If you would like a copy of this data, please email elucas@kff.org.

Data analysis by KHN data editor Elizabeth Lucas and KHN senior correspondent Jordan Rau. Data visualizations by KHN producer Caitlin Hillyard.

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Bajo la administración actual, la multa promedio se redujo a $28,405, muy por debajo de los $41,260 en 2016, el último año en el cargo del presidente Barack Obama, según muestran registros federales.

La disminución de las multas es uno de los ejemplos más concretos de cómo la administración Trump está dando marcha atrás la agresiva regulación de servicios de atención médica de Obama, en respuesta a la insistencia de la industria.

Alentados por la industria de hogares de adultos mayores, de multar a estos hogares por cada día que no cumplían con los requisitos, como lo hizo la administración de Obama, a emitir una multa única por dos tercios de las infracciones, según registros.

Eso reduce las sanciones, dando a los hogares menos incentivos para reparar prácticas defectuosas y peligrosas antes que alguien termine lastimado.

“El comportamiento [en los hogares] no está cambiando de la manera que queremos”, dijo el doctor Ashish Jha, profesor de la Escuela T. H. Chan de Salud Pública de Harvard. “Para un hogar pequeño podría ser dinero real, pero para los más grandes es más probable que sea un error de redondeo”.

Desde que Trump asumió el cargo, la administración ha prestado atención a múltiples quejas sobre las supervisiones entusiastas en hogares. Se les otorgó a las instalaciones una moratoria de 18 meses para pagar multas por violar ocho normas nuevas de salud y seguridad. También se revocó una regla de la era Obama que prohibía a los hogares solicitar de manera preventiva que los residentes se sometan a un arbitraje para resolver las disputas, en lugar de acudir a los tribunales.

La disminución de las multas se produjo incluso cuando los Centros de Servicios de Medicare y Medicaid (CMS) emitieron multas financieras con un 28% más de frecuencia que bajo Obama. Esto se debe a que comenzó cerca del final del mandato de Obama que exigía a los reguladores castigar a una instalación cada vez que un residente resultara lastimado, en lugar de dejarlo a su propia discreción.

Si bien esa política aumentó el número de multas más pequeñas, las más grandes se volvieron menos comunes. La cantidad total recaudada bajo Trump cayó un 10% en comparación con el total en el último año de Obama, de $127 millones bajo Obama a $114 millones con Trump. (KHN comparó las sanciones durante 2016, el último año de Obama en el cargo, con las sanciones de Trump desde abril de 2017 hasta marzo de 2018, el mes más reciente para el cual los funcionarios federales dicen que los datos están completos de manera confiable).

Los CMS dijeron que han revisado las múltiples reglas que regulan las multas en ambas administraciones para hacer que sus castigos sean más justos, más consistentes y mejor adaptados a los hogares, con la meta de mejorar la atención. “Continuamos analizando el impacto de estos eventos combinados para determinar si son necesarias otras acciones”, dijeron los CMS en un comunicado.

La medida es ampliamente consistente con otras políticas amigables con la industria de la administración Trump en el sector de la atención médica. Por ejemplo, la administración ha ampliado el papel de los planes de salud de corto plazo que no cubren todos los servicios, les ha dado a los estados más libertad para cambiar sus programas de Medicaid y ha instado al Congreso a permitir que .

Beth Martino, vocero de la American Health Care Association, un grupo comercial de hogares de adultos mayores, dijo que el gobierno federal ha “regresado a un método para aplicar multas de una manera que incentiva la resolución de problemas” en lugar de penalizar a “las instalaciones que están tratando de hacer las cosas bien”.

Las pautas de penalización se endurecieron en 2014, cuando el gobierno de Obama instruyó a los funcionarios a . Para el año 2016, se emitieron en dos tercios de los casos. Esas multas promediaron los $61,000.

Cuando asumió Trump, la industria de hogares se quejó de que las multas estaban “fuera de control” y que se habían vuelto desproporcionadas comparado con las deficiencias. “Hemos visto un aumento dramático en [multas] que se emiten retroactivamente y se usan como castigo”, escribió Mark Parkinson, presidente del grupo de hogares, en marzo de 2017.

Los CMS estuvieron de acuerdo en que las multas diarias a veces resultaban en castigos determinados por el resultado de una inspección aleatoria en lugar de la severidad de la infracción. Si los inspectores visitaran una casa en abril, por ejemplo, y descubrieran que una práctica inadecuada había comenzado en febrero, las multas diarias acumuladas serían el doble de si los inspectores hubieran ido a la instalación en marzo.

Pero cambiar a la preferencia de multas por instancia significa multas mucho más bajas, ya que estas multas tienen un límite de $21,393, ya sea que se apliquen por instancia o por día. Las casas que pagan sin impugnar la multa reciben un descuento del 35%, lo que significa que actualmente pagan un máximo de $13,905.

Esos máximos se aplican incluso a los hogares que se considera que han cometido el nivel más grave de violaciones, lo que se conoce como peligro inmediato porque las prácticas del hogar ponen a los residentes en un riesgo inminente de lesiones. Por ejemplo, una residencia en Mississippi recibió una multa de $13,627 después de quedarse sin medicamentos , en Atlanta. Los CMS también redujeron una suma de multas diarias de $54,600 a una sola multa de $20,965 para un hogar en Nuevo México donde los trabajadores no habían desinfectado adecuadamente los equipos para evitar que las .

En promedio, las multas por instancia bajo Trump estuvieron por debajo de los $9,000, según los registros.

“Estas son empresas multimillonarias: $9,000 no es nada”, dijo Toby Edelman, abogado senior de políticas del Center for Medicare Advocacy, una organización sin fines de lucro en Washington.

Las multas diarias grandes, con un promedio de $68,080, todavía se emiten cuando una instalación no ha corregido una infracción después de ser citada. Pero incluso en esos casos, a los funcionarios de los CMS se les permite hacer excepciones y emitir una multa si el hogar no tiene antecedentes de violaciones sustanciales.

La agencia advirtió que las comparaciones de multas promedio son engañosas porque el número total de inspecciones que resultaron en multas aumentaron bajo Trump, de 3.5% en 2016 a 4.7%. Las circunstancias que justifican las multas que no se emitieron antes tienden a imponer penalizaciones en el lado más bajo.

Sin embargo, KHN halló que las sanciones económicas por daños inmediatos se emitieron en menos casos bajo Trump. Y cuando se emitieron, las multas promediaron un 18% menos que en 2016.

