A Simple Truth: Nursing Homes are Run By Financiers – Not Medical Professionals


Dave Kingsley

Nursing Home Investors Care about Cash Flow. They are Not Into Charitable Care.

It’s amazing to me how far nursing home industry lobbyists are getting with their hardship pleas. At this time they are being rewarded by legislatures for letting their workforce deteriorate to a crisis level. There are some simple truths – perhaps simple logic – regarding why qualified, competent medical professionals are hard to find these days.

Let’s start with the cutting edge of corporate finance: the “time value of money.” Investors calculate their free cash flow over five years before investing their money. Their decision is based on yearly cash flow discounted to the present time. This means that they determine what a dollar is worth at the present time versus what it will be worth in 1, 2, 3, 4, or 5 years if invested in a project or business. I won’t bother my readers with the formula for determining “net present value,” but debt financing of real estate and tax arbitrage play a major role in that calculation.

In the case of the nursing home industry, real estate is debt financed. Reimbursement for capital costs such as depreciation and interest typically exceed payment on loan principal and flow into the cash channel that will be “earnings” pocketed by investors. At some point, principals will equal and begin to exceed returns from real estate and debt tax advantages. The property will be flipped at that point.

Keeping food costs low, paying substandard wages, dangerously low staffing, and putting sick, fragile, elderly and disabled people in a room with a stranger are techniques for increasing cash flow from Medicare, Medicaid, self pay, managed care, and whatever other form of third party payer reimbursing care.

Why Would Investors Be in The Nursing Home Business if It Weren’t A Profitable Business?

Because privatized, tax-funded, medical care is financialized (finance overrides medical care) decisions regarding care are frequently and generally based on financial metrics. The quality of care is confined within the parameters of expected cash flow (discussed above). Furthermore, with “cash as King,” immediacy of returns rather than long-term planning and reinvestment for a better medical care system in the future drives decision making about staffing and overall conditions in acute care, long-term, and skilled nursing facilities.

The problem is this: the public, the media, and legislators do not have a good overall view of how the nursing home system works from a financial perspective. Federal and state agencies have been derelict in making accessible, understandable, financial and ownership data available to researchers and the public in general. California is more advanced in this regard than other states but still has a way to go in making the system fully transparent in that state.

In the past few weeks, I reviewed 2020 cost reports of 205 facilities in San Diego, San Bernardino, and Orange counties. I entered data regarding revenue, net income, number of beds, and the proportion of revenue from various third party payers (e.g., Medicare, Medicaid, Managed Care, etc.). As opposed to the claim from a Kansas nursing home lobbyist that providers have a median net income of 1/2 percent, I’m finding a median of close to 7% even though many claims of losses look dubious to me. Furthermore, net income is not a reflection of earnings or cash flow. Depreciation and interest are expensed on the income statement even though these are not cash expenses.

Nothing in the cost reports will tell us how much cash is extracted through real estate transactions. Nor do they indicate how much cash is flowing into parent corporations and holding companies. We know how much that is for public listed corporations – most of which are real estate investment trusts – because we can easily access financial reports they file with the SEC. As my colleague Charlene Harrington and I have pointed out, they were not hurt by COVID in 2020 (“COVID-19 had little financial impact on publicly traded
nursing home companies “J Am Geriatr Soc. 2021;1–4. https://doi.org/10.1111/jgs.17288). We will soon have an article in The International Journal of Healthcare Research regarding the robust financial performance of The Ensign Group since issuing a IPO in 2007.

The late Roy Christensen, founder of both Genesis and The Ensign Group, and his family have become fabulously wealthy by channeling money out of their large chain of facilities into stock options, stock awards, and executive pay. The Ensign Group is rapidly acquiring facilities and undertaking financial maneuvers like spin offs for the purpose of moving property around without incurring capital gains and corporate income taxes. They have also channeled a large share of their hundreds of millions in stock over the years into a variety of family trusts, which keeps their wealth intact and away from the IRS.

House Subcommittee on the Coronavirus Ignores Nursing Home Deaths. That is a Human Rights Violation.


Dave Kingsley

U.S. House Committee Eliminates 141,000 Patient and 2,177 employee Nursing Home Deaths From Reality: Nothing to See There.

According to the Center for Medicare & Medicaid Services (CMS), 141,084 nursing home patients and 2,177 employees have died from the Coronavirus pandemic (https://data.cms.gov/covid-19-nursing-home-data). The House Select Committee on the Coronavirus under the leadership of Congressman James Clyburn – one of the three most powerful Democrats in the House – addressed 249 deaths in meatpacking plants but totally ignored nursing homes.

I have carefully read the Subcommittee’s recently released report More Effective, More Efficient, More Equitable and can find absolutely nothing about the biggest loss of life in an institutionalized population in the history of the United States (see: https://coronavirus.house.gov/news/press-releases/select-subcommittee-s-year-end-staff-report-highlights-oversight-work-releases). Adobe Acrobat PDFs have a search function. Having utilized that function on the report, I can say with certainty that words such as nursing homes, long-term care, skilled nursing, nursing home industry, or any other word that would suggest that elderly and people with disabilities institutionalized in these facilities were of any concern whatsoever to the subcommittee.

How can 141,000 patient and 2,177 employee deaths in one institutionalized population – which constitutes about one percent of the U.S. population in any one year but nearly 20 percent of the COVID-19 deaths since the pandemic appeared in 2020 – be erased from reality? Whose interests are being served by these types of hearings in Congress? Indeed, there has, in fact, been no real serious investigation by the U.S. Congress or any state legislature into the nursing home coronavirus tragedy (at least none that I have found).

