Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes as required by the Affordable Care Act of 2010, rather than relying as it had before on the nursing homes’ own unverified reports.

The payroll records revealed lower overall staffing levels than homes had disclosed, particularly among registered nurses. Those are the highest-trained caregivers required to be in a nursing home, and they supervise other nurses and aides. Medicare mandates that every facility have a registered nurse working at least eight hours every day.

“It’s a real positive that they actually are taking the payroll-based system seriously, that they’re using it to punish those nursing homes that either aren’t reporting staffing or those that are below the federal limit,” said David Grabowski, a professor of health care policy at Harvard Medical School. “Could they do more? Sure, but I think it’s a really good start.”

Nursing home industry officials have acknowledged that some facilities are struggling to meet the new payroll reporting requirements. Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services including nearly 2,000 nursing homes, said the lowered star ratings were disappointing and attributed them largely to a workforce shortage.

“Our members are battling on multiple fronts to recruit and retain all types of qualified staff, and nurses in particular,” she said in a statement.

Medicare rates nursing homes on a five-star system, and the homes’ failures to either keep the facilities consistently staffed with registered nurses or to provide the data to prove they were doing so led the government to give its lowest rating for staffing to 1,387 of the nation’s 15,616 skilled nursing facilities, according to a Kaiser Health News analysis of the latest data released by Medicare. They all received one star out of a possible five on July 25, when Medicare updated its website, replacing the first ratings based on payroll data issued in April.

In footnotes on the site, Medicare said those homes either lacked a registered nurse for “a high number of days” over three months, provided data the government couldn’t verify or didn’t supply their payroll data at all. The downgraded homes reported seven or more days without any registered nurses, the analysis found.

For roughly half of the homes, the downgrades lowered their overall star ratings, which are the measures displayed most prominently on the site. But some of the homes saw their overall ratings stay the same or even rise, buoyed by their scores on other quality measures. Seventy-nine are still rated with a coveted five stars.

While the Kaiser Health News analysis found substantially lower average staffing of nurses and aides at for-profit facilities than at nonprofits and government-owned homes, the number of downgraded nursing homes was roughly proportionally divided among the three categories, indicating an industry-wide issue with staffing by registered nurses in particular.

Medicare concedes that because the payroll system is geared toward reporting hourly work, salaried staff may not always be reflected correctly, especially if they were working overtime. But Medicare the nursing homes in April that the downgrades would be coming if facilities continued to show no registered nurses on duty. The agency noted it has been preparing nursing homes since 2015 for the new payroll system.

“We’ve just begun to leverage this new information to strengthen transparency and enforcement with the goals of improved patient safety and health outcomes,” the Centers for Medicare & Medicaid Services said in a statement.

The new payroll data, analyzed by Kaiser Health News, showed that for-profit nursing homes averaged 16 percent fewer staff than did nonprofits, even after accounting for differences in the needs of residents. The biggest difference was in the number of registered nurses: At the average nonprofit, there was one RN for every 28 residents, but at the average for-profit, there was only one RN for every 43 residents. Researchers have repeatedly found lower staffing in for-profit facilities, which make up 70 percent of the industry.

The data also revealed that nursing homes have large fluctuations in staffing. The average nursing home had one licensed nurse caring for as few as 17 residents or as many as 33, depending on the day. On the best-staffed days, each certified nursing assistant or other aide cared for nine residents, but on the worst-staffed days, each aide was responsible for 16 residents.

Weekend staffing was particularly sparse. On weekends on average, there were 11 percent fewer nurses providing direct care and 8 percent fewer aides.

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She cried out in pain. A hospital clinician later discovered her hip was dislocated.

That was not the only injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice a day with a potent blood thinner despite written instructions to stop.

“She said, ‘I just feel so tired,’” her daughter, Laura Clark, said in an interview. “The nurses were saying she’s depressed and wasn’t doing her exercises. I said no, something is wrong.”

Her children also discovered that Snipes’ surgical wound had become infected and infested with insects. Just 11 days after she arrived at the nursing home to heal from her hip surgery, she was back in the hospital.

The fall and these other alleged lapses in care led Clark and the family to file a lawsuit against the nursing home. Richmond Pines declined to discuss the case beyond saying it disputed the allegations at the time. The home agreed in 2017 to pay Snipes’ family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes’ case was extreme, return trips from nursing homes to hospitals are far from unusual.

With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.

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“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’” said , a professor of health care policy at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Payment Advisory Commission.

“We’re better, but not well,” Grabowski said. “There’s still a high rate of inappropriate readmissions.”

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

“And they never quite get back to normal,” he said.

‘She Looked Like A Wet Washcloth’

Communication lapses between physicians and nursing homes is one recurring cause of rehospitalizations. Elaine Essa had been taking thyroid medication ever since that gland was removed when she was a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2013 when a bout of pneumonia sent her to the hospital.

