Upheaval in the Nursing Home Industry

December 18, 2023

A dark web of nursing home owners make patient care difficult to assess


Image of a woman in blue scrubs holding the hand of someone else, in a caring way.
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Washington, D.C. — A small group of lesser-known nursing home chains with poor patient safety records are taking over a growing share of the long-term care industry as some of the larger players abandon the business.

Federal and state regulators have been slow to keep up with ownership changes, hampering critically needed increased oversight of recidivist companies. Some of these bad actors – which through acquisitions have doubled or tripled in size in recent years – have averaged over $100,000 in penalties. That’s three times the national level.

These are among the findings of a just-released Good Jobs First report, “Care At Risk: Upheaval in the Nursing Home Industry.” The report gathers and analyzes for the first time 28,000 regulatory enforcement actions from all 50 states, covering the past five years. The penalty records were obtained from both the federal Centers for Medicare and Medicaid Services (CMS) and from state regulators, which share responsibility for overseeing nursing homes.

“Because ownership changes are so frequent in the nursing home industry, it’s difficult to track which company to hold to account for problems,” said Good Jobs First Research Analyst and report author Siobhan Standaert. “And in too many states, we don’t know how patients are being cared for because our public records requests were denied.”

The penalties paint a picture of serious problems at many sites. An Illinois-based facility operated by Aperion Care was fined $243,000 for failing to properly administer blood work resulting in a resident death. A facility tied to Infinity Healthcare was penalized over $300,000 for failing to prevent physical and sexual abuse between residents.

The report also reveals:

  • Huge gaps in records availability: 17 states fail to put information on penalty cases on their agency websites and refused to supply it in response to open records requests submitted by Good Jobs First.
  • States such as Oregon, California, and Arkansas have brought an average of over 15 cases per facility over the past five years and have imposed an average of more than $100,000 in fines per facility.
  • States such as Alabama and Maine have averaged fewer than 2 cases and under $25,000 in fines per facility.
  • Some firms with the worst penalty loads, such as Arcadia Care, Brius Health Care, Aperion Care, and Infinity Healthcare Management, also perform poorly in the federal government’s nursing home rating system, averaging only 2 on a 1-5 scale where 5 is best.
  • In many regulatory records, the circumstances behind the penalty were not available, making it difficult to assess the depth of problems.

The new nursing home staffing requirements announced recently by CMS may improve the situation in facilities across the country, but only if they are adequately enforced.

CMS also needs to improve its own information gathering. For a long time, the agency’s data collection failed to keep up with ownership changes in the nursing home industry, especially when private equity firms began making acquisitions in the early 2000s. This made it difficult to see how these ownership changes were affecting the quality of care.

A provision in the Affordable Care Act of 2010 was designed to rectify this by expanding ownership data collection by CMS and requiring that the data be shared with the public. That requirement was largely ignored until last year.

“It’s good to see CMS finally making a more serious effort to monitor complex ownership structures, but there still seem to be serious gaps in the agency’s system,” Standaert said. “Better transparency by itself will not eliminate deficiencies in the quality of care, but it will make it easier to identify the worst operators that most need to improve their practices.”

Read all of our findings here.