La frecuencia de las multas de peligro inmediato puede disminuir aún más. En junio, los CMS les dijeron a los inspectores que ya no se les exigía multar a las instalaciones a menos que las violaciones de riesgo inmediato resultaran en “lesiones graves, daños, deterioro o muerte”. Los reguladores todavía deben tomar algunas medidas, pero eso podría ser ordenar a la casa que tenga una capacitación organizada por un grupo externo, u ordenar cambios específicos en la forma en que funciona el hogar.

Barbara Gay, vicepresidenta de comunicaciones de políticas públicas en LeadingAge, una asociación de organizaciones sin fines de lucro que brindan servicios para adultos mayores, incluidos hogares, dijo que, bajo Trump, estos hogares “no sienten que hayan recibido un indulto”.

Pero los defensores de los consumidores dicen que las sanciones han vuelto a niveles demasiado bajos para ser efectivas. “Las multas deben ser lo suficientemente grandes como para cambiar el comportamiento de las instalaciones”, dijo Robyn Grant, director de política pública y defensa en National Consumer Voice for Quality Long-Term Care, una organización sin fines de lucro con sede en Washington. “Cuando ese no es el caso y la multa es intrascendente, la atención generalmente no mejora”.

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The average fine dropped to $28,405 under the current administration, down from $41,260 in 2016, President Barack Obama’s final year in office, federal records show.

The decrease in fines is one of the starkest examples of how the Trump administration is rolling back Obama’s aggressive regulation of health care services in response to industry prodding.

Encouraged by the nursing home industry, the from fining nursing homes for each day they were out of compliance — as the Obama administration typically did — to issuing a single fine for two-thirds of infractions, the records show.

That reduces the penalties, giving nursing homes less incentive to fix faulty and dangerous practices before someone gets hurt.

“It’s not changing behavior [at nursing homes] in the way that we want,” said Dr. Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health. “For a small nursing home it could be real money, but for bigger ones it’s more likely a rounding error.”

Since Trump took office, the administration has heeded multiple nursing home complaints about zealous oversight. It granted facilities an 18-month moratorium from being penalized for violating eight new health and safety rules. It also revoked an Obama-era rule barring homes from pre-emptively requiring residents to submit to arbitration to settle disputes rather than go to court.

The slide in fines occurred even as the Centers for Medicare & Medicaid Services issued financial penalties 28 percent more frequently than it did under Obama. That’s due to a begun near the end of Obama’s term that required regulators to punish a facility every time a resident was harmed, instead of leaving it to their discretion.

While that policy increased the number of smaller fines, larger fines became less common. The total amount collected under Trump fell by 10 percent compared with the total in Obama’s final year, from $127 million under Obama to $114 million under Trump. (KHN compared penalties during 2016, Obama’s last year in office, with penalties under Trump from April 2017 through March 2018, the most recent month for which federal officials say data is reliably complete.)

(Story continues below.)

CMS said it has revised multiple rules governing fines under both administrations to make its punishments fairer, more consistent and better tailored to prod homes to improve care. “We are continuing to analyze the impact of these combined events to determine if other actions are necessary,” CMS said in a statement.

The move is broadly consistent with the Trump administration’s other industry-friendly policies in the health care sector. For instance, the administration has expanded the role of short-term insurance policies that don’t cover all types of services, given states more leeway to change their Medicaid programs and to open their own hospitals.

Beth Martino, a spokeswoman for the American Health Care Association, a nursing home trade group, said the federal government has “returned to a method of applying fines in a way that incentivizes solving problems” rather than penalizing “facilities that are trying to do the right thing.”

Penalty guidelines were toughened in 2014, when the Obama administration instructed officials to . By 2016, those were used in two-thirds of cases. Those fines averaged $61,000.

When Trump took over, the nursing home industry complained that fines had spun “out of control” and become disproportionate to the deficiencies. “We have seen a dramatic increase in [fines] being retroactively issued and used as a punishment,” Mark Parkinson, president of the nursing home group, wrote in March 2017.

CMS agreed that daily fines sometimes resulted in punishments that were determined by the random timing of an inspection rather than the severity of the infraction. If inspectors visited a home in April, for instance, and discovered an improper practice had started in February, the accumulated daily fines would be twice as much as if the inspectors had come in March.

But switching to a preference for per-instance fines means much lower penalties, since fines are capped at $21,393 whether they are levied per instance or per day. Homes that pay without contesting the fine receive a 35 percent discount, meaning they currently pay at most $13,905.

Those maximums apply even to homes found to have committed the most serious level of violations, which are known as immediate jeopardy because the home’s practices place residents at imminent risk of harm. For instance, a Mississippi nursing home was fined $13,627 after it ran out of medications because it had been 373 miles away, in Atlanta.  CMS also reduced $54,600 in daily fines to a single fine of $20,965 for a New Mexico home where workers hadn’t been properly disinfecting equipment from spreading.

On average, per-instance fines under Trump were below $9,000, records show.

“These are multimillion businesses — $9,000 is nothing,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, a nonprofit in Washington.

Big daily fines, averaging $68,080, are still issued when a home hasn’t corrected a violation after being cited. But even in those cases, CMS officials are allowed to make exceptions and issue a single fine if the home has no history of substantial violations.

The agency cautioned that comparisons of average fines is misleading because the overall number of inspections resulting in fines increased under Trump, from 3.5 percent in 2016 to 4.7 percent. The circumstances now warranting fines that weren’t issued before tend to draw penalties on the lower side.

However, KHN found that financial penalties for immediate jeopardies were issued in fewer cases under Trump. And when they were issued, the fines averaged 18 percent less than they did in 2016.

The frequency of immediate-jeopardy fines may further decrease. CMS told inspectors in June that they were no longer required to fine facilities unless immediate-jeopardy violations resulted in “serious injury, harm, impairment or death.” Regulators still must take some action, but that could be ordering the home to arrange training from an outside group or mandating specific changes to the way the home operates.

Barbara Gay, vice president of public policy communications at LeadingAge — an association of nonprofit organizations that provide elder services, including nursing homes — said that, under Trump, nursing homes “don’t feel they’ve been given a reprieve.”

But consumer advocates say penalties have reverted to levels too low to be effective. “Fines need to be large enough to change facility behavior,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, a nonprofit based in Washington. “When that’s not the case and the fine is inconsequential, care generally doesn’t improve.”