When she returned to the nursing home — now named Wellsprings Post-Acute Care Center — her doctor omitted a crucial instruction from her admission order: to resume the thyroid medication, according to a lawsuit filed by her family. The nursing home telephoned Essa’s doctor to order the medication, but he never called them back, the suit said.

Without the medication, Essa’s appetite diminished, her weight increased and her energy vanished — all indications of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, did not grasp the cause of her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return from the hospital, “she looked like a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she demanded the home’s nurses check her mother’s blood pressure. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her deposition that the doctor told her, “I can’t believe that this woman is still alive.”

Essa died the next month. The nursing home and the medical practice settled the case for confidential amounts. Cynthia Schein, an attorney for the home, declined to discuss the case beyond saying it was “settled to everyone’s satisfaction.” The suit is still ongoing against one other doctor, who did not respond to requests for comment.

Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital.

Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.

“We’re always worried the bad nursing homes are going to get the message ‘Don’t send anyone to the hospital,’” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, where Sandra Snipes stayed, has a higher-than-average rehospitalization rate of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she was discharged to a different nursing home, according to the family’s lawsuit. But her hospital trips were not over: When she showed signs of recurrent infection, the second home sent her to yet another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and more than a liter of infected blood clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the blood thinner right off the bat, we don’t think any of this would have happened.”

Snipes returned home but was never able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t want to go back into the nursing home,” Clark said. “She was terrified.”

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .

The shift in the Medicare program’s penalty protocols was requested by the nursing home industry. The American Health Care Association, the industry’s main trade group, has complained that under Obama inspectors focused excessively on catching wrongdoing rather than helping nursing homes improve.

“It is critical that we have relief,” Mark Parkinson, the group’s president, wrote in a letter to then-President-elect Donald Trump in December 2016.

Since 2013, nearly 6,500 nursing homes — 4 of every 10 — have been cited at least once for a serious violation, federal records show. Medicare has fined two-thirds of those homes. Common citations include failing to protect residents from avoidable accidents, neglect, mistreatment and bedsores.

The new guidelines discourage regulators from levying fines in some situations, even when they have resulted in a resident’s death. The guidelines will also probably result in lower fines for many facilities.

The change in policy aligns with Trump’s promise to reduce bureaucracy, regulation and government intervention in business.

Dr. Kate Goodrich, director of clinical standards and quality at the Centers for Medicare & Medicaid Services (CMS), said in a statement that unnecessary regulation was the main concern that health care providers raised with officials.

“Rather than spending quality time with their patients, the providers are spending time complying with regulations that get in the way of caring for their patients and doesn’t increase the quality of care they provide,” Goodrich said.

But advocates for nursing-home residents say the revised penalties are weakening a valuable patient-safety tool.

“They’ve pretty much emasculated enforcement, which was already weak,” said Toby Edelman, a senior attorney at the Center for Medicare Advocacy.

Medicare has different ways of applying penalties. It can impose a specific fine for a particular violation. It can assess a fine for each day that a nursing home was in violation. Or it can deny payments for new admissions.

The average fine in recent years has been $33,453, but 531 nursing homes amassed combined federal fines above $100,000, records show. In 2016, Congress to factor in several years of inflation that had not been accounted for previously.

The new rules have been instituted gradually throughout the year.

In October, its regional offices from levying fines, even in the most serious health violations, if the error was a “one-time mistake.” The centers said that intentional disregard for residents’ health and safety or systemic errors should still merit fines.

A from CMS discouraged the directors of state agencies that survey nursing homes from issuing daily fines for violations that began before an inspection, favoring one-time fines instead. Daily fines remain the recommended approach for major violations discovered during an inspection.

Dr. David Gifford, the American Health Care Association’s senior vice president for quality, said daily fines were intended to prompt quick remedies but were pointless when applied to past errors that had already been fixed by the time inspectors discovered them.

“What was happening is you were seeing massive fines accumulating because they were applying them on a per-day basis retrospectively,” Gifford said.

But the change means that some nursing homes could be sheltered from fines above the maximum per-instance fine of $20,965, even for egregious mistakes.

In September 2016, for instance, health inspectors , a nursing home in Decatur, Ill., for failing to monitor and treat the wound of a patient whose implanted pain-medication pump gradually slipped over eight days through a ruptured suture and protruded from her abdomen. The patient died.

CMS fined Lincoln Manor $282,954, including $10,091 a day for 28 days, from the time the nursing home noticed the problem with the wound until supervisors had retrained nurses to avoid similar errors. An administrative law judge called the penalties “quite modest” given the “appalling” care.

The fines were issued before the new guidelines took effect; if the agency had issued a one-time fine, the maximum would have been less than $21,000.

Lincoln Manor closed in September. Its owner could not be reached for comment, and his lawyer did not respond to an interview request.

Advocates for nursing home residents say that relaxing penalties threatens to undo progress at deterring wrongdoing. Janet Wells, a consultant for California Advocates for Nursing Home Reform, said the changes come as “some egregious violations and injuries to residents are being penalized — finally — at a level that gets the industry’s attention and isn’t just the cost of doing business.”

