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Workforce shortages, facility closures straining Iowa’s long-term care system, ombudsman warns
Ombudsman urges lawmakers to tie funding to staffing and quality, tighten oversight during closures
Jan. 11, 2026 5:30 am
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Iowa’s long-term care system remains under mounting pressure from workforce shortages, high turnover and a wave of facility closures that have left vulnerable residents traumatized and at risk, according to a new report from the Iowa Office of the State Long-Term Care Ombudsman.
The office’s Federal Fiscal Year 2024 annual report, delivered to Gov. Kim Reynolds and state lawmakers late last month, documents persistent staffing instability, growing reliance on temporary agency workers and a sharp uptick in nursing home and assisted-living closures that the ombudsman says demand stronger oversight and clearer accountability for facility owners.
“These realities underscore the need for strategic investment and collaboration to protect vulnerable Iowans and strengthen care quality,” according to the report from State Long-Term Care Ombudsman Angela Van Pelt.
The office is responsible for identifying, investigating and resolving complaints made by or on behalf of Iowans in skilled nursing care settings like nursing homes, assisted living or residential care.
During the fiscal year, which ended Sept. 30, 2024, the ombudsman’s office resolved 1,086 complaints and closed 654 cases, completed 1,509 on-site visits across 415 facilities and responded to emergency closures that required rapid response and resident transfers. The report shows complaints have climbed steadily in recent years, rising from 653 in federal fiscal year 2021 to 1,086 in 2024.
The most common complaints raised by residents and families centered on care quality and staffing, followed closely by concerns about resident autonomy and rights. Ongoing problems with admissions, transfers and discharges also remained an issue, while complaints about facility conditions — including cleanliness, safety and overall environment — more than doubled over the past four years, signaling heightened concern about living conditions inside long-term care facilities.
Download: Office of the State Long-Term Care Ombudsman FFY 2024 Annual Report.pdf
Staffing shortages remain central concern
The report identifies workforce instability as the most persistent problem affecting Iowa’s long-term care facilities.
Facilities continue to struggle to recruit and retain qualified staff, while also experiencing high turnover among administrators and increasing reliance on provisional administrators who often lack the training or experience to manage complex operations, per the report. According to the ombudsman, that instability directly contributes to declining quality of care.
In an interview, Van Pelt said frontline jobs at the heart of the system are difficult and often poorly compensated, which makes it hard to recruit and keep workers.
“These are rough jobs,” she said, describing direct care work that involves high physical demands and constant exposure to end-of-life care. But she said the work is often “paid extremely low for the work that you do,” with limited advancement opportunities for CNAs and other direct care workers.
The report links chronic understaffing to inconsistent care plans, increased risk of medication errors and falls, and situations in which staff fail to recognize changes in residents’ health.
Van Pelt said improving staffing will require more than simply adding money to the system. She urged Iowa to move away from blanket Medicaid rate increases and instead tie new funding to concrete quality and workforce outcomes — such as lower turnover, stable CNA staffing levels and better resident care.
From a policy standpoint, she said the state should consider incentives or bonus-style payments tied to measurable results rather than automatic across-the-board increases.
“How is it that we can incentivize facilities to operate better?” she said.
She also urged lawmakers to curb overreliance on expensive agency staffing and redirect those dollars into higher wages and benefits for permanent workers, arguing that even modest increases could make frontline jobs more sustainable.
“If you’re having to pay that amount, is there a reason that somehow that can’t be filtered into paying your overall staff at a higher level?” she said.
Van Pelt also called for state-backed education grants and career-ladder programs so workers can build skills and advance. Any new public funding, she argued, should be conditioned on facilities demonstrating real investment in their workforce — wages, benefits, training and retention — rather than simply boosting their bottom line.
Beyond pay, she emphasized facility culture and leadership as major drivers of stability. Even homes that pay average wages, she said, can function well when administrators are present, supportive and engaged with residents — but corporate ownership structures can leave leadership stretched across multiple buildings and more removed from day-to-day problems.
Closures surge, leaving residents vulnerable
Iowa has experienced a sharp increase in long-term care facility closures, a trend the ombudsman described as destabilizing for residents, families and staff.
The report documents more than 20 closures in FFY 2023 and another 13 closures in FFY 2024. Poorly managed closures often create traumatic and unsafe conditions, the report states. Residents have been evacuated without essential belongings, faced delays in assessments and legal paperwork needed for placement, and, in some cases, have not had personal funds or property promptly returned. The ombudsman also cited instances in which residents’ rights to choose their next facility were overridden in favor of transfers to affiliated homes.
