Falling Short: Rebuilding elderly care in rural America

Rural nursing homes across the country, already understaffed, face significant new federal staffing requirements. With on-the-ground reporting from the Institute for Nonprofit News’ Rural News Network and data analysis assistance from USA TODAY and Big Local News at Stanford University, eight newsrooms, including Door County Knock, explore what the rule change would look like for residents in communities across America. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.

In 2015, Danelle Nickchen’s adult daughter died in a Michigan hospital after a long illness. Following this ordeal, Nickchen was struck by how much the quality of her daughter’s care was elevated by the nursing aides assigned to her.

“I wanted to take care of other people the same way they took care of my daughter,” said Nickchen, a Door County resident. 

Nickchen went on to get trained as a certified nursing assistant, often called a nursing aide. CNA training takes about four months in Wisconsin and can take place on the job. Candidates must pass an exam to get their certification. 

From 2016 to 2022, Nickchen worked in Door County as a CNA. She was employed at all three local skilled nursing facilities, commonly called nursing homes: the Pete and Jelaine Horton Center at Door County Medical Center, Sturgeon Bay Health Services (formerly known as the Dorchester), and Scandia Village in Sister Bay. 

Nursing care in long-term care facilities like nursing homes consists of some mix of CNAs, registered nurses and licensed practical nurses. LPNs train for one to three years, and RNs for two to four years. They are licensed to dispense medications, administer medical procedures and tests, and execute care plans, with additional LPN responsibilities varying by state.

But CNAs spend the most face-to-face time with residents. They perform fundamental, labor-intensive and personal caregiving tasks, such as helping residents out of bed, bathing, dressing, toileting, and eating. 

At the end of her time at Scandia Village, Nickchen said, she was assigned to 13 or more residents. No matter how fast she moved, getting each person ready to go down to the communal dining room for breakfast took a minimum of 20 minutes each, she said, and taking care of people the way she wanted to became impossible. 

“It’s the same type of care you’d give a toddler basically,” Nickchen said, “but with an adult person. Even if everything goes smoothly, I would have had to start before 4 in the morning.” Being assigned to that number of residents also does not allow for time to connect with often lonely seniors, she added, an important emotional component to quality care.

When Nickchen left the field in 2022 she was burned out and sad, she said. Many longtime staff members had left Scandia, she reported, and the home was relying mostly on traveling CNAs supplied by state agencies rather than local aides.

All three of Door County’s nursing homes meet state-mandated minimum ratios for the number of hours of direct care each patient should receive from staff: 2.5 hours of nursing care per day, with 30 minutes of that provided by a registered nurse.

However, all of them fail to meet the higher minimums contained in a pending federal proposal, according to a new analysis performed by Door County Knock in collaboration with other news organizations. They fall short especially when it comes to nursing aides.

That’s not uncommon, said Kim Marheine, a state long-term care ombudsman for the Wisconsin Board of Aging and Long Term Care.

“Door County isn’t unusual in the staffing stressors experienced in their nursing homes, or within health care systems broadly,” Marheine said. “What is being experienced in Door County is occurring throughout the state, and across the country.”

A long-time issue

Nursing aides are the lowest-paid workers in the lowest-paying healthcare industries: skilled nursing and senior housing. The national average hourly rate for a CNA was $17 as of 2022, according to the U.S. Department of Labor Statistics.

Low pay and physically demanding work are part of the reason chronic understaffing has been an issue in nursing homes since the 1980s. The industry has seen even bigger staffing losses since the onset of the Covid-19 pandemic.

Decades worth of academic and federal research shows that staffing levels affect quality of care, and understaffing causes dangerous situations for residents and workers. Marheine and her coworkers in the ombudsman program provide advocacy for and protect the rights of long-term care residents in Wisconsin. They hear from residents and their families every day about their experiences related to staffing shortages and read reports of investigations conducted by advocates and regulators that back up those stories, she said. 

“These (experiences) include issues such as slow or no response to call lights, residents not getting out of bed or missing appointments because there is not enough staff to assist, residents not being bathed or receiving personal cares often enough, a decline in activities available at nursing homes leaving residents with little to do throughout the day, etc.,” Marheine said in an email. “Understaffing has the potential to impact many, if not all, aspects of resident daily life.” 

Understaffing in nursing homes is something the federal government and industry regulators are seeking to change. In September 2023, the Biden administration issued a proposal that would require nursing homes to have an RN on duty 24/7 and provide almost 3.5 hours of nursing care per resident per day, with one of those hours provided by an RN and the rest by a CNA. 

Thirty-five states, including Wisconsin, have their own minimum nursing staff requirements, most of them lower than the Biden proposal. In 1988 the Wisconsin Department of Health Services set a mandate of 2.5 hours of skilled nursing care per resident per day. Thirty minutes of that is required to be performed by an RN or LPN. 

Recommended staffing minimums established in a 2001 report by the Centers for Medicare and Medicaid are higher than any issued by the states or the proposed federal minimums. According to the congressionally mandated report, 4.1 hours of nursing care split between RNs, LPNs, and CNAs is recommended. 

CMS is the agency responsible for regulating the industry, but it has never set a minimum number of nursing care hours for each resident before. The agency is currently reviewing the Biden administration’s proposal and public comments and is expected to make a decision about required minimums next year.

