A state-run nursing home for veterans found itself among the lowest-ranked long-term care facilities in Arkansas after federal health officials gave it a one-star rating earlier this year.
The Centers for Medicare and Medicaid Services gave the Arkansas State Veterans Home in Fayetteville a one out of five-star rating in January after the facility failed to submit staffing data. The nursing home previously had a three-star rating, according to Dr. Lee Fleisher, chief medical officer and director of the Center for Clinical Standards and Quality at the federal agency.
The star rating system reflects a nursing home's performance in health inspections, staffing assessments and quality of care. The Fayetteville facility, which is run by the Arkansas Department of Veterans Affairs, has a three-star rating for quality of care and one-star ratings for health inspections and staffing levels.
While state officials say the staffing levels at the Fayetteville home now outpace those at top-rated facilities, inspections revealed the nursing home struggled to meet minimum required levels in late 2020. The finding came as nursing homes across the country reeled from staffing shortages during the coronavirus pandemic.
Earlier this year, a resident left the facility unattended and injured himself. At the time, the facility was fully staffed, according to Sue Harper, a spokeswoman for the state Department of Veterans Affairs.
After the staffing violations and the resident walking out of the facility, the nursing home received nearly $50,000 in state and federal fines.
Since missing the deadline in January, the Fayetteville home has completed all staffing updates. Staff turnover impacted the timely submission of the report, Harper said.
Administrators noted that the rating represents a "point in time" assessment of the facility. By improving the facility's performance in health inspections and quality measure assessments, state officials expect that the facility's overall rating will rise to at least three stars by the end of the year.
While state officials are concerned by the one-star rating, staffing levels at the facility now surpass those at other Arkansas nursing homes with five-star staffing ratings, according to Harper.
In June, the Fayetteville home reported an average of 5.89 hours of direct care per resident per day. Arkansas requires a minimum of 3.36 hours per resident.
"Fayetteville's reputation for superb quality care and word-of-mouth from families of its current residents maintains a high referral rate with eight to 20 inquiries/applications weekly," Harper said in an email statement.
To bolster staffing levels, the facility has relied on contract labor and overtime staff pay. Harper noted that contract labor cost is a concern for the facility. The facility is staffed by 46 state employees and around 68 part-time contract workers. The department had 55 staff vacancies as of Friday.
The drop in rating and sanctions indicate that the level of care at the current Fayetteville facility was "very poor," according to Martha Deaver, president of Arkansas Advocates for Nursing Home Residents.
"Staffing is the number one quality indicator," she said. "When you don't have enough staffing, you can't feed veterans ... you can't turn them over so they don't receive bedsores."
SHORT-STAFFED
In recent months, federal officials have emphasized the importance of meeting staffing levels in long-term care facilities. The Centers for Medicare and Medicaid Services signaled in January that it would begin posting turnover rates and weekend staff levels on its website. Last month, the agency announced new inspection guidance that would help uncover noncompliance with staffing requirements, according to a news release from the agency.
"The covid-19 pandemic has highlighted the importance of staffing for the well-being of residents and it's more important now than ever that CMS release any information related to staffing that can improve quality," Chiquita Brooks-LaSure, administrator for the federal agency, said in a January statement.
Since the start of the coronavirus pandemic, nursing homes across the country have struggled to hire and retain staff. A study released last month by the American Health Care Association found that 6 out of 10 nursing homes were restricting new admissions because of staffing shortages. Of the 759 nursing home providers surveyed, the association found that 98% were having difficulty hiring new employees.
"The survey shows the severe and persistent workforce shortage nursing home providers have been facing with too many facilities still struggling to hire and retain staff despite making every effort," said Mark Parkinson, president of the association, in a statement at the time.
The Fayetteville facility, which offers around-the-clock care to veterans and eligible dependents, is among 43 one-star nursing homes in the state. There are 220 federally inspected long-term care facilities in Arkansas, according to an online federal database. Of these homes, 10 have one-star staffing ratings.
The federal ratings are designed to allow residents and their family members to easily compare long-term care facilities. Star ratings do not affect a nursing home's eligibility for federal funds, Fleisher said in a statement.
RECENT INSPECTIONS
Along with overseeing the 90-bed facility in Fayetteville, the state Department of Veterans Affairs collaborates closely with the state Department of Finance and Administration to run the Arkansas State Veterans Home in North Little Rock. Earlier this year, the North Little Rock facility saw its one-star rating rise to four stars.
The Fayetteville facility received roughly $8.2 million in annual revenue -- from Veterans Affairs per diem, Medicaid, private pay and Medicare income -- in fiscal year 2022 and paid $9.2 million in operating expenses for a net loss of $1 million.
