An Iowa woman blames nursing home staff shortages for her mom's death. Will new rules help?

Five years after her mother moved into a nursing home, Diane Hathaway says the decision to trust that facility with her mother's care “was the biggest mistake of my life.”

Evelyn Havens moved into a rural southern Iowa nursing home in late 2019 after her osteoarthritis, a degenerative disease, made it difficult for her to get dressed, bathe and do other personal care on her own.

During the 13 months Havens lived at the facility, Hathaway said she received substandard care, which Hathaway believes ultimately led to her death in January 2021 at the age of 96. Hathaway declined to publicly name the facility for fear of repercussions.

State inspectors would later cite the nursing home with five federal regulatory violations based on Hathaway's complaints, but Hathaway said more needs to be done to prevent neglect and abuse of nursing home residents. That's why she approves of the Biden administration's new rules raising staffing requirements.

“Staffing mandates I certainly applaud because at the end of the day, I do think it was inadequate staffing that was the most likely contributor to what happened to mom," said Hathaway, a Glenwood resident who has become an outspoken advocate for increased regulation of Iowa nursing homes.

The U.S. Centers for Medicare and Medicaid Services published final rules on Friday mandating that most of the roughly 15,000 nursing homes in the U.S. meet minimum nurse staffing requirements that will be phased in over the next five years.

The federal rules, announced last month by the Biden administration, take aim at chronic neglect or delays in care for nursing home residents nationwide caused by ongoing workforce shortages in the industry. Federal officials say the new requirements will significantly reduce the risk of unsafe and low-quality care of older Americans.

Only about a third of Iowa nursing homes currently meet the new standards, data shows.

Iowa nursing homes have been the subject of fierce criticism in recent years over recurring issues of poor quality care of residents. CMS data shows 14% of Iowa's more than 400 nursing homes were cited for insufficient staffing last fiscal year — more than double the national average of about 6%.

But the rules have raised alarms for nursing homes owners and administrators, who say federal officials don't offer any solutions to overcome the long-term challenges they face in recruiting and retaining health care workers. They argue that without more aid, the rules will serve only to further limit access to care for older Iowans.

"Our concern is having this one-size-fits-all ratio is going to do more harm than good," said Shannon Strickler, president and CEO of LeadingAge Iowa, an advocacy organization for not-for-profit aging service providers.

More: Nursing homes must meet minimum federal staffing levels under Biden rule

Among new standards: A registered nurse on duty 24 hours a day

The new rules require every nursing home that receives federal Medicare or Medicaid funding to provide a minimum of 3.48 hours of direct care from nursing staff, including registered nurses and nurse aides, to each resident per day. That care must include 33 minutes from registered nurses, and 2.5 hours from certified nurse aides.

Facilities would also be required to have a registered nurse on duty 24 hours a day, seven days a week.

At current staffing levels, only 125 of the more than 400 nursing homes in Iowa, or about 32%, meet these federal requirements, according to CMS data.

Just over half of the state's nursing homes — 54% — do meet the federal agency's interim requirement to have enough nurses to work 3.48 hours per day, per resident. However, fewer facilities meet the provisions for registered nurses and nurse aides.

Facilities in Iowa would need to hire more than 1,300 new direct-care staff to meet these federal requirements, totaling about $89.3 million in additional wages annually, according to an estimate from the Iowa Health Care Association, which opposes the federal mandate.

Nationwide, only 19% of nursing homes would meet that federal standard based on their current staffing levels, per a KFF analysis.

Nursing homes say they may have to turn away prospective patients

Nursing homes in urban areas would have three years to comply with the new federal rules, while rural nursing homes would have five years. Some facilities can also apply for a "hardship exemption" to the rules under certain criteria.

CMS has also pledged $75 million to a national campaign to increase nursing home staffing, which includes financial incentives for nurses to work in nursing homes.

Still, Strickler with LeadingAge Iowa believes it will be impossible for some facilities, especially those in rural parts of the state, to meet that mandate because the nursing professionals needed to meet the growing demand in the state "just don't exist." She noted that rural health care providers in particular struggle to find qualified applicants.

