top of page

How Nursing Homes' Worst Offenses Are Hidden From the Public

Thousands of problems identified by state inspectors were never publicly disclosed because of a secretive appeals process, a New York Times investigation found.

Tammy Bowman and her husband. Ms. Bowman’s sister died in an Indiana nursing home that did not isolate residents suspected of having Covid-19.

Credit...Johnathon Kelso for The New York Times

By Robert Gebeloff, Katie Thomas and Jessica Silver-Greenberg Dec. 9, 2021

In Arizona, a nursing home resident was sexually assaulted in the dining room.

In Minnesota, a woman caught Covid-19 after workers moved a coughing resident into her room.

And in Texas, a woman with dementia was found in her nursing home’s parking lot, lying in a pool of blood.

State inspectors determined that all three homes had endangered residents and violated federal regulations. Yet the federal government didn’t report the incidents to the public or factor them into its influential ratings system. The homes kept their glowing grades.

A New York Times investigation found that at least 2,700 similarly dangerous incidents were also not factored into the rating system run by the federal Centers for Medicare and Medicaid Services, or C.M.S., which is designed to give people reliable information to evaluate the safety and quality of thousands of nursing homes.

Many of the incidents were uncovered by state inspectors and verified by their supervisors, but quashed during a secretive appeals process, according to a review of thousands of pages of inspection reports and nursing home appeals, which The Times obtained via public-records requests. Others were omitted from the C.M.S. ratings website because of what regulators describe as a technical glitch.

The Times this year has documented a series of problems with Medicare’s ratings system. Much of the data that powers the system is wrong and often makes nursing homes seem cleaner and safer than they are. The rating system also obscures how many residents are receiving powerful antipsychotic drugs.