MINNEAPOLIS — A resident of a Two Harbors, Minnesota, nursing home received the wrong medication dose 39 times in a row last spring, resulting in emergency hospitalization for seizures the drugs were supposed to prevent.

A federal investigation of Waterview Shores found other medication errors and documented the mistakes, resulting in a $203,412 fine for substandard care — one of the largest in state history.

Waterview Shores is not alone, though, in its struggles to meet federal nursing home standards. A Minnesota Star Tribune analysis of federal data found that the quality of care has slipped at nursing homes across the state.

The number of Minnesota nursing homes with a one-star overall rating, the federal government’s worst grade, rose from 34 in 2019 to 64 last month. Federal fines for neglectful or substandard care have tripled from $2.3 million to $8.2 million in the same timeframe.

At the same time, the number of nursing homes in the state has fallen from 376 in 2019 to less than 340.

With the oldest members of the massive baby boomer generation just turning 80, the timing couldn’t be worse for the decline in both quantity and quality of nursing homes. The generation’s long-term care needs are expected to overwhelm Minnesota’s capacity.

The federal government grades on a curve, so there will always be some one-star nursing homes. It also adjusted how it calculates fines and ratings over the past decade.

But elder-care advocates said those factors don’t fully explain the erosion of quality grades for Minnesota’s nursing homes.

“If they come in at a one, I’m sorry, they are god awful,” said Kristine Sundberg, executive director for Elder Voice Advocates, a nonprofit seeking to end abuse and neglect of vulnerable adults in Minnesota.

Growth in for-profit owners

The state has responded to the growing need for long-term care by investing in supports that allow seniors to live at home longer, and licensing more than 2,000 assisted-living facilities. Some have sophisticated medical capabilities.

“Many assisted livings are basically what nursing homes used to look like just five, 10 years ago,” said Tetyana Shippee, a researcher at the University of Minnesota’s Center for Healthy Aging and Innovation.

But, she said, nursing homes remain vital and their demise will hurt senior citizens and younger adults with complex mental and physical disorders, or who can’t afford alternatives. (The government-subsidized Medicaid program for low-income and disabled Americans covers nursing homes, but does not cover room-and-board expenses in assisted-living facilities.)

“It’s really hitting the state’s most vulnerable people disproportionately,” Shippee said.

The Terrace at Crystal ranked 15th among Minnesota nursing homes this year in the medical complexity of its residents, federal data showed. It shut down this summer after its owner couldn’t meet payroll.

When the state stepped in to keep the Terrace open while its 58 residents moved out, its manager discovered alarming disrepair. Court records described a nursing home fouled with rodents, mold and standing water, and where bottled water was needed because fountains and refrigerators were broken.

State operators found similar decay in 2023 when they took over Bay View Nursing and Rehabilitation Center in Red Wing. Lawmakers approved special payments to try to save the nursing home, because it served fragile Minnesotans who suffered brain injuries or needed mechanical ventilators to breathe. But it closed months later after the owner stopped paying workers.

Leaders of Minnesota’s nursing home industry said a lack of state investment has contributed to nursing homes’ struggles. Lawmakers approved $300 million in rescue funding to prevent the closure of nursing homes that were hit hard by the COVID-19 pandemic, but they haven’t increased payment rates to keep up with wage growth, said a statement from the Long-Term Care Imperative.

The advocacy group, which represents two nursing home trade groups in Minnesota, is hoping to gain legislative support for a plan that guarantees quality long-term care for seniors within 45 minutes of their homes.

“Families in many communities already struggle to find care close to home,” the organization said in its statement. “Quality and access are not competing priorities. Minnesotans deserve both.”

The Terrace and Bay View were for-profit businesses, which have been found in national research to have more problems. Minnesota had some of the nation’s highest quality-of-care rankings when its nursing homes were all owned by nonprofit charities, religious organizations or hospitals, Shippee said. Now, for-profit owners control 30% of Minnesota’s nursing homes, including 50% of the homes with one-star grades.

Some researchers have cautioned that this association doesn’t prove that for-profit owners cause more problems. Its possible that they simply operate nursing homes that others won’t touch.

Homes shutter amid declining care

The SEIU union representing nursing home workers in Pennsylvania this June accused for-profit owners of neglecting their nursing homes while squeezing as much federal reimbursement money out of them before closing.

