By Steve Moran

A few weeks ago I wrote an article titled “The Nursing Home Flim-Flam Game.” I sent a draft copy to LeadingAge and AHCA, and it would not be an exaggeration to say THEY HATED IT! One person hated it so much that they yelled at me (I bet they would not use quite the same description, but that is how it felt.) …

If you are a regular reader, you know we have courage and are 100% willing to tackle topics and issues that others would not touch with a 10-foot pole. At the same time, we are committed to only publishing content that will make the industry better. On reflection, while I have not particularly changed my thinking with respect to big issues in the original article, it needed reworking.

It needed additional context. This is my second attempt, I confess this time I did not ask for comment in advance. Last time was simply too painful.


A reminder: I am a huge fan of senior living, including nursing homes. Like nothing else in the whole world, senior living — including nursing homes — when done right, has the power to transform the lives of older people, their families, and those working in senior living.

There are many, many operators who are providing amazing care and creating amazing lives for residents, families, and team members, given the constraints of reimbursement, regulations, the staffing crisis, inflation, and so much more. If you are one of those providers, I am your biggest fan, and this is not about you.

Finally, I would welcome more open, public dialog about these really difficult issues. Foresight TV is standing ready to talk about these topics with integrity and honesty.

Nursing Home Realities 

  • You can never completely eliminate the bad apples in any industry. There are always individuals and organizations that only care about extracting money, and while it should be the goal of the senior living industry to drive that number to zero, practically, this is impossible.That being said, right now, the number of nursing home operators providing inadequate care is clearly too large, and industry thought leaders need to confront this reality. Some honestly want to do it better and don’t know what to do, but there are others that simply don’t care.
  • Until the last few weeks, when interest rates and inflation have spiked, nursing homes have been selling at extraordinarily high per-bed prices, which suggests to the public and policymakers that nursing homes are in better financial shape than they claim.
  • There is real concern about death rates in for-profit nursing homes owned by private equity groups, though what is less clear is how much of that is simply a short-term “COVID effect” that unfairly taints the entire for-profit world of nursing homes (something critical to the health care system). This is something that needs more study.
  • The reason we have so many nursing home regulations is that too many nursing homes have been negligent in caring for their residents. The counterargument is that the problem is the public narrative rather than reality. Maybe, but I have a couple of news alerts set up for the term “nursing home,” and nearly every day there’s a story about how a nursing home was neglectful in caring for residents, and they are painful stories. This is an opportunity for the industry to capture these stories and provide a counterpoint.
  • It is clear that nursing homes in many states (maybe all) are not receiving adequate reimbursement from the federal government to provide the right kind of care for Medicaid residents. It is also true that there are too many operators who would find ways to pocket those increases without substantially improving services.
  • Many large nursing home organizations have created layered corporate entities that make it nearly impossible to understand who is responsible when things go wrong and hold them accountable. It is complicated, because often there are legitimate business reasons to do this. It is something the industry needs to address head-on and figure out.


  • The early days of COVID were brutal for everyone, and in particular, nursing homes. There were many things hospitals and regulators did that resulted in many more deaths in nursing homes than should have occurred, and there has been little or no accountability for this happening.Even more important and completely ignored, many — most — nursing homes and senior living communities proactively went above and beyond what was required by government entities and undoubtedly saved tens of thousands of resident and team member lives.
  • The government response to COVID tests, PPE, and other resources was pathetic.
  • During the early days and even today, regulations with respect to COVID are crazy moving targets that hurt residents and make it much harder to provide humane, high-quality care and living experiences.
  • The entire regulatory system is grossly broken. The regulations do not make residents safer. Compliance costs billions of wasted dollars a year. Regulations make it hard to create programs that actually serve residents and their families.
  • Regulators end up being harder on good facilities than they are on bad ones, because if they applied the same standards to bad ones, they would have to be shut down.
  • The civil penalty fine system that supposedly increases incentives to provide good care is abused by inspectors without reason. This leads to fines that are so ridiculous and expensive and consequences so severe that instead of making care better, facilities are forced to spend tens of thousands fighting these abusive citations and fines.
  • The government should be paying higher reimbursement.
  • The horror stories told in the press and in hearings are the worst of the worst and generally not representative of typical care.

Strong Efforts

The leaders of AHCA and LeadingAge are fighting to make the nursing home ecosystem better. They have a burning passion to improve the lives of residents, team members, and families. We simply need to figure this out together.