ARAPAHOE, Neb. — Alan Thomas was the last holdout.
All the other residents of the assisted living and nursing home in Arapahoe had moved to new facilities.
Twenty miles north to Elwood.
Sixteen miles south to Beaver City.
Thirty miles northeast to Bertrand.
Alan was returning home — just six blocks away — leaving the place where he lived for the past five years.
The Good Samaritan Society said the nursing home was closing on Dec. 31, so Heidi Thomas, Alan's wife, chose to keep him there until the final day.
“I told the administrator I’d be there at 11:59 p.m. to pick him up," Heidi said. "Just because I wanted to be a stick in the mud."
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She picked him up at lunchtime.
For 60 years, this facility often served as the final home for residents of this town of about 1,000 people located about 35 miles south of Lexington. When its closure was announced Nov. 1, residents had 60 days to move out.
Arapahoe residents said the 60-day notice wasn't enough time. Not to completely reimagine how to care for the aged and disabled in their community. Not to prevent loved ones from moving away from their hometown. Not to figure out what happens next.
What happened in Arapahoe is unfolding in communities all across Nebraska as nursing homes, facing financial shortfalls and staffing shortages, shut their doors.
It leaves the residents of those towns with questions about where they and their loved ones will go in their most vulnerable years.
"I know our answer is for Alan to live at home, because if I leave the community three or four times a week (to visit him elsewhere), then I'm not part of my community anymore," Heidi said. "I'm part of the highway. And that's not my vision for how life works."
In 2021, closures of assisted living and nursing home facilities happened in Arapahoe, Valentine, Tecumseh, Ravenna and Omaha.
Nebraska had 225 licensed long-term care facilities in May 2016, according to state licensing officials. The most recent report listed 206 facilities.
The struggles have continued this year.
Pioneer Memorial Rest Home in Mullen must hire a director of nursing, a night nurse and several certified nursing assistants in the coming weeks or it will be forced by the state to close, according to an article in the Hooker County Tribune.
The rest home is struggling to fill three to four nursing shifts every week. Current staff members are working five to seven days a week, 16-hour days.
Hooper Care Center in Hooper closed Feb. 10 after nearly 30 years. The facility is a member of Vetter Senior Living.
According to a statement from the company, the closure of the facility was brought on by "the critical shortage of health care employees."
"We are sorry for the disruption and pain this may have caused for residents, their loved ones, our team members, and their families as well as the community of Hooper."
It's three weeks after the closure of Arapahoe's nursing home and snow is falling outside the Thomas house.
A neighbor boy scoops snow off the driveway and the wheelchair ramp leading to the front door.
Inside, Alan sits in a recliner in the living room. Linda Lampe, a nurse aide employed through Caring Friends In-Home Care, playfully scratches at the bottom of Alan's foot to keep him awake.
Equipment taken from the nursing home is scattered around the house. A sit-to-stand lift is in the kitchen. A hospital bed is in a bedroom. A wheelchair in the living room serves as another chair when the Thomases have guests.
Family photos hang on the walls and rest on bookshelves. Heidi's Good Samaritan Society name tag from her employment at the nursing home sits on a bookshelf. It has the company's mission written on it: "In Christ's Love, Everyone Is Someone."
Alan and Heidi, who have been married for 15 years, have known each other since they were kids growing up in north-central Nebraska and dated right after high school. Alan kept an old calendar that has Heidi's phone number written on the days they had dates. After first marriages for both, the pair reconnected after Alan found Heidi through a website called classmates.com.
Alan, 59, has Parkinson's disease and Lewy body dementia. They are diseases that affect the chemicals in the brain and can lead to problems with thinking, movement, behavior and mood. Both are progressive diseases that get worse with time.
Alan lived in a recliner for a year and a half during the COVID-19 lockdown, and, as a result, Heidi, 56, said her husband's hips no longer work and he has diminished leg muscles.
Linda pushes the sit-to-stand lift from the kitchen into the living room so Alan can practice standing. She straps him into the machine and it slowly lifts him out the chair until he's upright.
"Hang on, cowboy," Linda tells Alan when he's standing. "You know how this horse can buck."
