Rural residents face diminishing access to quality nursing homes

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Darrell Hoemann

Champaign-Urbana Nursing and Rehab (302 Burwash Ave, Savoy) on Monday, April 6, 2020. The care facility has been cited for a deficiency in infection prevention and control in 2019. Photo by Darrell Hoemann/CU-CitizenAccess

Pressure ulcers, gangrene, sepsis and amputation. 

That is what a nursing home resident suffered while under the care of Aperion Care Cairo in 2018, according to state inspection document. 

The resident first developed treatable wounds at the facility, but no documentation of physician notification or treatment initiation was found, according to a quarterly report by Illinois Department of Public Health.

The resident’s condition deteriorated over the next three months, which eventually resulted in an emergency “guillotine” amputation through the knee and a subsequent above-the-knee amputation. 

The facility failed to recognize the development of pressure ulcers and did not implement measures to promote healing, according to the report. The facility was also cited for, among other things, failure to ensure residents are free from significant medication errors, to protect residents from abuse and to provide enough food/fluids to maintain residents’ health. 

Indeed, Aperion Care Cairo received 35 citations for various deficiencies in just the last year alone, according to the database managed by the federal Centers for Medicare & Medicaid Services. And the home has been cited for abuse and is on the Special Focus Facility list for “a history of persistent poor quality of care.”

Comment from Aperion officials was requested several times but they did not respond to repeated phone calls and emails.

But while prospective residents and their families might want to avoid a nursing home with such a record, Aperion Care Cairo is the only Medicare & Medicaid certified nursing home in Alexander County, which is located in southwest Illinois. That leaves its population of just over 8,000 people little choice of a nursing home unless they are willing to travel out of the state to Kentucky, where the closest nursing home that takes part in federal payment reimbursement programs is located about 15 miles away. 


While there are non-Medicare & Medicaid certified facilities that are closer, those nursing homes do not take part in payment reimbursement programs. Illinois has approximately 1,200 long-term care facilities. However, only 722 are Medicare & Medicaid certified nursing homes, which means nearly 500 facilities do not participate in federal payment reimbursement programs. 

In fact, many rural counties in Illinois face the same lack of choice when it comes to high-quality nursing homes. Rural nursing homes are buffeted with a number of issues that often lead to understaffing and low quality of care. In addition, some nursing homes in rural areas are closing because of financial challenges.

There are 52 counties in Illinois with a population of under 30,000, according to the 2010 U.S. Census, and 45 of which has three or fewer nursing homes. Pope, Pulaski and Putnam, three counties with over 16,000 people in total, have no nursing homes within the counties. 

“Usually the rural areas have few nursing homes in the region, and many of those might be the for-profit ones that have poor quality,” said Charlene Harrington, long-time researcher and expert on the nursing home industry.

People who live in these areas not only have a lack of choice in nursing homes, but the options they do have might not provide quality nursing care. 

For example, Piatt County has a population of 16,729 and two nursing homes that are Medicaid & Medicare certified. However, both nursing homes received one star out of five for overall ratings on Nursing Home Compare, the official U.S. government site for Medicare. 

Moreover, even if the residents of Piatt County are willing to relocate to the closest metropolitan area for high quality care, they might find themselves with few options as well. 

In the next county over, Champaign County has a population of over 200,000 and seven Medicare and Medicaid certified nursing homes. However, five out of the seven facilities also received one out of five stars for overall rating on Nursing Home Compare. One of the nursing homes currently has a COVID-19 outbreak.

Rural nursing home closures

The shortage of high-quality nursing homes in rural areas is further exacerbated by nursing home closures. 

About 20 long-term care facilities closed since 2016, according to the inventory of long-term care services by the Health Facilities & Services Review Board, most of which cited financial struggle as a main reason for their closures. 

For example, North Adams Home in Mendon, a town with a population of 953 in the 2010 census, announced its closure in late 2019. After four decades of operation, the board of directors to the facility stated that it has become increasingly difficult to remain viable. The facility was reported to struggle financial due to the decline and delay in the state’s Medicaid reimbursement. 

Another facility, Pleasant Hill Village located in Girard, a rural town with a population of 2,103 in the 2010 census, closed its skilled nursing care facility in 2018. The Board of Directors announced that they can no longer financially support the operation. 

The statement released claimed the state owes the facility over $2 million in approved and pending applications. 

“The State of Illinois pays $128.48 per resident day. However, the current cost of providing quality care is approximately $160 per day,” the statement said. “Low reimbursement, along with months of state money in arears, renders continuing this service unfeasible.” 

High share of Medicaid recipient 

Many nursing homes attribute the struggle to a low Medicaid reimbursement rate. A report by the Health Care Council of Illinois found a $519 million annual gap between cost of care in Illinois nursing homes and the state Medicaid funding to the facilities. 

While that is the case for all nursing homes in the state, facilities in low-income, rural areas are often burdened with a high percentage of residents who are dependent on Medicaid. 

An adult whose income is under 138 percent of the federal poverty level is eligible for Medicaid, which translates to $1,366 per month for an individual and $1,845 per month for a couple. 

Medicaid provides health insurance for some of the poorest people in the state. According to healthinsurance.org, there are 606,670 people covered by Medicaid in Illinois as of July 2018.  

“High-Medicaid nursing homes are found in both urban and rural areas. As one would expect, they tend to be concentrated in poorer areas,” Grabowski said. 

As a result, many rural areas with less resources end up with a high share of Medicaid recipients in their nursing homes, he said. The quality of care in these nursing homes are often not up to standards. 

“Study after study has supported this idea that nursing homes with higher shares of Medicaid have worse quality. And that’s just simply that you get what you pay for here,” Grabowski said. 

People in rural communities also tend to use traditional nursing homes much more than Home and Community Based Services, due to a number of factors, said Andrew Coburn, an expert on rural health and on public health policies. 

Home and Community Based Service is a form of nursing that allows people to receive care in their own homes. In recent years, Medicaid spending on those services has been increasing as the demand rises. 

Coburn said consumer preference is an important driving factor for this trend. However, the expansion of Home and Community Based Services has been uneven across the country. 

“One of the key realities is rural places is that they tend to be real estate rich and income poor,” Coburn said.

People in rural communities are likely to own property but have less income to purchase different nursing services, making those services less affordable.  

Another factor is the displacement of younger people in rural communities, as family tend to be the primary caregivers for old people at home. 

According to a report by the Illinois Institute for Rural Affairs, the average age of Illinois residents in increasing, and rural counties have an older population than urban counties. 

The report also stated that the general trend is that “the more rural the county, the older the average person.” 

“In many communities, you have older people whose families have moved on and are living in an urban place, and you don’t have the same level of family support that you had 40 years ago,” Coburn said. 

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