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Anyone faced with the decision of placing a loved one in a nursing home knows it is one of the most difficult decision they'll ever make.  Finding the best one may be even harder.

When Sharon Althaus noticed problems at her mother's nursing home she started keeping a journal and taking pictures.

"They didn’t give her the heart pill that she needed," says Sharon.  "Her legs were in such bad condition that I could have just cried for her and that’s why she had been in pain for a month."

Sharon documented almost everything.

"There hadn't been hot water for a week."

Those are some of the problems Sharon says she encountered at not one nursing home, but four - four in the last year.

"When you go into the facility every day for one or two hours, you see things that most people don’t see."

Sharon doesn't think nursing home inspectors see everything either.

"Do they talk to the people?  Do they really talk to the people and the families that are in those facilities?"

28 people are now dedicated to inspecting Iowa's 442 long-term care facilities.  That's a reduction of ten positions compared to 2010.  REgulations require each facility by inspected at least once a year.  The inspection frequency increases if there are serious, ongoing problems.

Sharon's mother wasn't a resident at any of the following facilities, but these are some of the problems biggest problems inspectors discovered last fiscal year.

Davenport Lutheran Home was assessed the largest fine - $26,000 for two violations, one of which resulted in the death of a resident.  The facility appealed the fine and paid $16,900.

All American Restorative care of Washington, IA was assessed $18,000 in fines after a resident fell and laid on the floor for 48 minutes without assistance from staff.  The facility is appealing the fine.

Community Care Center in Stuart was originally fined $17,000 dollars.  One of the violations:  Giving a resident too much Coumadin, a blood thinning medication.  Again the fine was reduced, in this case to $14,850.

Good Samaritan Society of Indianola is facing a $15,000 fine for multiple violations constituting imminent danger.  It too is appealing.

One of those facilities, All American Restorative Care is also a Special Focus Facility.  It's a federal watch list, so to speak, of facilities with a history of serious quality issues.

Also on the list:  Careage of Newton, Regency Rehab and Skilled Nursing in Council Bluffs and Perry Health Care Center, although The Center for Medicare and Medicaid Services say it is showing signs of improvement.

"I think the system is very flawed," says Sharon.

One of the potential flaws - understaffing.

"We often hear it referred to as the toughest job you’ll ever love," says Di Findley, the Executive Director fo The Iowa Caregivers Association.

It represents Iowa's 50,000 plus direct care providers.  Those are the people providing hands on care to nursing home residents.

"You know it’s a profession that is grossly underpaid and undervalued by society in general," says Findley.  "One in four do not have health care themselves."

Findley says that leads to high turnover, which according to The Direct Care Worker Advisory Council cost employers $126 million last year.

"When you’ve got that kind of churning, or that kind of turnover that certainly has an impact on the residents or the people living in that facility, because you don’t have the consistency of caregivers."

During the next legislative session, Findley will ask the lawmakers to establish a Board of Direct Care Professionals.

"We’re talking about a major, major systems changes," says Findley.

But there is some opposition.

Steve Ackerson, the Executive Director of The Iowa Health Care Association says he's in favor of it in some areas, but not for direct care workers in nursing homes.  I.H.C.A. represents most of Iowa's nursing and assisted care facilities.  The non-profit's 2011 tax form shows it collected nearly $2.5 million in membership dues and educational fees, some of which is reimbursed by Medicaid.

It also has a political action committee.  Since January, It has contributed at least $155,000 to politicians and political parties.

"I believe our providers do a very good job of having adequate staffing," says Ackerson.

But a 2010 Kaiser Family Foundation survey shows Iowa ranks dead last compared to other states in the average number of hours nurses spend with residents.  In Iowa, the average is 3.5 hours per day.  In Alaska, the highest ranking state, it's 5.4.

Ackerson says an increase of just a dollar an hour for each direct care worker in Iowa would cost the state $25 million.

"That's the problem we have," says Ackerson.  "It's the funding."

And the problem with funding, according to Ackerson is directly correlated to reimbursement rates.

"Our reimbursement is usually about $9,000 less per resident in our buildings.  That’s just the national average, but our quality of care is high.

Sharon Althaus disagrees.  She wonders why Iowa's nursing home industry - an industry with annual revenues of more than $1.3 billion - can't pick up a greater portion of the tab.  So do advocates for residents and care givers on the front lines.

"We know what the issues are.  The providers know what the issues are.  Many are doing some very creative things," says Findley.  "But yah, it's not that hard to figure it out."

Related Links: 

Nursing Home Rankings  

State Inspection Reports

Kaiser Family Foundation Survey

Iowa Long Term Care Ombudsman

Iowa Department of Inspections and Appeals

Iowa Caregiver's Association