The Dayton Daily News investigation found:

• Thirty out of the 123 nursing homes in the nine county region received the federal government’s lowest rating for overall staffing levels as of February, which is one out of five stars.

• Nursing homes with the lowest staffing ratings performed worse on their latest health inspections than the best staffed nursing homes, according to Medicare records. Ohio nursing homes with the lowest staffing ratings received an average score of 2.4 on their last inspections, on a scale of one to five. Those that scored the highest staffing rating scored an average 3.7 stars on their last inspections.

• Nursing home staffing turnover is high in Ohio. Some hospitals and other health care companies can pay better than nursing homes and competition for workers is high. The average pay for a Dayton-area nurse aide is $13.30 an hour, comparable to competing wages for factory and restaurant workers.

Ohio nursing homes care for 75,000 people with health needs that require around the clock access to assistance, and at low staffed nursing homes, residents are at risk of injuries, long waits and poor care. The Dayton Daily News examined the situation at local nursing homes which had one-star staffing ratings and had recent state inspections of complaints that the state found were caused by low staffing.

MORE COVERAGE: Ohio nursing home inspectors have high turnover, miss deadlines

The federal government provides an online consumer guide for choosing a nursing home called Nursing Home Compare. Until last summer the information on staffing levels at each nursing home was self-reported. Then last summer the staffing data started to be based on nursing home payroll data, and the number of nursing homes with the worst federal rating for staffing — one out of five stars — climbed both locally and statewide.

The ratings revealed that nursing home staffing and retention remains a critical problem that patient advocates, nursing homes and regulators and are struggling to resolve.

Chip Wilkins, Dayton Long-Term Care Ombudsman program director, who advocates for the rights of nursing home residents, said his office frequently has to respond to low staffing complaints.

“I’ve already had three calls this morning about facilities that did not have adequate staffing over the weekend,” Wilkins said Monday morning. “One facility only had two aides working on Saturday and Sunday for a 90-plus bed facility because everyone called off.”

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Administrators with nursing homes — even those with high staffing ratings — told the Dayton Daily News they are struggling to recruit and retain staff amid low unemployment. They said Medicaid doesn’t pay enough to cover the cost of caring for a resident, much less give raises. Some also criticized the Medicare.gov rating system, saying it doesn’t always paint an accurate picture of a facility’s quality of care.

Several patient advocacy groups, however, said even with the amount that Medicaid pays, many nursing homes could be doing more to spend their dollars on safe staffing levels.

Signs of staffing problems

The Dayton Daily News found serious staffing shortages at many of the nursing homes with one star staffing ratings.

The staffing rating for Hawthorn Glen Nursing Home in Middletown slid from two stars in 2017 to its current one star.

In February 2018, a state inspector cited Hawthorn Glen Nursing Home in Middletown and reported it “failed to provide adequate staffing on the secured memory care unit.” The inspector found sometimes the facility left its dementia unit without any staff. The director of nursing told the inspector that the dementia unit has the most falls in the facility, and that she had asked for more help on that unit especially at night but was denied her request, according to reports.

At a subsequent inspection in April, an inspector again found the same problem. The inspector reported that records showed a frequently incontinent patient was bathed once in the past 30 days. A nurses aide told the inspector she had a hallway with 28 residents and then she was running back and forth every two hours to the dementia unit.

Hawthorn Glen management did not return calls and two emails requesting comment.

Hawthorn Glen is listed as one of three nursing homes owned by Mariner Management Group of Dayton. The others are Walnut Creek Nursing and Rehabilitation Center in Kettering and Greenbriar Nursing Center in Eaton. Mariner Management was incorporated in Dayton in 1992, state records show.

All of the nursing homes had the lowest rating for overall staffing. Walnut Creek and Greenbriar also did not return multiple requests for comment.

Walnut Creek was lowered under the new staffing rating system from a three-star staffing rating in 2017 to its current one star.

At Greenbriar Nursing Center in Eaton, a state inspector cited the nursing home for having insufficient staffing in August 2018. The inspector found two aides were assigned to care for a combined 47 residents. One aide told inspectors “there was only one of her and it was just too much to expect. She stated she did it because she cares for the residents and they deserve good care.”

Staffing standards

Nursing homes can be cited by the state for not having sufficient staffing to provide necessary care or for not having a registered nurse present at least eight hours per day. In Ohio, nursing homes also need to provide 2.5 hours of direct care per day to each resident.

Another local facility, Englewood Health and Rehab, was cited several times over the last year for insufficient staffing problems.

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A visitor to Englewood Health and Rehab called the police in May 2018 after finding one nurse and a cafeteria worker at the facility, according to a police report. A police report states officers spoke with two nurses who said there were two aides working and “management is aware of the staffing issue.”