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Her right forearm and her pacemaker were inside one of the alligators that lived in the pond.

Like 4 in 10 residents in assisted living facilities, Walker, 90, had dementia. Shortly after midnight one day in July 2016, she slipped out of her facility, Brookdale Charleston, as she had done a few days before. This time, no one noticed her missing for seven hours.

“No one should have to pass away that way,” her granddaughter Stephanie Weaver said.

Assisted living facilities were originally designed for people who were largely independent but required help bathing, eating or with other daily tasks. Unlike nursing homes, the facilities generally do not provide skilled medical care or therapy, and stays are not paid for by Medicare or Medicaid.

Dementia care is the fastest-growing segment of assisted living. As these residences market themselves to people with Alzheimer’s and other types of dementia, facilities across the country are straining to deliver on their promises of security and attentive care, according to a Kaiser Health News analysis of inspection records in the three most populous states.

In California, 45 percent of assisted living facilities have violated one or more state dementia regulations during the past five years. Three of the in 2017 were related to dementia care.

In Florida, 1 in 11 assisted living facilities have been cited since 2013 for not meeting state rules designed to prevent residents from wandering away.

And in Texas, nearly a quarter of the facilities that accept residents with Alzheimer’s have violated one or more state rules related to dementia care, such as tailoring a plan for each resident upon admission or ensuring that staff members have completed special training, according to nearly six years of records.

“There is a belief in our office that many facilities do not staff to the level” necessary to meet the unanticipated “needs of residents, especially medical needs,” said Fred Steele, Oregon’s long-term care ombudsman. “. They are setting staffing ratios that maybe aren’t being set because of the care needs of the residents but are more about the bottom line of their profits.”

Uneven Regulation

These concerns, though particularly acute for people with dementia, apply to all assisted living residents. They are older and frailer than assisted living residents were a generation ago. Within a year, 1 in 5 experience a fall, 1 in 8 visit an emergency room and 1 in 12 have an overnight hospital stay, according to the Centers for Disease Control and Prevention. Half are .

“Assisted living was created to be an alternative to nursing homes, but if you walk into some of the big assisted living facilities, they sure feel like a nursing home,” said Doug Pace, director for mission partnerships with the Alzheimer’s Association.

Yet the rules for assisted living remain looser than for nursing homes. The federal government does not license or oversee assisted living facilities, and some .

The government does not publish quality measures as it does for nursing homes. Inspections usually are less frequent, and fines are generally far lower than what a nursing home might incur for a similar mistake.

Lindsay Schwartz, an associate vice president at the National Center for Assisted Living, an industry group, said facilities must balance safety with allowing people with dementia to move about as freely as possible and to socialize.

“Dementia is a difficult disease,” she said. “Freedom of movement is incredibly important for overall health, mind, body and spirit. You can’t keep people in isolation.”

The industry says rigid government regulations don’t mesh with the individual approaches that assisted living facilities aspire to create for residents.

But residents’ families, their lawyers and advocates say the violent behavior of agitated residents and escapes could be avoided with better training and more staff. Eliza Cantwell, a Charleston, S.C., plaintiffs’ lawyer, said too many facilities were accepting residents they weren’t prepared to adequately care for because they wanted to maximize their income.

“They don’t have the qualified personnel to take care of these people, and they’re taking care of them anyway,” she said.

Cantwell is representing Weaver in a suit against Brookdale for emotional distress, which Weaver says came from being among the first people to discover her grandmother’s body. Brookdale has already settled a wrongful-death claim from Bonnie Walker’s estate.

The company declined to discuss Weaver’s lawsuit and said in a statement that “our everyday focus and priority is to keep residents safe.” Brookdale called Walker’s death “an unfortunate accident” and said it has retrained its staff.

A year after Walker’s death, after four inspections, the South Carolina Department of Health and Environmental Control fined Brookdale for 11 violations, including not properly performing night checks and letting staffing drop below required levels. The penalty: $6,400.

“I worked as a law enforcement agent for the Department of Natural Resources, and I’ve written wildlife tickets larger than what DHEC did,” Weaver said. “This was nothing.”

‘Get Him Away From Me’

Nearly a quarter of the nation’s assisted living facilities either house only people with dementia or have special areas known as memory care units. These wings have locked doors and other safeguards to prevent residents from leaving. The facilities often train staff members in techniques to manage behavior related to these diseases and provide activities to keep the residents engaged and stimulated.

These units usually are more expensive, with monthly costs averaging $6,472, compared with $4,835 for regular assisted living, according to a survey by the National Investment Center for Seniors Housing & Care, a group that analyzes elder care market trends. Senior housing investors in annual returns over the past five years, higher than for apartment, hotel, office and retail properties, according to the center. Beth Burnham Mace, chief economist at the center, said memory care unit construction was outpacing all other types of senior housing.

Aggressive behavior, a hallmark of dementia, is a major problem in assisted living facilities. One , published in 2016, found that 8 percent of assisted living residents were physically aggressive or abusive toward residents or staff.

In the dementia unit of The Point at Rockridge, an assisted living facility in Oakland, Calif., a resident identified in court papers as Ian began to follow another resident, Olivia Deloney, an 88-year-old with dementia. Before retiring, she had been dean of students at a school for the blind.

“That man is crazy,” one employee recalled Deloney saying, according to the employee’s sworn statement. “Get him away from me.”

In September 2015, Ian grabbed Deloney and threw her to the ground, breaking her right hip, a video shows. When paramedics were putting her into a stretcher, Ian tried to kick her, and the emergency workers had to keep him away, the police report said.

Afterward, the administrators told Deloney’s daughter, Simone Stevens, that they had not known that Ian, a retired university facilities engineer, was dangerous, her lawsuit said.

“They just made it sound like it was like a freak accident: ‘He’s really just a calm and likable resident,’” Stevens said in an interview.

A state investigation report said The Point had been trying to address his behavioral problems before the attack. State regulators , saying in their report that there was “insufficient” evidence that the facility had “clear knowledge” Ian would be a danger to other residents.

But when Stevens sued The Point, her lawyer, Felicia Curran, discovered that Ian’s agitated behavior, including pushing and shoving, had been the reason his wife initially placed him there. At The Point, he had punched one aide in the shoulders, grabbed another by the neck and jumped on a third and beaten her, employees said in statements taken by Curran.

