Auditor criticizes state for nursing home inspections that violate federal standards • Iowa Capital Dispatch

“Of course, many of us have heard about the terrible consequences for nursing home residents,” Sand said Monday. “People dying in nursing homes, people lying in beds with no care, and all kinds of fines being imposed and then suspended.”

Iowa has 403 Medicare and Medicaid-certified nursing facilities, serving approximately 20,000 seniors and disabled individuals.

In May, the Iowa Capital Dispatch reported that federal data showed that more than 43% of all Iowa nursing homes were not meeting upcoming federal staffing requirements, and last year, 21 Iowa nursing homes had three to five administrators change in a 12-month period.

Sand noted that while Iowa is not complying with federal orders imposed by the Centers for Medicare and Medicaid Services, which pays states to inspect homes for compliance with federal regulations, he is not aware of any actions taken by CMS against Iowa for noncompliance.

Sand, a Democrat, said he believes one factor contributing to the problem is the lack of attention paid to the issue by the GOP-controlled Iowa Legislature and Republican Gov. Kim Reynolds.

“We’ve seen the Legislature put a lot of effort — and the governor put a lot of effort into other things, like the culture wars,” he said. “If we’re well below the national average in nursing home inspections, why wouldn’t we fund additional inspections? The whole point of inspections is to make people understand that someone can come in and take a look. That helps them take better care of our elderly and vulnerable residents. I think that should be a priority.”

The governor’s office and the Iowa Department of Inspections, Appeals and Licensing did not immediately respond to requests for comment on Sand’s findings.

Sand’s office used publicly available data from CMS to prepare the report. The report, Sand said, took into account the national pause in nursing home inspections during the COVID-19 pandemic.

While the average interval between completed annual recertification inspections meets the federal mandate of 387 days or less, the state average in Iowa is 514 days, or 4.2 months longer than federal regulations require. The average in bordering states was 495 days, the auditor’s office said.

The issues of staffing levels and turnover were also discussed.

In addition to inspections, the new report also addresses Iowa’s nursing home staffing levels. Sand noted that Iowa currently ranks 46th in the nation in the number of licensed nursing staff per capita.

According to a new report, 45.2% of Iowa nursing homes that report staffing information to the federal government do not meet the latest federal standards for overall nurse staffing levels. Iowa nursing homes average 1.32 hours of licensed nursing staff per resident per day. That’s below the national average of 1.53 hours.

The report also highlights a long-standing problem in the nursing home industry in Iowa and other states: high staff turnover.

More than half of the nursing staff who worked at an Iowa nursing home between June 2023 and May 2024 left their positions during that same one-year period, the auditor’s office reported. As a result, Iowa had the 17th-highest nursing staff turnover rate in the country.

Staff turnover and understaffing in general have long been recognized as the single largest contributor to poor quality resident care. High turnover contributes to staffing shortages and an overreliance on temporary staff who are unfamiliar with individual residents and their specific medical needs.

The Iowa Capital Dispatch reported that federal data shows 14% of Iowa’s 422 nursing facilities were cited for understaffing in fiscal year 2023. That’s more than twice the national average of 5.9%.

Only five other states — Hawaii, Michigan, Montana, New Mexico and Oregon — had worse records for meeting the staffing requirement. Iowa’s neighbors, Nebraska, South Dakota, Wisconsin and Missouri, had between 2% and 6.8% of their facilities understaffed in 2023.

The data shows that in the fourth quarter of 2023, the homes in Iowa with the lowest levels of nursing staffing were Arbor Springs in West Des Moines, Midlands Living Center in Council Bluffs, Linn Haven Rehab & Health Care in New Hampton, Pleasant Acres Care Center in Hull, Northbrook Healthcare and Rehabilitation Center in Cedar Rapids, Crest Haven Care Center in Creston and Aspire in Perry. All reported less than 2.5 hours of total nursing care per resident per day, according to the report.

Sand: Salaries are comparable to McDonald’s

Sand said Monday that he believes low pay is to blame for the staff turnover problem in nursing homes.

“A lot of this work is really underpaid,” he said. “People are doing what you would really call the Lord’s work, right? They’re dressing people, helping people bathe… But they could make just as much money flipping burgers at McDonald’s.”

In recent years, Iowa lawmakers have tried to address the issue of low caregiver pay with legislation that requires homes to use a portion of increased Medicare payments to increase employee pay. But as the Capital Dispatch reported earlier this year, not all Iowa homes have complied with the law, and the agency that monitors compliance has no enforcement authority.

Monday’s report from the auditor’s office also indicates that Iowa, where many nursing facilities have filed for bankruptcy in recent years, may still be “over-stocked” with nursing homes, with occupancy rates much lower than in many other states.

Iowa’s nursing homes have 27,412 beds, the auditor’s office said, but they house only 19,937 residents, which translates to an occupancy rate of just under 73%. With an average of 49 residents per nursing home, Iowa currently has the fourth-lowest population density per nursing facility in the country.

Two Democratic state senators, Claire Celsi and Janice Weiner, issued a statement Monday saying the auditor’s report “confirms with cold, hard data what we have known for months: Governor Reynolds’ administration is failing to protect seniors in Iowa nursing homes.”

Senate Democrats have proposed a legislative package for the 2025 session that includes four bills focused on the quality of long-term care in Iowa. Various elements of the package would require more frequent inspections, impose stiffer penalties for violations and hire 30 more nursing home inspectors.