A 'Nursery to Nursing Home' campaign for a rural Wisconsin community could help the well-being of children, older adults

Members of Groundswell Collective advocate for their 
'Nursery to Nursing Home' campaign (Photo The Yonder)

In Walworth County, Wisconsin, a local community group called Groundswell Collective proposed to turn a vacant wing of the county’s nursing home into a combined childcare center and senior-living space, reports Madeline de Figueiredo for The Daily Yonder.

Like many rural communities, this county has faced challenges such as a lack of child care and senior care, as well as the loneliness and isolation that can come with living in a rural area with long winters.

Abriana Krause, who lives and works in the area as a childcare provider, told the Yonder, "In Walworth County, all 2,240 licensed childcare slots, spread across the 35 active centers listed on the DCF [Department of Children and Families] website, are already full. That leaves nearly 2,680 children without stable care." Similarly, Wisconsin is projected to need 33,000 long-term care beds by 2030.

To support their proposal, the Groundswell Collective has relied on research that shows the benefits of intergenerational care, such as "boosting the well-being of both children and older people, reducing isolation, improving cognitive and physical health for older people, and cultivating empathy and connection in young children," Figueiredo explains. Intergenerational care has also been linked to dispelling age stereotypes and a renewed sense of care that affects entire communities and fosters lasting relationships.

Research also shows that the benefits intergenerational spaces offer can "extend to the caregiving staff," Figueiredo reports. "Daily interaction with both children and older adults can enhance the work environment and make intergenerational centers more rewarding for staff." There’s hope that this initiative will help the county retain nursing staff.

After almost a year of the community organizing around the proposal, the Walworth County Board approved funding in November for a feasibility study on the intergenerational care center.

Analysis: Nursing home patient capacities have shrunk, with rural areas posting the greatest decreases

Rural areas had the greatest declines in available nursing
home beds since 2019. (Pixabay photo via Medical Express) 

Despite the rapidly aging U.S. population, nursing home capacity has shrunk nationwide since 2019. According to Sadie Harley for the University of Rochester Medical Center, a recently published study in JAMA Internal Medicine showed that 25% of U.S. counties "experienced decreases in the number of supported nursing home spots by 15% or more," with rural areas reporting the greatest declines.

The dwindling number of nursing home placements for older Americans translates into "nearly 4,000 fewer beds available for new patients each day," Harley writes. "But this decline was not felt by all communities equally. It varied widely across geographic regions, with rural counties more likely to face declines of 25% or more."

Rural communities are already grappling with fewer physicians, hospital closures and strained emergency medical services. The loss of nursing home spots presents another challenge, leaving more rural residents with few other options than to travel farther for ongoing care.

Within the U.S. medical system, nursing homes provide vital care to seniors who need regular medical treatment but don't require the expertise of hospital services. They also offer interim care for patients leaving the hospital who aren't yet ready to care for themselves at home. Harley explains, "The reduction in nursing home capacity was linked to longer hospital stays, especially extended stays of 28 days or more."

The decline in nursing home care spots isn't a reflection of the number of beds a facility has. Harley adds, "This study estimated nursing homes' operating capacity by taking other resource constraints into account." Study author Brian McGarry, told Harley, "The facility may not have the staff or other resources to fill every bed."

Long-term care facilities face immigration crackdown and looming Medicaid cuts

Jackline Conteh is a nursing assistant in Va. She emigrated 
to the U.S. from war-torn Liberia. (KFF News photo)

Long-term care facilities call for immigration reform and push against Medicaid cuts as the sector faces "a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending," reports Jordan Rau of KFF Health News. "More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies."

While labor shortages are not new to the eldercare sector, once the Trump administration canceled the industry's "protected" status in January and allowed Immigration and Customs Enforcement to raid health care facilities, the dynamics changed. Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults, told Rau, “People may be here on a green card, and they are afraid ICE is going to show up."

The long-term and senior care industries are "urging the federal government to expand legal immigration channels for essential workers in healthcare and other sectors," reports Kimberly Bonvissuto of McKnights. "The Essential Worker Immigration Coalition sent a letter to Homeland Security Secretary Kristi Noem that [said] the shortage of legal immigration channels for essential workers 'threatens the stability of our supply chains, the viability of small businesses and the strength of the American economy.'"

Besides additional staffing shortages brought on by immigration issues, long-term care facilities continue to lobby against the Republican party's Medicaid spending cuts, which passed the House and are under Senate review. Rau writes, "Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid."

Given the current issues, providers, patients and employees all have reasons to be concerned. "The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care," Rau writes. Jackline Conteh, a U.S. nursing assistant originally from Liberia, told him, "If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents? What will become of our old people that we’re taking care of?"

