The care at Landmark of Louisville Rehabilitation and Nursing was abysmal when state inspectors filed their survey report of the Kentucky facility on July 3, 2021.

Residents wandered the halls in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate with a stick, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead gash. That person was allowed to roam and enter the beds of other residents. In another case, there was sexual touching in the dayroom between residents, according to the report.

Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors. The director of housekeeping reported that the dining room was unsanitary. Overall, there was a critical lack of training, staff and supervision.

The inspectors tagged Landmark as deficient in 29 areas, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The issues were so severe that the government slapped Landmark with a fine of over US$319,000 − more than 29 times the average for a nursing home in 2021 − and suspended payments to the home from federal Medicaid and Medicare funds.

But problems persisted. Five months later, inspectors levied six additional deficiencies of immediate jeopardy − the highest level.

Landmark is just one of the 58 facilities run by parent company Infinity Healthcare Management across five states. The government issued penalties to the company almost 4½ times the national average, according to bimonthly data that the Centers for Medicare & Medicaid Services first started to make available in late 2022. All told, Infinity paid nearly $10 million in fines since 2021, the highest among nursing home chains with fewer than 100 facilities.

Infinity Healthcare Management and its executives did not respond to multiple requests for comment.

Race to the bottom

Such sanctions are nothing new for Infinity or other for-profit nursing home chains that have dominated an industry long known for cutting corners in pursuit of profits for private owners. But this race to the bottom to extract profits is accelerating, despite demands by government officials, health care experts and advocacy groups to protect the nation’s most vulnerable citizens.

To uncover the reasons why, The Conversation delved into the nursing home industry, where for-profit facilities make up more than 72% of the nation’s nearly 14,900 facilities. The probe, which paired an academic expert with an investigative reporter, used the most recent government data on ownership, facility information and penalties, combined with CMS data on affiliated entities for nursing homes.

The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under weak and poorly enforced regulations with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health.

Meanwhile, owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporations. Federal regulators have neglected the problem as each year likely billions of dollars are funneled out of nursing homes through related parties and into owners’ pockets.

More trouble at midsize

Analyzing newly released government data, our investigation found that these problems are most pronounced in nursing homes like Infinity − midsize chains that operate between 11 and 100 facilities. This subsection of the industry has higher average fines per home, lower overall quality ratings, and are more likely to be tagged with resident abuse compared with both the larger and smaller networks. Indeed, while such chains account for about 39% of all facilities, they operate 11 of the 15 most-fined facilities.

With few impediments, private investors who own the midsize chains have swooped in to purchase underperforming homes, expanding their holdings even as larger chains divest and close facilities.

“They are really bad, but the names − we don’t know these names,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a nonprofit law organization.

In response to The Conversation’s findings on nursing homes and request for an interview, a CMS spokesperson emailed a statement that said the CMS is “unwavering in its commitment to improve safety and quality of care for the more than 1.2 million residents receiving care in Medicare- and Medicaid-certified nursing homes.”

“We support transparency and accountability,” the American Health Care Association/National Center for Assisted Living, a trade organization representing the nursing home industry, wrote in response to The Conversation‘s request for comment. “But neither ownership nor line items on a budget sheet prove whether a nursing home is committed to its residents.”

Ripe for abuse

It often takes years to improve a poor nursing home − or run one into the ground. The analysis of midsize chains shows that most owners have been associated with their current facilities for less than eight years, making it difficult to separate operators who have taken long-term investments in resident care from those who are looking to quickly extract money and resources before closing them down or moving on. These chains control roughly 41% of nursing home beds in the U.S., according to CMS’s provider data, making the lack of transparency especially ripe for abuse.

A churn of nursing home purchases even during the pandemic shows that investors view the sector as highly profitable, especially when staffing costs are kept low and fines for poor care can easily be covered by the money extracted from residents, their families and taxpayers.

A March 2024 study from Lehigh University and the University of California, Los Angeles also shows that costs were inflated when nursing home owners switched to contractors they controlled directly or indirectly. Overall, spending on real estate increased 20.4% and spending on management increased 24.6% when the businesses were affiliated, the research showed.

“This is the model of their care: They come in, they understaff and they make their money,” said Sam Brooks, director of public policy at the Consumer Voice, a national resident advocacy organization. “Then they multiply it over a series of different facilities.”

This is a condensed version of an article from The Conversation’s investigative unit. To find out more about the rise of for-profit nursing homes, financial trickery and what could make the nation’s most vulnerable citizens safer, read the complete version.