In November, the Trump administration exempted nursing homes that violate from penalties for 18 months. Homes must still follow the rules, which are intended, among other things, to reduce the overuse of psychotropic drugs and to ensure that every home has adequate resources to assist residents with major psychological problems.

Rodney Whitlock, a health policy consultant and former Republican Senate staffer, said health inspectors “are out there looking for opportunities to show that the nursing homes are not living up to some extremely tight standards.” He said while the motivation for tough regulation was understandable, “the fines don’t make it easier to hire people and doesn’t make it easier to stay in business.”

In June, CMS rescinded another Obama administration action that banned nursing homes from pre-emptively requiring residents to submit to arbitration to settle disputes rather than going to court.

“We publish nearly 11,000 pages of regulation every year,” the agency’s administrator, Seema Verma, said in . That paperwork is “taking doctors away from what matters most: patients.”

Janine Finck-Boyle, director of health regulations and policy at LeadingAge, a group of nonprofit nursing homes and other entities that care for older people, said the group’s members had been struggling to cope with regulations.

“If you’re a 50-bed rural facility out West or in the Dakotas,” she said, “you don’t have the resources to get everything done from A to Z.”

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A Kaiser Health News analysis of four years of federal inspection records shows 74 percent of nursing homes have been cited for lapses in infection control — more than for any other type of health violation. In California, health inspectors have cited all but 133 of the state’s 1,251 homes.

Although repeat citations are common, disciplinary action such as fines is rare: Nationwide, only one of 75 homes found deficient in those four years has received a high-level citation that can result in a financial penalty, the analysis found.

“The facilities are getting the message that they don’t have to do anything,” said Michael Connors of California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “They’re giving them low-level warnings year after year after year and the facilities have learned to ignore them.”

Infections, many avoidable, cause a quarter of the medical injuries Medicare beneficiaries experience in nursing homes, according to . They are among the most frequent reasons residents are sent back to the hospital. By one , health care-associated infections may result in as many as 380,000 deaths each year.

The spread of methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant germs has become a major public health issue. While Medicare has begun penalizing hospitals for high rates of certain infections, there has been no similar crackdown on nursing homes.

As average hospital stays have shortened from to in 2012, patients who a generation ago would have fully recuperated in hospitals now frequently conclude their recoveries in nursing homes. Weaker and thus more susceptible to infections, some need ventilators to help them breathe and have surgical wounds that are still healing, two conditions in which infections are more likely.

“You’ve got this influx of vulnerable patients but the staffing models are still geared more to the traditional long-stay resident,” said Dr. Nimalie Stone, the CDC’s medical epidemiologist for long-term care. “The kind of care is so much more complicated that facilities need to consider higher staffing.”

The Centers for Medicare & Medicaid Services (CMS), which oversees inspections, has recognized that many nursing homes need to do more to combat contagious bugs. CMS last year required long-term care facilities to put in place , detect outbreaks early on and limit unnecessary use of antibiotics through a stewardship program.

But the agency does not believe it has skimped on penalties. CMS said in a statement that most infection-control violations have not justified fines because they did not put residents in certain danger. For instance, if an inspector observed a nurse not washing his or her hands while caring for a resident, the agency said that would warrant a lower-level citation “unless there was an actual negative resident outcome, or there was likelihood of a serious resident outcome.”

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In November, CMS waived penalties for 18 months against facilities that violate the new stewardship rule. The industry had said nursing homes needed more time to prepare. (The moratorium does not affect , which took effect last January.)

Holly Harmon, the senior director of clinical services at the American Health Care Association, a nursing home trade group, said the industry has made strides in combating infections through better training and encouragement for staff members to look for gaps in infection control and to speak up about them. The percentage of nursing home residents with urinary tract infections — the only type of infection all nursing homes must report to Medicare — has dropped by more than half since 2011.

“Infection prevention control is a priority,” Harmon said. “The path really is focused on continuous improvement.”

The facilities are getting the message that they don’t have to do anything.

Michael Connors, California Advocates for Nursing Home Reform

A Sick Patient, A Family Complaint, Little Action

James Morris said he did not see such dedication when his mother, Georgina, entered Astoria Nursing & Rehabilitation Center in Sylmar, Calif., in October 2015. “Workers were coming in and out without washing their hands,” he said.

While there, Georgina Morris, 86, fell ill to a particularly virulent strain of , known as C-diff. Morris said he insisted his 86-year-old mother, who was severely dehydrated, be sent to the hospital, where she stayed for 10 days. She has had subsequent flare-ups of the infection that required rehospitalization and, later, a fecal transplant, in which doctors transferred stool from a healthy patient into her bowels, a procedure that can treat the infection by introducing bacteria that counter the C-diff germs.