“It was an everyday thing for him to chase staff and be physically aggressive,” one declared. Aides posted a photo of him in their kitchen, warning colleagues to watch out for his violent outbursts, and employees once locked themselves in bathrooms for protection, according to records in the case.

“They should have never had him there in the first place,” Stevens said.

Tracee DeGrande, the president of Integral Senior Living, which owns The Point, wrote in a statement that the episode was not typical. “Our staff associates work hard to care for residents, many of whom would have nowhere to go if we didn’t provide a place for those living with dementia and Alzheimer’s disease,” she wrote.

After the attack, The Point evicted Ian. Deloney returned to the facility, but, less stable after surgery, she fell and broke her hip again. She stopped eating and died that December, according to her family’s lawsuit, which blamed The Point for not increasing supervision in light of Deloney’s weakened state.

The Point paid $1.9 million to settle the case. DeGrande wrote that the “settlement was in no way an admission of responsibility for what ended up as a difficult and sad situation.”

To calm agitated residents, some facilities are on psychotropic drugs, which carry increased risk of strokes, falls and confusion. An funded by the National Institutes of Health has discovered that 27 percent of residents with dementia take an antipsychotic medication, and most lack documentation assuring the drugs are justified, said the lead investigator, Sheryl Zimmerman, a health researcher at the University of North Carolina at Chapel Hill.

Zimmerman said such drugs are often not necessary if residents are cared for by experienced aides who can de-escalate troubling behaviors and know techniques that engage and soothe those with dementia. But she said low pay and frequent turnover make that difficult. “The workforce could be better trained than they are,” Zimmerman said.

Requirements Vary By State

Staffing and training requirements vary greatly from state to state. A and led by Paula Carder, a professor at Portland State University, found that only seven states required facilities to have a registered nurse. States required anywhere from two to 30 hours of training for dementia unit workers. A handful of states required no specialized training, according to the study. Carder found that 19 states set minimum staff-to-resident ratios for dementia units, while the others left it to the facilities.

North Carolina requires one of the tightest staffing ratios in the nation for dementia units: residents during the day and evening.

In a lawsuit, Michele Mullen asserted that Franklin Manor Assisted Living in Youngsville, N.C., did not meet North Carolina’s staffing minimums on a third of the days her mother, Claire Murphy, lived there in 2015 and 2016.

She said she would find her mother with her pants wet with urine all the way down to her knees, according to a deposition she gave in the lawsuit. Mullen said aides had repeatedly misplaced her mother’s walker. She would see her mother holding onto the hallway railing as she tried to get to her room. On New Year’s Day in 2016, her mother fell and was hospitalized for a fractured arm.

Gregory Nicoluzakis, the general counsel for Saber Healthcare Group, which owns Franklin Manor, said in an email that Mullen’s allegations were inaccurate. “We believe it is telling that Ms. Mullen admitted her mother to our facilities on three separate occasions despite having the choice of other providers,” he wrote.

Drew Hathaway, an attorney for Mullen, said there were no better alternatives nearby that had memory care units. “There are not that many facilities in these rural areas,” Hathaway said. “That’s the sad reality.”

Franklin Manor was fined in 2016 for not following doctors’ orders that two residents needed to use walkers. In February, the state cited it for not supervising five residents, all with histories of falling, who had fallen and injured themselves. Nicoluzakis said Franklin Manor was in compliance with state regulations.

Mullen ultimately removed her mother from Franklin Manor; Murphy died last December.

“I would say, ‘Mom needs to go to the bathroom.’ ‘Mom needs help with this,’” Mullen recalled in her deposition. “And they would look at me and actually say, ‘Why don’t you do it?’”

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Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes as required by the Affordable Care Act of 2010, rather than relying as it had before on the nursing homes’ own unverified reports.

The payroll records revealed lower overall staffing levels than homes had disclosed, particularly among registered nurses. Those are the highest-trained caregivers required to be in a nursing home, and they supervise other nurses and aides. Medicare mandates that every facility have a registered nurse working at least eight hours every day.

“It’s a real positive that they actually are taking the payroll-based system seriously, that they’re using it to punish those nursing homes that either aren’t reporting staffing or those that are below the federal limit,” said David Grabowski, a professor of health care policy at Harvard Medical School. “Could they do more? Sure, but I think it’s a really good start.”

Nursing home industry officials have acknowledged that some facilities are struggling to meet the new payroll reporting requirements. Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services including nearly 2,000 nursing homes, said the lowered star ratings were disappointing and attributed them largely to a workforce shortage.

“Our members are battling on multiple fronts to recruit and retain all types of qualified staff, and nurses in particular,” she said in a statement.

Medicare rates nursing homes on a five-star system, and the homes’ failures to either keep the facilities consistently staffed with registered nurses or to provide the data to prove they were doing so led the government to give its lowest rating for staffing to 1,387 of the nation’s 15,616 skilled nursing facilities, according to a Kaiser Health News analysis of the latest data released by Medicare. They all received one star out of a possible five on July 25, when Medicare updated its website, replacing the first ratings based on payroll data issued in April.

In footnotes on the site, Medicare said those homes either lacked a registered nurse for “a high number of days” over three months, provided data the government couldn’t verify or didn’t supply their payroll data at all. The downgraded homes reported seven or more days without any registered nurses, the analysis found.

For roughly half of the homes, the downgrades lowered their overall star ratings, which are the measures displayed most prominently on the site. But some of the homes saw their overall ratings stay the same or even rise, buoyed by their scores on other quality measures. Seventy-nine are still rated with a coveted five stars.

While the Kaiser Health News analysis found substantially lower average staffing of nurses and aides at for-profit facilities than at nonprofits and government-owned homes, the number of downgraded nursing homes was roughly proportionally divided among the three categories, indicating an industry-wide issue with staffing by registered nurses in particular.

Medicare concedes that because the payroll system is geared toward reporting hourly work, salaried staff may not always be reflected correctly, especially if they were working overtime. But Medicare the nursing homes in April that the downgrades would be coming if facilities continued to show no registered nurses on duty. The agency noted it has been preparing nursing homes since 2015 for the new payroll system.

“We’ve just begun to leverage this new information to strengthen transparency and enforcement with the goals of improved patient safety and health outcomes,” the Centers for Medicare & Medicaid Services said in a statement.

