Nursing home administrators praise their workers, saying many are drawn to the work by an urge to help people and give great care.
"There are a lot of other businesses and industries out there that a nursing assistant could go work in and make more money," Shreve said. "Go work at Best Buy, you know, work at the turkey factory."
The impact of staffing can be profound.
At St. Anthony Health Center, a frequent visitor told state inspectors doing a routine survey that she saw residents sit unattended for long periods, get out of chairs on their own and get agitated waiting for help to the bathroom. One nurses aide said she was concerned about residents' safety. Another said it was sometimes difficult to get to beeping alarms when they're busy with other residents.
The survey, completed Jan. 20, cited the home for insufficient staffing, at the same time noting multiple falls. The home's executive director, Marcia Lindig, wouldn't answer specific questions about the survey. She wrote in a statement that the home is committed to continually improving care, but can't guarantee that elderly and frail residents, often suffering cognitive impairments and other challenges, will never have an accident.
A pricey obstacle
The biggest roadblock to more staffing, by all accounts: money.
Nursing home care is already expensive. Depending on the resident's needs, the homes receive from $3,000 to almost $9,000 a month per resident in Minnesota, according to the state Department of Human Services. The average monthly cost is $4,858.
About $1.35 billion was spent on nursing home care in Minnesota in 2007, according to the department. Medical Assistance paid for $813 million in fiscal year 2008.
More seniors are choosing assisted living and other types of care before going into a nursing home. That means today's residents are more fragile than those who lived in nursing homes years ago.
"We've decreased our reliance on nursing homes. We've increased the severity of patients in them ... and we've not kept up with workforce development," said Dr. Steven Miles, geriatrician and professor at the Center for Bioethics at the University of Minnesota Medical School. "There's not enough training. There's not enough staff. There's not enough nursing supervision. There aren't enough aides."
At a minimum, Minnesota requires that homes provide two hours of nursing care per resident per day. Federal regulations say a nurse must be on duty 24 hours a day.
Both say homes must have "a sufficient number of qualified nursing personnel on duty" to meet residents' needs, but give no number or ratio.
The federal Centers for Medicare & Medicaid Services (CMS) regulates nursing homes nationally and contracts with states to enforce the regulations. It calculates expected staffing levels for each nursing home, taking into account the severity of their residents' needs and time needed to care for them. Using those expected staffing levels, 278 of 371 Minnesota nursing homes are understaffed.
Shreve said those federal numbers have been criticized, in part because staffing numbers are collected only about once a year, reflecting a two-week snapshot, and don't account for turnover or retention -- both significantly related to quality of care.
They don't count activity staff and others with direct contact with residents and don't accurately measure new ways of staffing that some nursing homes have adopted, he said.
One federal study in 2001 found a high staffing ratio helps only to a point. For long-term residents, it found, staffing above 4.08 hours of care per resident each day didn't improve quality of care.
Little Sisters of the Poor nursing home in St. Paul is one of about 90 nursing homes in the state that has higher staffing than CMS expected.