Nursing Homes' 'Bonus for Bad Care' Scandal: A Utah Spotlight on a National Crisis, and Why It Matters for Seniors and Families

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.

What Does It Mean for Seniors and Their Families?For families, this means betrayal amid vulnerability. You select a "high-performing" home based on CMS stars, only to face neglect that drains savings, risks physical and psychological health, and emotional well-being, and strips seniors and their families of dignity.  For everyone, the financial toll is brutal: your taxes subsidize understaffing, leading to falls, infections, and worse, resulting in lawsuits and increased medical expenses, all of which are subsidized by taxpayer dollars.  Emotionally, it's devastating; trust is shattered, guilt amid suffering divides families and communities, and institutional alternatives only spread the misery, resulting in the "acuity mismatch" that we discussed in "Rising Malpractice Claims in Assisted Living."  Facilities profit from your trust, but care lags.Strategies to Avoid the Trap: Beyond Awareness to Autonomy

• 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.

Conclusion: Bonuses for Bad Care Are a Call to Action

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. 

Social Media Abuse in Nursing Homes: A Decade of Dignity Violations and the Urgent Case for Aging in Place

In the quiet corners of social media, where staff from nursing homes once shared "funny" moments with colleagues, a darker reality lurks: photos of residents with taped pig snouts, videos of aides spraying cleaning chemicals on a resident's private areas, and clips of dementia patients encouraged to vape. These aren't isolated pranks; they're part of a persistent pattern of demeaning, humiliating abuse, revealed in a 346-page report titled “Snapped and Exposed: Social Media Abuse in America’s Nursing Homes.” *Warning: the depictions can be graphic and heartbreaking*  Compiled by elder mistreatment expert Eilon Caspi and funded by Colorado's Long-Term Care Ombudsman Program, the report is based on 100 state investigations from 2017 to 2025 across 30 states compiled from ProPublica's Nursing Home Inspect database. The report documents over 200 such incidents, affecting 147 residents, 88% of whom suffer cognitive impairments. 
For readers of the Aging-in-Place Planning and Elderlaw Blog, this isn't just a scandal; it's a stark indictment of institutional care's dehumanizing risks, where privacy violations, retaliation against whistleblowers, and eroded empathy turn caregivers into objectifiers. As we've explored in such articles as: 

• Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place, 
• Optimizing Aging in Place: Leveraging Medication Management to Reduce Hospitalizations,  
• Navigating Family Disagreements in Caring for Others: Tips for Harmony and Legal Safeguards; 
• Frequent Use of Technology Slows Cognitive Decline: Empowering Seniors to Thrive in a Digital Age; and
• Integrating Supported Decision-Making into Advanced Directives and Estate Planning Documents: Empowering Seniors for Autonomous Aging in Place;

proactive tools like advanced directives, supported decision-making (SDM), caregiver agreements, and trusts can prevent such betrayals by prioritizing home-based dignity over facility dependence. This article unpacks the report's findings, the human cost of objectification, and why aging in place, bolstered by legal safeguards, remains the safer, more humane path.A Decade of Digital Cruelty: The Report's Alarming Findings
Caspi's report builds on ProPublica's landmark 2015 exposé, which first spotlighted staff sharing explicit resident photos on Snapchat, prompting a 2016 CMS memo asserting such abuse was unlawful (federal law prohibits causing mental/psychological harm). In 2016, the National Council of State Boards of Nursing (NCSBN) also published  "A Nurse's Guide to the Use of Social Media" (2018, updated 2023),  a concise, 12-page resource aimed at nurses, stressing that social media breaches can destroy trust and careers. It warns against posting identifiable patient info (even without names), as details like diagnoses or locations can reveal identities. Examples include sharing "hilarious" patient stories or photos. Consequences are stark: license revocation, lawsuits, and jail for HIPAA violations. Best practices, says the Guide, include strict privacy settings, no patient mentions, and reporting breaches, framed as ethical duties to maintain "dignity and respect" in nurse-patient relationships. Yet, a decade later, violations persist: Over 200 posts from 132 perpetrators (73% certified nursing assistants, or CNAs), including nudity, feces smears, and forced "performances" like singing with taped faces. Victims were overwhelmingly frail, 48% with moderate to severe cognitive impairment, making them easy targets for amusement.
The report's data paints a grim picture: These incidents occurred in less than 1% of the nation's 15,000 nursing homes, but underreporting is staggering, with dementia obscuring complaints, and implicit and explicit threats of retaliation and/or intimidation preventing others. Staff often dismissed harm, and facilities fail to investigate, despite CMS mandates. Caspi notes, "This form of abuse is deeply concerning, it is underrecognized, and understudied," calling for stronger enforcement and training. 
Caspi recently conducted a Webinar entitled "Abuse Posted on Social Media in Nursing Homes: A Hidden Danger to Older Adults,"  hosted by the Long Term Care Community Coalition, and published a series of tips on preventing social media abuse by staff in a guest column for McKnight’s last year. The Human Cost: Privacy Violations, Retaliation, and the Erosion of EmpathyThe privacy angle is devastating: Residents, stripped of consent, become unwitting stars in viral mockery, their vulnerabilities (incontinence, confusion) weaponized for likes. One case featured a CNA spraying cleaner on a man's genitals in a lift, captioned "Hygiene time!," a violation not just of HIPAA but of basic humanity. Retaliation looms large: As ProPublica found in 2015, whistleblowers were labeled "troublemakers," deterring accountability. Staff who report or complain face firing or shaming, fostering a culture of silence.  Imagine what that culture visits upon patients, weak, vulnerable, needy, and utterly reliant on their abusers. 
But the deeper wound is objectification, where residents become "props" for "content" rather than people. Objectification is, by definition, dehumanizing. If all people merit dignity, the vulnerable aged deserve it more. This loss of empathy signals disinterested care: When aides see a 90-year-old with dementia as a "funny meme" instead of a person with stories and fears, and a family who are left no alternative but to trust those to whom responsibility, by definition, is given, quality of care plummets, and misery is widely spread. 
The report shows that 73% of perpetrators were CNAs, who are systemically underpaid and overworked, suggesting that burnout breeds callousness. Caspi warns of "dismissive attitudes" downplaying humiliation, leading to unchecked neglect. In a system where facilities routinely fail to meet staffing standards, this empathy erosion manifests as delayed responses or ignored needs, turning "care" into cruelty.  
To victims and their families, though, it's more than cruel. It’s a profound betrayal of trust, that strikes harder than the same act by a janitor or kitchen worker. Why? Because CNAs aren’t peripheral staff; they’re the frontline guardians of dignity, trained, licensed, and entrusted with the most intimate care. 
The CNA’s Unique Role: Intimacy, Training, and Licensure
CNAs are the hands-on heart of long-term care, spending 70-80% of their direct resident time on bathing, feeding, toileting, and mobility, tasks that demand trust, intimacy, and vulnerability. Unlike janitors (focused on environment) or food workers (meal delivery), CNAs are licensed healthcare professionals with:

