A new investigation has peeled back the curtain on a troubling contradiction in American nursing home care: facilities receiving millions in taxpayer-funded bonuses for "high-quality" performance are often mired in allegations of neglect, understaffing, and abuse that endanger residents' lives. The report, published by Fox13 in Salt Lake City, centers on Utah's Upper Payment Limit (UPL) program, which has allocated over $1 billion in federal funds to nursing homes since 2017 to improve care for Medicaid-eligible elderly and disabled adults. Yet, an analysis of federal data by a law firm revealed that UPL facilities underperform compared to non-UPL ones in staffing, health inspections, and overall ratings, despite the subsidies. For readers of the Aging in Place Planning and Elder Law Blog, this isn't a distant Utah tale; it's a microcosm of a national epidemic where profit motives and regulatory expediency clash with patient safety. These revelations underscore the urgent case for proactive planning to prioritize home-based care over institutional risks. As we've delved into in "Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place," tools like advance directives, supported decision-making (SDM) agreements, technologies, aids, and trusts can help families sidestep these pitfalls, preserving dignity and assets amid a system where "bonuses for bad care" seem to be the norm.The Utah Scandal: Millions in Bonuses Amid a Culture of NeglectUtah's UPL program, designed to boost Medicaid reimbursement rates for nursing homes serving low-income residents, has distributed over $100 million annually since 2013, ostensibly to enhance staffing, training, and quality. The Fox13 analysis of CMS data from 2017-2025, however, paints a grim picture: UPL facilities scored lower in staffing (average 2.8 hours/resident/day vs. 3.2 for non-UPL), health inspections, and overall ratings (3.5 stars vs. 3.8), while accruing more deficiencies tied to abuse and neglect. One chain, Beaver Valley Hospital (licensing more than 40 facilities), pocketed $26 million since 2016. Yet, St. George Rehabilitation facility (under Ensign Group) faces lawsuits alleging untreated bedsores, falls, and "beyond disgusting" care, including a resident left in feces for days. Another, Gunnison Valley Hospital, received $20.9 million amid "below-average" staffing and high turnover.
Families like Doni Hunt Webb's in St. George, featured in the Fox13 report, recount "real people suffering," with CNAs averaging one per 20 residents amid "high turnover." The report ties this to a 2017 audit that revealed Beaver Valley kept 51% of the funds for administrative "seed money," with little oversight. In other words, funds intended for improving care were instead used to subsidize profits. Utah DHHS defends the program as preventing closures, but critics, such as attorney Barry Toone, counter: "When you look at every metric, they're not doing better." Amid reports that nearly one in four facilities fail to meet staffing standards, this "bonus for bad care" raises red flags: taxpayer dollars (over $1 billion in Utah alone) are subsidizing subpar care, where neglect escalates to tragedy.Is This a Utah Problem or a National Epidemic?
While the report highlights Utah's UPL program, it's far from unique. It's a microcosm of a nationwide crisis where bonuses reward reported metrics, rather than actual positive outcomes. Federal data repeatedly reveal that "the overwhelming majority of US nursing homes are operating with insufficient staffing to meet the basic needs of their residents." According to Long Term Care Community Coalition (LTCC) federal data reveals that a shocking 9 in 10 nursing homes fall below their expected staffing levels. In the fourth quarter of 2024, 36% of facilities reported having zero (0) presence of a medical director, despite federal requirements that a medical director oversee the quality of clinical care provided in every facility. Facilities aren't even making it easier for residents to cope; the average facility provided less than ½ minute (30 seconds) per resident day of a mental health service worker’s time. The CMS's Incentive Payment Program (IPP) and Quality Reporting Program (QRP) have awarded more than $10 billion in bonuses since 2018. For-profit chains (accounting for most of the market) continue to provide the worst outcomes. This explains why many residents view nursing home life as a "Fate Worse than Death," and why we warned that "More is not Always Better" - CMS Adds Staffing Information to Care Compare. Consider, also, the following:
- NYT: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public;
- Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death;
- Nursing Home Compare Does Not Accurately Reflect Patient Safety In Nursing Homes;
- Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators.
- Ruthlessly Investigate and Evaluate Facilities: In the worst cases, where institutional care is unavoidable and necessary, use every tool available, and don't default to the cleanest, closest, or most convenient facility. Check out our article, Choosing a Nursing Home or Skilled Nursing Facility: Navigating the Long-Term Care Crisis , for comprehensive guidance and links to valuable tools and information. Use ProPublica's Nursing Home Inspect for abuse history; demand social media policies in contracts.
- Legal Shields: To incentivize aging in place and prevent unnecessary and avoidable institutionalization, deploy legal tools ranging from advance directives to trusts. Check out our articles, Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place. Include in SDM and advance directives: "Choose homes with no abuse history; fund home care first." Trusts should withhold payments for poor care.
- Home as Priority: Use advance directives. Deploy technology. Leverage HCBS waivers (Missouri/Ohio) for aides.
- Caregiver Networks: Build SDM teams to monitor care; report red flags via ombudsmen (1-888-678-7277).
- Advocate for Reform: Support calls for bonus audits; contact your senator to tie payments to verified staffing.
The Tennessee scandal reveals a system rewarding neglect, but you can opt out. While this article has provided a thorough analysis of taxpayer-funded care failures, it is by no means comprehensive. The landscape evolves rapidly. Readers must remain vigilant, consulting ProPublica, AARP, and elder law attorneys while evaluating risks. By combining awareness with SDM and trusts, families can safeguard independence and thrive while aging in place. For support, consult a professional—your security depends on proactive engagement.
