tries calling facilities farther away. She had to place some people up to 60 miles away from their hometowns. She said the families would have preferred her to find something closer. “But when I can’t, I can’t, you know? My hands are tied.”