Rural elders are estimated to endure much more abuse than what is reported. Protecting them comes with speaking up.

Rural adults are less likely to report
abuse. (Photo by Danie Franco)

While research on elder abuse in rural areas may be limited, evidence shows that one in 10 elders report being abused. A report from the National Center on Elder Abuse said that for every report of abuse ”there are 24 incidents that may go unreported,” according to Liz Carey in an article for the Daily Yonder.

“Older adults living in rural and remote areas are at greater risk of abuse because of their geographic isolation, lack of support services, and poorer health,” Carey said.

These conditions may work to conceal abuse. Rural elders tend to have less education and fewer financial resources that could, “possibly [create] barriers to leaving abusive situations,” according to a Rural Health Research Center (RHRC) study quoted by Carey.

Alexis Swendener, co-author of the RHRC policy brief, told the Daily Yonder that it was difficult to know the scope of the problem. “Some of the laws are about vulnerable adults or dependent adults. Some of them have age defined in them and some of them don’t.”

The study looked at reports of emotional abuse, financial abuse, physical abuse, sexual abuse, neglect and self-neglect. Swendener told the Daily Yonder that sexual abuse and self-neglect were the least likely to be “clearly mentioned.”

Nels Holmgren, the director of Aging and Adult Services in Utah, said in an interview with the Daily Yonder that a key element to protecting elders is reporting. However, he also said due to a sense of independence and lack of services in rural areas, people are less likely to ask for help.

When electrical companies shut off electricity for wildfire prevention, nursing homes can be caught unaware

Nursing homes are often forgotten during emergencies.
(Adobe Stock photo)

As climate change worsens extreme weather, some electric companies are opting to cut power as a wildfire prevention tool. The loss of electricity to entire regions, sometimes with little notice, has left some nursing home facilities scrambling for power during inclement weather.

With the increasing prevalence of preemptive power cuts, "nursing homes are being forced to evaluate their preparedness," reports Kate Ruder for KFF Health News. "But it shouldn't be up to the facilities alone, according to industry officials and academics: Better communication between utilities and nursing homes, and including the facilities in regional disaster preparedness plans, is critical to keep residents safe."

In the country's western half, nursing homes are particularly vulnerable and less likely to be prepared. "More than half of the nursing homes are within 3.1 miles of an area with elevated wildfire risk, according to a study published last year," Ruder explains. "Yet, nursing homes with the greatest risk of fire danger in the Mountain West and Pacific Northwest had poorer compliance with federal emergency preparedness standards than their lower-risk counterparts."

While the federal government mandates that nursing facilities have disaster preparedness plans, those plans don't always "include contingencies for public safety power shut-offs, which have increased in the past five years but are still relatively new," Ruder reports. "And nursing homes in the West are rushing to catch up."

Debra Saliba, director the University of California's Anna and Harry Borun Center for Gerontological Research, said "making sure nursing homes are part of [broader] emergency response plans could help them respond effectively to any kind of power outage," Ruder writes. "Too often, nursing homes are forgotten during emergencies because they are not seen by government agencies or utilities as health care facilities, like hospitals or dialysis centers, Saliba added.'"

These centers offer specialized care for aging adults that allows them to live at home instead of in nursing homes

PACE centers offer multiple types of care under one
roof. (National PACE Association photo)

As people age, most don't want to live in nursing homes. But when faced with extensive medical needs, many older adults end up in institutionalized care. While some older adults may need that degree of attention, a lesser-known option known as PACE (Program of All-Inclusive Care for the Elderly) is gaining popularity as a cheaper, healthier alternative to nursing homes. "PACE has long flown under the national radar as an elder care option," reports Anna Claire Vollers of Stateline. "PACE centers provide government-funded medical care and social services to people older than 55 whose complex medical needs qualify them for nursing home care, but who can live at home with the right sort of help."

Given the preference of most individuals and their families to avoid nursing homes, considering a PACE center is a logical step. Vollers writes, "By 2030, one in five Americans will be over age 65, and most older adults say they would prefer to remain living in their homes for as long as possible. . . . . [The program has] recently attracted significant interest from lawmakers because it can keep people at home and may cost less than nursing home care."

The PACE model offers companies and health care systems a way to meet clients' health needs without lengthy inpatient stays. Each center provides a range of medical treatments, including physical therapy, vision and dental care, counseling and lab work. Centers also offer opportunities to get out of the house and socialize by providing a dining hall for meals and gathering areas for puzzles and games. Vollers reports, "Center social workers can help clients obtain needed items such as walkers and at-home wheelchair ramps."

Robert Greenwood, senior vice president for communications and member engagement at the National PACE Association, told Vollers, "It's definitely gaining momentum. In the last couple of years, we've had maybe six or seven new PACE programs open a year. In the last couple of months, we've had about four PACE programs open each month. There are 50 organizations in the pipeline for the next two years."

