Virginia Mireles worked as a Certified Nursing Assistant (CNA) at Golden Ours Convalescent Home in Grant, Nebraska, for 15 years. She was there until the last light was turned off about two years ago.
“The nursing home was my home. Really after those years, it became my home. So it meant a lot to me,” she said.
As a CNA, Mireles helped patients with personal hygiene and nutrition. She made sure they were comfortable. The COVID-19 pandemic challenged Mireles and her colleagues to keep the home running and the patients safe while also dealing with staffing departures. Still, she said she loved the work.
During the height of the pandemic, Golden Ours hired traveling nurses with higher salaries to stay open, ultimately draining its monetary resources.
Eventually, COVID-19-related deaths at the home and financial problems doomed the facility. Perkins County Health Services closed Golden Ours in July 2022.
Mireles found a new job as a human resources assistant for a feedlot in Imperial, Nebraska. She also helps translate and interpret for Spanish-speaking employees. She mostly works from home and misses spending time with co-workers.
At the nursing home, she earned $16.70 per hour. Now, she makes $20 an hour.
“I didn't realize that my pay was a little low until I started working for Imperial Beef,” Mireles said.
Mireles said she appreciates helping Spanish speakers navigate the professional world at Imperial Beef but loved her job at Golden Ours.
“I do want to be a CNA again. I love what I used to do,” she said.
Now that Golden Ours is closed, Grant and all of Perkins County are without a nursing home. One resident was relocated to the next closest home in Ogallala—about 20 minutes from Grant. Another was moved even further to Lincoln, which is nearly 300 miles away.
Not enough nurses
Nursing home closures are creeping across Nebraska and other parts of the Midwest.
Since 2020, 13 Nebraska nursing homes have shuttered, according to the American Health Care Association (AHCA).
During that time, 25 Kansas nursing homes, 27 in Missouri, and 36 in Iowa closed their doors.
According to the Center for Medicare Advocacy (CMA), 22 nursing homes in Iowa closed in 2022 alone because of poor quality of care and low occupancy.
Staffing shortages and quality of care concerns are the leading reasons long-term care facilities shut down, according to the AHCA and the CMA. The pandemic didn’t help matters, stretching employees and resources to their limits.
Even before COVID-19, many nursing homes struggled to meet the “sufficient” recommended staff-to-patient ratios, said Mark Parkinson, CEO of the AHCA and National Center for Assisted Living.
Depending on the state, the required ratios can run from no minimum to one CNA per every five residents. Failure to maintain recommended ratios can hinder a company from bringing in new residents. That leads to narrower profit margins, Parkinson said.
“If you don't have enough staff to get your occupancy up to that break-even level, it just won't work,” he said. “And that's what's happened in hundreds of these buildings that have closed. They haven't been able to hire the registered nurses or the certified nurse aides.”
The shortage of all nursing home staff is a problem, but an “acute problem” is finding registered nurses (RNs), Parkinson said. And, for prospective health care workers, nursing homes often don’t top the list of desirable places to work.
“It's really hard to work in a nursing home,” he said. “There are often better alternatives for nurses, whether it's working in a hospital or working with an agency where they can pick their own assignments and their own hours.”
The Nebraska Center for Nursing projects the state will be short 5,436 nurses across the health care industry by 2025.
Of that number, an estimated 800 could be needed in nursing homes in Nebraska, according to calculations confirmed by the Nebraska Center for Nursing.
Gerard Brogan with National Nurses United, a union and association supporting nearly 225,000 nurses, said working at an understaffed nursing home has led many nurses to fear for their patients’ health and their own careers.
“Your license is in jeopardy if you're there when there's a poor patient outcome,” he said. “A patient will die or a patient will fall out of bed, break a leg — the nursing home gets sued, the nurse gets hauled in front of their board of nursing for negligent patient care. Again, I could not exaggerate how poor the working conditions are in nursing homes.”
Brogan said the pandemic catalyzed an exodus of health care workers because of “the egregious manner in which nurses — not just nurses — doctors, all healthcare workers, were treated during the COVID pandemic: literally putting their lives at risk, lack of support, lack of PPE (personal protective equipment).”
Quality of care concerns
Liz Jones is a registered nurse working in Broken Bow, Nebraska. When she was a teenager, her grandparents lived in the Broken Bow Care and Rehabilitation Center. It closed in April 2019.
Jones remembers her grandparents looking disheveled and unkempt while living there. Generally, she says she and many of her nursing friends feel that poor quality of care boils down to not enough staff members.
“I have heard of other nurses who have left facilities just because it wasn't safe,” she said. If a nurse is put in charge of too many patients, she said, “there's no way you can safely take care of all those people. And that's a liability on your personal license and your conscience.”
One barrier to hiring more nurses and other nursing home staff could be pay.
According to a survey by the American Nurses Association, the Midwest pays nurses some of the lowest salaries in the U.S.