Van Pelt said the pace of closures reflects both financial strain and broader structural questions about how Iowa’s long-term care footprint matches its population needs — especially in rural areas where multiple facilities may operate below sustainable occupancy levels.
She also pointed to cases where the quality of care itself becomes a driver of closure, and to ownership transitions — including private equity acquisitions — that can unravel and leave residents and staff caught in the fallout.
Calls for stronger accountability and coordination
To address those issues, the ombudsman is urging enhanced regulatory enforcement, stricter owner accountability during closures and clearer safeguards for resident funds and property.
In the interview, Van Pelt said Iowa needs to be far more proactive and structured when homes are in trouble — not just when the doors are about to close. She wants owners and administrators held responsible through the entire wind-down, making sure residents are safely transferred, their trust fund money is repaid, and essentials like dentures and eyeglasses are returned, instead of “falling off the grid.”
“I would like to see that tightened up a little,” she said, arguing that management organizations should be required to stay present and accountable “till all of this is done and everybody’s transferred out.”
Van Pelt also floated a state-level “SWAT team” — a rapid-response, boots-on-the-ground support model — to step in and help struggling administrators before a crisis forces shutdown. The idea, she said, is to provide practical support early, when leadership is overwhelmed and the “bottom starts kind of falling out,” rather than arriving only after closure becomes inevitable.
A central recommendation in the report is the creation of a shared, electronic involuntary transfer and discharge portal.
Under current practice, nursing homes submit involuntary transfer or discharge notices to the ombudsman’s office in multiple formats — including certified mail, email and regular mail — a system the report says creates delays, administrative burdens and risks for residents facing tight appeal deadlines.
A shared portal would allow facilities to submit required notices electronically in a standardized format, ensuring the ombudsman receives them promptly and can respond before residents lose the right to appeal, according to the report.
Van Pelt said missed or late notices can effectively block residents from exercising their rights. While nursing facility residents often have only a short window to appeal an involuntary discharge, her office sometimes receives notices weeks after the fact — too late to help.
When asked what lawmakers should prioritize if they act on only one idea, Van Pelt pointed to the portal as the “low-hanging fruit” that could quickly improve outcomes by getting notices into a shared system and triggering faster intervention.
Beyond enforcement changes, the ombudsman is urging lawmakers to invest in long-term care volunteer programming, particularly in rural areas where residents may have little family involvement and limited oversight.
Strengthening the volunteer program, the report argues, would expand rural oversight without adding full-time staff, help prevent abuse and neglect through early intervention, and reduce emergency transfers, hospitalizations and investigations — improving outcomes and lowering costs.
Van Pelt said her office also needs more capacity for outreach and marketing to make sure families and community members understand the ombudsman program exists and know how to use it.
“So many people don’t even know we exist,” she said, arguing that better outreach and volunteer engagement could create more “extra eyes” in facilities and stronger advocacy for residents who might otherwise be isolated.
The report also calls for expanding resident and family councils, especially in rural and underserved communities, to give residents and families a stronger voice in daily care decisions and facility accountability.
“These are cost-effective, high-impact strategies, that will improve oversight, enhance quality of care, and ensure efficient use of taxpayer resources,” the report states. “By investing in these priorities, Iowa can build a safer, more sustainable long-term care system that honors the dignity and rights of every resident.”
Danielle Sample, director of communications for the Iowa Department of Health and Human Services, said the ombudsman’s office has worked closely with HHS, the Department of Inspections, Appeals & Licensing and insurers that coordinate care for Iowa Medicaid members to ensure smooth transitions during facility closures.
“Most recently, the office led efforts to update the Closure and Crisis Manual, clarifying agency roles to protect resident outcomes,” Sample said. “We recognize the need to review measures that hold administrations and owners accountable during closures, aligning them with current regulations and practices.”
HHS said workforce shortages are a nationwide challenge, and while funding is a concern, “any increases should be tied to quality standards and direct care staffing.”
Sample noted this is the first year an electronic discharge and transfer portal has been recommended in the report, and said other states are moving in that direction. She said HHS “is committed to evaluating recommendations, sharing information, and engaging in ongoing conversations to safeguard residents’ rights and improve care.”
Advocates: Transparency and real pay growth needed
Advocates for older Iowans and the caregivers who support them said the ombudsman’s report captures long-standing, unresolved problems — and warned that without stronger follow-through from state leaders, the same pressures driving poor care and closures will deepen as Iowa’s population ages.
