COLUMBIA, Mo. (KMIZ)

Missouri nursing homes rank among the worst in the country for the amount of care provided to residents, and ongoing staffing shortages may be adding to the problem and putting residents' health and safety at risk.

Federal guidelines from the Centers for Medicare and Medicaid Services require skilled nursing facilities to provide at least 3.48 hours of care per resident daily.

According to the Missouri Department of Health and Senior Services, there are 1,111 long-term care facilities across the state. That includes 486 skilled nursing facilities.

A Missouri Alliance for Long-Term Care Reform report labeled 68 out of 161 skilled nursing facilities as "troubled" based on CMS's one-star overall rating (out of five) and the facilities' reporting of less than the federally required 3.48 hours of care per resident per day.

The facility can also receive one star if it was placed in the Special Focus Facilities Program, which is designed for nursing homes with a history of serious quality issues.

The remaining one-star facilities, about 93, were not included in the report because they either reported providing more than 3.48 hours of care or they failed to adequately report their care hours entirely, said Nicole Lynch, policy and advocacy director with VOYCE, a non-profit advocating for long-term care residents.

"On average, a resident could go to another state in our country and receive more care than they receive here in Missouri, which is abysmal," Lynch said.

Lynch said facilities with missing or unreliable staffing data were excluded for one of three reasons.

Five of the 68 "troubled" skilled nursing homes are in Mid-Missouri.

According to Medicare data, North Village Park reported providing just 1 hour, 41 minutes of care per resident per day — significantly longer than the federal requirement of 3.48 hours and the Missouri average of 3 hours and 24 minutes. The facility also reported only 6 minutes of registered nurse care per resident per day, falling far short of the national average of 40 minutes and the Missouri average of 27 minutes.

A January report also found the facility failed to ensure that ordered medications were available and administered. However, it remains unclear whether the issue stemmed from the physician not ordering the medications or from the pharmacy failing to supply them in a timely manner. No documentation shows the facility attempted to obtain the meds from a backup pharmacy.

According to CMS, Four Seasons Living Center in Sedalia reported providing just 1 hour and 19 minutes of total nurse staff care per resident per day — well below the national average of 3 hours and 52 minutes and the Missouri average of 3 hours and 24 minutes. Registered nurse care was reported at only 6 minutes per resident per day.

In October 2024, the facility was issued a $54,249 citation for failing to provide and implement an effective infection prevention and control program. This was categorized as "immediate jeopardy" to resident health or safety.

The facility reportedly failed to flush feeding tubes, apply barrier cream and clean wounds.

Both North Village Park in Moberly and Four Seasons Living in Sedalia are owned by Reliant Care Management Company LLC.

"North Village Park (“NVP”) and Four Seasons Living Center (FSLC) provide skilled nursing services to many individuals who, due to their behavioral conditions, require nursing home care," the company said in a statement to ABC 17 News. "These residents require different care than traditional nursing home residents. For example, a typical geriatric resident requires care hours centered on activities of daily living (“ADL”).

"These ADLs include self-care tasks such as bathing, dressing, eating and using the restroom. Residents with behavioral issues are usually younger and do not need assistance in these routine daily tasks. Their care is focused on managing their mental disease or illness. As a result, the care hours for behavioral residents cannot be compared with care hours given to residents at a traditional nursing home. NVP and FSLC strive to provide excellent care to this underserved population and continues to implement new programs to improve the quality of care and the quality of these residents’ lives,"

The other "troubled' skilled nursing facilities in Mid-Missouri in the report include:

State Region 7 had the highest number of troubled nursing facilities, with 20, while Region 10 had the fewest, with just one.

The report found Missouri's troubled facilities chronically understaff to maximize profitability to the detriment of resident care, and facilities throughout the state have failed to:

"Common situations, pressure ulcers, medication errors, instances of abuse, sexual abuse, resident elopement from the facilities," Lynch said.

A pressure ulcer, also known as a bed sore, is an area of tissue damage caused by unrelieved pressure, friction, or shearing on the body, according to the report. These ulcers can lead to pain, disfigurement, and a higher risk of infection. They’re often the result of extended hospital stays or limited movement.