Alan's Parkinson's diagnosis came in 2007. At the time, the neurologist told Alan that dementia would come into his life — either soon or years down the road.
Alan never did like the word "dementia." He called it "mad cow disease."
"If he has an opportunity to engage in sarcasm, he's happy," Heidi said, noting that her husband has maintained his sense of humor despite his illnesses.
Slowly, however, Alan had to give up some things as his symptoms worsened. He stopped refereeing wrestling. He quit golfing. Long car rides became difficult.
"It was just gradual," Heidi said. "There really wasn't a time or a year that everything came to a screeching halt."
In December 2015, Alan had an annual checkup. He had been experiencing a lot of hallucinations and paranoia. After a week in the hospital, Alan had a diagnosis of Lewy body dementia and orders for 24-hour supervision.
Heidi, a full-time special education teacher, hadn't explored the option of having around-the-clock care. She started paying someone to take care of Alan while she was at work, had help from relatives and stayed with Alan the rest of the time. On advice from her pastor, Heidi put Alan on a waiting list at the nursing home.
Heidi didn't know how long it would take to get Alan into the nursing home, which residents said was always full and often had a waiting list. The facility was licensed for 30 people in nursing care and 13 in assisted living.
While the couple waited, Heidi started making modifications to the house, which was built in the 1930s. Between flooring, drywall, painting and making everything accessible for a wheelchair, each room that Heidi modified cost about $5,000.
The bathroom was stripped down to its studs, the plumbing was changed and hand grips were installed so everywhere Alan went he would have something to grab.
Doorways in the house also were widened to fit a wheelchair.
But in the end, it wasn't enough. Alan wasn’t sleeping at night. And if he fell, it took grown men to help get him up again.
Alan didn't want to give up driving. He didn't want to be away from home. He didn't want to stop living with his wife.
Still, when an opening in the nursing home came after eight months on the waiting list, that was the best choice.
“It hurt my heart because when you can no longer take care of your spouse, that feels really hard," Heidi said.
After Alan moved into the nursing home in November 2016, Heidi would pick him up and bring him home on the weekends so they could spend more time together.
The nursing home already was a familiar place for the Thomases. For eight years, Heidi had been working at the nursing home during the summer, helping out in the laundry room or kitchen.
When the pandemic began, the nursing home implemented COVID-19 restrictions. Heidi quickly realized the only way she would be able to see her husband would be as an employee.
She started working again in the laundry room and kitchen but wanted to see Alan for more than for food and clothing drop-offs, so she became a certified nursing assistant.
Alan never had to go without Heidi. Or wonder why she wasn't there.
"I think if I would have gone the length of time that other people had to go without seeing their family members, he would not have recognized me later," Heidi said.
“People with dementia need that regular contact, because left in four walls for endless number of days, you make up stories. And it's hard to get back that time if you don't have regular communication.”
Monday through Friday, Heidi taught at school. She spent Saturdays and Sundays at the nursing home; some weekends, she would log 30 hours because of staff shortages.
"The more I was down there, the more I got to see Alan, so it was beneficial for him," she said. "And so it was beneficial for us. And they needed the help."
Beneficial, but exhausting. The pandemic put added stress on teachers and nursing home staff. Heidi was doing both jobs, seven days a week.
At the nursing home, workers had to do their jobs as well as provide compassion for the residents who were stuck in their rooms 24 hours a day. Residents couldn't see their families or clergy or even visit the hairdresser.
Heidi said staff mowed through supplies because nothing could be reused due to safety concerns and time constraints.
Sometimes, traveling nurses were brought in to fill shifts. Officials said the traveling nursing agencies sometimes charge $100 to $200 an hour to provide staff.
“When I have a substitute teacher at school, it costs a fraction of what I get paid," Heidi said. "When you call in a nurse to cover a shift, it costs three times more than you're paying your nurses. And so you can't do that. We wouldn't be able to run a school if that's how much we paid substitute teachers.”
Prior to the November announcement, Heidi said, she didn't think people in the community had a clue the nursing home could close.
"Although I wasn't that surprised, I was disappointed because every single community — no matter whether you're rural or in the city — everybody has aging and disabled people," she said. "So that's a dilemma that our community has to figure out. How does that look now?”
