The Patty Elwood Nursing Facility, part of the Country Winds Manor family, has announced they will be closing as of Jan. 6, 2023.  The facility has been offering dementia care-specific care as a CCDI unit since 2006, and has been in operation since 1999.  The facility cites financial challenges, including skyrocketing travel agency staffing costs. (submitted photo)
The Patty Elwood Nursing Facility, part of the Country Winds Manor family, has announced they will be closing as of Jan. 6, 2023. The facility has been offering dementia care-specific care as a CCDI unit since 2006, and has been in operation since 1999. The facility cites financial challenges, including skyrocketing travel agency staffing costs. (submitted photo)
After several difficult years and many obstacles faced, Cresco’s Country Winds Manor – known locally as the Patty Elwood Center and Donald Lundak Assisted Living Center – will close its doors as of Jan. 6, 2023. Country Winds follows Postville Good Sam Nursing Home in closing, highlighting financial difficulties the Senior Care industry has faced for several years. While the COVID-19 pandemic did the industry no favors, it may now be the tipping point for whether many small, non-profit rural homes can continue to function financially. 
Country Winds had difficulty filling staff vacancies – as have most healthcare facilities – and also had saw a change of not only their Director of Nursing twice in the past year (most recently in October), but a new Administrator within the past 12 months. Sandy Chilson, NHA, started with Country Winds in December of last year. She noted there had been 14 closures across the state in 2022 according to the Iowa Healthcare Association, with three more pending closures like theirs.
Offering a 24-bed secure dementia-specific care center and 12 dementia-specific assisted living apartments, Country Winds has been a steadfast staple for dementia care in the area, with some residents moving in from over two hours away due to the specialty care provided. The facility has been at full occupancy in the last few months after struggling with occupancy through COVID-19 but has continuously struggled to fill the Assisted Living facility, with only two current occupants.
“Since I started with Country Winds last year, we had to recertify and reopened the assisted living apartments in May, as the whole assisted living was closed by the previously contracted management company. We have two tenants currently, and we were hoping by enrolling the facility into the Elder Waiver program, we would be able to have more tenants move in. We’ve had a lot of interest and tours, and people saying they should get their loved ones in before winter, but it’s just too little too late,” said Chilson. 

The reality of closure
In 2021, almost exactly one year ago, Howard County Supervisors approved $200,000 of American Rescue Plan Act funding to Country Winds to prevent its closure, which did buy some time for the staff, residents and families. The home was rejected for a state Economic Injury Disaster Loan this year, and rising costs have continued to impact the facility.
Country Winds Manor is now focusing on what they can achieve: a graceful transition for residents and staff. “We’re working with the families to ensure residents can be transferred where families want them before the weather is terrible. As a CCDI specializing in dementia care, some of our residents can be difficult to place in other facilities, so we’re trying to be as proactive as we can,” said Chilson.
Often, nursing facilities can see a dementia resident as a liability, especially if residents are prone to wandering. One wandering resident that walked out of an unsecured facility, or a staff that didn’t investigate an alarm can lead to crippling fines from state and federal oversight agencies, potential lawsuits and loss of state and federal revenues that can be a death knoll to any facility. 
Chilson continued, “We’ve had three residents transfer to their new homes this week, and we will continue to help families find options. We’ve also been working with Iowa Workforce Development, and other area nursing facilities who have shared their vacancies to ensure our staff have something to fall back on as well.
“We have around 48 staff at Country Winds. The people who have stuck through have been amazing. They have a true passion for caring for the residents. It was tough pre-COVID finding enough help, and once COVID hit, we have seen an exodus away from healthcare jobs. It’s been difficult to fill vacant positions, and that can lead to contracting agency staff, which are very expensive.”

Dementia-specific care home
Also known as the Patty Elwood Center, the dementia-specific nursing facility has been a much-needed and well-used resource for many families, generally touting an extensive waiting list. In 2014, the facility reported over 50 daily calls for referrals of new residents, and this demand for specialized care was a driving factor in Decorah’s Aase Haugen Senior Services expansion of their CCDI Unit to securely serve up to 23 residents in 2016. 
Chilson said, “I’ve been in the long-term care industry since 1994 – I love this industry, or I wouldn’t have been in it so long. It’s heartbreaking, because you know these facilities that have closed, or are closing have touched so many people and so many lives.” Chilson continued, “But, I have to really look at the next few years if I even want to continue in this role and this industry. Organizationally, financially and regulatorily speaking, I think it’s going to get worse. It’s just so sad.”

