Richard McGuire had noticed a deteriorating level of care for his 95-year-old mother at a Des Moines nursing home facility in 2016. Staff was slow to arrive to assist her. "One told Mom's friend there how much she liked her jewelry, and suggested she could give her some," he recalls. Then she was hospitalized for what was finally diagnosed as an overmedication issue. "My sister and I didn't feel comfortable keeping her there," he says.
They moved her to a Boone County facility, closer to his home, where she lived for four more years. "The nurses and CNAs were excellent, although they were understaffed," he says. "But all of a sudden, things starting changing, along with turnover in managers. The staff began wearing monitors and Mom was charged every time one came to her room to assist her beyond a certain quota. It seemed kind of tacky. I assumed the home was under different ownership," he says.
Like most Americans, McGuire didn't know who owned his mom's nursing home, but he knew that it no longer provided the same level of care. He suspected that its financial margins might be as precarious as the health of many of its elderly and ill residents.
Almost one year ago I wrote What's Next: Nursing Home Deserts?, focusing on the closures of 19 Iowa nursing homes in 2022. All but three were in rural Iowa.
I interviewed Brent Willett, Iowa Health Care Association (IHCA) president and CEO about the impact of the Covid-19 aftershocks, combined with the state's lagging Medicaid reimbursement rate. The Iowa legislature did allocate more funding into the budget for nursing homes. But a proposed $25 million increase by the House was shaved down to $15 million in negotiations with the Senate.
Almost 30 Iowa nursing homes have closed in the past two years.
Federal Floor to Ramp Up Staff
My column also highlighted a proposal by the Centers for Medicare & Medicaid Services (CMS) to mandate federal minimum staffing levels at nursing homes, including the requirement to have a Registered Nurse on site 24/7. These new standards would be phased in over three years. Rural facilities would have five years to comply.
"Issuing a mandate this spring would require more than 2,100 additional direct care staff in Iowa nursing homes," Willet told me at that time. "These people don't exist. We're hopeful practical minds will prevail."
The proposal's public comment period ended on November 6, and 47,000 comments were submitted. Fifteen Republican governors, including Kim Reynolds, objected to the proposed rule. The IHCA estimates 96% of Iowa's nursing homes would be unable to comply.
Despite the staffing challenges required by the proposed rule, I would advocate for our governor and state legislators to find ways to help nursing homes meet the requirements. (The CMS proposal would allow for hardship exceptions.)
Iowa Oversight Ranks Near Bottom
This week's column looks beyond the serious ramifications of nursing home closures to examine the issues of understaffing and inadequate state oversight eroding the quality of caregiving.
I've followed the consistently excellent reporting of Clark Kauffman at the Iowa Capitol Dispatch revealing a number of nursing home tragedies: the death of a resident who froze after an exterior door locked behind her, a resident whose leg had to be amputated due to gangrene, and recent alleged sexual assault of a resident by a male caregiver.
This week I listened to Sen. Claire Celsi's request for bipartisan Senate Oversight Committee hearings on nursing home issues. Chairwoman Sen. Amy Sinclair denied the request one day later, stating that it would "distract" staff from "their important work monitoring these facilities".
Indeed, as Celsi pointed out during Thursday's press conference, Iowa's 46 nursing home inspectors are hard pressed to get their work done at Iowa's 414 nursing homes. Iowa ranks 49th in the U.S. in its ratio of inspectors to nursing home facilities, based on fiscal year 2022 data reported by a U.S. Senate committee.
Celsi also noted that four Iowa nursing homes have been added to six other Iowa homes already on the CMS list of the nation's worst care facilities. Iowa is the source of 3% of nursing home citations in the U.S., even though Iowa only has 1% of the U.S. population's residents aged 65 and older.
Of course, many nursing homes are providing optimal care under difficult circumstances. But too many are falling far short of their responsibility to protect vulnerable residents.
Former Nurse Suffers Inadequate Care
Why has this happened in Iowa? Is it tied to the increasing acquisition of nursing homes by private equity firms? What about Iowa's 49th ranking in the ratio of patients to staff? Whose fault is this?
Mary Weaver, Rippey, Iowa, is a former surveyor for the Iowa Department of Inspections and Appeals who spoke at the Senate Democratic press conference this week. Weaver was part of a team surveying nursing home and home care facilities. Earlier this month, she wrote a column for the Greene County News Online, sharing the story of a good friend and former nursing co-worker now living in a southeastern Iowa nursing home.