John Hale, co-owner of The Hale Group, an Ankeny-based firm that advocates for older Iowans and caregivers, said expanding volunteer engagement could provide local “eyes and ears” inside facilities and help surface problems earlier. But Hale questioned whether state leaders will champion the recommendations, saying the ombudsman program has lost visibility since reorganizations folded the office into the Iowa Department of Health and Human Services.
He argued the office needs more capacity not only to respond to complaints, but to do more routine, proactive visits that can “take the temperature” of facilities and help prevent small problems from becoming crises. Hale also urged a stronger early-warning approach to identify facilities heading toward closure — including more transparency around ownership and finances and tougher screening when facilities change hands.
Hale said the report’s transfer-and-discharge portal recommendation is overdue modernization, arguing that relying on mail and scattered submissions slows oversight and makes it harder to protect residents facing tight appeal deadlines.
Di Findley, executive director of Iowa CareGivers, said the workforce crisis persists for familiar reasons: low wages, limited affordable health coverage, lack of respect for direct care workers and few career-growth opportunities for those who want to remain in the field. She said worker burnout — compounded by a slow recovery from the COVID-19 pandemic — has worsened retention.
Agency workers can keep doors open, Findley said, but the pay gap between agency and permanent staff can accelerate turnover. “Agency staff is better than no staff,” she added, while still emphasizing that raising wages is the most direct path to retention.
If policymakers use Medicaid increases as a wage strategy, Findley said, the money should come with accountability requirements to ensure it reaches direct care workers. She pointed to Iowa CareGivers’ wage and benefit survey work with Iowa Workforce Development and urged lawmakers to use the findings to guide wage policy. She also said training investments can fall short without statewide systems that make credentials portable.
And she noted closures can devastate workers financially and emotionally — especially when staff have built strong relationships with residents — sometimes even staying to help through the final transfers without pay.
Lawmakers respond
With Iowa lawmakers headed back to the Capitol this week, advocates and Democratic leaders said the report will test whether the state is willing to tie funding to measurable workforce and quality outcomes — and whether state government will adopt stronger tools to manage closures and resident transfers.
Melissa Saitz, communication director for Iowa House Republicans, said lawmakers have passed several bills in recent years to help Iowa seniors by increasing the monthly allowance that nursing home residents collect through Medicaid for personal living expenses, ensuring adequate Iowa Medicaid reimbursement to nursing homes, providing oversight of change of ownership of nursing facilities, and completing nursing facility inspections in a timely manner.
“House Republicans would gladly review any legislative proposals submitted by stakeholders,” Saitz told The Gazette.
Democratic leaders said the report reinforces concerns they’ve raised for years about staffing, accountability and oversight — and urged GOP leadership to pursue policies that boost wages and tighten enforcement rather than relying on voluntary fixes.
House Minority Leader Brian Meyer, D-Des Moines, said he was “surprised and a little bit shocked” by parts of the report. Meyer said lawmakers should consider stronger minimum staffing expectations and focus on pay, saying $15 to $20 an hour “is probably not where we need to be” for frontline workers caring for “society’s most vulnerable.”
He also urged more oversight and accountability, including tougher consequences for facilities that repeatedly fail to correct deficiencies. He said he was intrigued by the ombudsman’s proposal for a centralized transfer and discharge portal, calling it a potential solution “that might be a solution that works for everybody.”
Senate Democratic Leader Janice Weiner, D-Iowa City, said the ombudsman’s recommendations “largely comport” with long-term care legislation she and the late Sen. Claire Celsi worked on, including proposals to strengthen safeguards and increase the state’s ability to sanction poor performers.
Weiner said Iowa needs more capacity for oversight — including more frequent announced and unannounced inspections — and said Senate Democrats have pushed measures aimed at stronger procurement standards, limits on arbitration agreements and higher penalties for serious violations. She also said lawmakers should expand community-based and “aging at home” options to reduce costs and keep Iowans in their homes.
Weiner also urged closer scrutiny of ownership changes — particularly private equity acquisitions — that she said can prioritize profits over resident care. She added that Democrats are willing to work with Republicans on a menu of options, including safeguards such as allowing cameras in resident rooms with appropriate privacy protections.
“I hope this serves as an impetus so that we can make progress on that,” Weiner said.
Comments: (319) 398-8499; tom.barton@thegazette.com
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