The Nursing Home COVID Tragedy Was Avoidable. Therefore, It Is an Atrocity and a Human Rights Violation.

Elderly and disabled Americans were allowed to die because an industry failed to spend the money necessary to save them. The U.S. government has turned over the care of frail and disabled people to an industry well paid to care for them. It is well known and scientifically proven that the industry charged with responsibility for patients in nursing homes has consistently placed shareholder value above medical care. That fact has been demonstrated repeatedly and consistently for the past 70 years that federal and states funds have supported a privatized long-term care and skilled nursing system.

Here are the facts:

Epidemiologists and other scientists renowned in the field of emerging diseases have warned for decades that pandemics like we have experienced in the 2000s would become worse (e.g. See Laurie Garrett, The Coming Plague).

SARS taught the world a lesson about pandemics and the vulnerability of nursing home patients. Hong Kong and other Asian countries took steps to counter future pandemics. The Hong Kong Guidelines were well known throughout the world and yet the U.S. nursing home industry and government regulatory agencies ignored those guidelines while the industry created sophisticated legal and financial structures to drain ever more tax and reimbursement dollars out of the system for the benefit of executives and shareholders (See: https://www.cmaj.ca/content/192/19/ES11; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899229; https://www.ncbi.nlm.gov/pmc/articles/PMC723424/; https://www.theguardian.com/world/2020/may/19/mps-hear-why-hong-kong-had-no-covid-19-care-home-deaths.)

Political contributions suggest that the nursing home industry has tremendous sway over congressional and agency oversight. For instance, of the top 100 2019-2020 contributions to Congressman Clyburn – which total over $1 million dollars – approximately half came from corporations and lobbying groups with a vested interest in nursing home finance.

The American Health Care Association – the nursing home corporation lobbying organization – contributed $10,000 to Congressman Clyburn in the 2019-2020 cycle, but it is important to recognize that the nursing home industry is primarily a finance-insurance-real estate as well as a medical industrial complex with interlocking interests between real estate, finance, and medical sectors of the economy. Therefore, consider the following donations to Chairman Clyburn in 2019-2020:

American Healthcare Association (nursing home corporation Lobby): $10,000

National Association of REITs: $10,000

National Bankers Association: $10,000

American Hospital Association: $10,000

National Association of Realtors: $10,000

Johnson & Johnson: $10,000

KMPG: $10,000

Investment Corporation Institute: $10,000

USAA: $10,000

CVS Health: $10,000

Capital Financial: $10,000

Deloitte: $10,000

Abbot Lab: $10,000

Eli Lilly: $10,000

Bank of America: $10,000

Pfizer: $10,000

Pensare Acquisition Group: $10,000

Prudential: $19,000

AFLAC: $34,925

Government & Industry Abuse of An Institutionalized Population is A Human Rights Violation Causing A Massive Number of Fatalities. Government Officials Must Be Held Accountable. But there is No Organized Political Movement to Force that to Happen.

The U.S. government has a long history of looking the other way while widespread abuse and neglect continues pervasively throughout a privatized nursing home system funded with taxpayers’ hard earned dollars. Furthermore, over that 70-year history, an aging enterprise has been spawned by the Older Americans Act and do-gooder contributions to 501C3 organizations. We have Area Agencies on Aging, all sorts of aging-related professional organizations, gerontology professional groups, advocacy groups, the AARP, and countless other special interest organizations have settled into a comfortable relationship with government agencies responsible for regulating nursing homes and the industry itself, which has a high powered PR machine. An ongoing game of rope-a-dope between the industry and advocates over minor tweaks to a system that should be ended not mended takes place ad nauseum, ad infinitum in legislatures across the land.

Nursing home neglect and abuse continues on a regular basis while shareholders and executives get fabulously rich from Medicaid and Medicare funded commercial real estate. It appears, however, that a coalition of so-called senior advocacy organizations cannot mobilize to force congress to take a hard look at the COVID-19 nursing home tragedy that didn’t have to happen.

This Country Simply Does Not Care About Old And Disabled People: We Are Expendable for the Sake of Profit


Dave Kingsley

At Least 150,000 COVID Deaths in Nursing Homes & The House Select Subcommittee on the Coronavirus Crisis Doesn’t Even Bother to Mention It.

On any given day in the United States, approximately 1.5 million Americans will be patients in nursing homes. Throughout the year, 3 million people will either be permanent (long-term) or short-term rehabilitation patients in government-funded, long-term care/skilled nursing facilities. During the past two years, these institutionalized individuals have accounted for at least 150,000 of the 800,000 U.S. COVID deaths. Hence, nearly 20% of COVID fatalities occurred in one institutionalized group comprising less than 1% of the U.S. population.

Yesterday the House Select Select Subcommittee on The Coronavirus Crisis under the leadership of Chairman James Clyburn released a report of the committee’s oversight hearings regarding the COVID pandemic. The report entitled “More Effective More Efficient More Equitable: Overseeing an (sic) Improving and Ongoing Pandemic Response” (https://coronavirus.house.gov/news/press-releases/select-subcommittee-s-year-end-staff-report-highlights-oversight-work-releases) makes no mention that I can find of the largest mass fatality occurring in any institutionalized population in U.S. history. Not even the troops during WWI suffered as large a fatality rate from the flu pandemic as have elderly and disabled patients in U.S. nursing homes during the COVID pandemic.

