Axios investigates: Iowa's nursing home crisis

Why it matters: The Wells' situation is one that many families around the state say they are contending with right now.

• Iowa is part of a national nursing home crisis that came to a head during the pandemic, with critical staffing shortages that still persist.
• Recently alleged nursing home abuse or neglect in the metro include a client who contracted gangrene and had to have a leg amputated and a person who froze to death.

Catch up fast: Leslie had leukodystrophy, a genetic disease that causes cognitive impairment, movement disorders and seizures.

• The couple moved to Edgewater's independent living center in West Des Moines in 2018, looking ahead to the possibility that she'd eventually need the center's long-term care.
• She moved into the facility's long-term care on Jan. 19, 2021.

Yes, but: Leslie stayed there just over a month before Sam says he had her transferred to Deerfield assisted living facility in Urbandale because of poor care, which he believes was due to staffing shortages.

• Leslie's care improved and she regained some weight in the weeks after she was relocated, Sam says. She died about four months later.

Edgewater declined to comment on the allegations from the Wells' or other cases documented in inspection reports, citing privacy restrictions.

• The facility has not been short-staffed in the last five years, Lisa Ryan, director of communications for WesleyLife, Edgewater's parent company, said in a statement to Axios.
• Inspection reports during that time also do not reflect understaffing issues at the facility.

Zoom in: Sam's handwritten notes document three times within a month when he alleges Leslie soiled herself while waiting as long as 90 minutes for bathroom assistance at Edgewater's long-term care facility.

• They also show she fell five times, including an incident on Feb. 19, 2021, that resulted in a head injury later documented in a state complaint.

Of note: Edgewater's care plan did not address Leslie's falls.

• The facility also lacked documentation showing whether its staff had notified her doctor or family about the Feb. 19, 2021 fall, as is required under federal rules for nursing homes that accept Medicare or Medicaid, according to state inspection documents.
• The facility was not fined in Leslie's case but paid a $9,500 fine in July 2022 linked with falls involving other residents, state documents show.

Separately, Edgewater was fined after a resident was found in November 2019 outside without shoes for at least 20 minutes just before 5am.

• Her toes were purple but she was otherwise OK, according to the state's report of the incident.
• The $500 fine cited a malfunctioning door alarm.

Zoom out: Iowa does not require minimum staffing ratios in nursing homes. Its rules instead focus on whether facilities meet resident needs.

• The state's direct-care nursing home staffing standards amount to just over two hours per resident per day for a 100-bed facility, according to a 2021 report by the National Consumer Voice for Quality Long-Term Care.
• That's just over half of the national staff mandate proposed earlier this year by the Biden administration.

State of play: Sam and his family now advocate for nursing home reforms.

• "The most vulnerable in our state are being abused and neglected at the places most trusted with their care. When are we going to protect those Iowans' right to life?" their daughter Dacè Wells wrote to lawmakers in June.

Nursing home closures accelerate from pandemic

Since 2020, Iowa has experienced a sharp increase in nursing home closures statewide.

Why it matters: The closures are primarily due to a lack of available workforce to help keep facilities afloat, Brent Willett, president of Iowa Health Care Association previously said.

• Shortages can lead to lower care quality.

By the numbers: In 2021, one nursing facility closed in western Iowa.

• By 2022, that accelerated to 17 nursing homes
• There have been 11 closures in 2023.

The big picture: 13% of the nation's total nursing home closures in 2022 occurred in Iowa, Radio Iowa reports.

Staffing shortfalls projected for years to come

Nearly 42% of Iowa's nursing homes have self-reported staffing shortages, according to data published earlier this year by the AARP.

Why it matters: It's a national problem that is expected to persist for years, according to a report in August from the American Health Care Association (AHCA).

Zoom in: Iowa's nursing home staff shortages were ranked as the 11th-worst in the U.S. by the AARP.

• Minnesota topped the list, with almost 60% of facilities with staffing shortfalls. Kansas and Wisconsin were both above 45%.

What they're saying: The average hourly rate for Iowa nursing home workers is around $16, which is lower than the rate in many other industries and makes it difficult to find or retain staff, Brad Anderson, president of AARP Iowa, tells Axios.

• Plus, facilities in rural areas are often spread out in less densely populated areas, which can make it harder to find staff, he added.

The big picture: The AHCA says the nursing home industry lost 250,000 employees, or about 15% of its workforce, during the pandemic.

• That's contributed to the closure of nearly 600 nursing homes nationally since 2020.
• And more than half of those still operating were turning away prospective patients as of June.
• The return of pre-pandemic workforce levels are not anticipated until 2026, according to the AHCA.

Nursing home complaints double between 2019 and 2022

Iowa's "immediate jeopardy" nursing home complaints more than doubled — from 39 to 83 — between 2019 and 2022, according to data from the Iowa Department of Inspections, Appeals and Licensing.

Why it matters: They're among the most serious level of complaints — situations where a provider's noncompliance resulted in serious injury or death, or could have done so.

• They took priority over lower-level complaints during the pandemic, which led to a backlog in other investigations.

Zoom in: There were 410 total complaints pending against Iowa nursing homes that were at least 30 days old in June 2022, according to Iowa Capital Dispatch.

• Of those, 201 were more than 120 days old.

State of play: The inspections department reduced the number of pending complaints to 161, a more than 60% reduction between June and August of this year.

• All immediate-jeopardy complaints were investigated within a federally required timeframe, generally three business days, agency spokesperson Stefanie Bond tells Axios.

The big picture: Multiple states have bigger complaint or facility inspection backlogs than Iowa, according to a review of federal data published in February by Newsweek.

• Roughly 22% of Iowa nursing homes had not been inspected every 15 months as required under federal law.
• More than 50% of inspections were overdue as of Feb. 19 in Missouri, Alabama, Kentucky, Idaho and Maryland.

Iowa nursing homes were fined more than 1,000 times in three years

Iowa nursing homes were fined or denied payment as a penalty more than 1,000 times in the last three years, according to data published in September from the Centers for Medicare and Medicaid Services.

State of play: The fines resulted in more than $12.7 million in penalties, the 14th highest state total in the country.

• Iowa had the second-greatest number of penalties per capita behind Massachusetts.

Zoom in: Two Iowa nursing homes are listed as Special Focus Facilities (SFF) and are operating under additional scrutiny by the Centers for Medicare and Medicaid Services (CMS) because of a history of serious quality issues — Arbor Court of Mount Pleasant and Aspire of Primghar.

Meanwhile, 10 others are SFF candidates, including one cited for violations tied to four resident deaths, Iowa Capital Dispatch reports.