James Morris complained about Astoria to health authorities shortly after his mother left. Records show inspectors waited 18 months, until a regularly scheduled review in May 2017, before investigating her case. Such delays are common: California Department of Public Health cases remain open, on average, for nearly 20 months.

Although inspectors faulted Astoria workers for not cleaning their hands while treating Georgina Morris, they could not definitively determine whether she contracted the infection there or before she arrived. But the inspection found other infection-control lapses throughout the home. A housekeeper cleaned the wall with the same cloth used to wipe the toilet. A patient had a dirty intravenous line left in longer than necessary. The inspector watched as a worker failed to wash her hands after delivering a breakfast tray to a contagious resident in isolation.

It was the second consecutive year inspectors cited the home for substandard infection control that had the potential to harm residents. Both citations were below the level that could trigger fines.

Astoria did not respond to requests for comment.

Homes Cited Repeatedly But Few Punishments

Elsewhere, health regulators are similarly reluctant to assert that nursing home errors led to patient infections or put patients in imminent danger. Only 161 homes among the 12,056 that violated infection-control rules were cited at those higher levels since 2014, according to KHN’s analysis.

The value of lower-level citations as deterrents is questionable: Authorities have cited 7,045 homes more than once over infection-control lapses, including 942 that racked up four or more violations, the analysis found.

“Perhaps a bigger stick might be more helpful,” said Joseph Rodrigues, California’s long-term-care ombudsman.

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In January, an inspection of Decatur Nursing and Rehabilitation in Decatur, Texas, found that one nurse didn’t wash her hands after picking up a bottle of medication that fell on the floor and another nurse didn’t properly clean a syringe.

Two months after citing the home, inspectors were back to issue another violation. This time, a resident died from the flu after a contagious resident who lived across the hall was let out of isolation earlier than the CDC recommends. Only then did inspectors issue a citation at the most serious level.

Decatur did not respond to requests for comment.

Inspection records show nurses and aides are often not familiar with basic protocols, such as wearing protective clothing when coming into contact with contagious residents and isolating them from others in the home and visitors. Others are not trained properly on how to clean patients. Still others, in a rush and understaffed, take shortcuts that compromise sanitary precautions.

“We’ve always been shocked at how often we’ve personally witnessed people providing care in facilities and not washing their hands, which has got to be the most basic thing in infection control and prevention,” said Sherry Culp, who as Kentucky’s long-term-care ombudsman advocates for aggrieved nursing home residents.

This year in New Mexico, 25 residents of the Rehabilitation Center of Albuquerque, part of the Genesis Healthcare chain, developed urinary tract infections because nurses and aides cleaned residents’ genitals and catheters in unsanitary ways, according to an inspection report.

Another recurring problem stems from nurses and aides infecting residents because they come to work ill knowing they would not get paid for the sick time, said Dr. David Nace, an associate professor at the University of Pittsburgh School of Medicine.

During a norovirus outbreak in January at Fir Lane Health & Rehabilitation Center in Shelton, Wash., at least six infected employees returned to work without waiting the minimum 48 hours after their symptoms abated. Inspectors discovered the virus ultimately spread to 32 employees and 43 residents — more than 40 percent of those living in the home.

Fir Lane and the Albuquerque home did not respond to requests for comment.

“They have these draconian policies for taking off,” Nace said, speaking broadly about the nursing home industry. “And if you don’t have the draconian policies, then everyone takes off. That plagues the entire health care industry.”

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Despite the collapse of the latest Senate effort to repeal the Affordable Care Act, congressional Republicans are still keen on shrinking the amount of Medicaid money Washington sends states.

Down the line, this would create problems for the nation’s 1.4 million nursing home residents, two-thirds of whom are covered by the state-federal health care program for low-income and disabled people.

Medicaid already pays less than other forms of insurance. As a result, nursing homes make more than 10 percent on Medicare residents, on the rest of their residents because so many have care paid for by Medicaid.

If the feared reductions come to fruition, states would likely respond by either lowering their payment rates or restricting whom they cover and for how long. And the quality of care, experts say, would deteriorate further.

These four charts, based on a Kaiser Health News analysis of ratings from the federal government’s , show how care suffers in nursing homes where Medicaid is the dominant payer for residents.

The government rates nursing homes on a scale from one to five stars, based on overall quality. Factors weighed: how well each facility performs on government inspections, how many nurses and aides it employs, and how healthy its residents are as judged by such measures as how often they fall, get infections or are admitted to the hospital.

The chart below shows the big picture: Nursing homes with higher percentages of residents covered by Medicaid earn fewer stars on the federal government’s overall quality rating system. One-star homes (lowest quality) average 69 percent of residents on Medicaid; Five-star (highest quality) average 49 percent of residents on Medicaid.