Lack of the public’s interest in accountability for 150,000+ preventable deaths is a signal to the elderly and disabled that we are not valued as human beings. Politicians are acting like “nothing to see there.” The press, the public, and politicians, are ready to move on like “that didn’t really happen.” “Did it?” The nursing home system is sickening and disgusting as it is. But for a society to seemingly not care much about the failure of a very profitable, taxpayer funded industry to properly care for patients in their charge and agencies like CMS failing to make them care amounts to euthanasia by neglect.

I’m outraged that “aging enterprises” aren’t raising bloody hell about the disaster brought on vulnerable, unprotected, aging and physically challenged people. These organizations claim they represent the elderly, but their silence is deafening:

  • American Geriatrics Society (AGS)
  • American Society on Aging.
  • Leadership Council of Aging Organizations (LCAO)
  • National Association of Area Agencies on Aging (N4A)
  • National Council on Aging.
  • Justice in Aging.
  • Alzheimer’s Association.
  • Senior Medicare Patrol.
  • Administration on Aging.
  • National Center on Elder Abuse.
  • AARP
  • Kansas Advocates for Better Care
  • And Many Others

That the boards of these groups and their paid professional staffs haven’t come together in a coordinated effort to hold accountable a very profitable well-rewarded, industry and the agencies of government they have captured (e.g. CMS, KDADs, etc., etc., etc. …… .) is shameful. Congressman Clyburn and other politicians need to hear from organizations purporting to advocate for the elderly and disabled.

Congresspersons and Senators have certainly heard from the nursing home industry. Congressman Clyburn and Speaker Nancy Pelosi both received $10,000 from the AHCA PAC. Indeed, Democrats are beneficiaries of two-thirds of AHCA PAC money. They don’t need to buy the Republicans – they are on board with whatever corporations want. Any hearing, any report, any statement, from a politician regarding the elderly are of dubious value when the politicians involved are taking money from the industry.

I’m afraid that aging enterprises and paid professionals have fallen comfortably into the good ole boy and girl networks operating inside the Washington, D.C. beltway and all of the state capitols. Speaking truth to power is a risk that might get them marginalized and ousted from the group.

Executive Compensation for CEO’S of Major Nursing Home Chains did not Decline Significantly During 2020: For Most, it Increased by a Significant Amount

    The nursing home lobby operating in Washington and state capitals is continuing its long running financial hardship campaign.  An article in the latest issue of Provider (the main propaganda organ for the industry) claims that COVID presented such a serious financial blow to providers that enhanced financial assistance from government would be the only way to implement needed substantive reform. The reform needed, according to the article, is due to increasing demand in long term care services (Patrick Connole, “COVID Challenges Bring Opportunity for Systemic Changes,” June 2020, 9-10).

    The article states that “With the majority of nursing homes already operating on razor-thin margins, the cost of making improvement will not be possible without financial assistance.”  Perhaps the razor thin margins to which the author is referring apply to the LLC listed as the owner and not to all the other LLCs such as the property LLC, the management LLC, the rehab LLC, the medical transport LLC, etc.  Certainly, holding companies and REITs have not fared badly at all during 2020 and the height of the COVID pandemic.[i]

    One would think that the entities at the top of the financial food chain would have taken a major hit and pared back their CEO pay considerably if the razor thin margins at some point in the flow of capital diminished shareholder value.  However, as the table below suggests, CEO pay for major nursing home operator/real estate chains listed on a public exchange were either enhanced by a large amount over 2019 and 2018 or remained steady.

    The above table does not display the proportion of total pay that is due to an “incentive bonus.”  Nevertheless, in cases where a major increase year over year appears for an executive, a large amount is for performance, which one must assume is financial performance.  The loss of life throughout the companies overseen by the executives in the table was a historical first for institutionalized U.S. populations.  An estimated 132,000 to 140,000 people in the care of these CEOs unnecessarily lost their lives.

    The government funded companies headed by CEOs at issue in this blog post are increasingly powerful players in taxpayer subsidized long-term and skilled nursing. In blog posts ahead, I will be discussing the growth of their power and influence.  For instance, the ManorCare property sold off by the private equity firm The Carlyle Group is now owned by Welltower and operated through a Welltower-Pro-Medica joint venture.

In the future, I will be blogging about the convoluted ownership structures in the nursing home industry and the complexification of that facet of the business due to the creativity of corporate lawyers and financial experts. Without exposing the financial trickery employed by providers, the public will be victimized by falsehoods of lobbying groups such as the AHCA/NCAL and others.

NOTE: The data in this post were derived from proxy statements filed with the Securities & Exchange Commission. In the future, I will be discussing compensation for board members and other officers/executives of major LTC/SKn corporations.

[i] Kingsley DE, Harrington C. COVID-19 had little financial impact on publicly traded nursing home companies. J Am Geriatr Soc. 2021;1–4. https://doi. org/10.1111/jgs.1728

The COVID-Tragedy from the Perspective of A Leader in the Disability Community

Lydia Nunez Landry,

Certified Long-Term Care Ombudsman

disabled disability advocate

Submitted for the United States Committee on Finance record at a hearing on:
A National Tragedy: COVID-19 in the Nation’s Nursing Homes

Wednesday, March 17, 2021

Chairman Wyden, Ranking Member Crapo, and distinguished Members of the Committee,

