Iowa State Auditor Rob Sand said Monday that Iowa is violating federal rules on timely inspections of nursing homes.
At a press conference on Monday, Governor Sund said the Iowa Department of Inspection, Appeals and Licensing has demonstrated “inadequate performance” in overseeing nursing homes and has not met federal requirements for nursing home inspections. Governor Sund said Iowa’s nursing homes are currently in a crisis.
The auditor’s comments came in conjunction with the release of an official report from the state auditor’s office that found Iowa is inspecting nursing homes on average every 17.1 months — more than four months longer than the federal mandate that requires nursing home inspections to be conducted on average every 12.9 months.
In addition to the federal requirement that all facilities be inspected an average of every 12.9 months, CMS requires states to inspect each nursing home at least once every 15.9 months. The auditor’s report found that the state is also not meeting this requirement. The report found that 85.4% of Iowa’s 403 nursing homes had inspectors miss the 15.9-month deadline at least once during the past three inspection cycles.
“Obviously, many of us have heard about the horrible outcomes for nursing home residents,” Sand said Monday, “people dying in nursing homes, people lying in their beds without any care, and all sorts of fines being levied and then suspended.”
Iowa is home to 403 Medicare- and Medicaid-certified nursing homes, housing approximately 20,000 seniors and people with disabilities.
In May, the Iowa Capital-Dispatch reported that federal data showed more than 43 percent of Iowa nursing homes are not meeting upcoming federal mandates on staffing, and last year, 21 Iowa facilities saw between three and five nursing home managers change over a 12-month period.
Sand noted that while Iowa does not meet federal mandates imposed by the Centers for Medicare & Medicaid Services (CMS), which pays states to inspect homes for compliance with federal regulations, he is not aware of any actions being taken against the state for not complying with federal regulations.
Sund, a Democrat, said he thinks part of the problem is that the Republican-dominated Iowa Legislature and Republican Gov. Kim Reynolds haven’t paid enough attention to the issue.
“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 nursing home testing is well below the national average, why not fund additional testing? The purpose of testing is to get people to understand that someone may come to see them, so we can better care for our elderly and vulnerable residents. I think that should be the priority.”
The governor’s office did not immediately respond to a request for comment on Sund’s findings.
Diane McCool, a spokeswoman for DIAL, the agency that inspects Iowa nursing homes, said Sund “issued a misleading report” based on outdated or inaccurate data and “inaccurate” performance measures.
“The audit report is inaccurate, incomplete and confusing,” McCool said. “It is also a waste of taxpayer money because the Centers for Medicare and Medicaid Services (CMS) will release the results of the state inspectorate’s independent investigation after the end of the federal fiscal year — two weeks later. In short, DIAL is conducting its inspections of nursing homes in a timely manner and meets federal requirements.”
McCool added that as of Monday, 99% of Iowa’s nursing homes had completed their regular inspection period, which is 15.9 months this fiscal year, and the remaining 1% were scheduled to be completed by the end of September. He said DIAL is “conducting nursing home inspections in a timely manner.”
Sund’s office used publicly available data from CMS in preparing the report, which Sund said took into account the pause in nursing home inspections nationwide during the COVID-19 pandemic.
The report found that while federal law requires the average time between completed annual recertification inspections to be 387 days or less, the Iowa average was 514 days, 4.2 months longer than the federal law requires. The average for neighboring states was 495 days.
Staffing levels and turnover rates also covered
In addition to the testing issue, the new report also addressed the staffing levels at Iowa’s nursing homes, with Sund noting that the state currently ranks 46th in the nation in the number of certified nursing staff per resident.
A new report finds that 45.2 percent of Iowa nursing homes that report staffing information to the federal government do not meet the latest federal standards for overall nursing staff levels. Licensed nursing staff in Iowa nursing homes work an average of 1.32 hours per resident per day, below the national average of 1.53 hours.
The report also highlights a long-standing challenge in the nursing home industry in Iowa and other states: high staff turnover.
According to the auditor’s report, more than half of the nursing staff who worked in Iowa nursing homes from June 2023 to May 2024 left the facilities during that same one-year period, making Iowa the state with the 17th highest nursing staff turnover rate in the nation.
People are really doing what could be called God’s work? … But they can make just as much money flipping burgers at McDonald’s.
– Iowa State Auditor Rob Sand
Staff turnover, and general staff shortages, have long been considered the biggest cause of poor quality resident care. High turnover leads to staff shortages and an over-reliance on temporary staff who are not familiar with each resident and their specific medical needs.
The Iowa Capital-Dispatch reported that federal data shows 14% of Iowa’s 422 nursing homes have staffing shortages for the 2023 fiscal year, more than double the national average of 5.9%.
Only five states — Hawaii, Michigan, Montana, New Mexico and Oregon — performed worse than Iowa in complying with adequate staffing requirements. Iowa’s neighbors — Nebraska, South Dakota, Wisconsin and Missouri — had between 2% and 6.8% of facilities facing staffing shortages in 2023.
The data showed that the Iowa facilities with the lowest nurse staffing levels in the fourth quarter of 2023 were Arbor Springs in West Des Moines, Midland Living Center in Council Bluffs, Lynnhaven Rehabilitation & Healthcare in New Hampton, Pleasant Acres Care Center in Hull, Northbrook Healthcare & Rehabilitation Center in Cedar Rapids, Crest Haven Care Center in Creston and Aspire in Perry. All of the facilities provided fewer than 2.5 total hours of nursing care per resident per day, according to the report.
Sandoz: Wages are equivalent to McDonald’s
Sand said Monday he believes low wages are contributing to nursing home turnover issues.
“A lot of these jobs are really low-paying,” he says. “They’re doing what is really God’s work – dressing people, helping them bathe. But they could be flipping burgers at McDonald’s and making just as much.”
In the past few years, Iowa lawmakers have tried to address the issue of low wages for caregivers by drafting bills that would have required nursing homes to use a portion of increased Medicare payments to boost employee compensation. But as the Capital Dispatch reported earlier this year, not all Iowa nursing homes are in compliance with the law, and the agency that oversees compliance lacks enforcement power.
The auditor’s report Monday also suggested that Iowa, where many nursing homes have filed for bankruptcy in recent years, has a much lower nursing home occupancy rate than facilities in many other states and may still be “overbuilt.”
According to the auditor’s report, Iowa’s nursing home capacity is 27,412 beds, but there are 19,937 residents, for an occupancy rate of just under 73%. With an average of 49 residents per nursing home, Iowa currently has the fourth-lowest resident density per nursing home in the nation.
Democratic state senators Claire Celsi and Janice Weiner issued a statement Monday saying the audit report “confirms with cold hard data what we’ve known for months: Governor Reynolds’ administration is failing to protect Iowa’s seniors in 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 mandate more frequent inspections, impose tougher penalties for violations and mandate the hiring of 30 additional nursing home inspectors.