The North Little Rock home collected nearly $12.5 million in revenue and paid $12 million in operating expenses, for a net income of $465,000.
Both facilities were able to cover their expenses and neither exceeded its appropriation in fiscal year 2022, Harper said. Along with state-run veterans homes across the country, the Arkansas facilities received federal covid aid, which helped cover the shortfall at the Fayetteville facility.
The recent rating increase at the 96-bed North Little Rock facility was due to a steady rise in its quality measure rating and a three-star rise in its staffing rating. The home also saw its health inspection rating increase from one to two stars, according to Fleisher.
Of the 96 licensed beds at the North Little Rock facility, 90 are taken. The Fayetteville nursing home currently has 67 of its 90 licensed beds taken.
Last month, the North Little Rock home reported an average of 4.77 hours of direct care per resident per day, clearing the state's minimum requirement by 1.41 hours, Harper said.
While the North Little Rock facility has a one-star lead on the Fayetteville home in its health inspections rating, it has nevertheless recently received 12 health citations for deficiencies compared to Fayetteville's six. The average number of health citations at facilities in Arkansas is 8.8, according to federal reports.
An inspection of the North Little Rock facility completed in December lists deficiencies ranging from failing to keep medication secure to improperly blending food to minimize the risk of choking. Officials determined the level of impact for each of the deficiencies to be "minimal harm or potential for actual harm," according to the report.
In the most recent federal complaint inspection of the Fayetteville facility, officials determined that staff had failed to improve supervision policies after a resident left the home and injured himself.
The man had wandered from his room on the fifth floor in February and exited the building around 11 p.m. through a door that led to a back alley. Maintenance staff found the man on the ground roughly an hour later about 50 feet from the door with facial wounds and a shoulder injury, according to the inspection completed in March.
Officials noted that the director of nursing immediately initiated hourly checks for "recently eloped residents" for four weeks after learning that the facility's supervision policies were deficient in early March.
The facility received a $42,245 federal fine after the inspection, according to records from the Centers for Medicare and Medicaid Services.
During the facility's latest standard federal health inspection, officials determined that staff failed to maintain "resident dignity and a homelike environment" by serving meals in Styrofoam cups and bowls. The June 2021 inspection also found that employees failed to properly store oxygen tubes to prevent cross-contamination, date food items and ensure that a licensed pharmacist reviewed drug records.
The three latest federal infection control inspections found no health deficiencies at the facility.
In the last three months of 2020, state officials found that the Fayetteville home failed to meet minimum staffing levels. In November of that year, the nursing home was short on 32 of 90 shifts, which constituted a "pattern of failure" under state law, according to the latest inspection completed by the Arkansas Office of Long Term Care in February 2021.
State officials assessed a fine of $7,500 for the staffing violations and denied new admissions to the home until the facility submitted a report addressing the "pattern of failure."
After learning of staffing violations during the first month of the state audit, facility administrators requested federal funds, offered "liberal overtime" and bolstered staff with contract labor, according to the facility's plan of correction.
The staffing constraints began when the facility admitted residents faster than the home was able to recover from attrition during the first seven months of the pandemic, according to the plan of correction.
"When the traditional staffing lifelines were also taxed by covid-19, the home lost the ability to consistently cover shifts," the corrective action plan reads.
NEW FACILITY
To improve conditions for nursing home residents in Fayetteville, state officials are seeking a $30 million federal grant to build a new facility.
The current nursing home for veterans is on the University of Arkansas for Medical Sciences Northwest campus in a wing that was not designed to be a long-term care facility. The six-floor building can be difficult for residents to move around in, especially during emergencies. The home, which opened in 2006, also lacks a kitchen.
After considering their options, state officials favored building a new 96-bed facility, state Secretary of Veterans Affairs Nathaniel Todd said in a meeting Tuesday.
State officials anticipate that the new nursing home could open as soon as 2026 when the lease on the current home expires.
The recent one-star rating will not affect plans for construction. State officials expect to apply for the federal grant this month, according to Harper.
The recent reports aren't the first time audits have highlighted deficiencies at the Fayetteville facility. In 2013, officials found that neglect factored into the death of one resident and the injury of another.
Before the recent rating increase at the North Little Rock facility, administrators grappled with staffing shortages and filling empty beds. Two years after the state-of-the-art facility opened in 2017, the home was operating at a $120,000-a-month deficit.
Information for this article was contributed by Doug Thompson of the Northwest Arkansas Democrat-Gazette.