My name is Lydia Nunez Landry and I am writing to you today not as someone the American Health Care Association and LeadingAge would reduce to the characterization (in their ‘Care for Our Senior’s Act’) of a “frail [or] elderly adult with underlying health conditions” at risk of dying from COVID “630 times higher than an 18 to 29” year old, that is, someone these lobbyists designate as prone to death. Rather, despite reductions of people like me—or any other marginalized group—to underlying health conditions or comorbidities or biased stereotypes, I write to you today as an alive and thriving disabled woman, one who lives in and contributes to her community, and as someone who questions the motives of those who attribute grave injustice toexploited or oppressed people’s own supposed deficiencies. Without a supportive partner to care for me in our home, I could as easily have died from neglect or COVID-19 in the average nursing home. My point here is to show that the long-term care industry is peddling this narrative simply to avoid responsibility for wrongdoing; that is, they want to pretend that people are dying in their facilities not because of the industry’s negligence, greed, or malfeasance, but instead because disabled and older people have a particular tendency to die en masse. The narrative in ‘Care for Our Senior’s Act’ is yet another example of the industry’s connivery and manipulation (I will append a brief example at the end of my testimony to show how they advance this narrative by playing with statistics).

    Generally speaking, when any group of people are marked as suspect or inferior in some manner, when they are segregated and denied the resources and liberties that others enjoy, their flourishing will indeed be impeded, and they will be at a greater risk of contracting infections or disease. This is evidenced throughout history from the decaying and dank tenement houses of the early 19th century, the horrific conditions of the Warsaw ghetto, to the abuses that occurred in state institutions for people with disabilities. Given a deadly pandemic combined with deplorable (or at best unsafe) conditions, where people are segregated and treated as fungible objects from which to extract government benefits (or cheap labor), even AHCA and LeadingAge lobbyists like Mr. Mark Parkinson or Mr. David Gifford might be at a mortality risk 630 times higher than 18 to 29 year olds not forced to endure similar circumstances. (The industry’s claims are rarely supported by evidence, and with brief examination, can be shown inaccurate. Their act is at best slipshod and indicates an arrogance reinforced by years of overindulgence and a lack of accountability.)

    In contrast to those who are key players on K Street or spend most of their time in boardrooms or lobbying in the halls of Congress, I want to emphasize that my perspective is informed by my advocacy work in nursing homes where I have spent a great deal of time. I form bonds with residents. I know many of their spouses and children’s names, where they were from, the hobbies they enjoyed, and the kind of work they did. All of this they generously shared with me. I learned what it was like working in a Pennsylvania textile mill in the 1930s, surviving a chemical plant explosion in Texas and the revolution in Cuba, and growing up in Mexico in the 1940s. I have heard stories from war brides from France and Vietnam or the time a woman had to sew thousands of sequins by hand on her daughter’s quinceanera dress. I feel myself privileged to be granted the opportunity to listen. And unlike CEOs who earn $1,427,192 for lobbying, state ombudsman programs rely on volunteers. I have dedicated my life to this issue and yet rare is the occasion that I am asked to contribute to this topic. I—and other disability justice activists—have not been lavished the same platforms to speak given to long-term care industry CEOs and lobbyists. As a result of this, the voices of significantly disabled people, those at imminent risk of institutionalization or those in institutions, are squelched by the industry narrative. When I initially started out as ombudsman, I applied the principle of charity to the industry’s narrative, but with careful appraisal of the incongruity between what residents, families, ombudsmen, advocates, experts, HHS regulators, CNAs, CMS, and the OIG evidenced compared to the industry’s slant, it became apparent that industry representatives either have a deficient understanding of the culture and operations their business practices engender, or worse, they are impervious to the suffering of disabled people. Choosing not to see injustice or corruption, however, seems contrary to their lofty mission statements and commitments they have made to taxpayers.

On occasion, circumstances force us to confront the ugliness and brutality that inevitably festers where we sequester vulnerable people; stories of abject cruelty rip away the veil of inattention we cultivate to block from our view the relentless mill of everyday abuse, neglect, and hopelessness. In these moments of outrage, we perceive the true nature of institutionalization and perhaps even what we must do, but those flashes of insights quickly fade. Soon those with vested interests haul out the timeworn reform narratives and “bad apple” scapegoats that persuade us to look away again, to participate in systemic neglect from afar. 

As a LTC ombudsman I could not simply look away from the toll of daily abuse and neglect residents experience or ignore their justified feelings of abandonment and the despair it begets. My ombudsman work bears out what ought to have long been obvious to any attentive person, namely, that segregating people in institutions can never foster or indeed ever permit equal treatment.[1] Nor—as over a hundred years of disability history attests[2]—can this model be fixed through reform. We cannot fix that which, by its nature, leads to systemic human rights violations. Severing people (like older and disabled people) from their homes and communities necessarily devalues them as persons and citizens. The diminishment is felt immediately. The freedoms they enjoyed vanish as institutional regiments constrict the courses of their lives. These utilitarian routines deprive them of their privacy and autonomy for the sake of efficiency and cost-effectiveness. Confined in these facilities without the projects and relationships that endowed their lives with meaning and shaped their social identities, they experience a kind of social death.[3] And so too their former communities, continuing on without them, lose the connection to them as full persons still deserving of the moral consideration and respect we are obliged to confer on those people in the community. Isolated, powerless, and dehumanized, people institutionalized inevitably suffer grave harms, not only from abuse and neglect, but from the very act of banishing them from the moral communities that granted the rights and benefits they are now denied.

To be sure, congregate institutions try to simulate community to hide these realities, but such ersatz contrivances are no substitute for genuine social inclusion and belongingness; the simulations are parodies. Such a model cannot produce “person-centered care” no matter how many CMS regulations we enact and enforce. Nor can quarterly congressional hearings and regulatory tweaks—informed by the usual actors they serve to benefit—amount to anything more than theater, political performances that strike those people who must endure the injustice as thoughtless cruelty.