So far, PACE centers have had bipartisan support. Vollers reports, "Tennessee state Rep. Caleb Hemmer, a Democrat representing Nashville, and state Sen. Bo Watson, a Republican representing Hamilton County (which includes Chattanooga), are cosponsoring legislation that would expand PACE across the state." Hemmer told Stateline, "Even I was amazed when I visited. You walk in, and it’s nice and clean, it smells good, and there are activities for people. It’s a place I would want to send a loved one.”

For examples of PACE care in rural communities, click here and here.  To discover more about PACE, click here.

Nonprofit news outlets collaborate to produce series with localized stories about rural impact of nursing home rules

The Maine Monitor's package shows whether each nursing
home meets staffing standards or not. (Map adapted by TRB) 

By Alana Rocha

Editor, Rural News Network
Institute for Nonprofit News

Residents of some rural areas across the country have a more nuanced understanding of local nursing homes’ staffing struggles — and how proposed federal requirements may worsen them — thanks to a collaboration led by INN’s Rural News Network and other partners.

The project, “Falling Short: Rebuilding elderly care in rural America,” combined on-the-ground reporting from seven rural newsrooms with data analysis, support and visualizations from USA Today and Big Local News at Stanford University. Support from the National Institute for Health Care Management made the project possible.

If implemented, rural nursing homes across the country would have about two years to comply with proposed federal rules. But, as the “Falling Short” collaborators found, many of those facilities already struggle to recruit and retain skilled workers. Most are nowhere near able to comply with the new staffing minimums.

The collaboration provided essential resources for nuanced storytelling. Big Local News and USA Today investigative data reporter Jayme Fraser worked together to clean the data and developed a “story recipe” the journalists followed to write articles and get ideas for local sources.

Newsroom collaborations like this are a win-win, Sophia Paffenroth, community health reporter at Mississippi Today, said in a post-series survey: “For us, they generate more reach, offer some extra funding, and connect us to valuable networking and resources.”

Other nonprofit newsrooms in the project were the Barn Raiser in Kansas, Carolina Public Press, the Door County Knock in Wisconsin, JOLT (Journal of Olympia, Lacey and Tumwater) in Washington, and Maine Monitor.

We got the milk, but where's the carton? Dairy farmers face an unexpected dilemma.

The USDA requires milk offerings at
breakfast and lunch. (American Dairy photo)

America's dairy industry has a new problem -- not enough 4 oz. cartons to put the milk in before shipping it to "care homes, hospitals, prisons, cruise ships and schools," reports The Economist. "School districts are scrambling." The Department of Agriculture "requires milk to be offered at school during breakfast and lunch. . . . For some pupils, school is the only place they receive dairy food. Districts are reimbursed for each half-pint of milk offered to pupils at low or no cost. Milk can arrive in schools as quickly as 72 hours after leaving the farm."

How did this happen? Dairy supplier Cream-O-Land and other dairy suppliers source their cartons from Pactiv Evergreen. The company "blames higher-than-usual demand. Dairies use the summer to stock up. This supposedly did not happen this year," The Economist reports. "Dairies disagree, seeing no changes in demand or inventory. Other packaging firms are busy because Pactiv Evergreen's customers are begging for cartons."

Because schools and other businesses are required to serve milk, the USDA and many states relaxed some of their requirements. "Schools can now serve milk out of jugs. Districts are stocking up on cups and lids. Some schools are offering juice," The Economist adds. "To fix things, Pactiv Evergreen says it has upped its output. It has also resurrected a defunct generic brand and will use its design for all cartons, rather than interrupting the line to change logos. This should speed production and increase capacity by 10%. Shipments are expected to begin in early December."

Meanwhile, the U.S. dairy industry is already facing declining sales due to competition from plant-based "milks." Not having enough cartons was yet another challenge. Danielle Wiener-Bronner of CNN reports, "To help ease the burden on schools — and dissuade them from turning to non-milk alternatives — the American Dairy Association North East issued tips to dairy suppliers, suggesting that they offer to help pour milk themselves, donate cups or spearhead a cup donation drive, among other solutions."

Proposed new rules for nursing homes have sparked warnings and fear; rural residents are the most vulnerable

National Cancer Institute photo, Unsplash

The Centers for Medicare and Medicaid's new staffing mandates were met with alarm and fear, with descriptions including 'a disaster,' 'insanity', and 'catastrophic.' The Biden Administration's "proposed federal staffing mandate will be impossible for the nation's nursing homes to meet, limiting access to care for our seniors," reports The American Health Care Association. "CMS released the one-size-fits-all mandate earlier this year, despite its own study finding no level of staffing guarantees quality of care."