For most, the closing of the Arapahoe facility meant moving to a nursing home in another town. For example, Hazel Cross celebrated her 106th birthday in Arapahoe before moving to a facility in Elwood. She died Jan. 21.
But when the closure was announced, Heidi decided to move Alan home. The modifications she'd already made to her home helped. And friends drove to Hastings, got a wheelchair ramp and installed it outside the Thomases' home after Heidi discovered it would take months to get one through Medicaid.
To keep Alan at home, Heidi will need to make more home modifications, and she had to purchase a new van that works with Alan's wheelchair — a $40,000 expense.
Alan has two certified nursing assistants and certified medication aides, both former employees of the nursing home, who help take care of him so Heidi can go to work and sleep at night.
Alan's medical paperwork alone is a part-time job. Heidi sometimes has to take a day off of work just to get it all done.
Her share of Alan's medical costs after insurance and Medicaid didn't change when she brought him home from the nursing home. But she is spending more money on groceries and household items, and the electric bill has increased by about $60 a month.
She worked hard the last year and a half because she believed it was the right thing to do. Now, she believes moving Alan home was the right decision.
"I'd rather work hard trying to make home work," she said. "It's way more meaningful."
Ron Ross, president of Rural Health Development, summed up the issues facing the nursing home industry as "a perfect storm."
For years, nursing home officials have said facilities have struggled, in large part, because state Medicaid payment rates have fallen further and further below operating costs.
In Nebraska, the amount Medicaid pays is on average $40 less per resident per day than what it costs to take care of those residents, nursing home representatives said.
Jalene Carpenter, president and CEO of the Nebraska Health Care Association, said the $40-per-day estimated shortfall doesn't fully account for recent wage inflation.
Gov. Pete Ricketts in December asked the federal government for approval to increase Medicaid reimbursement to Nebraska nursing homes by $20 per bed per day between Jan. 1 and June 30. That would generate an additional $21 million in income to long-term care facilities, Ricketts said, which have been hurt by inflation and staff shortages.
Ricketts' request was recently approved for nursing homes and will be retroactively applied, but it likely isn't enough.
"That $20 a day is still only about half of what they needed just to get to the break-even point," said Kirsten Reed, chief executive officer of LeadingAge Nebraska, which represents nonprofit providers of senior housing and services in Nebraska.
“Our nursing facilities are in dire straits," Reed said. "They don’t have enough revenue to pay staff what they need in order to recruit and retain those staff. And that means they’re unable to take on any additional residents.”
Without additional residents, the facilities can't break even.
“It’s a vicious circle,” Reed said.
Carpenter said workforce recruitment and retention has been a persistent challenge, and the chronic Medicaid underfunding has left providers struggling to compete for qualified caregivers.
Then came the COVID-19 pandemic. Carpenter said the pandemic disrupted the labor market, so that now, current and potential staff are being recruited to the highest bidder.
Representatives from nursing homes recently told a legislative committee they were forced to boost starting wages for certified nursing assistants to $20 or $22 an hour, up from $12.50 an hour, yet still are unable to fill all the staff vacancies.
Good Samaritan Society, which operated the facility in Arapahoe, also closed facilities in Valentine and Ravenna.
According to its website, Good Samaritan Society has locations in more than 20 states and is an affiliate of Sanford Health, which "is the largest and fastest-growing nonprofit rural health system in the U.S."
The website shows that Good Samaritan Society has 24 locations throughout Nebraska.
Nate Schema, president and CEO of the Good Samaritan Society, said in a statement that the pandemic has put unprecedented stress on the senior care industry, forcing the company to make difficult decisions about how and where it can provide services.
"Persistent staffing challenges, a decline in the number of residents at our locations and increased operating costs threaten the long-term sustainability in some communities," Schema said. "As a result, the Good Samaritan Society recently closed three skilled nursing facilities in Nebraska."
Schema praised Ricketts' decision to temporarily increase Medicaid reimbursements to keep up with the actual costs of care the company provides.
"Unfortunately, operating and labor costs have continued to skyrocket at an unsustainable rate during this pandemic," Schema said. "We need permanent funding and workforce solutions to ensure seniors have access to high-quality care and services they need and deserve, no matter where they live."