Only a transformative shift in public policy can end these injustices. This shift will require scrutinizing narratives widely considered axiomatic. These include the beliefs that institutionalization is an unavoidable consequence of aging and disability, that institutions provide safer environments (a claim long used to rationalize the barbarity of social removal despite evidence demonstrating the contrary), that uprooting people from the homes, communities, and personal identities they spent lifetimes nurturing is compatible with our most revered social ideals, and finally that we can outsource our humanity—that is, our moral and social obligations to one another, including our disabled parents and children—as a revenue source for corporations and the workers they exploit and expect humane results. 

By now, we know these outcomes of the institutional model; it is a model that objectifies deeply human concerns and favors economic values and imperatives such as competitiveness, efficiency, and profit margins, values that tend to attract predatory actors. And yet we persist with it, and one must ask why. Why do we continue to allow neglect, abuse, and dehumanization to go unchecked? Why do we allow those same predatory actors to manufacture and control the narratives that frame these issues, and indeed provide them platforms in the halls of Congress and in the media to influence unwitting advocates? Why do we persist with this cultivated naivety in the face of so much everyday suffering? The poor human rights records of congregate care facilities long predate the COVID-19 crisis, but the crisis has laid bare the preexisting conditions that led to deaths of over 181,000 disabled people in these institutions.

The horrors I witnessed as an LTC ombudsman keep me up at night, but also inform my disability justice work. And both my insomnia and activism partly derive from frustration. In deference to the industry, the system defangs oversight.  I have fought countless nursing home attempts to involuntarily discharge residents only to have found that those residents, some with severe dementia, had disappeared the following week—to where, the nursing home curiously had (or at least offered) no clue. Sitting at their bedsides, I have held residents’ hands as they recounted instances of rape and abuse, often by staff. Residents have had limbs amputated due to a lack of wound care, understaffing, and poor training. I have seen residents gasp for air as nursing home staff rationed oxygen to save money. I have called Health and Human Services on multiple occasions for residents due to cruel instances of retaliation, only to leave the residents open for more of the same because they sought assistance from a deliberately debilitated regulatory system. Finally, I, myself, have been threatened on multiple occasions by staff and operators. Despite my notifying HHS regulatory and the Ombudsman Program, nothing of substance was done. To the industry, ombudsmen are gnats to swat away; they well know consequences will not be forthcoming. After all, there are few if any consequences for the negligent deaths of residents.

Culture change is impossible within the institutional habitus, particularly so when professional and agency advancement, corporate profit, race, age, and ableism are added to the brew. From the institutional point of view, the dehumanizing model is working as intended. Hence, pumping in ever more money to fund the same solutions and reforms will not bring about different results. As we have seen during the COVID-19 pandemic, nursing homes made record profits from taxpayer funded COVID subsidies, yet COVID cases and deaths, along with non COVID deaths resulting from inadequate infection control practices and severe understaffing, continued to rise.

There will be no substantive change until we end the Medicaid institutional bias by diverting taxpayer funds away from institutions and to programs that maintain or reestablish community integration. As I often explain, nursing homes are the most subsidized industry in the United States and increased monetary rewards serve only to entrench industry malfeasance. Diverting Medicaid dollars to fund HCBS not only reaffirms our commitments to the Americans with Disabilities Act (ADA), the Supreme Court’s Olmstead decision, and our professed democratic principles, it will also do more to soften the resolve of a recalcitrant industry (and similar nonprofits) than years of congressional hearings. In the long run, we will waste fewer resources on researching deficient industry practices and developing complex strategies to instigate change (only to be undone by lobbyists), on Office of Inspector General (OIG) and the U.S. General Accounting Office (GAO) investigations, on Ombudsman programs, on regulatory agencies to maintain the illusion of oversight, on healthcare costs resulting from the industry’s negligence, and on subsidizing the industry’s cost of doing business.


Lydia Nunez Landry

Certified Volunteer Long-Term Care Ombudsman

Organizer for Gulf Coast Adapt


As promised, I want to briefly review a few of the rhetorical and statistical practices employed by the industry and their lobbyists to reframe the human catastrophe exacerbated by the negligent practices in LTC facilities. The author of Care for Our Seniors Act, which aspires to learn from “tragedy” and implement bold solutions, concedes that LTC facilities were the epicenter of the “once-in-a-century” pandemic’s ravage. The force-of-nature language distances the 170,000 deaths (now up to 181,286 deaths) from any culpable agent. And indeed, no one is to blame for the virus, just as we can blame no one for a major flood. But we can blame them for negligent and habitual substandard practices (such as not maintaining levees) that substantially worsen the toll. The author mentions “independent research” by “leading…experts” which shows that “COVID-19 outbreaks in nursing homes are principally driven by the amount of spread in the surrounding community.” The only actual research offered—conducted in May, 2020, long before the vast majority of cases occurred—did conclude that size and location of facilities were factors while traditional metrics such as star ratings and prior citation for poor infection control were not. (Most of the citations were articles from industry magazines, one of which mentioned the article just cited.) It’s unclear how this exonerates the industry. Moreover, the study, thus interpreted, becomes an outlier, as much more research has found direct links between poor quality ratings and significantly higher numbers of COIVD cases and deaths (see here and here).