The new payroll data, analyzed by Kaiser Health News, showed that for-profit nursing homes averaged 16 percent fewer staff than did nonprofits, even after accounting for differences in the needs of residents. The biggest difference was in the number of registered nurses: At the average nonprofit, there was one RN for every 28 residents, but at the average for-profit, there was only one RN for every 43 residents. Researchers have repeatedly found lower staffing in for-profit facilities, which make up 70 percent of the industry.

The data also revealed that nursing homes have large fluctuations in staffing. The average nursing home had one licensed nurse caring for as few as 17 residents or as many as 33, depending on the day. On the best-staffed days, each certified nursing assistant or other aide cared for nine residents, but on the worst-staffed days, each aide was responsible for 16 residents.

Weekend staffing was particularly sparse. On weekends on average, there were 11 percent fewer nurses providing direct care and 8 percent fewer aides.

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The records for the first time reveal frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. On the worst-staffed days at an average facility, the new data show, on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest.

The data, analyzed by Kaiser Health News, come from daily payroll records Medicare only recently began gathering and publishing from more than 14,000 nursing homes, as required by the Affordable Care Act of 2010. Medicare previously had been rating each facility’s staffing levels based on the homes’ own unverified reports, .

The payroll records provide the strongest evidence that, over the past decade, the government’s five-star rating system for nursing homes often exaggerated staffing levels and rarely identified the periods of thin staffing that were common. Medicare is now relying on the new data to evaluate staffing, but the revamped star ratings still mask the erratic levels of people working from day to day.

At the Beechtree Center for Rehabilitation & Nursing here, Jay Vandemark, 47, who had a stroke last year, said he often roams the halls looking for an aide not already swamped with work when he needs help putting on his shirt.

Especially on weekends, he said, “it’s almost like a ghost town.”

Nearly 1.4 million people are cared for in skilled nursing facilities in the United States. When nursing homes are short-staffed, nurses and aides scramble to deliver meals, ferry bedbound residents to the bathroom and answer calls for pain medication. Essential medical tasks such as repositioning a patient to avert bedsores can be overlooked when workers are overburdened, sometimes leading to avoidable hospitalizations.

“Volatility means there are gaps in care,” said David Stevenson, an associate professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe and to eat every single day.”

Dr. David Gifford, a senior vice president at the American Health Care Association, a nursing home trade group, disagreed, saying there are legitimate reasons staffing varies. On weekends, for instance, there are fewer activities for residents and more family members around, he said.

“While staffing is important, what really matters is what the overall outcomes are,” he said.

While Medicare does not set a minimum resident-to-staff ratio, it does require the presence of a registered nurse for eight hours a day and a licensed nurse at all times.

The payroll records show that even facilities that Medicare rated positively for staffing levels on its , including Beechtree, were short nurses and aides on some days. On its best-staffed days, Beechtree had one aide for every eight residents, while on its lowest-staffed days the ratio was 1-to-18. Nursing levels also varied.

The Centers for Medicare & Medicaid Services, the federal agency that oversees nursing home inspections, said in a statement that it “is concerned and taking steps to address fluctuations in staffing levels” that have emerged from the new data. This month, it said it would lower ratings for nursing homes that had gone seven or more days without a registered nurse.

Beechtree’s payroll records showed similar staffing levels to those it had reported before. David Camerota, chief operating officer of Upstate Services Group, the for-profit chain that owns Beechtree, said in a statement that the facility has enough nurses and aides to properly care for its 120 residents. But, he said, like other nursing homes, Beechtree is in “a constant battle” to recruit and retain employees even as it has increased pay to be more competitive.

Camerota wrote that weekend staffing is a special challenge as employees are guaranteed every other weekend off. “This impacts our ability to have as many staff as we would really like to have,” he wrote.

New Rating Method Is Still Flawed

In April, the government started using daily payroll reports to calculate average staffing ratings, replacing the old method, which relied on homes to report staffing for the two weeks before an inspection. The homes sometimes anticipated when an inspection would happen and could staff up before it.

The new records show that on at least one day during the last three months of 2017 — the most recent period for which data were available — a quarter of facilities reported no registered nurses at work.

Medicare discouraged comparison of staffing under the two methods and said no one should expect them to “exactly match.” The agency said the methods measure different time periods and have different criteria for how to record hours that nurses worked. The nursing home industry also objected, with Gifford saying it was like comparing Fahrenheit and Celsius temperatures.

But several prominent researchers said the contrast was not only fair but also warranted, since Medicare is using the new data for the same purpose as the old: to rate nursing homes on its website. “It’s a worthwhile comparison,” said David Grabowski, a professor of health care policy at Harvard Medical School.

Of the more than 14,000 nursing homes submitting payroll records, 7 in 10 had lower staffing using the new method, with a 12 percent average decrease, the data show. And as numerous studies have found, homes with lower staffing tended to have more health code violations — another crucial measure of quality.

Even with more reliable data, Medicare’s five-star rating system still has shortcomings. Medicare still assigns stars by comparing a home to other facilities, essentially grading on a curve. As a result, many homes have kept their rating even though their payroll records showed lower staffing than before. Also, Medicare did not rate more than 1,000 facilities, either because of data anomalies or because they were too new to have a staffing history.

There is no consensus on optimal staffing levels. Medicare has rebuffed requests to set specific minimums, declaring in 2016 that it preferred that facilities “make thoughtful, informed staffing plans” based on the needs of residents.

Still, since 2014, health inspectors have cited 1 in 8 nursing homes for having too few nurses, federal records show.

With nurse assistants  in 2017, nursing homes compete for workers not only with better-paying employers like hospitals, but also with retailers. Understaffing leads predictably to higher turnover.

“They get burned out and they quit,” said Adam Chandler, whose mother lived at Beechtree until her death earlier this year. “It’s been constant turmoil, and it never ends.”

Medicare’s payroll records for the nursing homes showed that there were, on average, 11 percent fewer nurses providing direct care on weekends and 8 percent fewer aides. Staffing levels fluctuated substantially during the week as well, when an aide at a typical home might have to care for as few as nine residents or as many as 14.

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A Family Council Forms

Beechtree actually gets its best Medicare rating in the category of staffing, with four stars. (Its inspection citations and the frequency of declines in residents’ health dragged its overall star rating down to two of five.)

To Stan Hugo, a retired math teacher whose wife, Donna, 80, lives at Beechtree, staffing levels have long seemed inadequate. In 2017, he and a handful of other residents and family members became so dissatisfied that they formed a council to scrutinize the home’s operation. Medicare requires nursing home administrators to listen to such councils’ grievances and recommendations.