The angry reaction and warnings are particularly problematic for rural Americans. "As nursing home closures continue across the country, 'nursing home deserts' are expanding, and the proposed federal staffing mandate is expected to exacerbate the problem," reports Amy Stulick of Skilled Nursing News. "This is despite attempts to make the potential policy change easier for providers in rural markets, which are especially vulnerable to access issues. Operators in these areas point to the 24-hour RN requirement as being especially devastating."

Finding nurses, let alone 24-hour nurses, is impossible in certain areas. Nate Schema, CEO of the Evangelical Lutheran Good Samaritan Society, "says the organization's facilities located in 'deep rural communities' will struggle the most with the 24-hour RN rule," Stulick writes. "In communities like Bloomfield, Nebraska, pop. 1,000, or Miller, South Dakota, pop. 1, 300, Schema isn't sure where Good Samaritan will find even six RNs; the Miller facility hasn't had a night nurse for upward of three years."

"The ability to have a nursing home open in a small town is getting more difficult because of the disparity between Medicaid reimbursement and overall costs, says Accura HealthCare CEO Ted LeNeave," Stulick reports. "Accura operates 34 communities across Iowa, Minnesota, Nebraska and South Dakota." LeNeave told Stulick: "The provider relief fund helped to mask how bad those problems were. Once that cash dried up, buildings started closing. This concept of a nursing home desert is an area where residents need nursing home care, but there's no access to them. Then they have to drive 45 minutes to an hour to be somewhere else."

Michael Beal, CEO of Care Initiatives, told Stulick, "It doesn't matter if it's 5, 10 or 15 years, if there's no additional reimbursement, it's just a timing question on when that will affect [rural operators]; it just kicks the can down the road." Stulick reports: "Beal added that the suggested rule of 'adding that an arbitrary number of staff hours per resident day without a reimbursement mechanism, and the ability to actually hire staff puts rural operators in an 'untenable situation.'"

Berkshire Eagle, Seven Days, Vermont Standard, Nantucket paper big rural winners in New England newspaper awards

Slide from awards presentation

The Berkshire Eagle scored big in the New England Newspaper and Press Association awards, which were announced Thursday during the group's semiannual online conference.

The Eagle, of Pittsfield, Mass., was judged the best small daily (less than 9,000 print circulation), with The Keene Sentinel of New Hampshire and the Record Journal of Meriden, Conn., as runners-up. 

The Eagle was judged to have the best editorial, "chastising the Catholic diocese in western Massachusetts for trying to subpoena a reporter's notes which would reveal confidential sources" and calling on legislators to pass a shield law like most other states have to protect reporters. 

And the Eagle won two of NENPA's Publick Occurrences awards, named for America's first newspaper and honoring 13 pieces that were judged to be the best in New England journalism in the past year. The rural or rural-impact winners included the Eagle's reports on nursing homes and hazardous-materials shipments on trains that go through its region; projects by Seven Days of Burlington, Vermont, on child care and the pandemic's impact on housing in the largely rural state; the Lewiston Sun Journal's "Homeless in Maine" series; the Concord Monitor's series on police spending and policies all over New Hampshire; and CT Mirror's "Elder Care Reckoning" series that prompted reforms in Connecticut.

The best small weekly newspaper in New England was judged to be the Vermont Standard of Woodstock, with runners-up the Milton Times of Massachusetts and the St. Albans Messenger of Vermont. The best large weekly (over 4,000 circ.) was the Inquirer and Mirror of Nantucket, Mass.; runners-up were the Martha's Vineyard Times and sister papers in Maine, the Mt. Desert Islander of Bar Harbor the Ellsworth American. The best mid-size daily (circ. 9,000-20,000) was The Day of New London, Conn., with Massachusetts' Daily Hampshire Gazette of Northampton and the Greenfield Recorder runners-up. The Concord Monitor was judged best small Sunday paper.

As pandemic-era funding runs dry, many rural nursing homes are closing -- a loss for families and local economies

Bloomberg map, from CMS and Census Bureau data

Amid increasing medical costs, depopulation and a national nursing shortage, hundreds of rural nursing homes are closing, leaving economic losses and care deserts behind, reports Lauren Coleman-Lochner and Martin Z. Braun of Bloomberg. "Across the country, almost 690 nursing homes have shut their doors since 2020, according to the Centers for Medicare & Medicaid Services. The American Health Care Association, an industry trade group, expects the number to keep ticking up in the coming years because of a combination of rising labor costs, falling enrollments and government reimbursements that fall far short of paying the bills."