Instead of dueling studies, we might focus on statistics. The author notes another force of nature behind the deaths, namely time: aging and the fragility of bodies. The virus just happens to target the frail and elderly adults with underlying health concerns that live in their facilities. The author incorrectly asserted that the average age of nursing home residents is 85, but correctly asserted that most residents have underlying conditions, as indeed most people over 65 years old have multiple chronic conditions, in and out of LTC facilities. First some numbers:

The U.S. has approximately 52 million citizens aged 65 or greater. Of them, 430,000 have died from complications of COVID-19 infections. Of those, 130,000 died in nursing homes—the author mentioned 170,000 deaths, but that includes congregate facilities the data from which is sparse, so I shall stick with the 130,000 in nursing homes (NHs). Thus, 300,000 died elsewhere than a NH. NHs warehouse approximately 1.4 million residents, ~ 90% of whom are 65+ years old. The total number of cases in NHs is, at the moment, 643,314, and, for non-NH people in the same age group, 2,666,625. Looking at the bare infection and death numbers, one might think that nursing homes did well—too well, in fact, for the author’s contentions.

But consider again that most people over 65 years old have chronic conditions and most people, even with their bleach wipes, have rudimentary infection controls in their homes. Now, 9.28% of the 1.4 million people in NHs have died from COVID; we can round that up to 1 in every 10. But if non-NH people in the same fragile age group died at that rate, we would have an incredible 4,342,857 more deaths than we do, as only 1 in 167 non-NH elderly people died from COVID. Indeed, examining only those infected, you are nearly twice as likely to die (20% vs. 11%) if you’re in a NH than not. Indeed, the infection rate in NHs is 46% vs. 5.3% for non-NHs fragile people. 

Now, ultimately, industry spokespeople will claim that the deaths occurred because all these people are interacting in close quarters, and so on. But this is not something that can be fixed, and so it underscores why we need to turn back to community integration instead of warehousing people in admitted death traps.

[1] See, for example, Liat Ben-Moshe, Decarcerating Disability: Deinstitutionalization and Prison Abolition (Minneapolis, MN: University of Minnesota Press, 2020).

[2] Sara F. Rose, No Right to Be Idle: the Invention of Disability, 1840s–1930s (Chapel Hill, NC: The University of North Carolina Press, 2017).

[3] Jana Králová, “What Is Social Death?” Contemporary Social Science 10, no. 3 (2015): pp. 235–248, https://doi.org/10.1080/21582041.2015.1114407.

Kansas Legislature Grants Nursing Home Corporations Immunity from Law Suits for Failing to Protect Patients in Their Care

Due to the persistent efforts of LeadingAge, American Health Care Association, and a host of nursing home providers and suppliers, the Kansas legislature passed a bill that protects long-term care providers from law suits for dereliction and negligence during the COVID-19 pandemic. The legislation grants immunity to providers except for “gross negligence” on the part of the staff. Good luck with proving that.

Sympathy expressed for the operators is one of the most disgusting facets of the proponents’ framing of the issues. According to the Kansas City Star, “proponents of the bill argued that nursing homes were not given proper guidance and resources from state agencies at the onset of the pandemic.” Senator Kellie Warren, a Leawood Republican, was quoted as saying, “That we as a state didn’t provide those things but we’re also not going to provide them immunity is an untenable situation for adult care homes” (https://www.kansascity.com/news/politics-government/article250201305.html).

I’ve seen this frame before. The industry is blaming government agencies for not providing them with sufficient training in infectious disease control and for not providing them with personal protective equipment. Providers have been well-reimbursed and investors have extracted excessive funds out of a care system for frail elderly and disabled patients, but they don’t believe they are expected to operate their businesses professionally.

If you follow the press releases on the AHCA/NCAL website, this framing of the issue will sound very familiar. The attitude of the industry is “it’s not our fault, we didn’t know anything about rapidly spreading novel viruses.” Although the long-term care industry has been in the business since 1950, and although it has spawned millionaires and billionaires, operators aren’t capable of taking proper care of people for whom they are paid to be responsible.

I’m wondering what planet I’m living on when I see learned helplessness as an excuse for gross negligence and incompetence. And I say to activists, journalists, and others, please don’t think that the non-profit arm of this business is qualitatively better than the for profits (with the exception of a tiny number of not for profit facilities). The Evangelical Lutheran Good Samaritan chain is the largest non-profit and one of the largest in general. It’s care is as subpar as the low quality for-profits (which is most of them).

LeadingAge: The Non-profit Nursing Home Lobbying Organization is Leading the Charge for Immunity

Rachel Monger, the lobbyist for LeadingAge Kansas, expressed her opposition to an earlier immunity bill in Kansas worked out between Governor Kelly and the legislature. She was of the opinion that the bill did not go far enough in relieving providers of responsibility for neglect and dereliction because “the affirmative defense shield” left providers open to attack. Ms. Monger is of the opinion that the earlier legislation “amount to ‘demoralizing punishment.”

I’ve seen Ms. Monger in action several times at legislative hearings. For instance, I observed her argument against stiffer regulation of psychotropics. She claimed that the providers had a profit margin of a half percent. In corporate speak, this sounds like child babble, but she was waving the Clifton, Larsen, Allen (CLA) annual report around, which is bogus. I look at these industry propaganda pieces every year.

What are Nursing Homes? What Are Operators Expected to Know?

The attitude of the industry is this: “We’re running medical facilities full of medically vulnerable patients, but we can’t be expected to know much about infectious diseases.” In other words, their business is protecting and enhancing shareholder value – not reinvesting earnings in innovative and higher quality, medically ethical, professional care. It’s about the money. If they say, “it’s not about the money,” it’s about the money. Warehousing people at the lowest possible cost is their mode of running their institutions.