A prime reason for the disparity, researchers have found, is that nursing homes with the most Medicaid residents can’t afford as many nurses and aides. Medicare assigns a second type of star rating representing staffing levels and based on the ratio of nurses to residents. As the chart below shows, the staffing differences are huge: The average five-star home has enough nurses and aides to provide 5.4 hours of care a day for each resident while the average one-star home provides 3.0 hours of daily care per resident. At the best-staffed homes (five stars), only 4 of 10 residents are on Medicaid, meaning the remainder of residents are more lucrative for those facilities. At the worst-staffed homes (one star), 7 of 10 residents are on Medicaid.

Low staffing is just one factor behind inferior quality ratings for homes that rely heavily on Medicaid, said Dr. David Gifford, senior vice president for quality and regulatory affairs at the American Health Care Association, a nursing home trade group. A home’s ability to buy medical equipment, medications and oxygen and to keep the building operating can also suffer.

The government publishes a third set of stars representing the results of health inspections. State inspectors give citations to homes that don’t protect residents from bed sores, accidents, infections and other types of harm. The third chart, below, shows how homes with more health violations usually also have more Medicaid beds. At nursing homes with worst inspection records (one star), an average 65 percent of residents are on Medicaid. Facilities with the best inspection records (five star) have an average 47 percent of residents on Medicaid.

“It’s very likely that if Medicaid payment rates freeze or decline, there would be adverse effects,” said Vincent Mor, a professor at the Brown University School of Public Health. “Nursing homes that can will get out of the Medicaid business if it’s at all possible. Those that can’t will try to keep their beds as full as possible and live with a negative margin and reduce food, reduce staff and try to struggle along.”

Mor said the Medicaid cuts might not even save the government money in the end. “When Medicaid nursing homes are poor and perform poorly, their hospitalization rate increases, and Medicare pays for those hospitalizations. If I’m a nursing home and I can barely afford my patients, I’m going to send my patients to the hospital.”

This final chart shows, by state, the percentage of nursing home residents who rely on Medicaid. In Alaska, 83 percent of nursing home residents are covered by Medicaid. Iowa is the only state where Medicaid does not cover a majority of nursing home residents.

KHN’s coverage of end-of-life and serious illness issues is supported by and its coverage related to aging & improving care of older adults is supported by .

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Around the country, facilities have been caught unprepared for far more mundane emergencies than the hurricanes that recently struck Florida and Houston, according to an examination of federal inspection records. Those homes rarely face severe reprimands, records show, even when inspectors identify repeated lapses.

In some cases, nursing homes failed to prepare for basic contingencies.

In one visit last May, inspectors found that an El Paso, Texas, nursing home had no plan for how to bring wheelchair-dependent people down the stairs in case of an evacuation. Inspectors in Colorado found a nursing home’s courtyard gate was locked and employees did not know the combination, inspection records show. During a fire at a Chicago facility, residents were evacuated in the wrong order, starting with the people farthest from the blaze.

Nursing home inspectors issued 2,300 violations of emergency-planning rules during the past four years. But they labeled only 20 so serious as to place residents in danger, the records show.

In addition, a third of U.S. nursing homes have been cited for another type of violation: failing to inspect their generators each week or to test them monthly. None of those violations was categorized as a major deficiency, even at 1,373 nursing facilities that were cited more than once for neglecting generator upkeep, the records show.

“That’s the essential problem with the regulatory system: It misses many issues, and even when it identifies them, it doesn’t treat them seriously enough,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy. “It’s always the same story: We have some pretty good standards and we don’t enforce them.”

In the wake of at Rehabilitation Center at Hollywood Hills, Fla., following Hurricane Irma, heightened attention has focused on , with which nursing homes must comply by mid-November. Those were prompted by nursing home and hospital deaths during Hurricane Katrina in Louisiana in 2005.

Dr. David Gifford, senior vice president for quality and regulatory affairs at the American Health Care Association, a nursing home industry group, said facilities have gotten better at handling disasters after each one. Most evacuations go smoothly, he said.

“After each one of these emergencies we’ve learned and gotten better,” Gifford said.

But advocates for the elderly say enforcement of rules is as great a concern, if not greater.

Dr. David Marcozzi, a former director of the federal emergency preparedness program for health care, said that inspectors — also known as surveyors —  should observe nursing home staff demonstrating their emergency plans, rather than just checking that they have been written down.

“If you have not implemented and exercised plans, they are paper tigers,” said Marcozzi, now an associate professor at the University of Maryland School of Medicine. “The emphasis from the surveyor has to be ‘Show me how you do this.’ ”

Gifford said pre-planning and drills, which are important, only go so far in chaotic events such as hurricanes.

“No matter what planning you might have, what we have learned from these emergencies is these plans don’t always work,” he said. Nursing homes take surveys seriously and face closure if they do not fix flaws inspectors identify, he added.

Inspection results vary widely by state, influenced sometimes by lax nursing homes or more assertive surveyors, or a combination, according to an analysis of two types of emergency-planning deficiencies. In California, 53 percent of nursing facilities have been cited for at least one of two types of emergency-planning deficiencies, and a quarter have been cited in Texas. No nursing home in Indiana, Mississippi or Oregon was issued violations for those two emergency-planning violations during the past four years.