In 2022, the median income for an RN across the country rose to $80,000, according to the National Nursing Workforce Survey. That was a $10,000 increase from 2020.
Iowa sits at the bottom of the state list with an RN median salary of $68,000. In Nebraska, RNs earn a median wage of $70,441, the fifth lowest in the nation.
Jones said she remains inspired in her job because she can offer dignity to those who need it.
“Taking care of residents and their last stages of life and providing them with the care they deserve is really important to me,” Jones said.
Midwestern states have slightly bumped up Medicaid reimbursement rates for nursing home care, Parkinson said. But, he said, pushing rates even higher would allow facilities to hire and retain more nurses and take in more residents.
Making care work
Married for 67 years, Charlene and James Goff grew up near the central Nebraska town of Burwell. They now live together in the town’s only nursing home, the Burwell Community Memorial Health Center. The nonprofit facility has a five-star rating, according to the Centers for Medicare and Medicaid Services (CMS). That means the center provides above-average quality of care, according to CMS.
The Goffs said they are grateful to live in the community they know.
“Our family is within five, six miles of the facility — practically all of them. They're wonderful about coming to visit. So that's kind of what keeps us going,” James Goff said.
In other towns where nursing homes are closed, seniors move farther away from their families. This can lead to loneliness for the residents and longer, more dangerous journeys for their families during the hazardous winter months. The closest facility outside of Burwell is about 17 miles away in Ord.
Local services and management were key in turning around the nursing home in Burwell, according to administrator Tim Groshans.
“We're reminded every day of what our purpose is and our purpose is taking care of the elderly,” he said. “So, we never lose sight of our passion and purpose.”
When he became the administrator of the home in 2009, it was $650,000 in debt and outsourced management services. The Burwell Community Memorial Health Center expanded to a new facility in 2019 and is staying afloat.
The new facility was designed and built with nursing care in mind, Groshans said. A new HVAC system allows fresh air to flow through the building at a high rate. Visitors and staff are screened for COVID-19 and flu symptoms before entering, even today. Groshans said he doesn’t think he will end the practice because it benefits everyone.
The home retains about 75% of its staff each year because of robust benefits and wages, Groshans said. At Burwell, he said, nursing assistants make $20 per hour while registered nurses can earn up to $40 an hour.
According to the 2022 national workforce survey, the average RN in Nebraska makes nearly $34 an hour.
Employees can rent a duplex owned by the nursing home for several days at a time. That lodging is handy when long-distance commuters want to stay off the roads in the winter.
Groshans said that the nursing home also fully pays for employees’ health insurance and reimburses mileage for staff who drive long distances to work.
“I think it goes back to the idea of that not-for-profit model. We kept our vision on three things: salaries, benefits and physical plant. And so if we’re top-notch in all three of those areas, from a not-for-profit definition, I think we’re doing the right thing,” Groshans said.
Even though it was a challenge for nursing homes, the pandemic revealed the need to further prioritize staff, Groshans said.
“It made us get massively aggressive with ‘how far are you willing to push your wages and benefit package,’ because you better be able to attract them,” he said.
Nearly five hours to the southeast, a nursing home administrator sees community buy-in as the biggest factor keeping its nursing home alive and well.
Lori Rieger is the administrator at ANEW Healthcare and Rehab in Hiawatha, Kansas. The company recently acquired the nursing home formerly known as Maple Heights Nursing & Rehabilitation Center in northeast Kansas.
ANEW owns 16 skilled nursing and assisted living facilities in Iowa, Kansas and Missouri.
“I think community support is big,” Rieger said. “I think you have to have that support from your community, especially your medical community.”
Nursing home care in Hiawatha has had success using services offered by local doctors and therapists, Rieger said.
John Rainbolt, an administrator at Griswold Rehabilitation & Health Care Center in Griswold, Iowa, said more people choose assisted living facilities “because (assisted living facilities) were born in a hospitality model.”
Through rehabilitation care, assisted living facilities help people heal and move back home, Rainbolt said.
“Nursing homes need to die, and they need to be reborn,” Rainbolt said. “It's taking care of the staff that can take care of our people.”
Training more nurses
When it comes to the range of care for senior citizens, assisted living facilities are generally geared toward people recovering from an illness or injury. Nursing homes can tend to needs like end-of-life care, memory support, and daily hygiene and living needs.
Nursing homes, assisted living facilities, clinics and hospitals all compete for the same nurses in rural areas.
Larger nursing homes in urban areas are able to hire more staff with competitive wages not offered in rural parts of the country, Rainbolt said, adding that the Centers for Medicare and Medicaid Services needs to address that imbalance.
CMS recently approved a rule that would require one RN to be on-site at nursing homes around the clock. Previously, facilities only had to staff an RN for eight hours per day.
According to KFF Health News, about 80% of nursing homes will need to hire more registered nurses to comply.