Campbell is an adjunct assistant professor at Columbia University and a contributing writer at the Garrison Project, an independent news organization that focuses on mass incarceration and criminal justice.

Harrington is an advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021.

Read More

It's actually fairly rare that a company files for Chapter 11 bankruptcy without throwing off signs that it's in deep financial trouble. Observant customers sometimes see the signs.

You might notice lower staffing levels or poor inventory in a retail setting. Restaurants facing financial troubles might drop the quality of their ingredients, cut portion sizes, or find other ways to cut corners.

Related: Fast-food chain closes restaurants after Chapter 11 bankruptcy

It's generally impossible to cut your way to a good financial position unless you were making huge mistakes in the first place. A company might find some savings by examining its operations and focuing on waste in areas customers don't see, but giving people less almost never works.

In many businesses, especially when companies are publicly traded, signs of upcoming financial trouble are obvious. 

Public companies have to report their financial results and when there's more money going out than coming in, and cash balances get low, observant analysts can see a company likely to default on its bills that may be headed for bankruptcy well before it happens.

CreditSafe Head of Brand Ragini Bhalla recently shared her company's Financial & Bankruptcy Outlook: Transportation Report and some comments on it with TheStreet. 

The report shows that three big-name companies in the travel/transportation space are facing significant financial risk, which is reflected in their stock prices. Bhalla gave some color as to why companies in those markets are struggling.

The transportation industry faces a crisis  

Bhalla shared her thoughts on what Creditsafe found.

"We are reflecting on the current challenges faced by transportation companies and the total industry outlook. During the pandemic, M&A activity in the industry soared, as transportation players and investors made deals to extend capabilities and acquire high-performing assets. To that end, deal values soared from $51 billion in 2020 to more than $150 billion in 2021, before it dipped to $95 billion in 2022," she said in an email to TheStreet.

Bhalla said she sees a different pattern in 2024.

"While M&A activity in the transportation industry cooled down in 2023, industry insiders are projecting that 2024 will be the year of consolidation. If that’s the case, then it will be more important than ever for both sides (sellers and buyers) to do their due diligence," she wrote.

Not every company that would benefit from being acquired will survive the M&A scrutiny.

"This should include various elements, such as running business credit checks on potential acquisitions to make sure they would be a good investment and aren’t in dire financial straits. It should also include running comprehensive compliance checks to make sure potential acquisitions aren’t violating sanctions, haven’t been convicted of regulatory violations, and aren’t involved in unethical practices like bribery, corruption, fraud, and the use of child/forced labor," she added.

One airline, two rental cars are at risk

Spirit Airlines  (SAVE) has been on unofficial bankruptcy watch since the company's merger with JetBlue  (JBLU)  fell apart. There are real questions as to whether the super-low-cost airline model works, and Creditsafe sees a real risk of the airline ending up filing for Chapter 11 bankruptcy.

"Earlier this year, Spirit Airlines said it was looking to refinance its debt and hopes to refinance $1.1 billion of debt due in 2025," according to Creditsafe. "To make matters worse, the airline doesn’t have a stable track record of paying bills on time."

Not paying bills on time is often a sign that a company is running out of cash.

"Late payments increased over several months in 2023. For example, the number of late payments (1-30 days) rose from 7.00% in September 2023 to 30.87% in October 2023. A similar pattern occurred soon after when the number of late payments (1-30 days) rose from 6.37% in November 2023 to 30.54% in December 2023 and then again to 51.08% in January 2024," Creditsafe data showed.

Investors are shying from the stock. Shares were at $4.29 down 73.8% on the year as of Friday.

Two rental car companies, Avis Budget Group  (CAR) and Hertz (HTZ) are facing similar woes.

"Avis Budget Group's long-term debt has consistently increased for the last three years, and how late the company paid its bills spiked drastically from 8 days late in March to 31 days in April and remained high until September 2023," Creditsafe shared.

Hertz has been following a similar path.

"The company’s number of delinquent payments (91+ days) increased consistently during the second half of 2023. For instance, the number of delinquent payments (91+ days) rose from 4.64% in August to 6.90% in September, then rose again to 10.73% in October 2023, indicating it is having trouble paying its bills," according to Creditsafe.

Avis Budget closed Friday at $107.70 and are down 39.2% this year. Hertz finished Friday at $7.58, down 25.7% on the year.

Read More

Read More