Many rural places already face depopulation and staffing shortages across several sectors, so the struggles for a small long-term care facility are amplified. "America's elder-care deficit is particularly acute in the Midwest and parts of the South, where a larger portion of the population age 65 and older resides in rural counties; in North Dakota, it's 46%, double the average nationwide, according to Census Bureau data," Coleman-Lochner and Braun write. Residents in these regions face further stress because finding a new nursing home, which may be hundreds of miles away, "causes families to splinter and can become yet another contributor to depopulation."

In smaller towns, a care facility is often the largest employer, so when it closes, the economic domino effect begins with job losses and trickles down. When a long-term care facility closed in Mott, North Dakota, pop. 700, "Business at the town's drugstore dropped 40% . . . , according to owner Chuck Oien. His wife's grocery store also saw a decline," Bloomberg reports, "as did restaurants and hotels that catered to out-of-town family members when they visited."

The pandemic "didn't cause the troubles at hundreds of U.S. nursing homes, but it sure didn't help," Bloomberg reports. "The number of workers in nursing homes and residential-care facilities dropped by 210,000 between February 2020 and June 2023, according to the Bureau of Labor Statistics, as nurses and caretakers sickened or quit, feeling burned out. CMS estimates that nursing homes lose more than half their workers each year. . . .The federal aid directed at hospitals and nursing homes during the early part of the pandemic temporarily covered up the fundamental problems with the industry's economics, says Kelly Arduino, head of the healthcare practice at advisory firm Wipfli. With government assistance winding down, there will be more financial distress and closures." Arduino told Bloomberg: "It's only going to get worse. We all see it coming. We don't see a mechanism for how to fix it."

Proposal for more nursing-home staff seen as unattainable by many owners; resident advocates say it's not enough

Nursing homes may not be ready for 'tsunami' of baby boomers.
(Photo by G.A. Pflueger, Unsplash)

Nursing homes have struggled for decades to find a sustainable business model that provides optimal staffing numbers for resident care. Now federal officials have released "a proposed rule requiring the nation’s nursing homes to hire minimum numbers of front-line caregivers, a long-anticipated response to decades of complaints about neglect and abuse in an industry that critics say is unprepared for the tsunami of seniors heading its way from the baby boom," reports Christopher Rowland of The Washinton Post.

The Centers for Medicare and Medicaid Services proposed "minimum nurse staffing standards . . . per resident for registered nurses and . . . nurse aides," as well as a requirement to have a registered nurse at the nursing home around the clock. Many industry stakeholders consider the proposal futile. Rowland explains, "Without a supply of prospective workers, it will be impossible to meet the requirements of minimum staffing, the industry has argued. They also contend that Medicaid reimbursement rates need to be significantly increased if more workers are required in facilities." Nathan Schema, president and chief executive officer of the Evangelical Lutheran Good Samaritan Society, which operates a large chain of nonprofit nursing homes, told Rowland: "I just can’t understand how CMS is effectively trying to fix the roof while the house is on fire. It’s the beginning of the end for small-town nursing homes."

Rowland adds, "A fifth of nursing homes would have to hire registered nurses to meet the requirement, the government estimates." LeadingAge, the largest association for nonprofit nursing homes, told USA Today that the proposed regulation would be impossible for many nursing homes to meet. “There are simply no people to hire—especially nurses,” said Katie Smith Sloan, the group's president and CEO. “America’s under-funded, long-ignored long-term care sector is in a workforce crisis.” Sloan said nursing homes would have to “reduce admissions or even close” if the rule takes effect.

"While the industry reacted negatively to the proposed rule’s release, the guidelines also disappointed advocates for better treatment of residents in chronically short-staffed nursing homes, who contend the rule does not go far enough and enshrines substandard levels of care," Rowland reports. "Advocates for better quality care in nursing homes say the industry’s high staff turnover rates point to the true problem: insufficient pay and poor working conditions."

Feds propose the first minimum-staffing rules for nursing homes, and they are weaker than the industry expected

Federal officials' proposed minimum standards for nursing-home staffing are weaker than expected, Bridget Early reports for Inside Health Policy.

The nursing-home industry had anticipated a proposal for about 4.1 hours of employee work time per resident day, meaning that a home with 25 residents would require 18 staffers (times 4.1 hours per resident day = 175 hours per week, divided by 40 hours per week = 17.9 employees).

Instead, Early reports, "The minimum staffing scenarios assessed in the report ranged from 3.3 HPRD to 3.8 HPRD," which would call for 14.4 to 16.625 employees to cover 25 residents.

The regulation could have major implications for rural nursing homes, which generally have more difficulty recruting and retaining staff than those in cities.

The regulation, proposed by the Centers for Medicare and Medicaid Services, "cleared the White House Office of Management and Budget on Tuesday, Aug. 29, the same day a CMS study underpinning the rule was leaked and created a firestorm among stakeholders," Early reports. "The White House budget office also canceled its two remaining stakeholder meetings on the issue in the wake of the leak. The proposed rule had been pending at OMB since May 30. The two meetings were scheduled for the first and second weeks of September. The meetings were requested by the Organization of Nurse Leaders and the Association of Jewish Aging Services."

