The Iowa Department of Inspections, Appeals and Licensing oversees nursing homes in the state of Iowa. (Photo via Getty Images; logo courtesy of the State of Iowa)
Iowa Auditor of State Rob Sand said Monday that the State of Iowa is in violation of federal requirements for the timely inspection of nursing homes.
In a press conference Monday, Sand cited the “poor performance” of Iowa’s Department of Inspections, Appeals and Licensing in overseeing nursing homes while failing to meet federal requirements for inspecting those care facilities. Sand said Iowa’s nursing homes are currently in crisis.
The auditor’s comments were made in conjunction with the release of a formal report from the Auditor of State’s Office that found Iowa has been conducting nursing home inspections, on average, every 17.1 months – which is more than four months beyond the federal mandate that requires such homes to be inspected, on average, every 12.9 months.
In addition to the federal mandate for inspecting all homes on a 12.9-month average, CMS also requires states to inspect each individual care facility at least once every 15.9 months. According to the auditor’s report, the state has failed to meet that requirement, as well. The report says that for 85.4% of Iowa’s 403 nursing homes, inspectors missed the 15.9-month deadline on at least one occasion during the past three inspection cycles.
State Auditor Rob Sand appears on Iowa PBS’ “Iowa Press” in April 2021. (Screenshot via Iowa PBS)
“Obviously, so many of us have heard about terrible outcomes for nursing home residents,” Sand said Monday. “People dying in nursing homes, people laying in beds without any care, and all kinds of fines are being levied and then being suspended.”
Iowa’s 403 Medicare- and Medicaid-certified nursing facilities are home to roughly 20,000 elderly and disabled individuals.
In May, the Iowa Capital Dispatch reported that federal data showed more than 43% of all Iowa nursing homes do not meet upcoming federal mandates on staffing levels, and that last year 21 Iowa homes each cycled through three to five nursing home administrators over the course of 12 months.
Sand noted that while Iowa isn’t meeting the federal mandates imposed by the Centers for Medicare and Medicaid Services, which pays the states to inspect homes for compliance with federal regulations, he’s not aware of any action taken by CMS against Iowa for lack of compliance.
Sand, a Democrat, said he feels one factor contributing to the problem is the lack of attention given the issue by the GOP-controlled Iowa Legislature and Republican Gov. Kim Reynolds.
“We’ve seen the Legislature putting a lot of effort – and the governor putting a lot of effort into other things, like culture wars,” he said. “If we are way below the national average in nursing home inspections, why would we not fund additional inspections? The entire purpose of the inspection is to make people understand that someone may be coming in to take a look. That helps them do a better job of taking care of our elderly and vulnerable residents. It seems to me like 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.
In preparing the report, Sand’s office used publicly available data from CMS. The report, Sand said, took into consideration the national pause on inspections of nursing homes during the COVID-19 pandemic.
While the average gap between completed, annual recertification inspections is federally mandated to be 387 days or less, Iowa’s statewide average has been 514 days, or 4.2 months longer than what is required by federal regulations. The average in bordering states was 495 days, the auditor’s office reported.
Staffing levels, turnover also addressed
In addition to the inspections issue, the new report also addresses staffing levels in Iowa’s nursing homes. Sand noted that Iowa now ranks 46th nationally in the number of licensed nursing staff per resident.
According to new report, 45.2% of Iowa nursing homes that report staffing information to the federal government do not meet the newest federal standards for overall nursing-staff levels. Iowa homes average 1.32 hours of work performed by licensed nursing staff, per resident, per day. That’s below the national average of 1.53 hours.
The report also highlights a longstanding problem in the nursing home industry in Iowa and other states: high turnover among the staff.
More than half of the nursing staff who worked in an Iowa nursing home between June 2023 and May 2024 left their position at that facility during that same one-year period, the auditor’s office reported. The result was that Iowa had the 17th highest rate of nursing-staff turnover in the nation.
Folks are doing what really you could say is the Lord’s work, right? … But they could make just as much flipping burgers at McDonald’s.
– Iowa Auditor of State Rob Sand
Staff turnover, and staff shortages in general, have long been considered the biggest contributor to poor quality resident care. High turnover contributes to staffing shortages and to excessive reliance on temporary workers who aren’t familiar with individual residents and their specific medical needs.
The Iowa Capital Dispatch has reported that federal data shows 14% of Iowa’s 422 nursing facilities were cited for insufficient staffing in fiscal year 2023. That’s more than double the national average, which was 5.9%.
Only five other states – Hawaii, Michigan, Montana, New Mexico and Oregon — had a worse record of compliance with the sufficient-staffing requirement. Iowa’s neighboring states of Nebraska, South Dakota, Wisconsin and Missouri had no more than 2% to 6.8% of their facilities cited for insufficient staffing in 2023.
The data indicates the Iowa homes with the lowest nurse staffing levels in the fourth quarter of 2023 were Arbor Springs of West Des Moines, Midlands Living Center of Council Bluffs, Linn Haven Rehab & Health Care of New Hampton, Pleasant Acres Care Center of Hull, Northbrook Healthcare and Rehabilitation Center of Cedar Rapids, Crest Haven Care Centre of Creston and Aspire of Perry. All reported less than 2.5 hours of total nursing care per resident, per day, according to the report.
Sand: Wages are comparable to McDonald’s
Sand said Monday that he believes low wages are contributing to the turnover problem in nursing homes.
“A lot of this work is really poorly paid,” he said. “Folks are doing what really you could say is the Lord’s work, right? They are dressing people, they are helping people bathe … But they could make just as much flipping burgers at McDonald’s.”
In years past, Iowa lawmakers attempted to address the issue of low pay for caregivers with legislation that requires homes to use a portion of their increased Medicare payments for increased employee compensation. 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, which has seen a number of care facilities file for bankruptcy in recent years, may still be “overbuilt” in terms of nursing homes, with occupancy rates that are well below those of facilities in many other states.
Iowa’s nursing homes have a capacity of 27,412 beds, the auditor’s office reported, but only 19,937 residents, which contributes to an occupancy rate of just under 73%. With an average of 49 residents per nursing home, Iowa now has the nation’s fourth-lowest density of residents per care facility.
Two Democratic state senators, Claire Celsi and Janice Weiner, issued a statement Monday that said the auditor’s report “validates with cold, hard data what we’ve known for months: Gov. Reynolds’ administration is failing to protect seniors in Iowa nursing homes.”
Senate Democrats have a proposed a legislative package for the 2025 session that includes four bills focusing 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 require the hiring of 30 additional nursing home inspectors.