Asked to explain the rarity of severe citations in emergency preparation, the federal Centers for Medicare & Medicaid Services, which oversees inspections, referred a reporter to its on its website.

The danger of high temperatures for elderly residents, which the Hollywood Hills case shows can be disastrous, has been well known. In a heat wave in 2000, in a Burlingame, Calif., facility died and six others suffered severe dehydration, heat stroke or exhaustion.

During the past four years, inspectors have cited 536 nursing homes for failing to maintain comfortable and safe temperature levels for residents. Inspectors deemed 15 as serious, including two where patients were harmed, records show.

“There is undoubtedly little, if any, enforcement of the laws since we see the same tragedies repeated time and again,” said Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.

Clarification: This story was updated on Sept. 19 clarify to make clear that 53 percent of nursing facilities in California and a quarter of them in Texas were cited for at least one of two types of emergency-planning deficiencies — not both types of deficiencies.

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These plans are recent additions to the Medicare Advantage market, where private plans have become an increasingly popular alternative to traditional fee-for-service coverage. Unlike other plans, these policies offered by long-term care companies often place a nurse in the skilled nursing facility or retirement village, where they can talk directly to staff and assess patients’ conditions. Some provide primary care doctors and nurses to residents in the homes or in affiliated assisted living facilities or retirement villages with the aim of staving off hospitalizations.

“The traditional model is making decisions based on paper, and in our model, these decisions are being made by clinicians who are really talking to the staff and seeing the patient,” said Angie Tolbert, a vice president of quality at PruittHealth, which began offering its plan to residents in 10 of its nursing homes in Georgia last year. “It’s a big shift in mindset.”

Not everyone finds such plans superior. Some patients who are in disputes with the insurers have faulted the nursing home staff — who work for the same company — for not helping challenge decisions about coverage. They complain that the company holds an unfair advantage over Medicare beneficiaries.

“There’s a conflict there,” said Toby Edelman, a senior attorney with the Center for Medicare Advocacy.

In an Erickson Living retirement village in Silver Spring, Md., Faith Daiak signed up for an Erickson Advantage plan sold by a nurse whose office was in the main village building, according to her son, J.J. Daiak. After a bout with the flu last February weakened her enough to need a 10-day hospitalization, she was sent to her village’s skilled nursing facility. There, the insurer repeatedly tried to cut short her stay.

Erickson Advantage first said it would stop paying for Daiak, 88, because she wasn’t getting healthier in the nursing facility. Her son appealed by pointing out that Medicare explicitly said as part of the 2014 settlement of that patients do not have to be improving to qualify for skilled nursing care.

Daiak’s appeal was denied, but the issue was sidelined in March when her rapid weight loss in the nursing home sent her back to the hospital, he said.

After Daiak returned to the nursing home with a feeding tube in her stomach, the insurer again tried to curtail her time there, saying she did not need that level of care. The family successfully appealed that decision after noting that Medicare’s manual said feeding-tube maintenance required the skilled care of a nursing facility.

In April, Erickson Advantage again said it would not continue paying for Daiak’s stay. It reversed that decision after Kaiser Health News asked the company about the case, J.J. Daiak said. He said the plan did not explain its turnaround.

While this Medicare Advantage plan touts its “team that knows you personally and wants to help,” J.J. Daiak said he found the registered nurse at Erickson’s Silver Spring community not helpful. “All I see is her trying to get Erickson out of having to pay for the nursing home,” he said. He subsequently switched his mother to traditional Medicare coverage with a supplemental Medigap policy, which she had until this year.

Erickson Living, the parent company of the nursing home and insurer, declined to discuss individual cases but noted that Medicare has given its insurance plans the best quality rating of five stars. In a written statement, the company said that “medical service determinations for Erickson Advantage members are based on reviews by licensed clinical staff and clinical guideline criteria. Our primary focus is always on ensuring that the healthcare being provided for our residents matches a patient’s needs and established clinical treatment protocols.”

Edelman said the dispute was particularly troubling because Erickson’s retirement villages are marketed on the promise that the company will care for seniors in all stages of aging. “They don’t tell you what they won’t pay for,” she said.

Popular Alternative

There are nearly 18 million enrollees in the overall Medicare Advantage market. Medicare pays private insurers a set amount to care for each beneficiary. In theory, this payment method gives the insurers motivation to keep patients from needing costly medical services such as hospitalizations.

A subset of Medicare Advantage plans are designed exclusively for people who either require or are expected to require at least 90 days of skilled services from nursing homes, assisted living facilities or other long-term care institutions. UnitedHealthcare directly offers three-quarters of these plans with about 40,000 enrollees, far more than those offered by nursing home companies. Matthew Burns, a UnitedHealth spokesman, said the majority of the company’s plans are rated four stars or better on Medicare’s five-star quality scale.

“Our plans offer members quality and peace of mind — and they are considered above average to excellent by CMS quality and performance standards,” he said in a statement.

