SYRACUSE, Neb. — Many rural communities like this one face a health care dilemma: Is it better to have a nursing home that struggles to hire workers or no nursing home at all?

The national debate over that question will heat up now that federal regulators have proposed to improve care by setting minimum staffing levels for all U.S. nursing homes.

Rural nursing homes would have five years to comply with some of the rules, versus three for their urban counterparts. Facilities also could apply for "hardship exemptions." But industry leaders predict the rules could accelerate a wave of closures that has already claimed hundreds of rural nursing homes.

Some families that rely on the Good Samaritan Society home in Syracuse, Nebraska, fear the regulation could hasten its demise.

Turning people away

The facility is the town's lone nursing home. It is running at barely half its licensed capacity, and managers say they've been turning away prospective residents because they can't find enough staff to care for more.

Lana Obermeyer, whose mother lives there, says employees take good care of residents. "Are they overworked? Probably," she says. "Isn't everybody these days?"

The Biden administration proposal, released Sept. 1, is intended to ensure higher-quality care by requiring a minimum number of hours of average daily staffing per resident, including 2.5 hours from certified nurse aides and 33 minutes from registered nurses.

The proposal also would require around-the-clock coverage by at least one registered nurse at every nursing home. Regulators estimate 1,358 rural nursing homes, including 58 in Nebraska, would need to add nurses to meet that standard.

Patient-safety advocates have long pressed the government to impose such standards to prevent neglect of nursing home residents. They blame the industry for letting its staffing problems fester for decades, and many hoped the federal proposal would be more stringent.

The proposal would not affect assisted living centers, which are designed to care for people with less severe health problems.

'It would kill half of these people'

Syracuse, which has about 1,900 people, serves a farming region in southern Nebraska. Its red-brick nursing home sits near a cemetery, a hearing aid store, and a tractor dealership. It would need to hire several more aides and an overnight registered nurse to meet the requirements.

Most of the nursing home's 46 residents are from the area. So are most employees. Staffers often care for their former teachers, coaches, and babysitters. They know each other's families.

If the facility closed, many residents likely would be transferred to larger nursing homes in the city of Lincoln, a 40-minute drive northwest, or Omaha, which is an hour northeast. They would be placed among strangers.

"I truly think it would kill half of these people," says Obermeyer, whose mother, Sharon Hudson, has been in the Good Samaritan home five years.

Obermeyer lives less than a block away, and she walks over to see her mom several times a week. Hudson also enjoys frequent visits from other locals, who stop by to see her after visiting their own parents in the facility.

Hudson has advanced Alzheimer's disease. She can no longer speak many words, but she smiles and giggles often, and tries to communicate with garbled sentences. "She's a very happy, happy person," Obermeyer says.

Ideally, she would be served in a specialized "memory care unit," for people with dementia. The Good Samaritan home once had one, but the unit closed several years ago for lack of staff. The wing now sits dark.

Better reimbursement, but closures anyway

Ten Nebraska nursing homes have shut down since 2021, says Jalene Carpenter, president of the Nebraska Health Care Association. Most have been in small towns.

The state's long-term care facilities have raised wages as much as 30% in recent years, partly because Nebraska joined most other states in substantially increasing how much its Medicaid program pays for nursing home care, Carpenter says. But many of the state's 196 remaining nursing homes are limiting admissions because of staffing shortages, she says. "It's unsustainable."

Carpenter says part of the problem is that the population of seniors who need care in many rural areas outpaces the supply of working-age adults. Job seekers have plenty of choices outside of health care, many with better hours and less stress. She notes that nine rural Nebraska counties had no registered nurses in 2021.

'The sky is falling'

A prominent consumer advocate scoffed at claims that rural facilities would be unable to comply with the proposed staffing rules.

"That's always their first response: 'We're going to have to close,'" says Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. "It's like, 'The sky is falling.'"

Smetanka says the industry should have improved working conditions and wages long ago, and she contends the proposed standards are too lenient.

Regulators shouldn't offer rural nursing homes extra time to meet the staffing rule, she says. "Residents in rural facilities have the same level of needs as those in urban facilities," she says. "Every resident deserves quality care today."

Smetanka's group favors offering incentives, such as pay raises and housing assistance, to employees in the long-term care industry. It also wants the government to strengthen options for care in people's homes instead of in facilities.

Industry leaders have suggested easing immigration rules to allow more workers from other countries. Smetanka says that such workers might help ease the staffing shortage but that they shouldn't be subjected to the poor conditions and low pay that have driven many previous employees away.

Closures in Iowa, too

In Iowa, 27 nursing homes have closed over the past two years, according to the Iowa Health Care Association. Most were in rural areas. About 400 remain open in the state.

John Hale, an Iowa advocate for improved long-term care, says he sympathizes with rural residents who worry about facilities closing. But he says companies sometimes use staffing woes as an excuse to shutter money-losing facilities.

Hale has roamed the halls of Iowa's Capitol for years, trying to persuade legislators to protect vulnerable seniors and people with disabilities. He says minimum staffing proposals have always been blocked by the nursing home industry, which receives millions of state and federal tax dollars from Medicaid. The industry's message to government officials boils down to "give us more money and leave us alone," he says.

Hale noted Iowa's government sets minimum staffing levels for child care centers to ensure kids' safety, but hasn't done so for seniors in care facilities. "I just wonder what that says about our values as a government and as a people," he says.

The longtime federal standard for nursing homes has been that they have "sufficient" staff. Hale says that vague standard is akin to replacing speed limit signs with suggestions that motorists drive "at reasonable speeds."

The Good Samaritan home in Syracuse is rated three out of five stars for overall quality on the nursing home comparison website run by Medicare. Its staffing level is rated at four stars, although its reported ratio of staff hours to residents was below national and Nebraska averages.

The Good Samaritan Society, which owns the nursing home, is one of the country's largest nonprofit chains of care facilities. In 2021, it reported nearly $78 million in losses on nearly $1 billion in revenue. The company is owned by the giant Sanford Health system, based in South Dakota. It has closed 13 nursing homes in the past two years, mostly in rural areas.

Good Samaritan Society President Nate Schema says he fears the proposed federal staffing standards would spark more closures, forcing rural residents to seek care far from their hometowns. Family members would not be able to visit as often, he says. "Are they going to have to drive 20 or 30 or, God forbid, 100 miles?"

In a letter to federal regulators, Schema writes that his company owns 139 nursing homes in 19 states, with nearly 1,700 open positions. At one facility in rural South Dakota, he says, a night-shift nursing job has been vacant for three years.

Where are the people to hire?

The possibility of closure is on the minds of residents and families at the Good Samaritan nursing home in Syracuse.

Resident Nellie Swale said she knows people who had to transfer to the facility from other nursing homes that closed. They were stressed and saddened by the move, she says. "Old people really depend on routines," she says.

Certified nursing assistant Karena Cunningham tells residents she hopes the Syracuse nursing home stays open. But, she says, "we can't make them any promises."

Cunningham considered looking for a less stressful job, but she couldn't leave. "It's my family here. I love the friends I've made," she says.

The facility currently has 82 employees, with 10 vacant full-time positions. The company said it spent $150,000 in the past year raising pay at the facility. The lowest starting wage for a nurse aide there has reached $18 an hour, a 30% increase from 10 months earlier.

Cunningham says that with a bigger staff, the nursing home could accept more residents, including those with complicated issues, such as addiction, mental illness, or severe obesity.

A national minimum staffing rule sounds like it would make sense, "in a perfect world," she says.

"Bring me these people that we're supposed to have for staff," Cunningham says. "Where are they?"

KFF Health News, formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.