Sandy Ferreira, who makes health care decisions for Effie Hamilton, a blind resident, said Hamilton broke her arm falling out of bed and has been hospitalized for dehydration and septic shock.

“Almost every problem we’ve had on the floor is one that could have been alleviated with enough and well-trained staff,” Ferreira said.

Beechtree declined to discuss individual residents but said it had investigated these complaints and did not find inadequate staffing on those days. Camerota also said that Medicare does not count assistants it hires to handle the simplest duties like making beds.

In recent months, Camerota said, Beechtree “has made major strides in listening to and addressing concerns related to staffing at the facility.”

Hugo agreed that Beechtree has increased daytime staffing during the week under the prodding of his council. On nights and weekends, he said, it still remained too low.

His wife has Alzheimer’s, uses a wheelchair and no longer talks. She enjoys music, and Hugo placed earphones on her head so she could listen to her favorite singers as he spoon-fed her lunch in the dining room on a recent Sunday.

As he does each day he visits, he counted each nursing assistant he saw tending residents, took a photograph of the official staffing log in the lobby and compared it to what he had observed. While he fed his wife, he noted two aides for the 40 residents on the floor — half what Medicare says is average at Beechtree.

“Weekends are terrible,” he said. While he’s regularly there overseeing his wife’s care, he wondered: “What about all these other residents? They don’t have people who come in.”

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She cried out in pain. A hospital clinician later discovered her hip was dislocated.

That was not the only injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice a day with a potent blood thinner despite written instructions to stop.

“She said, ‘I just feel so tired,’” her daughter, Laura Clark, said in an interview. “The nurses were saying she’s depressed and wasn’t doing her exercises. I said no, something is wrong.”

Her children also discovered that Snipes’ surgical wound had become infected and infested with insects. Just 11 days after she arrived at the nursing home to heal from her hip surgery, she was back in the hospital.

The fall and these other alleged lapses in care led Clark and the family to file a lawsuit against the nursing home. Richmond Pines declined to discuss the case beyond saying it disputed the allegations at the time. The home agreed in 2017 to pay Snipes’ family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes’ case was extreme, return trips from nursing homes to hospitals are far from unusual.

With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.

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“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’” said , a professor of health care policy at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Payment Advisory Commission.

“We’re better, but not well,” Grabowski said. “There’s still a high rate of inappropriate readmissions.”

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

“And they never quite get back to normal,” he said.

‘She Looked Like A Wet Washcloth’

Communication lapses between physicians and nursing homes is one recurring cause of rehospitalizations. Elaine Essa had been taking thyroid medication ever since that gland was removed when she was a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2013 when a bout of pneumonia sent her to the hospital.

When she returned to the nursing home — now named Wellsprings Post-Acute Care Center — her doctor omitted a crucial instruction from her admission order: to resume the thyroid medication, according to a lawsuit filed by her family. The nursing home telephoned Essa’s doctor to order the medication, but he never called them back, the suit said.

Without the medication, Essa’s appetite diminished, her weight increased and her energy vanished — all indications of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, did not grasp the cause of her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return from the hospital, “she looked like a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she demanded the home’s nurses check her mother’s blood pressure. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her deposition that the doctor told her, “I can’t believe that this woman is still alive.”

Essa died the next month. The nursing home and the medical practice settled the case for confidential amounts. Cynthia Schein, an attorney for the home, declined to discuss the case beyond saying it was “settled to everyone’s satisfaction.” The suit is still ongoing against one other doctor, who did not respond to requests for comment.

Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital.

Safely Home Or Back To The Hospital?

Download the data to see how skilled nursing homes in the U.S. performed on two metrics of quality.

Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.

“We’re always worried the bad nursing homes are going to get the message ‘Don’t send anyone to the hospital,’” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, where Sandra Snipes stayed, has a higher-than-average rehospitalization rate of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she was discharged to a different nursing home, according to the family’s lawsuit. But her hospital trips were not over: When she showed signs of recurrent infection, the second home sent her to yet another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and more than a liter of infected blood clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the blood thinner right off the bat, we don’t think any of this would have happened.”

Snipes returned home but was never able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t want to go back into the nursing home,” Clark said. “She was terrified.”

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“It looked like a piece of black charcoal” and smelled “like death,” her daughter Cindy Hatfield later testified. After Pierce, a patient at a Memphis nursing home, was transferred to a hospital, a surgeon had to amputate much of her leg.

One explanation for Pierce’s lackluster care, according to financial records and testimony in a lawsuit brought by the Pierce family, is that her nursing home, Allenbrooke Nursing and Rehabilitation Center, appeared to be severely underfunded at the time, with a $2 million deficit on its books in 2009 and a scarcity of nurses and aides. “Sometimes we’d be short of diapers, sheets, linens,” one nurse testified.

That same year, $2.8 million of the facility’s $12 million in operating expenses went to a constellation of corporations controlled by two Long Island accountants who, court records show, owned Allenbrooke and 32 other nursing homes. The homes paid the men’s other companies to provide physical therapy, management, drugs and other services, from which the owners reaped profits, according to court records.

In what has become an increasingly common business arrangement, owners of nursing homes outsource a wide variety of goods and services to companies in which they have a financial interest or that they control. Nearly three-quarters of nursing homes in the United States — more than 11,000 — have such business dealings, known as related party transactions, according to an analysis of nursing home financial records by Kaiser Health News. Some homes even contract out basic functions like management or rent their own building from a sister corporation, saying it is simply an efficient way of running their businesses and can help minimize taxes.

But these arrangements offer another advantage: Owners can establish highly favorable contracts in which their nursing homes pay more than they might in a competitive market. Owners then siphon off higher profits, which are not recorded on the nursing home’s accounts.

The two Long Island men, Donald Denz and Norbert Bennett, and their families’ trusts collected distributions totaling $40 million from their chain’s $145 million in revenue over eight years — a 28 percent margin, according to the judge’s findings of fact. In 2014 alone, Denz earned $13 million and Bennett made $12 million, principally from their nursing home companies, according to personal income tax filings presented in court.

Typical nursing home profits are “in the 3 to 4 percent range,” said Bill Ulrich, a nursing home financial consultant.

In 2015, nursing homes paid related companies $11 billion, a tenth of their spending, according to financial disclosures the homes submitted to Medicare.

In California, the related party transactions at another nursing home chain, Brius Healthcare Services. Rental prices to the chain’s real estate entities were a third higher than rates paid by other for-profit nursing homes in the same counties, according to .