Challenges industry-wide
Nursing facilities utilize agency staffing, also known as travel nurses and CNAs, to shore up any lack of facility-employed positions to stay in compliance with federal and state regulations for number of hours of care per day.  Each nursing facility is required to have a registered nurse on duty for eight consecutive hours each day, seven days each week. But RN’s just out of school normally don’t choose employment at a nursing facility; and large hospitals like Mayo Health Systems drive up the average per-hour cost for RNs and LPNs within an hour’s drive, which includes much of rural northeastern Iowa and southeastern Minnesota. 
“Agency staffing costs is the clincher for us. We are currently paying $100 per hour for a registered nurse, with a minimum for that staff of 48 hours each week,” Chilson detailed. An agency or contract CNA can cost as much as $50/hour ($2,000/week for full-time). “Right now, we’re dependent on two nurses and five FTE CNAs. The cost is exponential.”
The current charge for private pay residents is $7,350 per month. Medicaid reimbursement averaged $6,180 per month in 2022, nearly $1,200 less each month for every Medicaid resident.  
In addition to stagnant reimbursements from Iowa Medicaid, (Country Winds’ rate was $6,358.50 in October 2021, and are based in part on expense data from three years prior) facilities must contract staff to fill vacancies to meet regulation, spending upwards of three times standard wages for contract staff. Having an additional $13,440 per month in RN costs alone can quickly blow out even the most cautious budget. Agency totals for all staff can quickly climb to $20,000 per month if more than one full-time staff is needed.  
Food costs have skyrocketed for facilities just as they have in all homes. Nursing facilities provide three meals each day and snacks for all their residents, including juice, milk, coffee and other items. Chilson added, “You don’t want to skimp on or get low-quality food, the residents deserve good food.” 
Utility costs have also dramatically increased, and a facility simply cannot raise their rates enough to cover costs without pricing themselves out of the market in rural areas. “This is a rebasing year for Medicaid rates, but it wouldn’t help. They are so behind the times with costs it just won’t ever be enough,” Chilson explained.  
During COVID, prices for disposable masks, gowns, gloves and more escalated to often over six times their normal price, and burned through budgets like wildfire. Many facilities are still trying to recover from the added expenses and losses from reduced occupancy. 
Chilson stated, “The industry as a whole is set up to fail. Pay the lowest possible, make do with less and expect the highest outcomes. The goal [resident care] is not what it needs to be, and the restrictions put on us [nursing facilities] certainly don’t help.”
Chilson is referring to the increased focus on documentation of every action by staff and the punitive nature of the regulations as imposed and surveyed by state and federal agencies. Many healthcare staff left the industry during COVID, disillusioned by the separation of residents and families, as well as incensed by vaccine mandates and ever-changing guidance and requirements. “I wanted to be a nurse to help people, not to spend time on a computer or push pills quickly,” lamented an LPN who left the nursing industry in 2021.  

What’s ahead?
Having two nursing facilities close within the Driftless region should be a sign that the system as-is it does not favor the small, rural facility. State initiatives have encouraged and favored keeping elders in their homes, utilizing home health care and public health services as long as possible, instead of moving to an institutional setting. The industry was expecting a major baby boomer wave of admissions, which simply never materialized.  
The Centers for Medicare & Medicaid Services announced that it plans to decrease pay for skilled nursing facilities by $320 million in fiscal 2023. These facilities are where people go after surgery to rehabilitate so they can return home. This is the only area nursing facilities can actually make money on services provided to shore up the continued losses.
Currently, there are anywhere from 18 to 30 nursing homes in Iowa facing receivership, where they have defaulted on loan payments or rent for their facilities. Eight Iowa OpCo-owned facilities have less than 40 days cash on hand, and 10 QHC facilities (includes two assisted livings) owe over $6 million in state and federal fines and has filed for bankruptcy last year.
While the “remain-in-your-home” model can help to keep costs lower than nursing facility care for Medicaid participants, it can be an isolating factor that reduces social interactions for elders and may hasten physical and mental decline. Nursing homes are required by federal and state regulations to provide a wide range of services and care options elders simply do not receive in their own homes.
Currently, Iowa’s Department of Inspections and Appeals (DIA) Health Facilities Division lists 391 free-standing nursing facilities. That’s 14 less than last year, and three more facilities across the state are pending closure within the next 60 days. 
Chilson elaborated, “When the rules you must abide by can change twice in one day, and you are expected to be ‘in compliance’ with them or face fines and penalties right away, it’s tough. Add to that the financial losses, the bad rap, and lack of staffing. It’s so sad. This is the aftermath of COVID-19 on nursing facilities. You don’t recover from that.”