In November 2023, the report says North Village Park in Moberly was cited for failure "to ensure residents were free from unnecessary physical restraints" and "failed to ensure chemical restraints were not used unless medically necessary."

Regulators wrote that this increased the likelihood of residents experiencing serious physical and psychosocial harm.

EverTrue Lenior Woods in Columbia is a five-star facility, according to CMS. Located in south Columbia, the facility includes three neighborhoods, each housing around 20 residents.

Administrator of Care Center and Assisted Living at Lenior Woods

Charice Hilgedick, the administrator of the care center and assisted living, said the facility's care hours exceed the federal standard thanks to a strong team approach.

"So that's 3.6 to 3.8 hours of direct care per resident day on all shifts," Hilgedick said.

CMS reports the facility provides 56 minutes of registered nurse care per resident per day. Higedick says there is an RN on site for eight hours per shift. However, she has faced staffing challenges over the years.

Licensed practical nurse Donald Thompson has worked at the facility for over 20 years and says no two days are the same.

"You're running from the time you get here to the time you leave, and lots of days I'm here a couple hours over my shift to finish charting and things like that," Thompson said.

Hilgedick said the team handles a wide range of responsibilities daily.

"Passing meds, doing skilled care, dressing changes, catheter care, tube feedings, any of those things, IVs," Hilgedick said.

Shelby Beasley has worked at the facility for just over five years and says the number of patients she handles daily is manageable, but it comes down to a team effort.

"I know on day shift it's usually me and another CNA and a charge nurse for those 19 residents," Beasley said.

Lynch said the differences in care among nursing homes often come down to ownership and priorities.

"Some owners are willing to put their resources financially into staffing their homes," Lynch said. "They're paying staff a higher wage, providing safe working environments, and offering employment benefits that staff deserve and want to see in a job."

For Hilgedick, it's a combination of challenges.

"Some of it is funding, some of it is just the politics of long-term care. Regulation is regulation, but funding plays a big role," Hilgedick said.

According to CMS, Lenior Woods received two health citations in its most recent inspection, including citations for failing to provide safe mechanical transfers for patients.

Hilgedick says the facility ensures staff receive the appropriate training each year to provide adequate mechanical transfer care.

One of the most significant setbacks came during the COVID-19 pandemic, which devastated nursing homes across the country and left many in Missouri struggling to recover. The industry has faced persistent staffing shortages ever since.

Pay also remains a key challenge. The physical and emotional demands of caregiving in nursing homes, along with low wages, contribute to workers not wanting to enter the field.

In Missouri, certified nurse assistants, certified medication aides and certified medication technicians (earn an average of $16 to $20 an hour — roughly the same as a fast food worker, but with significantly more responsibility.

Missouri Assisted Living Association executive director Ryan Redcay said the low pay does not reflect the time it takes to train and the overall responsibility of the job.

"To take the time for the certification, unfortunately, the pay doesn't compensate much for that," Redcay said.

According to Redcay, registered nurses and certified nurse assistants are the hardest positions to fill in long-term care facilities. Many providers are losing out to hospitals that can offer more competitive incentives.

"Larger hospitals are offering sign-on bonuses between $5,000 to $10,000," Redcay said. "That's not something a lot of our members can do."

State Sen. Stephen Webber (D-Columbia) has introduced a bill that would set minimum staffing requirements statewide and increase oversight. But the session ended with the bill yet to see a committee hearing.

Lynch said the Missouri Alliance for Long-Term Care Reform report has been submitted to Missouri lawmakers with several recommendations.

"Holding facilities accountable, whether that's to their finances, or to where there bottom line profits are being spent in addition to being held accountable to their regulations the nursing home industry highly regulated but the enforcement and oversight is not what we believe it should be we think there needs to be oversight and more transparency," Lynch said.

Another recommendation in the report is increasing funding for the Ombudsman Program, which sends advocates into nursing homes to meet with residents one-on-one.

Lynch points out that the program is underfunded and understaffed, with just one ombudsman serving 8,000 residents.

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