Such corporate webs bring owners a legal benefit, too: When a nursing home is sued, injured residents and their families have a much harder time collecting money from the related companies — the ones with the full coffers.

After the Pierce family against the nursing home, Denz and Bennett appealed, and their lawyer, Craig Conley, said they would not discuss details of the case or their business while the appeal was pending.

“For more than a decade, Allenbrooke’s caregivers have promoted the health, safety and welfare of their residents,” Conley wrote in an email.

Dr. Michael Wasserman, the head of the management company for the Brius nursing homes, called corporate structures a “nonissue” and said, “What matters at the end of the day is what the care being delivered is about.”

Networks of jointly owned limited liability corporations are fully legal and used widely by other businesses, such as restaurants and retailers. Nonprofit nursing homes sometimes use them as well. Owners can have more control over operations — and better allocate resources — if they own all the companies. In many cases, industry consultants say, a commonly owned company will charge a nursing home lower fees than an independent contractor might, leaving the chain with more resources.

“You don’t want to pay for someone else to make money off of you,” Ulrich said. “You want to retain that within your organization.”

But a Kaiser Health News analysis of federal inspection and quality records reveals that nursing homes that outsource to related organizations tend to have significant shortcomings: They have fewer nurses and aides per patient, they have higher rates of patient injuries and unsafe practices, and they are the subject of complaints almost twice as often as independent homes.

“Almost every single one of these chains is doing the same thing,” said Charlene Harrington, a professor emeritus of the School of Nursing at the University of California-San Francisco. “They’re just pulling money away from staffing.”

Early Signs Of Trouble

Martha Jane Pierce moved to Allenbrooke in 2008 in the early stages of dementia. According to testimony in the family’s lawsuit, her children often discovered her unwashed when they visited, with an uneaten, cold meal sitting beside her bed. Hatfield said in court that she had frequently found her mother’s bed soaked in urine. The front desk was sometimes vacant, her brother Glenn Pierce testified.

“If you went in on the weekend, you’d be lucky to find one nurse there,” he said in an interview.

After a stroke, Pierce became partly paralyzed and nonverbal, but the nursing home did not increase the attention she received, said Carey Acerra, one of Pierce’s lawyers. When Pierce’s children visited, they rarely saw aides reposition her in bed every two hours, the standard practice to prevent bedsores.

“Not having enough staffing, we can’t — we weren’t actually able to go and do that,” one nurse, Cheryl Gatlin-Andrews, testified in a deposition.

KHN’s analysis of federal inspection, staffing and financial records nationwide found shortcomings at other homes with similar corporate structures:

• Homes that did business with sister companies employed, on average, 8 percent fewer nurses and aides.
• As a group, these homes were 9 percent more likely to have hurt residents or put them in immediate jeopardy of harm, and amassed 53 validated complaints for every 1,000 beds, compared with the 32 per 1,000 that inspectors found credible at independent homes.
• Homes with related companies were fined 22 percent more often for serious health violations than were independent homes, and penalties averaged $24,441 — 7 percent higher.

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For-profit nursing homes employ these related corporations more frequently than nonprofits do, and have fared worse than independent for-profit homes in fines, complaints and staffing, the analysis found. Their fines averaged $25,345, which was 10 percent higher than fines for independent for-profits, and the homes received 24 percent more substantiated complaints from residents. Overall staffing was 4 percent lower than at independent for-profits.

Ernest Tosh, a plaintiffs’ lawyer in Texas who helps other lawyers untangle nursing company finances, said owners often exerted control by setting tight budgets that restricted the number of nurses the homes could employ. Meanwhile, “money is siphoned out to these related parties,” he said. “The cash flow gets really obscured through the related party transactions.”

The , which represents nursing homes, disputed any link between related businesses and poor care. “Our members strive to provide quality care at an affordable cost to every resident,” the group said in a statement. “There will always be examples of exceptions, but those few do not represent the majority of our profession.”

‘Piercing The Corporate Veil’

The model of placing nursing homes and related businesses in separate limited liability corporations and partnerships has gained popularity as the industry has consolidated through purchases by publicly traded companies, private investors and private equity firms. A encouraged owners to separate their nursing home business into detached entities to protect themselves if the government tried to recoup overpayments or if juries levied large negligence judgments.

“Holding the real estate in a separate real-property entity that leases the nursing home to the operating entity protects the assets by making the real estate unavailable for collection by judgment creditors of the operating entity,” the authors wrote. Such restructuring, they added, was probably not worth it just for “administrative simplicity.”

In 2009, the practice had flourished among nursing homes in Texas, which they studied because of the availability of state data. Owners had also inserted additional corporations between them and their nursing homes, with many separated by three layers.

To bring related companies into a lawsuit, attorneys must persuade judges that all the companies were essentially acting as one entity and that the nursing home could not make its own decisions. Often that requires getting access to internal company documents and emails. Even harder is holding owners personally responsible for the actions of a corporation — known as “piercing the corporate veil.”

At a 2012 Nashville conference for executives in the long-term health care industry, a presentation slide from nursing home attorneys titled “Pros of Complex Corporate Structure” stated: “Many plaintiffs’ attorneys will never conduct corporate structure discovery because it’s too expensive and time consuming.” The presentation noted another advantage: “Financial statement in punitive damages phase shows less income and assets.”

A lawyer in Alabama, Barry Walker, is still fighting an 11-year-old case against another nursing home then owned by Denz and Bennett, according to court records. Walker traced the ownership of Fairfield Nursing and Rehabilitation Center back to the men, but he said the judge had allowed him to introduce the ownership information only after the Alabama Supreme Court ordered him. That trial ended with a hung jury, and Walker said a subsequent judge had not let him present all the information to two other juries, and he dropped the men from the lawsuit. The home closed a few years ago but the case is still ongoing despite two mistrials.

“The former trial judge and the current trial judge quite frankly don’t seem to understand piercing the corporate veil,” he said. “My firm invested more in the case than we can ever hope to recover. Sometimes it’s a matter of principle.”

The complexity of the ownership in Pierce’s case was a major reason it took six years to get to a trial, said Ken Connor, one of the lawyers for her family. “It requires a lot of digging to unearth what’s really going on,” he said. “Most lawyers can’t afford to do that.”