Advocates for nursing homes are backing two bills introduced by State Sen. John Stinner of Gering in the Nebraska Legislature. Legislative Bill 988 would fund a formal study to look at assisted living Medicaid reimbursement rates. Reed said there has never been a true evaluation of what it costs to provide care for residents at assisted living facilities, which offer less-intensive care than nursing homes.
"We really don't feel comfortable continuing to ask for these incremental increases that really aren't fixing the problem," Reed said. "What we really need is a study that says this is what it actually costs to provide those services."
Legislative Bill 989 would appropriate $26 million in state funds to assist in improving rates for nursing facilities that provide Medicaid services. The state funds would be matched by $34.5 million in federal money. The Appropriations Committee has voted to put that money into its budget package. The committee also is looking to supplement that with some federal American Rescue Plan Act money.
Stinner said Nebraska’s nursing homes and assisted living communities are essential to the health and well-being of the state's seniors. He said the recent facility closures illustrate a need to look at Medicaid funding.
"We must do all we can to avoid additional facility closures," Stinner said. "It’s about access and making sure Nebraskans can remain in the communities they call home.”
Ross, who also is the former director of the Nebraska Department of Health and Human Services and a former state treasurer, said when nursing homes close in small towns, families have no choice but to move their family members to facilities farther away.
When a loved one is in a nearby nursing home, family and friends can stop by regularly to visit, Ross said. That doesn't happen as often when the relative or friend has to move away to a distant facility.
“Nobody likes to feel like they’re abandoned," Ross said. "That’s what happens when you go someplace where nobody knows you.”
“What does society want to do?" he asked. "Are we going to kick these people to the curb or are we going to treat them decently?”
On a Saturday afternoon in late January, Heidi loads Alan into their new van and drives to the school a few blocks from their house.
Heidi spent the morning judging a speech competition in Grand Island. Now the pair are heading to watch one of Alan's passions — wrestling.
Alan was a wrestling referee for 16 years. Today he is watching from the stands, wearing a black long-sleeve T-shirt that has "Arapahoe" written on the chest.
Everyone at the wrestling invitational knows Alan. He is greeted with a fist bump and a hat tip. Hugs and handshakes. One wrestling referee spies Alan and runs over to shake his hand while two competitors wait on the mat.
"He knows all the refs by name," Heidi said.
Across the mat from Heidi and Alan is John Koller, the wrestling coach for the hometown team. He's also the mayor of Arapahoe.
Mayor Koller found out the nursing home was closing at the same time as everyone else in town.
Koller and a few members of the City Council went to the Nov. 1 meeting for nursing home residents and their families where Good Samaritan Society announced the facility would close at the end of the year.
Schema, the CEO of Good Samaritan Society, said in a statement the 60-day notice was consistent with federal guidelines.
"Long-term challenges have unfortunately led to a situation in Arapahoe that is not sustainable," the statement said. "As a result, we made the difficult decision to close the facility."
After the announcement, Koller tried to look for solutions to keep the facility open, including exploring if the city could purchase it and run it. Instead, he said he discovered there would be terms and conditions attached to the future sale of the building. Those terms included a clause saying the property could not be used as a nursing home again, or for a number of other health care services.
In the statement, Schema said restrictions on the future use of a property are put in place in situations like this one when long-term care facilities face ongoing challenges such as difficulty hiring staff, inadequate Medicaid reimbursement rates and increased operating costs.
"Our expertise and experience indicate that long-term care operations in Arapahoe are not sustainable and that we have a responsibility to our residents to find them the care they need both now and into the future," the statement said.
Koller questions why that clause is necessary if the operation is not sustainable in Arapahoe.
The restrictions on the building felt like another blow to the town, residents said.
"That’s probably the most frustrating part about this whole thing," Koller said. "They made that decision for themselves and our community and never gave us the opportunity to respond or try to help with a resolution or play any role whatsoever in that process. And that makes it pretty tough.”
Koller said he believes there would have been financial support within the community to keep the nursing home open.
Asked whether he thinks another long-term care facility might be built and opened in Arapahoe, the mayor paused before answering.