• State-Mandated Training: 75-180 hours covering ethics, infection control, and resident rights (e.g., dignity, privacy, abuse prevention), and reporting requirements, all per CMS requirements.

• Certification Exams: Passing the National Nurse Aide Assessment Program (NNAAP) or similar exam, including a skills evaluation, typically hands-on demonstration of 5 randomly selected tasks (e.g., handwashing, taking vital signs, transferring a resident). 

• Ongoing Education: Annual in-services on HIPAA, rules, and regulations.

This isn’t janitorial or cafeteria work, it’s therapeutic. A CNA’s touch can heal or harm; their words can comfort or crush. To a victim and the victim's family, when a CNA turns to abuse, it’s not a "bad apple" in a low-skill job; it’s a trained protector turning predator, weaponizing intimacy.  Residents and their families depend on them for survival, making betrayal visceral. Nursing homes decry resident cameras for "privacy" while employees expose them online, a hypocrisy that underscores the power imbalance. Families denied oversight can't protect loved ones from this digital abuse, amplifying the case for home-based alternatives where privacy is under your control.The Bigger Picture: A Symptom of Institutional Care's Flaws
Persistence reflects systemic rot: low wages, high turnover, and profit-driven models that erode empathy, objectifying residents as "units" rather than humans. Private equity-owned facilities prioritize costs over training, fostering environments where abuse thrives. The victims, mostly cognitively impaired, highlight vulnerability: Without voice, they suffer in silence, their dignity commodified for a laugh.
For aging in place, this is a clarion call: Home care, with vetted supporters via SDM agreements, restores humanity.  Family and friends know your quirks, but don't exploit your embarrassing moments. Aging in Place planning protects your autonomy, keeps you in your home or community, and foregoes facilities where empathy fades.Solutions: Reclaiming Dignity Through Proactive PlanningEmpower yourself:

• 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: Include in directives: "Prohibit any recording or sharing of my image without consent; violation triggers trust penalties."

• SDM for Oversight: Nominate supporters to monitor care, reporting violations via state ombudsmen (1-888-678-7277).

• Prioritize Home: Use an aging-in-place trust, or incorporate aging-in-place planning in both advance directives and SDM. Fund private care agreements with family, as in our "SDM-Driven Supplemental Advanced Directive," keeping dignity intact.

• Advocate for Reform: Support Caspi's call for mandatory training and enforcement—contact your senator.

Conclusion: Dignity Denied, Independence DemandedA decade after ProPublica's wake-up call, social media abuse persists, a symptom of institutional care's empathy deficit. For seniors, it's a reminder: Facilities objectify; homes humanize. While this article has provided a thorough examination of the report and its implications, it is by no means comprehensive. The landscape of elder abuse evolves rapidly, influenced by regulatory changes and cultural shifts. Readers must remain vigilant, consulting sources such as ProPublica, AARP, and local elder law attorneys to evaluate their situations and identify risks. By combining awareness with tools such as SDM agreements and trusts, seniors and families can better safeguard independence and thrive as they age in place. For ongoing support, consult a professional and stay informed—your security depends on proactive engagement.