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'This is going to kill us': Oklahoma nursing homes brace for new federal staffing mandate

Country Club Care Nursing Home and Rehab closed in 2023 following financial strains during the COVID-19 pandemic. The Duncan nursing home was owned by Cayley Inmon's grandparents.
Jillian Taylor
StateImpact Oklahoma
Country Club Care Nursing Home and Rehab closed in 2023 following financial strains during the COVID-19 pandemic. The Duncan nursing home was owned by Cayley Inmon's grandparents.

Cayley Inmon was born into long-term care. The registered nurse (RN), who currently works at a nursing home in Duncan, grew up at Country Club Care Nursing Home and Rehab owned by her grandparents. She started in the kitchen at 18 and worked her way up to its director of nursing.

The nearly 60-year-old home she was raised in closed last year. Facilities like Inmon’s are already challenged because they’re underfunded by Medicaid, which compensates them at an average of $224.64 per resident, per day. The Oklahoma Health Care Authority projects the cost of treating a typical resident in a skilled nursing facility is $269.22 per day in FY 2025.

Inmon’s old facility faced more financial strain during the pandemic as its remaining employees worked overtime, battling infection and staffing shortages. After her grandfather died in October 2021, she took over for him as its administrator. But there was no financial path forward for the facility, and it closed.

Inmon spent months rehoming each resident until the last one, who was 106 and on hospice, moved out in May 2023. She almost left long-term care because of the facility’s traumatic closing, but she quickly decided to come back because it has always been her home.

Now, Inmon’s imagining what it might be like for facilities to close across the state. That’s because Oklahoma nursing homes are preparing for new rules from the Biden administration. They’re meant to improve safety and quality of care in Medicare- and Medicaid-certified long-term care facilities.

Through the mandate, the administration aims to tackle the issue of chronic staffing shortages, which can impact the quality of care seniors receive. But the rule doesn’t come with funds to facilitate it, and Oklahoma nursing homes say it asks them to find staff they can’t afford and that doesn’t exist.

What does the rule entail?

The final rule was informed by the feedback of over 46,000 public comments received by the Centers for Medicare & Medicaid Services (CMS). Those came from stakeholders like residents and their families, workers, advocates and industry members.

The rules will require the following of these facilities:

  • Facilities must provide a minimum total of 3.48 hours (3 hours and 29 minutes) of direct nursing care per resident, per day. 
  • The 3.48 requirement must include .55 hours (33 minutes) of care from a registered nurse per resident, per day and 2.45 hours (2 hours and 27 minutes) from a nurse aide per resident, per day. 
  • Facilities must have a registered nurse on site 24/7. 
  • Facilities must conduct a stronger annual facility assessment to improve the planning and identification of the resources needed to care for residents.
  • Facilities must develop a staffing plan to maximize recruitment and retention. 

The stronger assessments will determine whether facilities need to up their minimum requirements based on the level of care their residents need. The base standard might not be enough for some facilities.

Labor unions representing nursing home workers support the idea, saying it’s a major step toward strengthening the workforce. Oklahoma nursing home reform advocate Wes Bledsoe said more staff need to be available to care for the range of needs seniors come in with, especially as Oklahoma’s senior population continues to grow at increasing rates.

Oklahoma nursing homes currently operate with a staff ratio ensuring residents get 2.9 hours of direct care service, per day. The state also requires a licensed nurse on duty eight hours a day, seven days a week on the day shift.

An analysis by CliftonLarsenAllen, LLP, a professional services firm, found the rule would require Oklahoma to hire over 1,200 full-time employees, including 538 nurse aides and 715 RNs over the five years the rule is phased in. It will cost Oklahoma nursing homes an estimated $76 million per year.

CEO Steve Buck of Care Providers Oklahoma, which represents a portion of the state’s nearly 300 nursing homes, said the mandate is impossible.

“Out of nowhere, the long-term care sector is going to have to find 700-750 new RNs to meet the staffing mandate, and we're gonna have to ask those new RNs to consider working in the most rural parts of Oklahoma because this is a one-size-fits-all,” Buck said.

Gov. Kevin Stitt signed a letter to the Biden administration alongside 14 Republican governors, urging it to reconsider the mandate. Other lawmakers, like Lt. Gov. Matt Pinnell andU.S. Sen. James Lankford (R-Okla.), have also opposed the mandate and its particular threat to rural nursing homes.

Rural facilities like Inmon’s will have longer than urban ones to meet the requirements. Inmon’s home currently operates with four RNs, including herself. She calculates her facility will need to hire nine RNs in the next five years to meet the federal minimums.

“We would have an extra half a million dollars going towards payroll a year,” Inmon said.

Cayley Inmon stands outside the current nursing home she works at in Duncan.
Jillian Taylor
StateImpact Oklahoma
Cayley Inmon stands outside the current nursing home she works at in Duncan.

Can nursing homes find staff to meet this mandate?

Kimberly Green’s introduction to nursing homes began when she volunteered at one when she was 13. She went through college to become a medical speech pathologist, specializing in geriatrics. Now, she’s the COO of Diakonos Group, an Oklahoma-owned and operated long-term care provider.

Green has seen the impacts of the nursing home staffing crisis firsthand with the 2021 closure of one of the group’s facilities, Servant Living Center in Medford. The facility was the biggest employer in the town of under 1,000 people. Diakonos Group had turned it into a skilled nursing facility specializing only in geriatrics with a psychiatric diagnosis.