The union’s report called out Ephram Lahasky for “predatory” ownership. Lahasky operates more facilities in other states, but federal records show that he had ownership interests in 12 nursing homes in Minnesota in 2019. Five have shut down.

Lahasksy currently owns Highland Chateau Health and Rehabilitation Center in St. Paul, which has been stuck for two years on a federal “special focus” list of nursing homes that need heightened monitoring because they consistently fall short of care standards. Calls to the nursing home for comment weren’t returned.

Four other nursing homes have needed “special focus” in Minnesota since 2019, and three of them closed — including Bay View and the Terrace. The for-profit owner of the Terrace also operated a nursing home in Cannon Falls that closed after it was evacuated in 2023 because of water leaks and ceiling damage.

All nursing homes are struggling with staffing; 84 in Minnesota had to replace at least half of their nursing staff in the past year.

But the federal data shows lower rates of nurses and nursing aides per resident at for-profit vs. not-for-profit facilities.

“There are some legitimate staffing challenges,” Sundberg said. “There’s also some real greed problems.”

Waterview says problems are being fixed

Monarch Healthcare Management, based in Eagan, is the largest for-profit owner in Minnesota, acquiring 44 nursing homes since it formed a decade ago.

Only two of its facilities received five-star grades in the latest quality rankings. Sixteen received one-star grades, including Waterview in Two Harbors.

Chief Executive Marc Halpert said he couldn’t speak to problems with other for-profit owners, but that his company intends to be the solution to nursing home quality and access issues in Minnesota.

Monarch acquired several nursing homes when they were already poorly rated and at risk for closure, he said. Now it needs time to turn them around.

“I look forward to our facilities going up in the star ratings and showing why we are awesome,” said Halpert, whose company collaborated in 2022 with a University of Minnesota researcher to test whether robots could entertain residents and help keep them on schedule with eating and medications.

Monarch completed a $650,000 renovation of the Mala Strana nursing home in New Prague, and the facility’s federal grade bumped up from two stars to four.

Lisa Brinkhaus, 67, said she doesn’t like the food and had trouble at first with a couple of workers, but she is happy and credits Mala Strana and its caregivers for helping her walk after a fall at home left her temporarily paralyzed.

The retired veterinary technician returned to her room Nov. 4 with a tube of lotion that she won at Bingocize, a group activity that combines bingo and stretching exercises.

“They’re keeping me moving,” she said. “I can walk the length of a football field, three or four times a day sometimes.”

The mood was similarly upbeat Nov. 5 at Waterview in Two Harbors.

The most recent regular state inspection found only two minor problems.

The average inspection in Minnesota finds seven deficiencies, so Monarch leaders host celebrations any time their facilities beat that mark. Workers received free lunch and played carnival games for Monarch-themed swag or prizes that included extra vacation days.

The positive inspection could eventually boost Waterview’s one-star rating. The grades are updated monthly by the federal Centers for Medicare and Medicaid Services, based on nursing homes’ two most recent inspections, staffing levels and quality-of-care measurements.

For now, Waterview’s grade remains tied to this year’s medication errors, and the preventable hospitalization of a resident. Multiple caregivers had raised concerns, according to an investigative report, because there were conflicting drug dosages listed in that resident’s medical records.

But those concerns were not resolved. The resident ended up receiving weaker-than-prescribed doses for nearly two weeks of lactulose, which led to a dangerous buildup of ammonia in blood and caused the seizures. Two other residents missed medication doses as well.

The $203,412 federal fine as a result of these medication errors is the third-highest for a nursing home in Minnesota since at least 2019. Monarch leaders said the fine could delay renovations at Waterview that are intended to improve care.

Ratings over time

By national comparison, Minnesota fares better than many, ranking 15th highest among states in the average star ranking of its nursing homes. And while star grades have worsened in Minnesota since 2019, they have remained stable since 2023. Fines and the number of deficiencies found in inspections have tapered as well, offering some hope.

Sundberg of Elder Voice Advocates encouraged people to evaluate nursing homes by the consistency of their grades over time, and to compare results with other sources such as Elder Care IQ or Minnesota’s own nursing home report card.

“Everyone has problems once in a while,” Sundberg said. “That’s to be expected. They’re human, you know, but it’s the year after year ones that worry us the most.”

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