In June, Englewood Health and Rehab was cited by a state inspector for not having sufficient staffing. A resident told the inspector she couldn’t remember the last time she had a shower. One resident said he was still in bed at 11 a.m. since 5 p.m. the day before. Three residents were at a table at breakfast with dirty food trays in front of them that were confirmed by staff as left over from dinner the night before, reports said.

The Englewood nursing home was cited again in January 2019 for not having sufficient nursing staff. The plan of correction filed with the state says that the administrator will use bonuses, agency staff or clinical managers to make sure residents’ needs are met.

The nursing home said in a statement in response to questions for this article that it was acquired by a new new owner-operator in May, has a recruitment effort underway as well as a strategy to reward and recognize employees, and they are focused on reducing or eliminating the use of agency staffing.

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“The recruitment and retention of nurses and STNAs is critical to our success in meeting the needs of our patients and residents,” the nursing home said in a statement. “Candidly, like many other centers, we have struggled in this area, but we are making positive strides.”

Wilkins of the Dayton Ombudsman’s office said problems with short staffing are more widespread than those that are specifically cited for insufficient staffing. He said nursing homes are more commonly cited by the state for other problems that are resulting from low staffing.

“There’s a direct correlation between the number of staff and quality of care that’s provided to the residents. It makes sense — almost common sense — that traditionally the better the staffing the better the care residents are going to receive,” Wilkins said.

Pressure ulcers — also called bed sores — are a sign of not enough staffing, said Wilkins. Preventing and treating bed sores requires patients to be moved regularly. Sores can be painful or lead to infections and wounds.

Wilkins said one of the signs of staffing problems is the use of an outside staffing agency to fill shifts, which can be problematic because temporary staff don’t know a facility or a resident’s individual needs the way regular staff do.

Beavercreek Health and Rehab was cited in December for repeated delays in treating a resident’s painful urinary tract infection. The inspection report states the resident was told the reason was because they had agency nurses working. The nursing home has the lowest staffing rating.

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The nursing home’s management did not return requests for comment.

American Staffing Association said in a statement that using supplemental agency nurses is a “sound workforce strategy” for nursing homes in the current tight labor market. The trade group said it commissioned research that shows using staffing agency nurses “does not detract from patients’ overall satisfaction.”

How data is measured

Some nursing homes took issue with how the new federal data was measured or said it misrepresented the quality of care their residents receive.

Staffing alone doesn’t account for nursing home quality. The Dayton Daily News found examples of nursing homes with high staffing ratings but poor overall quality measures as well as nursing homes with thin staffing by federal standards but strong quality ratings. A high percentage of residents paying with Medicaid also didn’t always translate to low staffing ratings.

Chris Jones, administrator with Urbana Health and Rehabilitation Center, said his facility - which received a one-star rating for staffing - can have 75 to 80 percent of patients paying with Medicaid. Though they have struggled to recruit RNs the facility still gives each resident a little under three hours of daily care and Jones said they are meeting residents’ needs.

“If I were required to work in a building that was not providing good care, I’d walk,” Jones said.

He said the nursing home is challenged because Ohioans who can afford other options increasingly seek alternatives such as assisted living facilities or they stay home with support services. But that leaves nursing homes with low-paying patients on Medicaid, he said.

Natalie Rhodes, administrator-in-training with JAG Healthcare, which manages Union City Care Center in Darke County, said the nursing home could have used an outside staffing agency to earn a higher staffing rating than one star. But she said residents are already receiving proper care and the company uses no agency staffing as a rule because they want staff that knows residents’ individual needs.

“That’s something we are firm about. We will never use agency staffing because that does not promote quality of care,” she said.

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The formula for the staffing star ratings takes into account how sick a nursing home’s residents are, requiring more staff to care for sicker patients.

But Rhodes said she doesn’t think the complicated formula reflects the actual needs of their patients and the Medicare data shows the nursing home had no major citations at their last health inspection, which was in January.

Ombudsman Beverly Baltes visits local nursing or long-term care centers to help mediate resident and patient complaints and concerns. The Ombudsman's office has no regulatory authority but can often prevent state enforcement by working with facility mangers, residents and patients. Here, Baltes checks to make certain that resident/client rights are posted. TY GREENLEES / STAFF

Unemployment

Staffing and quality can suffer when the unemployment rate goes down, and the Ohio unemployment rate has dipped to a low 4.7 percent as of January.

Nursing homes have measurably higher quality during times of higher unemployment rates, said John Bowblis, with Miami University, who has researched nursing home economics. Turnover picks up in times of low unemployment, which matters for quality because if a nurse or an aide sees the same patient every day, they are more likely to identify health problems and know the resident’s unique needs, he said.