Early notes, "The nursing-home industry has lobbied hard against staffing minimums and has called for a White House event to explore alternatives, but patient advocates have backed staffing minimums."

Rural nursing homes closing because they can't find staff, uprooting residents who thought they had a forever home

Marjorie Kruger and son Dan White at the Evangelical Lutheran Good Samaritan
Society nursing home in Waukon, Iowa. (Photo by Tony Leys, Kaiser Health News)

Rural nursing homes are closing due to shortages of workers, and "The problem could deepen as pandemic-era government assistance dries up and care facilities struggle to compete with rising wages offered by other employers, industry leaders and analysts predict," reports Tony Leys of Kaiser Health News.

"Many care centers that have managed to remain open are keeping some beds vacant because they don’t have enough workers to responsibly care for more residents," Leys reports, noting shortages of "nurses, nursing assistants, and kitchen employees."

Last year, 13 of the 15 Iowa nursing homes that closed "were in rural areas, according to the Iowa Health Care Association," Leys reports. Brent Willett, the association’s president, told Leys, “In more sparsely populated areas, it’s harder and harder to staff those facilities,” partly because many rural areas have fewer working-age adults.

The closure of a nursing home or assisted-living facility can have traumatic effects on residents and their families. "The lack of open nursing home beds is marooning some patients in hospitals for weeks while social workers seek placements," Leys reports. "More people are winding up in care facilities far from their hometowns, especially if they have dementia, obesity, or other conditions that require extra attention."

Leys starts his story with Marjorie Kruger, 98, who "was stunned to learn last fall that she would have to leave the nursing home where she’d lived comfortably for six years" in Postville. She told him, “The rug was taken out from under me. I thought I was going to stay there the rest of my life.” Her son found her another home, "but she misses her friends and longtime staffers from the old one," Leys writes. "The Postville facility’s former residents are scattered across northeastern Iowa. Some were forced to move twice, after the first nursing home they transferred to also went out of business."

Many nursing homes sue residents' families, friends for debt

"Pursuing unpaid bills, nursing homes across this industrial city have been routinely suing not only residents but their friends and family," Noam Levey reports for Kaiser Health News. "The practice has ensnared scores of children, grandchildren, neighbors, and others, many with nearly no financial ties to residents or legal responsibility for their debts "The lawsuits illuminate a dark corner of America’s larger medical debt crisis, which a KHN-NPR investigation found has touched more than half of all U.S. adults in the past five years."

According to a Kaiser Family Foundation poll conducted for this project, about one in seven adults with health-care debt said they've been threatened with lawsuit or arrest, and 5 percent said they've been sued for debt. "The nursing-home industry has quietly developed what consumer attorneys and patient advocates say is a pernicious strategy of pursuing family and friends of patients despite federal law that was enacted to protect them from debt collection," Levey reports. "Nursing homes have gone after some families for tens of thousands of dollars. In a few cases, debts surpassed $100,000."

Nursing homes often justify the lawsuits with the admissions paperwork that friends and family sometimes sign without realizing they could be pursued for debt. Many people settle rather than go through costly, time-consuming court battles. "In most cases reviewed by KHN, the people sued didn’t have an attorney, which can be expensive," Levey reports. "In nearly a third, the nursing homes won default judgments because the defendants never responded, a common phenomenon in debt cases. In many cases, lawsuits sought interest rates as high as 18% on top of the debt." Nursing homes and their attorneys say they have to go through the courts to get bills paid, and that it's unfair to other residents and county taxpayers to allow residents who have assets to not pay what they owe. 

By federal law, nursing homes are prohibited from "requiring a resident’s relatives or friends to financially guarantee the resident’s bills," Levey reports. "Facilities cannot even request such guarantees. But consumer advocates say nursing homes slip the admissions agreements into papers that family members sign when an older parent or sick friend is admitted. Sometimes people are told they must sign, a violation of federal law. Sometimes there is barely any discussion."

Profiles of nursing-home residents by student-run Georgia weekly illustrate a bedrock community-journalism principle

Excerpt from the Echo's recent package

The Oglethorpe Echo in Macon County, Georgia, recently published a package featuring seniors at a local nursing home, with a photo and a paragraph with interesting tidbits from their lives. It's a powerful and simple but original idea that illustrates a basic principle of community journalism: People are interested in people, and in reading about them. 

Former Echo visual journalist and University of Georgia journalism student Julia Walkup interviewed and photographed the seniors earlier this year as part of a UGA photojournalism weekend workshop that encourages students to capture in-depth portraits of community members. 