"I'm not sure where we're expected to find the extra registered nurses," said Pam Harned, administrator for Karen Acres Healthcare Center in Urbandale. "I've been running a registered nurse ad almost continuously for the last 2-3 years. If there were registered nurses available, they would have already been hired."

Nursing homes also struggle with high turnover rates among their health care staff. A 2023 report from the Iowa Department of Health and Human Services estimated the average annual turnover rate was 52% among registered nurses and 72% among certified nurse aides.

“It doesn't matter if you give us three years or five years,” Strickler said. “You need to give us decades to come up with a workforce solution.”

More: 'Call lights not being answered for hours': Iowa nursing homes can't find staff to stay open

Once these rules are enforced, nursing homes will likely begin turning away prospective residents to comply with staffing ratios, limiting access for older Iowans who need skilled nursing care, critics argue.

Strickler said patients will be forced to travel farther for available care. Or some families may opt to keep their loved one at home longer than is safe.

Some worry Iowa may see more nursing homes close. Between 2022 and 2023, 27 facilities statewide have done just that, according to the Iowa Health Care Association. Most were in rural parts of the state.

"I think that we will see more closures," Harned said. "There are buildings that are already in financial distress. The cost of recruiting and retaining extra RNs that don't exist will be the breaking point."

In all, the Iowa Health Care Association says an estimated 2,352 residents would be at risk of losing care because of their provider's inability to meet the mandated staffing ratios.

The federal requirement "will needlessly exacerbate an extraordinary health care workforce crisis, tear at the fabric of our rural communities and limit long-term care services for Iowans," said Iowa Health Care Association President and CEO Brent Willett.

Gov. Kim Reynolds joined 14 other Republican governors last fall in a letter to ask President Joe Biden to reconsider the new rules, arguing the "complex, deep-rooted problem" cannot be solved "with a simple wave of the bureaucratic wand."

"If adopted, CMS’s proposed regulations will force many long-term care facilities in our communities to close, eroding access to healthcare for some of our most vulnerable citizens," the governors wrote.

More: Iowa Senate Republicans reject request to investigate nursing homes, say regulators too busy

Advocates say staffing requirements are long overdue

For those like Hathaway, who say their loved ones experienced neglect and poor quality care in an Iowa nursing home, the new federal rules are a welcome regulation on the industry. Hathaway said she believes more needs to be done to hold nursing homes accountable.

“(Residents) have endured horrific neglect, substandard care and death for decades, and this has just been an acceptable situation in the state of Iowa," she said. "They let the abuse and neglect and substandard care happen, and then intervene. On what planet does that make any sense? How about preventing it?”

Pat Hopes of Treynor echoed Hathaway's comments, saying nursing homes need to be made safer for current and future residents. Her sister Debbie Kerns, age 72, has been a resident of a memory care unit at a facility in Council Bluffs since she was diagnosed with Alzheimer's disease three years ago.

“When somebody’s putting a call light on, they wait and wait and wait and wait. That is just wrong," Hopes said. "It’s like they’re just dogs or something. (The staff) need to pay more attention and help them. They’re helpless.”

The two have partnered with Council Bluffs resident Julie Ryan to advocate for legislation to allow cameras to be installed in nursing home residents' rooms. That bill has been introduced at the Iowa Legislature for the past few years but hasn't passed.

Ryan's mother, Karen Markussen, who had Alzheimer's disease, lived in a nursing home for 5½ years before her death in January at the age of 90.

Ryan also agrees with nursing home officials that more needs to be done to attract a quality long-term care workforce in Iowa. Otherwise, she says the mandate “is like putting a bandage on a gaping wound.”

“It can’t hurt to have more staff of course, but I’m just not sure that’s going to solve the problem of neglect and abuse,” she said.

Michaela Ramm covers health care for the Des Moines Register. She can be reached at mramm@registermedia.com, at (319) 339-7354 or on Twitter at @Michaela_Ramm.

This article originally appeared on Des Moines Register: Iowa nursing homes say new staffing rules could force some to close