The facility filled up quickly with residents, but couldn’t attract staff.

Green said she’s tried everything to increase the number of RNs in her rural and urban facilities. She even started recruiting overseas, offering to sponsor the moves of people and their families to the U.S. They wanted 50 RNs, and only 10 came.

The organization helping Diakonos Group quit, saying they were wasting their recruiters’ time when they couldn’t offer competitive salaries. Candidates also didn’t want to move to areas in rural Oklahoma.

“It was like a punch in the stomach, 'cause we were so excited,” Green said. “We were progressive. We were investing this money. We were going to have the staff that everybody wanted. And we just couldn't.”

Green and Inmon said RNs don’t get enough exposure to long-term care in school, and often, hospitals can offer better pay and benefits to the already limited workforce. Oklahoma ranks 46th in the U.S. for nurses per capita.

Inmon said when she went through nursing school, her professors pushed her away from long-term care, and she never went to a nursing home for any training.

“If your RNs, when they're in school, never even get to see a nursing home or see how a nursing home works through clinicals, then how are we expected to get any of them coming out of school?” Inmon said.

Melissa Craft, the acting dean of the OU College of Nursing, said as patients get older and live longer, they require professionals like RNs who can handle the complexity of those patients' needs.

But, she said there’s room for improvement in recruiting and retaining these professionals — especially in settings like nursing homes.

“A lot of our nursing students when they come, they're thinking, acute care. … You think of working in a hospital, you think of working in NICU. I mean, so many of them want to take care of the little babies. I get that,” Craft said. “But there are so many other places where nurses are needed.”

The college is now using a well-timed federal grant to position its students in rural nursing homes for training.

“We are looking more and more about, 'How do we get back into this space?' It's a space that we've been in. It’s a space that we know we need to be in more,” Craft said.

But Adam Jordan, the administrator of Beadles Nursing Home in Alva, said his family’s home could easily meet and exceed the federal minimum if they could use licensed practical nurses (LPNs) instead of RNs. In Oklahoma, LPNs must graduate from an accredited program and pass an exam.

LPNs can count toward the .48 hours of direct care left over in the mandate’s requirements. People in the nursing home industry felt the rules marginalized LPNs' contribution to long-term care by only focusing on RNs and nurse aides.

“They were like, ‘What am I, chopped liver?’” said Dayna Jordan, the director of nursing at Share Convalescent Home in Alva.

She said adding RNs will not increase homes' quality of care.

“Them doing more paperwork assessments, all that quality measure tracking, all that jumping through the hoops to do all the stuff on paper that is required, and having staffing of that level is just gonna, to me, have us have to cut back on (nurse aides) and not be able to give them raises or incentives,” Dayna said.

A financial bump from the legislature

As Oklahoma nursing homes try to wrap their arms around finding professionals to meet the mandate, they're also worried about paying them. Green said in her super skilled nursing facilities, like Cearu Medical Resort in Tulsa, she runs some of the highest staffing levels in the entire state, at five hours and 45 minutes of nurse staff hours per resident, per day.

But that quality of care has come at a cost.

“I can tell you I've not made a penny in these buildings since the day they opened,” Green said.

Cearu Medical Resort in Tulsa.
Jillian Taylor
StateImpact Oklahoma
Cearu Medical Resort in Tulsa.

In 2023, the Oklahoma Legislature invested approximately $47.8 million in increasing long-term care provider rates. The funds replaced federal dollars these facilities received during the COVID-19 public health emergency.

This year, the legislature directed the Oklahoma Health Care Authority to appropriate $30 million toward improving long-term care provider rates. That state investment will be matched with $61.4 million in federal funds. Facilities will see the following bumps pending agency approval.

  • Nursing Homes: An average rate of $224.64 to an average rate of $244.78
  • Regular intermediate care facilities for individuals with intellectual disabilities: $155.23 to $170.44
  • Acute intermediate care facilities for individuals with intellectual disabilities: $186.64 to $206.02
  • AIDs nursing facility beds: $266.18 to $288.32

Senate Appropriations Chair Chuck Hall (R-Perry) said as a rural Oklahoman, he believes the best thing the legislature can do is provide seniors with a great quality of life in their hometown. He doesn't want to see residents have to move away from family because their nursing home closes.

He said Oklahoma will likely have to commit another estimated $30 million over the next 18 months because of the mandate. But he’s still worried about the staffing minimums being doable.

“Oklahoma will certainly commit to that because we don't want to lose more nursing homes. … “But I'm very concerned about the staffing needs and staffing shortage,” Hall said. “ I don't know where (they) will come from.”

Hall said the legislature needs to look into what it can do for Oklahoma health care providers.

“You've seen some small baby steps associated with that over the past couple of years, but I think it's going to be really on the forefront as we go forward to really encourage these health care providers to get back into rural Oklahoma,” Hall said.

Despite the investments the legislature is making in nursing homes, facilities will still, on average, be underfunded.

Nursing home employees like Green, Inmon and the Jordans worry that if most facilities are breaking even, or running in the red, this mandate could put nearly all facilities at risk of closure, leaving seniors and their families with fewer options.

“I know that God put me here on a mission, but I'm tired. I’m real tired. And so is my team,” Green said. “And this is going to kill us.”

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Jillian Taylor has been StateImpact Oklahoma's health reporter since August 2023.
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