I have been warning and will continue warning ad nauseum, ad infinitum, that by letting the industry off the hook for the 300,000 preventable deaths, the lives of medically fragile people in nursing homes will be seriously endangered. If operators and their corporate holding companies can get away with their negligence of the past year, the message will be this: the lives of people in your care aren’t that valuable, so cut costs, warehouse patients, and extract as much cash as possible out of the system.

Leading Age is Teaming Up with the Nursing Home Industry to Put One Over on U.S. Taxpayers

In case you haven’t heard of the “Care for Our Seniors Act”, you need to know that Leading Age, which holds itself out as an advocacy organization for nursing home patients, is teaming up with the American Health Care Association/National Center on Assisted living – the industry lobbying organization – to pass this proposed legislation. Despite a couple of good things in the bill, e.g. 24 hour presence of RN in a facility, minimal stockpile of PPE, and some other minor requirements, the proposed legislation is a sham: an industry maneuver to move past the terrible COVID-19 tragedy and squeeze more funding out of Medicaid.

Essentially, Leading Age is helping sweep the industry’s responsibility for the death of 300,000 nursing home patients under the rug. In addition to helping irresponsible providers escape accountability, LA & AHCA/NCAL are pushing for more taxpayer spending on long-term care without any of the needed financial transparency – needed by taxpayers if they are to find out how their money is being spent and how much is being drained out for excessive enhancement of shareholder value.

None of the real advocates I know would be opposed to spending what it takes to make the long-term care system humane and conducive to the well-being of patients. The Care for Our Seniors Act is a slight tweak at best. More likely, it will result in more shortened lives because it will not change the overall quality of care in America’s nursing homes.

Mark Parkinson, CEO of AHCA/NCAL is pushing the legislation by making incessant claims that the industry is in dire financial straits. That is false. His press releases include frames such as heroic and valiant efforts of providers in the face of financial hardship. Parkinson has been claiming that industry revenue will decline by $95 billion over two 2020 and 2021. He has presented no evidence to support that claim, because there is none. The truth is this: long-term care, as an industry, is so heavily subsidized by federal and state governments that it took no real hit in 2020. Providers have landed on their feet as the COVID pandemic is brought under control and will move ahead and continue to drain an excess amount of funds out of care into the pockets of investors.

It is important for advocates to force the long-term care industry to reveal its financial information. We can see the financial statements of publicly listed companies. A review of major public corporations in the long-term care industry reveals something far different than what Parkinson is putting out. The table below is just the beginning of our examination of annual 10-K reports submitted to the SEC.


Dave Kingsley

There Has Been No Meaningful Nursing Home Reform in Kansas. Please Advocates & Legislators Stop Believing there Has Been!

There appears to be a widespread misperception among activists, advocates, and legislators regarding nursing home reform in Kansas.  It is widely believed that Kansas Senate Bill 15, signed into law by Governor Kelly, would somehow significantly improve the quality of care by keeping rotten apples out of the system.  However, the system is comprised of rotten apples and the legislation touted as the answer to metastasized rottenness will not change that one iota.

What SB 15 does is this: (1) Requires evidence that applicants for a license have sufficient capital to operate for one year, (2) Submit a one-year operating budget, and (3) List all nursing home operations in which they have or have had an interest.  Current bad actors and future bad actors such as Life Care Centers, the Ensign Group, and most of the other providers will have no problem meeting the capital requirements.  Furthermore, their history and past and current operations are no big secret.

What long-term care corporations want to keep secret is their excessive extraction of Medicare and Medicaid funding on behalf of investors – at the expense of patients.  We need financial transparency, but the industry will plant its feet and go to the wall with advocates and activists over an open look at financial statements (except for the few publicly held corporations required to file financial reports with the Securities & Exchange Commission).  Furthermore, state agencies with licensing and monitoring responsibilities have become industry doormats. Therefore, the industry and regulatory agencies teamed up to trick Kansans into believing that some real reform has been enacted.

Anyone who doubts what I’m saying should check inspection reports on Nursing Home Compare.  Begin with the Life Care Center facility at Andover, Kansas, a facility so substandard that it doesn’t rate a one on NHC (it is a “special focus facility”).  The neglect and cruelty cited in the report will make you extremely mad – want to cry, scream, and kick things. The inspection was dated July 7, 2020.  There is no follow up discussed and no change in status.  But Life Care Centers (mainly its sole owner, multi-billionaire Preston Brooks) is still receiving Medicare and Medicaid funding for the Andover facility.

SB 15 was initiated by the industry, i.e., the Kansas Health Care Association.  The Skyline scandal was an embarrassment for the industry and agency toadies giving Joseph Schwartz licenses for 15 Kansas facilities.  They didn’t do due diligence and provided licenses to an unsavory character with a felony record.  He committed more crimes by pocketing deductions from employee paychecks for health care. Eventually, his theft of funding meant for patient care left all 15 facilities insolvent.  SB 15 is a ruse initiated by KHCA lobbyist Cindy Luxem and endorsed by the Kansas Department of Aging & Disability Services.  The public is lulled into believing that the act will result in real reform when in fact it is meaningless.

There has been no evidence that Schwartz didn’t have the capital required by SB 15.  Based on over $150 million in defaulted loans I have found, I believe he was sufficiently capitalized.  There have also been no indictment and prosecution of Schwartz even though he deducted pay from his employees for health insurance and never bought the insurance.  I think Kansas wants the whole Skyline scandal to go away.  It is so sad that so much of the rest of the country has bought into the state’s faux reform.