UGA students and faculty have staffed the Echo since last fall, when local resident Dink NeSmith, retired co-owner of a community newspaper chain, kept the owner from closing the 148-year-old weekly by turning it into a non-profit and getting the university involved.

Groundbreaking USA Today investigation rates every nursing home in the nation on its Covid-19 response

More than 140,000 U.S. nursing-home residents have died from Covid-19, including 71,000 in last winter's surge. At more than one-third of the nursing homes that reported outbreaks during the surge, no one died, but the performance of some others was much worse, USA Today reports.

In a year-long, first-of-its-kind analysis of the nation's more than 15,000 nursing homes, USA Today investigated questions of corporate responsibility left unanswered by government regulators or research papers, and revealed webs of nursing-home ownership previously invisible to consumers. They also interviewed nursing-home workers, families of the dead, government officials and industry experts. Armed with in-depth data, they scored the performance of every nursing home in the country.

Here's the main page for the multimedia package, which includes a deep dive into the unusually high death count among residents at a chain of Midwestern nursing homes, video interviews with family members of those who died, pointers on how to choose the right nursing home for your loved ones, an interactive database where you can look up how local nursing homes have fared, and more.

The investigation of Trilogy Health Services is a highlight of the package. USA Today reports that residents at the company's 115 nursing homes died of Covid-19 last winter at more than twice the national average rate for nursing homes (Trilogy disputes this) and government regulators missed such chain-wide trends because they focused on individual facilities. Trilogy, which was acquired in 2015 by a real-estate investment trust that plans to go public later this year, went further than any other business in cutting staff to generate more profit. The acquisition was unusual because the REIT purchased not only Trilogy's properties, but also the health-care operations inside the buildings.

Nursing homes in crisis as many low-wage employees quit

"Frustration is surging among the low-wage workers who make up the backbone of the nursing-home industry, as tens of thousands of their colleagues call out sick with Covid-19, inflaming shortages that already were at crisis levels," Rebecca Tan reports for The Washington Post. "Hailed as 'heroes' during the early months of the pandemic, these workers, most of whom are women and people of color, say they’re facing untenable levels of pressure. Government support has failed to end the crisis, advocates say, allowing care for the elderly and the infirm to worsen, forcing facilities to limit admission or close entirely and clogging up hospital beds. According to the U.S. Bureau of Labor Statistics, the nursing-home industry has lost more than 420,000 jobs since the start of the pandemic, reducing its workforce to the size it was 15 years ago."

There are many reasons for the shortages. Many workers retired early rather than deal with the pandemic, and others quit for higher-paying jobs that nursing homes can't compete with. That has compounded the temporary shortages caused by staff illnesses and resulted in a pressure cooker of stress for remaining workers, Tan reports. The problem has become so bad that many nursing homes and hospitals are telling Covid-infected workers to come back even if they may still be contagious.

"Even as the Omicron variant retreats, the staffing crunch will persist, nursing home leaders and unions say," Tan reports. "At community colleges, interest in skilled nursing courses has plunged, with some class sizes dropping to half what they were before the pandemic. Of those training to become nursing assistants, many are avoiding nursing homes, where they would earn a median annual wage of $30,120, according to federal data, and are looking instead for jobs as travel nurses or home health aides." That's particularly concerning as more Baby Boomers require skilled nursing.

"This is a crisis on steroids," David Grabowski, a Harvard Medical School researcher who studies the economics of aging and long-term care, told Tan. "The long-standing issue of underinvesting and undervaluing this workforce is coming back to bite us."

Referendum roundup: New York state rejects looser voting rules; Maine adopts vague 'right to food' amendment

Off-year elections are usually pretty quiet, but voters are often asked to decide questions large and small. This week there were 24 statewide refernda in six states. Here are a few with rural resonance:

In Maine, by share of population the most rural state, two-thirds of voters approved a first-in-the-nation constitutional amendment establishing a "right to food," even though there's considerable confusion over what it means. "Described as an outgrowth of the food sovereignty movement, the amendment says Mainers have a right to grow and consume food of their choosing," Chuck Abbott reports for the Food and Environment Reporting Network. That extends to popular issues such as raw milk and the right to save and exchange seeds as long as it doesn't violate laws or exploit natural resources.

"Supporters used the campaign to make the case the amendment would ensure the right to grow vegetables and raise livestock in an era when corporatization threatens local ownership of the food supply," Patrick Whittle reports for The Associated Press. "They positioned the amendment as a chance for Mainers to wrestle control of the food supply back from large landowners and giant retailers with little connection to the community."

Abbott reports, "Opponents said the amendment was so broadly written that it could override animal cruelty laws or open the gate to domestic livestock in urban backyards. The Bangor Daily News said the ambiguous wording would put judges in charge of interpreting what the amendment means at the practical level." The paper also noted that the amendment doesn't expressly mention hunger.