The University of Nebraska Medical Center (UNMC) at Kearney is building a new health care education facility to supply the need for more nurses and health care workers. The colleges of Nursing, Allied Health, Medicine, Pharmacy and Public Health are banding together to create the Rural Health Education Building.
The 100,000-square-foot facility is scheduled to open in early 2026.
College officials hope the total number of undergraduate nursing students will jump from 56 per year to 88, said Cathrin Carithers, assistant dean for the Kearney Division of UNMC’s College of Nursing.
“We have learned in health care, where students are educated, many times they stay,” Carithers said.
Additionally, Groshans said community colleges are important training grounds for rural areas and need to be better utilized to train health care workers..
The Nebraska Health Care Association (NHCA) president and CEO, Jalene Carpenter, said there are other education initiatives in the works to bring more nurses to Nebraska.
“One of those is called the health care talent pipeline. That's getting kids from K-12, exposed to health care science careers, through after-school programs and summer camps,” Carpenter said.
Legislative help
Lawmakers have been tinkering with ways to support the senior care industry in Nebraska. Two proposed measures that didn’t make it through the Nebraska Legislature this year could have increased Medicaid funding for nursing homes and assisted living facilities by nearly $30 million.
When the bills were proposed in February, the NHCA said the funding boost would have improved staffing levels.
The legislature did pass an appropriations bill with $1.5 million in American Rescue Plan Act funds allocated for rural assisted living facilities to serve Medicaid patients.
Carpenter said the federal funding is a small step in the right direction. She added that NHCA will attempt to gain more support for greater funding for nursing homes and assisted living facilities next legislative session.
Restoring care
Back in Grant, the community that lost Golden Ours Convalescent Home, local leaders are not giving up on establishing a new nursing home.
Mark Bottom is the president of the Western Sky Community Care Center board of directors. Western Sky is a nonprofit organization trying to open a new nursing home in Grant.
Bottom’s own mother lived at Golden Ours until it closed in 2022. After that, she moved to the facility in Imperial, about 27 miles away. She died shortly after moving.
Renae Bottom, Mark’s wife, is also a Western Sky Community Care Center board member. When she heard about Golden Ours closing, she thought of her own mother.
“My mind just immediately went to Mom and her well-being,” Renae Bottom said. “Your long-range mental plan was, ‘Well, we're here in this community and when it's time for Mom to need that care, if she does, then we have Golden Ours right here.’”
Her mother also moved to the facility in Imperial, Renae Bottom said.
“It was apparent in her aspect that she was just a little wide-eyed, a little confused at times in a different way than would be normal,” she said.
Mark Bottom said routines are crucial for older adults, and moving from one nursing home to another can derail their sense of stability.
Once Golden Ours closed, Bottom said it was paramount for his group to take up the old facility’s nursing bed licenses. This allowed the community to stay in the good graces of the Nebraska Department of Health and Human Services, he said.
”We quickly formed an LLC that purchased the licenses, which the hospital generously, basically, sold to us for $1 a piece,” Bottom said.
Since then, Western Sky changed to nonprofit status and has raised $2.5 million for a new nursing home. Bottom said it’s a sign of community support.
The group also applied for a potential $13.4 million grant and loan package from the U.S. Department of Agriculture to help build the new facility.
“We're not going to be the one (community) that said, ‘Crap, we don't have a nursing home anymore.’ We're going to be the ones that survive it and come together and it seems to have stuck,” Bottom said.
Bottom said he thinks things will be different this time around in Grant.
Leadership is important, he said, so the board hired Tim Groshans as a consultant to help.
Groshans’ first nursing home job was a CNA role at Golden Ours during high school.
“He has a unique loyalty to this community,” Bottom said. “And so he's given us so much effort and knowledge and wisdom into this.”
The planned Western Sky nursing home will take a lot of lessons from how Groshans helped revive the home in Burwell and another in Callaway, Nebraska.
The new building would house 40 nursing beds, Bottom said. That’s smaller than its allotted 50 licenses which they believe will be more successful, along with a nonprofit mission and purpose.
“The care seems to be much better at nonprofit nursing homes than for-profit nursing homes,” Bottom said.
Given the financial support from the community, Grant’s facility will attempt to accommodate more family gathering space compared to the Burwell facility. Other than that and the smaller bed count, the two will be nearly identical.
Bottom said Western Sky aims to be operational by the fall of 2025.
Once care is restored in Grant, the community hopes to carry on a legacy of quality health care, like Virginia Mireles did in her time working at Golden Ours.
“You really get to love those elders and just be part of their lives,” Mireles said.
This story comes from the Midwest Newsroom, an investigative journalism collaboration including IPR, KCUR 89.3, Nebraska Public Media News, St. Louis Public Radio and NPR.
Do you have a tip or question for us? Email midwestnewsroom@kcur.org.