Licensed practical nurse Kim Neuhalfen has seen her share of change in a 24-year career that has taken her from wound care to healthcare billing to work on a reservation and even to a four-year stint as a prison nurse.

But it’s now that she’s come back to long-term care that she’s scared about what the future holds. Mostly for her patients, sure, but also for the setting that she’s come to love in some ways more than all the others. 

That’s because she sees how a proposed federal staffing mandate will tighten the vise-grip already squeezing rural providers — including Neuhalfen’s employer — as they struggle to attract nurses and aides and keep admissions flowing.

As I talked with dozens of sources over the last several months for our Rural Peril series, it was the red flag that Neuhalfen raised that kept calling out to me from the cornfields of Nebraska.

Many of the patients the 5-star Good Samaritan Society-Bloomfield cares for now might not move to some other, far-away nursing home should the mandate come into play and force their small-town facility to close.

No, Neuhalfen warns. Many families in this close-knit community would rather bring their loved ones home and take on the role of unpaid caregivers in a corner of Nebraska that has very little, if any, professional home care support.

“My biggest concern is, of course, the residents,” Neuhalfen told me as we sat in Bloomfield’s recreation room last fall. “I’m so afraid our facility would close, which would mean what to our community? How are they going to take care of their elderly?”

She wonders how families will survive if they lose needed income to become caregivers, but she also thinks about the what-ifs that come with patients who don’t have the daily support they need from medical providers.

“Will their families have the medical background to decipher what is wrong with them? Are they in Afib? Have they aspirated? Do they have pneumonia?” Neuhalfen asks, before turning to the next concern.

What, she ponders, will happen to patients whose families simply can’t stop working and risk  leaving that loved one who needs care at home alone for too long?

“Who’s going to be able to come check on them?” she pleads. “Who’s going to get their meds? What are they going to eat? It just opens a whole Pandora’s box.”

Like many of those who participated in this series, Nuehalfen has no political ax to grind. She’s just one of the hundreds of thousands of nurses and aides who make up the backbone of the nation’s skilled nursing industry — and she cares a great deal for the patients she has been with during some of the most vulnerable moments of their lives.

Like several who shared perspectives with me, Neuhalfen teared up thinking of those she has served in her role, both during a previous 7-year stint at this facility and again since returning here last summer.

She’s picked up the extra hours to cover gaps when the building was understaffed; she knows all-too-well the stress of expecting to work three 12-hour shifts but being needed for four or five of them in a week.

She knows she and her colleagues could use more help. And residents would welcome more consistent caregivers to supplement their nursing ranks.

But, still, her mind goes back to the idea of a nursing home doing what it can with the good people it has vs. being forced to close in a few months or years because it is consistently out of compliance with a high-minded staffing rule that simply can’t be met with the funding and labor pool available.

Among Neuhalfen and colleagues who spoke with me, there’s a tacit recognition that the people who work here are already making sure the patients who live here get everything they need. Maybe more.

“What I like the best about long-term care is just being able to see progression, see improvement. You have more time spent with them so you have those bonds,” she says. “You get excited about their successes, and you hurt when they’re hurting. You just have that bond you don’t have in so many other nursing fields.” 

That’s exactly why she and so many others see the mandate, which federal officials say they will finalize later this year, as such a heavy-handed maneuver. To such devoted nurses, it’s never been about buildings. It’s about patients who may very well suffer, whether they are forced to move away or move home.

“There’s just so much that has not been thought out, not been thought through,” she says. “I think maybe their goal is well-meaning in trying to get more one-on-one care for residents, but we don’t want our facility to close and our residents have nowhere to go.”

Kimberly Marselas is senior editor of McKnight’s Long-Term Care News.

Opinions expressed in McKnight’s Long-Term Care News columns are not necessarily those of McKnight’s.