Michelle Gralnick, one of the leaders of Missouri Alliance for Long-Term Care Reform, holds up a photo of her parents, who were hospitalized for sepsis a combined eight times during their nine years in Missouri nursing homes due to poor care (Clara Bates/Missouri Independent).
Staffing at Missouri nursing homes ranks among the worst in the nation, with the latest federal data showing the state falls second-to-last for time spent caring for residents.
Each nursing home resident in Missouri receives just 3.37 hours of nursing care per day, on average, according to quarterly data released by Centers for Medicare and Medicaid Services late last month.
Only Texas ranked lower.
The staffing shortages imperil residents and create near-impossible working conditions, said nursing home staff and advocates who gathered at the Missouri Capitol Wednesday afternoon to urge legislative action.
Katherine Stewart, who works at Highland Rehabilitation Center in Kansas City, told reporters she is sometimes one of only two staff members supervising a floor of around 40 nursing home residents.
“We are struggling, trying to get all of these people taken care of,” Stewart said. “How are we supposed to get our job done if we don’t have enough staffing?”
At one point Stewart was attacked by a resident — a 30-year-old placed in a nursing facility due to mental illness — and two residents needed to intervene before a co-worker arrived.
Michelle Gralnick, one of the leaders of a coalition of advocates called Missouri Alliance for Long-Term Care Reform, said understaffing results in residents failing to receive help when they press their call buttons.
For instance, a resident pressing a call button may need help moving from their bed to the bathroom, and when they don’t get the help, could soil themselves, Gralnick said. And delays in helping them clean up can cause skin irritation and pressure sores, she said, which untreated can lead to sepsis.
“So while, while somebody may simply say, ‘Oh, well, what’s the difference between 10 minutes and 20 minutes,’ or ‘they can go in their pants,’ it really is a huge consequence,” Gralnick said. “And it has tremendous health implications, as well as issues of self-esteem and the person feeling helpless, powerless and demeaned.”
Gralnick said her parents were in nursing homes in Missouri for nearly a decade and were hospitalized a combined eight times for sepsis.
The group published a report Wednesday based on their analysis of federal data that highlights what they refer to as the state’s chronic understaffing of nursing homes, lack of proper oversight, financial misconduct and regulatory failures. In 2023, the St. Louis based nursing home Northview Village abruptly closed and residents were forced to move, bringing the issue of lack of financial transparency among nursing home owners into the spotlight.
Understaffing can cause mistakes administering medication and issues honoring residents’ do-not-resusicate orders, according to the report.
“Unsafe staffing to maximize profitability is often the culprit” of facility quality issues, the report states.
Almost 80% of Missouri nursing homes are for-profit.
Missouri has long fallen toward the bottom of nursing home quality rankings. In a 2023 report from AARP, Missouri ranked 47th in terms of safety and quality.
The report outlines legislative and funding changes to strengthen oversight and improve staffing levels.
One bill, sponsored by Democratic state Sen. Stephen Webber of Columbia, would increase oversight and create minimum staffing requirements statewide.
“This is an issue that every single Missourian should care about, because every single Missourian themselves could end up in a facility like this,” Webber said. “We can have a loved one ending up in a facility like this.”
Webber’s bill would require heightened scrutiny of transfers in ownership of nursing homes, which advocates say now operate in a loophole that evades state regulatory review. It would also impose heightened ownership scrutiny in the licensing process and establish a minimum staffing requirement, with penalties.
It hasn’t yet received a committee hearing.
“It’s really, really important that if you’re going to put a loved one in a healthcare facility, that you know who owns the facility, that you’re entrusting the life of some of the most important people in your life to,” Webber said, “and that you know who is profiting and who’s making financial decisions that impact a very vulnerable member of your family.”
Mandated staffing levels would not only help ensure resident safety, Webber said, but also worker safety.
Asked about obstacles, he said: “This is a powerful industry. There’s people who make a lot of money on this, and obviously they’re not trying to give up those profits.”
He’ll continue trying to spread awareness, he said, asking for hearings on the bill and “pushing forward on it year after year.
“Things take time in this building,” Webber said. “We understand that and it’s a fight worth having.”
State Rep. Kimberly-Ann Collins, a St. Louis Democrat, filed similar legislation. It has not been scheduled for a hearing, either.
A few other bills filed this session seem to go in the opposite direction, in terms of regulating long-term care facilities.
A bill sponsored by Republican state Rep. Dean Van Schoiack of Savannah, which has been voted out of committee, would reduce public disclosure of noncompliant long-term care facilities. If the noncompliance is corrected within 24 hours, and no resident experienced physical harm, then the state does not need to make public the noncompliance.
Van Schoiack said right now, when there’s a critical violation, facilities need to inform residents and families, “whether they got it resolved or not.”
“This gives them 24 hours to resolve this situation before they have to post it,” he said during the committee hearing,“and give notice only if nobody was injured.”
His bill also prohibits rules requiring facilities’ prospective employees to be assessed by physicians in order to be hired, which Van Schoaick said at the committee hearing was designed to reduce delays people face waiting for the physical and paying for it before they can get hired.
The Missouri Assisted Living Association testified in support of the bill, along with a nursing home administrator that operates over 60 residential care facilities. Nicole Lynch, a coalition leader and policy director of VOYCE St. Louis, an advocacy group for long-term care resident, opposed the bill for what she called “prioritiz[ing] facility interest over resident safety.”
It passed out of committee this week by a vote of 9 for and 4 opposed. (Two Democrats and two Republicans were opposed.)
A bill filed by state Sen. Mary Elizabeth Coleman for the third year in a row would make it so long-term care facilities in good standing don’t need annual onsite inspections from the state. Coleman, a Republican from Arnold, said in last year’s committee hearing it was designed to “reduce redundancy and paperwork” for assisted living while maintaining high levels of care.
The bill hasn’t progressed this year, but last year was opposed by VOYCE as well as the union representing nursing home workers, and AARP, who said there should be more industry oversight, not less.
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