United also underwrites Erickson’s policies, which have around 200 enrollees, and were the first Advantage plans offered by a long-term care operator. Under the arrangement, Erickson Advantage decides when a nursing home stay is covered.

Nick Williams, PruittHealth’s care integration officer, said its Medicare insurance plan has resulted in 30 percent fewer hospitalizations among residents since it began last year. The company intends to expand the insurance coverage to residents at 42 of its other nursing homes in Georgia. Other nursing home chains are experimenting with this model in Missouri, South Carolina, Virginia and elsewhere.

Anne Tumlinson, a Washington health care industry consultant who specializes in long-term care, said that when a nursing home’s company is on the hook for the cost of hospitalizations of their patients, it is more likely to make efforts to prevent them.

“It gets them out of hospitalizing people at the drop of the hat,” she said. “If you live in a nursing home or are living in assisted living and they have one of these plans going, they’re going to be investing heavily in 24/7 access to primary care.”

She said big insurers have so many different types of enrollees that they are less focused on the particular needs of nursing home patients. “They’re too big, they’re bureaucratic, and they are insurers, not providers,” she said.

The Costs Patients Face

In Hingham, Mass., Suzanne Carmick has been frustrated with the Erickson plan’s unwillingness to pay for most of her mother’s prolonged stay. Last October, 98-year-old Lorraine Carmick went into Erickson’s nursing home after a hospitalization. Eleven days later, Erickson Advantage notified Suzanne Carmick it would stop paying for the facility because it said her mother was strong enough to move with the help of a rolling walker. Under Medicare’s rules, nursing home stays are not covered if a patient does not need daily physical therapy. Erickson said two or three days was sufficient for Carmick.

Suzanne Carmick appealed the decision, saying Erickson exaggerated her mother’s recovery, noting that she had dementia, an infection and was wearing two stiff leg braces. She said getting therapy five days a week provided in the nursing home would help her mother recover faster.

“She still cannot stand up or sit down or go anywhere … without an aide helping her by pulling her up or setting her in a chair,” Carmick wrote. “She is improving but is now supposed to stop or decrease PT [physical therapy], and she must start paying out-of-pocket?”

After a week’s extension, the nursing home began billing her mother at its daily rate of $463, which rose to $483 this year as Lorraine Carmick remained in the nursing home. A Medicare appeals judge subsequently ruled Erickson’s action was justified, based on the testimony from the nursing home staff — all Erickson employees. If the insurer had covered a maximum stay, Carmick would have avoided more than $30,000 in bills she now owes. Suzanne Carmick said her mother has been on a wait list for six months for a bed on a less expensive floor in the nursing facility.

“It is a closed system where the skilled nursing facility, physicians and Medicare Advantage plan are all one and the same,” she said. “The Erickson Advantage plan is turning out to be quite a disadvantage at this point.”

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The facility where she died in 2012 was affiliated with a respected San Francisco hospital, California Pacific Medical Center, and shared its name. Fee had just undergone hip surgery at the hospital, and her family, pleased with her care, said they chose the nursing home with the hospital’s encouragement.

Laura Rees, Fee’s elder daughter, said she was never told that the nursing home had received Medicare’s worst rating for quality — one star. Nor, she said, was she told that state inspectors had repeatedly cited the facility for substandard care, including delayed responses to calls for aid, disrespectful behavior toward patients and displaying insufficient interest in patients’ pain.

“They handed me a piece of paper with a list of the different facilities on it, and theirs were at top of the page,” Rees said in an interview. “They kept pointing to their facility, and I was relying on their expertise and, of course, the reputation of the hospital.”

Fee had an obstructed bowel, and state investigators faulted the home for several lapses in her care related to her death, including giving her inappropriate medications. In court papers defending a lawsuit by Fee’s family, the medical center said the nursing home’s care was diligent. The center declined to discuss the case for this story.

The selection of a nursing home can be critical: 39 percent of facilities have been cited by health inspectors over the past three years for harming a patient or operating in such a way that injuries are likely, government records show.

Yet many case managers at hospitals do not share objective information or their own knowledge about nursing home quality. Some even push their own facilities over comparable or better alternatives.

“Generally hospitals don’t tell patients or their families much about any kind of patterns of neglect or abuse,” said Michael Connors, who works at California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “Even the worst nursing homes are nearly full because hospitals keep sending patients to them.”

Hospitals say their recalcitrance is due to fear about violating a government decree that hospitals may not “specify or otherwise limit” a patient’s choice of facilities. But that rule does not prohibit hospitals from sharing information about quality, and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality nursing homes while still giving patients all alternatives.

Such efforts to help patients are rare, said Vincent Mor, a professor of health services, policy and practice at the Brown University School of Public Health in Providence, R.I. He said that when his researchers visited 16 hospitals around the country last year, they found that only four gave any quality information to patients selecting a nursing home.