“I think it’s probably almost, almost impossible,” Koller said.
The mayor also predicted that other communities throughout the state could end up in the same position as Arapahoe.
“The rest home facilities, I think, are going to continue to close. It sure feels that way.”
Over a dinner of sausage, mashed potatoes and sauerkraut in their retirement community in Arapahoe, Doyle Wineland and Sandra Williamson trade barbs.
Williamson says she's originally from Chase County in Nebraska, about 55 miles south of Ogallala.
"They chased her out," Doyle quickly responds.
This group at this table at Prairie Pines 55+ Retirement Village is what manager Nancy Holliday has dubbed her "entertainment table."
Other residents may eat and dash back to their rooms. This table lingers — occasionally slowing down the staff trying to finish washing the dishes.
“If you can’t have a little fun, life’s not worth it,” said Mary Lou Wineland, Doyle's wife of 65 years.
This retirement community is for people 55 and older. The youngest resident is 83 years old. The oldest is 103.
The retirement community was once owned by Good Samaritan Society but was sold to a local investment group.
How did news of the Arapahoe nursing home's closure go over?
"Like a lead balloon."
"This town has been in an uproar ever since."
The closure is still big news at Prairie Pines, where Heidi's mother lives after moving to Arapahoe from South Dakota. One attraction for her and others in the retirement community was the assisted living and nursing home nearby, in case they needed additional help or their health took a turn for the worse.
Since the nursing home closed, Holliday has been fielding inquiries from people interested in her facility, which has 19 rooms and provides breakfast and lunch but is not an assisted living facility.
John Crawford's mother, Emma, lives in the retirement community. At 102, Emma can recite the birthdays of grandchildren and great-grandchildren, keeps up with her family on Facebook and plays Words With Friends on her iPad.
“She doesn’t want to go to the rest home until she gets old,” Crawford said with a laugh.
But in the past few months, the family started to notice that Emma was struggling to get around and fell twice in one day. The family felt like she needed more help. Yet her need for more care coincided with the closure of the nursing home.
“I’ve lived here all my life," John Crawford said of Arapahoe. "She’s lived here all her life.”
To keep Emma at the retirement community in her hometown, the family hired a full-time caregiver who previously worked at the nursing home. John Crawford and his two siblings also take turns staying the night with their mother.
When the conversation at the "entertainment table" turns to the nursing home closure, the laughter fades.
“When you’ve lived here so many years, you don’t want to go anywhere else,” Williamson said.
"If we leave here, where do we go?" Mary Lou Wineland said.
On a Tuesday evening in late January, the parking lot of the nursing home in Arapahoe is empty.
A dumpster sits in one corner. Pumpkins and gourds carefully arranged outside the nursing home have deflated like balloons and started leaking liquid that leaves round stains on the concrete.
Six blocks away, Heidi, bags in her arms, walks into the kitchen at her home after a day at school.
He smiles more in the next hour than he has all afternoon.
Heidi has brought home nachos for them to share. She pulls a table and a chair next to Alan's recliner. She loads up a chip and feeds it to Alan. Then she eats one herself.
There's someone at the front door.
Mark McCurdy, the town pharmacist, arrives to give Alan a COVID-19 vaccine. Heidi sits on the arm of the recliner and helps hold Alan’s shirt as the pharmacist pushes the needle into Alan's arm.
Alan closes his eyes.
“It’ll give me a reason to kiss you,” Heidi tells Alan and kisses the top of his head.
Alan likes to dance. Heidi said that's the thing he misses the most.
Sometimes, Alan and Heidi still dance. She'll use the sit-to-stand lift to get Alan up and then they'll sway to Luther Vandross.
Alan can stand there with Heidi for one minute and 43 seconds.
Heidi doesn't have the answers about how to keep nursing homes open, but she said she knows the current system that relies on Medicaid is inequitable and is one of the reasons the homes are closing.
"So how can we make that different is the important question to take away from Arapahoe, Nebraska," Heidi said. "How can people feel comfortable about aging?”
Heidi knows she and Alan aren't alone.
"There's an Alan Thomas in every community, and every community deserves to have an opportunity to care for their own people."