Watch this Space for Our Upcoming Interview with Michelle Neufeld, Manager of the Pleasant View Nursing Home in Inman, Kansas – A Home-Like Alternative to the Typical Skilled Nursing Institution

Five churches of different denominations, coming together in a small town in central Kansas to build a caring alternative to the typical nursing home institution, is a story we want to tell.  Hence, Kent Comfort will be interviewing Michelle Neufeld, the manager of Pleasant View nursing home in Inman, Kansas. The video of the interview will be posted on this blog.

Let’s face it, people overwhelming disdain nursing homes and never want to be in one.  The reason for that widespread attitude is the dehumanizing conditions people experience when they can no longer stay in their homes. The trauma of leaving our lifeworld of living space, family, friends, pets, neighborhood and enter a depersonalized medical institution to share a room with a stranger is something none of us ever want to experience.

I made a visit to Pleasant View during which I had the opportunity to speak with employees and residents.  The high rate of satisfaction in the home is palpable.  So, yes we can! We can provide long-term care that respects the dignity of patients. This enlightened alternative to the current system of long-term care is a model that is feasible.  We want our readers to know about it.

By Dave Kingsley

Nursing Home Corporations are Beginning to Release Fourth Quarter Earnings. Are their Hardship Pleas Merited? Or is it Propaganda?

The Ensign Group, Inc. (Nasdaq: ENSG) has Reported Robust Fourth Quarter Earnings – Now We Need to Discuss How Well They Protected Patients in Their Care from COVID

The information in this post is based on a conference call and webcast on February 4, 2021 at 10:00 A.M. PT (https://markets.businessinsider.com/news/stocks/the-ensign-group-reports-fourth-quarter-and-fiscal-year-2020-results-1030040511).  When Ensign’s annual 10-K report is available, we will analyze all quarterly reports and their annual results to determine their overall 2020 performance.  We are interested in the amount of revenue the corporation received in the form of CARES Act grants/loans and other subsidization from various federal departments (e.g., HHS, IRS, etc.).

During the 4th quarter (Oct, Nov, Dec), the COVID pandemic spiked to levels unseen prior to that time.  Here are a few highlights from the Ensign release of 4th quarter results, which includes annual results:

  1. Earnings per share of $0.82 represent an increase of 67.3% over the prior year quarter.

  2. Earnings per share of $3.06 represent an increase of 86.6% over the prior year.

  3. Revenue of $2.4 billion for the year is an increase of 18.3% over the prior year.

  4. Medicare days increased by 22.1% over the prior year; hence, skilled revenue increased by 14.7% over the prior year.

  5. Real estate segment income of $31.3 million is an increase of 79.2% from the prior year.

  6. 2020 net income of 174.6 million is an increase of 74.8% over 2019. Fourth quarter earnings of $44.9 million represents an increase of 33.9% over the 4th quarter of 2019.

Although Ensign stock crashed with the rest of the market in mid-March 2020, it has recovered and has been trading in the low $80s.  It closed on Friday, February 5, 2021 at $83.82.  Analysts have rated it as “strong buy” (https://www.msn.com/en-us/money/stockdetails/analysis/fi-a1rzsm).

CEO Barry Port had the following to say about 2020 operating results: “In spite of the continued challenges brought on as the result of the ongoing global pandemic, we are very happy to report another record quarter as we achieved our highest earnings per share in our history.”  He went on to praise the performance of “local teams” in protecting patients from COVID-19.

Whether The Ensign Group Deserves Praise for its Protection of Patients from COVID Remains to be Seen.  What Happened in Kansas City is not Strong Evidence that the Company Placed Care Over Extraction of Cash.

I must say that reading Port’s glowing report of Ensign’s infection and disease control effectiveness, I’m experiencing cognitive dissonance.  Last April, The Ensign Group’s Riverbend facility in Kansas City, KS began to appear in the local media as something of a poster child for COVID-19 deaths in nursing homes (e.g., Laura Bauer, “Two more COVID-19 deaths at Riverbend nursing facility in KCK reported Sunday,” https://www.kansascity.com/news/coronavirus/article241959296.html).

In January of 202 – prior to public awareness of the severity of the pandemic – the Riverbend facility received the lowest rating of 1 out of 5 stars on the CMS Nursing Home Compare website.  The facility was cited for lack of infectious disease control.  Apparently, fixing that problem was not a high priority for the company. As early as January, the world was becoming aware of a novel virus that could become a deadly pandemic outside of China’s borders.

I was interviewed by Fox4 News regarding the Riverbend situation and the nursing home industry in general. My words were reduced to rather meaningless soundbites.  Unfortunately, local and national media are not geared these days to in-depth research and analysis.  After focusing on the scandalous Riverbend deaths for a short period of time, the media jumped to the next scandal and then to the next scandal and on and on – from scandal to scandal.  No adequate analysis of the overall industry has been forthcoming.  Hence, Mark Parkinson and the AHCA can get away with claiming that the industry couldn’t afford to do any better than they have done.

Will the industry escape accountability for the deaths of people entrusted to its care?  Will our government, media, and the public just move on with no serious inquest into how corporations could remain profitable while they allowed perhaps 200,000 people in their facilities needlessly suffer and die? I’m horrified by the thought that the answer to these questions will be yes.  I’m not hearing much interest in pulling back the curtain on the opaque finances of the closely held corporations paid with Medicare and Medicaid dollars to determine what they could have and should have done to protect their patients.

By Dave Kingsley