“They’re giving them a laminated piece of paper” with the names of nearby nursing facilities, Mor said. For quality information, he said, “they will say, ‘Well, maybe you can go to a website,'” such as , where Medicare publishes its quality assessments.

The federal government may change this hands-off approach by requiring hospitals to provide guidance and quality data to patients while still respecting a patient’s preferences. The rule would apply to information not only about nursing homes but also about home health agencies, rehabilitation hospitals and other facilities and services that patients may need after a hospital stay.

“It has a substantial opportunity to make a difference for patients,” said Nancy Foster, a vice president at the American Hospital Association.

Even the worst nursing homes are nearly full because hospitals keep sending patients to them.

Michael Connors

But the rule does not spell out what information the hospitals must share, and it has yet to be finalized — more than a year after Medicare proposed it. The rule faces resistance in Congress: The chairman of the House Freedom Caucus, Rep. Mark Meadows, R-N.C., has included it on a Republicans should block early next year.

The government has created other incentives for hospitals to make sure their patient placements are good. For instance, Medicare cuts payments to hospitals when  within a month.

“Hospitals didn’t use to care that much,” said David Grabowski, a professor of health care policy at Harvard Medical School. “They just wanted to get patients out. Now there’s a whole set of payment systems that reward hospitals for good discharges.”

But sometimes hospitals go too far in pushing patients toward their own nursing homes. In 2013, for instance, regulators faulted a Wisconsin hospital for not disclosing its ties when it referred patients to its own nursing home, which Medicare rated below average. In 2014, a family member told inspectors that a Massachusetts hospital had “steered and railroaded” her into sending a relative to a nursing home owned by the same health system.

Researchers have found that hospital-owned homes are often superior to independent ones. Still, a third of nursing homes owned by hospitals in cities with multiple facilities had lower federal quality ratings than at least one competitor, according to a Kaiser Health News analysis.

The Lowest Rating

Medicare’s Nursing Home Compare gave the nursing home where Elizabeth Fee died one star out of five, meaning it was rated “much below average.” The hospital’s case managers told Fee’s family that the nursing home was merely an extension of the hospital and that “my mother would receive the same excellent quality of care and attention,” said Rees, her daughter.

But state inspectors found shortcomings in seven visits to the nursing home between August 2009 and October 2011, records show. Inspectors found expired medications during two visits and, at another, observed a nurse washing only her fingertips after putting an IV in a patient with a communicable infection.

Just four months before Fee arrived, inspectors cited the nursing home for not treating patients with dignity and respect and for failing to provide the best care. One patient told inspectors that her pain was so excruciating that she couldn’t sleep but that nurses and the doctor did not check to see whether her pain medications were working.

“Nobody listens to me,” the patient said. “I was born Catholic, and I know it’s not right to ask to die, but I want to die just to get rid of the pain.”

Fee ate little and had few bowel movements, according to the state health investigation. Fee’s family had hired a private nurse, Angela Cullen, to sit with her. Cullen became increasingly worried about Fee’s distended belly, according to Cullen’s affidavit taken as part of the lawsuit. She said her concerns were brushed off, with one nurse declining to check Fee’s abdomen by saying, “I do not have a stethoscope.”

On the morning of her death, an X-ray indicated Fee might have a bowel obstruction or other problem expelling stool, the inspectors’ report said. That evening, after throwing up a large quantity of matter that smelled of feces, she lost consciousness. She died of too much fluid and inhaled fecal matter in her lungs, the report said.

Bills Of More Than $150,000

In a court ruling, Judge Ernest Goldsmith of the San Francisco Superior Court wrote that Elizabeth Fee’s younger daughter, Nancy, “observed her mother drown in what appeared to be her own excrement.” Kathryn Meadows, the family’s attorney, said in a court filing that the nursing home’s bills exceeded $150,000 for the three-week stay.

Sutter Health, the nonprofit that owns the medical center and the nursing home, emphasized in court papers that Elizabeth Fee arrived at the facility with a low count of platelets that clot blood. Sutter’s expert witness argued that the near-daily visits from a physician that Fee received “far exceeds” what is expected in nursing home care.

The physician and his medical group have settled their part of the case and declined to comment or discuss the terms; the case against Sutter is pending. California’s public health department fined Sutter $2,000 for the violations, including for delaying 16 hours in telling the physician about Fee’s nausea, vomiting and swollen abdomen. Last year, Sutter closed the nursing home.

A week or so after Fee died, a letter addressed to her from California Pacific Medical Center arrived at her house. It read: “We would appreciate hearing about your level of satisfaction with the care you received on our Skilled Nursing Rehabilitation Unit, the unit from which you were just discharged.”

KHN’s coverage related to aging & improving care of older adults is supported by . Coverage of aging and long-term care issues is supported by .

Clarification: This story was updated to correct a reference to Elizabeth Fee.

This article first appeared on Ñî¹óåú´«Ã½Ò•îl Health News and is republished here under a .