"She did not receive her bath last Friday because there were not enough nurse aides working," Weaver reported. "On a recent day, her call light was not answered for 90 minutes, resulting in incontinence, or lying in her own urine for a length of time." Only one aide is on duty at night in this 35-bed facility, she wrote. Later, determined make it to the bathroom in time, Weaver said her friend fell when returning to her bed.
"When I worked as a surveyor from 1983 to 1985, the state of Iowa had 80 nursing home inspectors," Weaver says.
Most significantly, Weaver wrote that this nursing home now is owned by a New Jersey firm that also has purchased four other eastern Iowa nursing homes. The same firm now owns nine in Iowa.
Increasing Private Equity Ownership
An October, 2023 article in The Atlantic calculated that private-equity investment in nursing homes has grown from about $5 billion at the turn of the century to over $100 billion today. Private equity's modus operandi is reducing staff to maximize profits.
According to a working paper by the National Bureau of Economic Research using CMS data, health outcomes for residents at private equity-owned nursing homes are worse, "increasing short-term mortality". Based on data from 18,000 nursing homes between 2000 and 2017, it estimated that private-equity ownership was linked to about 22,500 premature nursing-home deaths from 2005 to 2017.
Private equity firms also have no obligation to disclose information about their finances, business risks, legal liabilities, or operations. The Biden administration is finalizing a new transparency measure that would require nursing homes to report more data on their owners, operators, and managers. More specifics also would be required concerning how nursing homes spend taxpayer funding.
Our state leadership also shares blame for employing a fraction of the nursing home inspectors needed, and then turning around to pay temporary private contractors $40 per hour or more to fill in the gaps. Our governor keeps talking about a state budget surplus. We're told there's no useful purpose for these funds, so they must be returned to us as tax cuts! If Iowa doubled its nursing home inspectors, it would put the state on par with many other states.
More initiatives, especially addressing staffing shortfalls and increasing oversight, must be addressed during this legislative session.
Why have hospitals largely regained their employees, but nursing homes have not? What is the role of nursing home lobbyists advocating for fewer regulations and less oversight, while Iowa taxpayers are providing greater support with few strings attached?
National Initiatives Needed, too
It's not just an Iowa issue. Earlier this year, Sen. Bob Casey (D-PA), chair of the Special Committee on Aging, unveiled the results of a year-long study of nursing homes entitled, "Uninspected and Neglected".
In fact CMS wants to work with the private sector and invest more than $75 million in tuition reimbursement, and other financial incentives. Iowa's Senate Democrats also are working on legislation to increase state inspectors, offer funds for alternative senior care, as well as training for direct care workers.
By 2050, one in four people in the U.S. will be 65 or older. Nursing homes are anticipating a baby boomer wave of admissions. "Demand for long-term care is predicted to increase by 20% over the next six to seven years," Willett told me earlier this year. "We don't have the workforce to adequately meet this increase."
Demographics also will continue to dominate. The rural population is older, sicker, and poorer, and has a higher percentage of residents with multiple chronic issues and co-morbidities. Many of their adult children have moved to better economic opportunities in more distant cities.
Who doesn't have a relative or close friend living at a nursing home in our state? The odds are that many of us will live out our days at one. Why isn't this issue urgent enough to hold a bipartisan Senate Oversight Committee hearing to learn what needs to change? It's almost as if state legislators and our governor don't want us to know.
I’m delighted to a be a member of the Iowa Writers’ Collaborative!
Columnists:
This past week, Senate Democrats called on the Governor to hold oversight hearings on the crisis of care in our nursing homes. The Senate Republican chair of their Oversight Committee, Amy SInclair and Gov. Reynolds stated these hearings were unnecessary. Quality care of our seniors must not be necessary, nor a priority.
Iowans value and respect older and dependent Iowans. To show that respect, the Governor and legislature needs to put money where their mouths are by investing in recruitment and retention of quality staff and dramatically improve oversight.
Convening nonpartisan task forces can happen tomorrow with one signature and forceful direction from our Governor..
Every Iowan with a friend or family in a nursing home or dependent care facility has an obligation to call for action and to reject Reynolds' downgrading of your concerns over your loved ones.
👍great summary. Now it’s time for action!