“The problem with nursing homes is that since most of their revenue comes from Medicare and Medicaid, they can’t increase the prices that they charge in order to pay staff more,” he said.

Nurse aides in the Dayton metro make $13.30 an hour on average, and at that wage, nursing homes are competing with retailers, factories, other health care sectors and each other to hire workers.

“The same hourly rate might be recruiting at a local Wendy’s, McDonald’s. And yet the individual who is going to be working in aging services has, we would argue, a long-term career path and at the same time a set of soft skills, in particular, that are critical for success in our field,” Brod said.

There is also high turnover for leadership positions such as administrators and directors of nursing, according to Wilkins.

Wilkins said his office is part of a multi-year research project on recruitment and retention and they have had 86 percent turnover of all the administrators and directors of nursing they are studying. One facility had 17 adminstrators in three years.

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Still, some local nursing homes have received the high marks for staffing. Bethany Village in Centerville has four out of five stars for staffing, a longtime administrator and doesn’t use any agency staffing to fill spots, according to Kathy Wilson, human resources manager.

Wilson said it is getting more difficult to attract workers as other industries are also heating up recruitment competition.

Lauren Coyle, director of nursing at Bethany, said applicants with past job experience tend to ask about patient ratios because they know how it can affect their ability to do the job. If they work for a facility where they are assigned too many residents to care for, they wouldn’t have time to focus on each person and to build relationships.

“It is very different taking care of 12 residents verses eight residents,” Coyle said.

TIPS FOR FINDING A NURSING HOME

It can be overwhelming trying to choose a nursing home for either you or a family member. We asked the experts, and these were their top advice to keep in mind while searching.

See what the right kind of care is.

The local office of the Area Agency on Aging does free assessments to determine if you or your loved one needs nursing home care. For some people, staying home is the best option and the agency can help connect you with community-based services. Call 1-866-243-5678 to be connected to the area agency serving your community.

Pick somewhere close to family.

The closer a nursing home is to family, the easier it is to visit. Family members are much more likely to visit if they are close to the nursing home, so location is an important part of choosing a place.

Take a tour. Then go visit unannounced.

While guided tours can be good for getting questions answered, experts say it’s valuable to go back to the nursing home to see how things are when not officially on tour. Do the staff seem over-worked or happy to be there? How often do you see nurses and aides walking the halls? Do the staff know residents by name and knock before entering their rooms? Are meals appetizing and served on time? Are call lights unanswered or is there loud overhead paging?

If you have a place in mind, check for past complaints.

Long-term care ombudsmen can’t recommend specific places, but can tell you what verified complaints have been filed for a particular nursing home. The Dayton region office can be reached at 937-223-4613. Not in the Dayton region? To be connected with your local long-term care ombudsman program, call 1-800-282-1206.

Look at your cost and coverage.

Confirm with the facility staff that the nursing home you consider will accept your insurance coverage, Medicaid or Medicare or that the rates are within your ability to pay privately.

See how the nursing home scored in state surveys.

All nursing homes in Ohio can be searched by name online on the Long-term Care Consumer Guide, which is run by the state government. See what kind of satisfaction score nursing homes received from annual surveys of both families of residents and residents. The guide will have other information like the services offered, facility policies and types of payments accepted. The guide is online at https://ltc.ohio.gov/FacilitySearch.aspx.

Check out Nursing Home Compare.

The federal government lets you browse the details of a nursing home, looking at its overall rating out of five stars and also at quality measures, staffing levels, recent safety inspections and more at Medicare.gov/nursinghomecompare.

Have a plan early.

While some nursing home stays are planned well in advance, others happen after sudden hospital admissions and procedures. Do your research in advance or you might have to work with a hospital social worker to make a hasty selection.

Where to get help

If a you aren’t getting required care at a nursing home, there are ways to seek help.

Ombudsman

Long-term care ombudsmen can't cite nursing homes for reported violations, but can look into complaints and work with the resident and nursing home to resolve the problem to the resident's satisfaction. The Dayton office can be reached at 937-223-4613 or 1-800-395-8267 and serves nursing home residents in Montgomery, Preble, Greene, Clark, Miami, Darke, Logan, Shelby, and Champaign Counties. Complaints can also be filled online at http://www.dayton-ombudsman.org/makeacomplaint.html. The ombudsman's office serving Butler, Clermont, Clinton, Hamilton, and Warren counties can be reached at 513-458-5518 or by emailing helpline@proseniors.org and put "Helpline" as the subject.

Ohio Department of Health

The Ohio Department of Health is the state agency that inspects nursing homes. To file a complaint go online or call 1-800-342-0553.