Local care levels

Door County nursing homes are currently meeting state requirements for minimum nursing staff. But none of them are meeting CMS’s recommendations or the Biden administration’s proposed requirements, according to an analysis of the latest federal staffing data in the Payroll-Based Journal from the U.S. Centers for Medicare and Medicaid. The analysis was completed by Door County Knock, USA TODAY and Stanford University’s Big Local News, as part of a national reporting collaboration coordinated by the Rural News Network.

CMS has been collecting payroll data since 2017 when the Affordable Care Act required nursing homes to submit direct care staffing information to CMS. Combined with resident census information, the data can be used to report on hours of care per resident per day. Taking that data and comparing it to the 2001 CMS recommended minimums and the lower Biden proposal minimums, one can see how many days a facility met them for RN, LPN and CNA staff. 

The biggest gap in staffing for local nursing homes is found between how many hours CNAs should spend caring for patients according to CMS and the federal government, and how many hours they actually are. 

Sturgeon Bay Health Services has the lowest CNA staffing levels of the three facilities in Door County. In the second quarter of 2023, Sturgeon Bay Health Services met the Biden proposal minimums zero out of 91 days. Scandia Village met the proposal’s requirements only seven days in the same time period.  

The Medical Center’s skilled nursing facility met the Biden proposal requirements for CNA staff 23 out of 91 days. It met the higher recommended minimum set by CMS for CNAs only 3 days in that same period. The Medical Center’s facility is the only local nursing home that met any of the CMS report recommendations or Biden proposal requirements 100 percent of the time, but that was for RN staff only. 

RN and LPN staffing levels fare better overall amongst Door County’s three facilities. Scandia Village and Sturgeon Bay Health Services met the higher CMS guidelines a little over 50 percent of the time. They met the lower required minimum for RNs under the Biden proposal about 75 percent of the time.

Door County facilities are not alone in failing to meet industry professionals’ recommendations for adequate care. In Wisconsin, 7 percent of the 319 nursing homes for which there is payroll data met the proposed requirements for CNA staff every day for 91 days, and only 5 percent of the nation's roughly 15,000 nursing homes met them during the same time period. 

As one of the 35 states that have their own staffing regulations, Wisconsin nursing homes met the proposed minimums for both RNs and CNAs on an average of 34 days out of 91 from April to June 2023. The Maine Monitor reports that over the same time period Maine nursing homes met the proposed minimum care hours from both RNs and CNAs an average of 59 out of 91 days, making the state second only to Alaska, and well above the national average of 18 days. Maine's nursing home staffing requirements also include minimum staff ratios. 

Not enough or too much

While the federal government’s proposal takes aim at potentially dangerous understaffing in long-term healthcare, it has been met with mixed feelings from those involved in the industry. 

Nursing home owners and operators argue if the proposal takes effect without more funding to back it up, it leaves facilities in an untenable situation. If that were to happen, “we’ll close,” said Sturgeon Bay Health Services director Kristin Molski. 

The proposal does not include minimum staffing hours for LPNs. A public comment letter from 60 experts in geriatrics, long term care, and nursing homes, predicted facilities will cut LPN jobs to pay for increasing the hours of RNs and CNAs. “Care is optimally provided using a nursing skill mix consisting of registered nurses, licensed vocational/practical nurses, and certified nursing assistants,” the letter said. 

Northeast Wisconsin Technical College’s Sturgeon Bay campus has a nursing program. It is hard to say if enrollment will be high enough to meet local staffing needs if the proposal goes into effect, said campus manager April Konitzer.

Enrollment in CNA training does not necessarily predict how many CNAs will be working after completing the course, Konitzer said. Nursing aide training is a prerequisite for the RN and LPN programs at NWTC. Many students continue on to the higher levels of training, according to Konitzer. 

As far as the federally proposed staffing requirements, Konitzer said she feels they are not comprehensive enough.

“Rather than just prescribing levels of care, I’d like to see us tackle shortages from another angle,” she said. She said the reputation of CNA work is particularly in need of an overhaul. Nursing students view it as hard work that is not paid well, and many of them bypass the field. 

In order to develop what she calls a “more vibrant pipeline”, Konitzer said NWTC works closely with the Medical Center to ascertain the Medical Center’s staffing needs. NWTC also offers nursing courses to public school students. This allows students who show an early interest in the nursing field to complete training as part of their high school curriculum. 

The Wisconsin Board on Aging and Long Term Care submitted comments in favor of minimum staffing standards, according to ombudsman Marheine and asked that the proposed rule go even further to address concerns about quality of care. 

Nickchen, the former CNA, said the proposal’s requirements are a start, but they are not going to make more CNAs magically appear. “I’d like to see higher pay, more training and smaller resident-to-staff ratios,” she said. Emphasis on those things would attract more people to the job and support existing CNAs to avoid burnout like hers, she said. 

“I didn’t feel like I could effectively care for these people,” Nickchen said. 

The Biden proposal was issued in September. The public comment period closed Nov. 6 and CMS is reviewing it. Depending on the CMS review, the requirements could go into effect next year. It is indicated in the proposal that rural areas like Door County would have more lead time than urban ones to fulfill the requirements, but all facilities would be expected to meet the standards within five years.