In Colorado, 54 percent of voters rejected a measure that would have raised $150 million to partially fund private, out-of-school learning for children by raising the marijuana tax five percentage points to 20%, Jenny Brundin and Bente Birkeland report for Colorado Public Radio.

Proposition 119 aimed to help children falling behind because of the pandemic by providing tutoring, enrichment opportunities in the arts, career and technical training, physical therapy, mental health services, support for students with special needs, and mentoring. However, "opponents of the measure said it would have taken dollars away from public education and would have instead funded private companies to provide services," Brundin and Birkeland report.

In Texas, voters approved two constitutional amendments by broad margins. "Proposition 3, which was approved 63% to 37%, bars governments from taking any action that "prohibits or limits religious services," Asher Price reports for Axios Austin. "The proposition is part of a much broader national Covid-19 debate that pits public health officials bent on stymieing the disease's spread against pastors who say they were protecting their practice of religion."

And Proposition 6, approved by nearly 88% of Texas voters, "gives residents of nursing homes and long-term care facilities the right to designate an 'essential caregiver' who could not, under most circumstances, be barred from in-person visits," Price reports. "The proposition comes after stories of elderly people enduring months of isolation as part of the fight against Covid-19." It's unclear whether nursing homes could bar essential caregivers who are unvaccinated or unmasked. Since nursing home workers must be vaccinated, it stands to reason that visitors would be more likely to infect residents. That could be particularly deadly, since nursing home residents are far more likely to die from Covid-19 than others.

Voters in New York rejected three amendments that would have broadened voting access by allowing same-day registration without proof of residency, let voters get absentee ballots without needing an excuse, and requiring that incarcerated New Yorkers be counted as living at their last place of residence in redistricting, Dana Rubinstein reports for The New York Times. Broadened voting access measures tend to benefit urban—and therefore more liberal—voters. And rural areas generally gain more political clout when prisoners are counted as local residents in redistricting.

Analysts say the measures were defeated because the language on the ballot was hard to understand, and because the Democratic party made little effort to boost the propositions, while the state Republican party used the ballot issues as lightning rods to turn out their base in an otherwise quiet election cycle, Rubinstein reports.

Pandemic roundup: Small-town Ky. mayor urges unvaxed to stay home to help hospital; Idaho's pain affects Washington

Here's a roundup of recent news about the pandemic and immunization efforts: 

Only one in four of the nation's 15,600 nursing homes are confident they can stay in business in the coming months, according to a recent survey, Mariel Padilla reports for The 19th. Such closures could be especially devastating in rural areas, where other resources are hard to find. Read more here.

In a Facebook video, the mayor of Corbin, Ky. (pop. 21,000), urged locals to get vaccinated, and asked the unvaccinated to stay home so they don't get infected and overwhelm the town's regional hospital. Baptist Health Corbin has had to contact facilities as far away as Pittsburgh to find intensive care unit beds for patients. Over half the patients at the 273-bed hospital have Covid-19. Read more here.

Idaho's hospitals are so overwhelmed with Covid patients that they are rationing care, but many locals remain skeptical of vaccines. Read more here. That is affecting Washington state, where the governor has implemented tough pandemic-control measures, is already strained from in-state patients. Some that has fostered resentment among many hospital workers in Washington. Read more here.

Vaccine misinformation isn't just coming from Russian bots and rightwing forums. It also frequently comes from "wellness" influencers on social media who exhort followers to eschew "chemicals" and embrace a more "natural" lifestyle. Read more here.

What is ivermectin, and how did people get the idea it can treat Covid-19? Read more here.

Coronavirus cases are nearing record levels in West Virginia. Seven months ago the state had one of the best vaccination rates in the country, but since then vaccination levels have dropped off. Now the state has an over-18 vaccination rate of 48%, the lowest of any state, leaving its residents more vulnerable to the Delta variant. Soaring coronavirus infections illustrate the challenges facing it and other states with low vaccination rates. Read more here, here and here.

A hospital CEO in rural North Carolina has become known for blunt Facebook posts defending the coronavirus vaccination and criticizing misinformation, conspiracy theories and the politicization of the pandemic. Read more here.

Though a rural Texas county has one of the state's highest vaccination rates, they're still struggling to reach herd immunity. That's because nearby counties have very low vaccination rates, highlighting the need for higher vaccination rates across the board. Read more here.

A hospital in rural Georgia is overwhelmed with Covid patients, so county leaders came up with a creative solution: they negotiated an agreement where county employees will help out at the hospital when they're not doing work for the county. A number of law-enforcement personnel and firefighters have expressed interest. Read more here.