The research paid off in a rare result: In 2016, the jury issued a $30 million verdict for negligence, of which Denz and Bennett were personally liable for $20 million. The men’s own tax returns bolstered the case against them. They claimed during trial they delegated daily responsibilities for residents to the home’s administrators, but they reported on their tax returns that they “actively” participated in the management. The jury did not find the nursing home responsible for Pierce’s death later in 2009.

The fight is not over. Denz and Bennett are appealing the verdict, the damages, their inclusion and the trial judge’s decisions. They argue that Tennessee courts should not have jurisdiction over them since they spent little time in the state and neither was involved in the daily operations of the home or in setting staffing levels. Their lawyers said jurors should never have heard from nurses who hadn’t cared directly for Pierce.

“No way did I oversee resident care issues,” Bennett testified in a deposition.

Deficient In The End

Whoever was responsible for Pierce’s care, her family had no doubt it was inadequate. Her son Bill Pierce was so horrified when he finally saw the wound on his mother’s foot, he immediately insisted that she go to the hospital.

“The surgeon said he had never seen anything like it,” Hatfield said in an interview. “He amputated 60 percent of the leg, above the knee.”

After her amputation, Pierce returned to the nursing home because her family did not want to separate her from her husband, who was also there.

At the trial, the nursing home’s lawyers argued that Pierce’s leg had deteriorated not because of the infection but because her blood vessels had become damaged from a decline in circulation. The jury was unpersuaded after nurses and aides testified about how Allenbrooke would add staffing for state inspections while the rest of the time their pleas for more support went unheeded.

Workers also testified that supervisors had told them to fill in blanks in medical records regardless of accuracy. One example: Allenbrooke’s records indicated that Pierce had eaten a full meal the day after she died.

Data editor Elizabeth Lucas contributed to this report.

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The shift in the Medicare program’s penalty protocols was requested by the nursing home industry. The American Health Care Association, the industry’s main trade group, has complained that under Obama inspectors focused excessively on catching wrongdoing rather than helping nursing homes improve.

“It is critical that we have relief,” Mark Parkinson, the group’s president, wrote in a letter to then-President-elect Donald Trump in December 2016.

Since 2013, nearly 6,500 nursing homes — 4 of every 10 — have been cited at least once for a serious violation, federal records show. Medicare has fined two-thirds of those homes. Common citations include failing to protect residents from avoidable accidents, neglect, mistreatment and bedsores.

The new guidelines discourage regulators from levying fines in some situations, even when they have resulted in a resident’s death. The guidelines will also probably result in lower fines for many facilities.

The change in policy aligns with Trump’s promise to reduce bureaucracy, regulation and government intervention in business.

Dr. Kate Goodrich, director of clinical standards and quality at the Centers for Medicare & Medicaid Services (CMS), said in a statement that unnecessary regulation was the main concern that health care providers raised with officials.

“Rather than spending quality time with their patients, the providers are spending time complying with regulations that get in the way of caring for their patients and doesn’t increase the quality of care they provide,” Goodrich said.

But advocates for nursing-home residents say the revised penalties are weakening a valuable patient-safety tool.

“They’ve pretty much emasculated enforcement, which was already weak,” said Toby Edelman, a senior attorney at the Center for Medicare Advocacy.

Medicare has different ways of applying penalties. It can impose a specific fine for a particular violation. It can assess a fine for each day that a nursing home was in violation. Or it can deny payments for new admissions.

The average fine in recent years has been $33,453, but 531 nursing homes amassed combined federal fines above $100,000, records show. In 2016, Congress to factor in several years of inflation that had not been accounted for previously.

The new rules have been instituted gradually throughout the year.

In October, its regional offices from levying fines, even in the most serious health violations, if the error was a “one-time mistake.” The centers said that intentional disregard for residents’ health and safety or systemic errors should still merit fines.

A from CMS discouraged the directors of state agencies that survey nursing homes from issuing daily fines for violations that began before an inspection, favoring one-time fines instead. Daily fines remain the recommended approach for major violations discovered during an inspection.

Dr. David Gifford, the American Health Care Association’s senior vice president for quality, said daily fines were intended to prompt quick remedies but were pointless when applied to past errors that had already been fixed by the time inspectors discovered them.

“What was happening is you were seeing massive fines accumulating because they were applying them on a per-day basis retrospectively,” Gifford said.

But the change means that some nursing homes could be sheltered from fines above the maximum per-instance fine of $20,965, even for egregious mistakes.

In September 2016, for instance, health inspectors , a nursing home in Decatur, Ill., for failing to monitor and treat the wound of a patient whose implanted pain-medication pump gradually slipped over eight days through a ruptured suture and protruded from her abdomen. The patient died.

CMS fined Lincoln Manor $282,954, including $10,091 a day for 28 days, from the time the nursing home noticed the problem with the wound until supervisors had retrained nurses to avoid similar errors. An administrative law judge called the penalties “quite modest” given the “appalling” care.

The fines were issued before the new guidelines took effect; if the agency had issued a one-time fine, the maximum would have been less than $21,000.

Lincoln Manor closed in September. Its owner could not be reached for comment, and his lawyer did not respond to an interview request.

Advocates for nursing home residents say that relaxing penalties threatens to undo progress at deterring wrongdoing. Janet Wells, a consultant for California Advocates for Nursing Home Reform, said the changes come as “some egregious violations and injuries to residents are being penalized — finally — at a level that gets the industry’s attention and isn’t just the cost of doing business.”

In November, the Trump administration exempted nursing homes that violate from penalties for 18 months. Homes must still follow the rules, which are intended, among other things, to reduce the overuse of psychotropic drugs and to ensure that every home has adequate resources to assist residents with major psychological problems.

Rodney Whitlock, a health policy consultant and former Republican Senate staffer, said health inspectors “are out there looking for opportunities to show that the nursing homes are not living up to some extremely tight standards.” He said while the motivation for tough regulation was understandable, “the fines don’t make it easier to hire people and doesn’t make it easier to stay in business.”

In June, CMS rescinded another Obama administration action that banned nursing homes from pre-emptively requiring residents to submit to arbitration to settle disputes rather than going to court.

“We publish nearly 11,000 pages of regulation every year,” the agency’s administrator, Seema Verma, said in . That paperwork is “taking doctors away from what matters most: patients.”

Janine Finck-Boyle, director of health regulations and policy at LeadingAge, a group of nonprofit nursing homes and other entities that care for older people, said the group’s members had been struggling to cope with regulations.

“If you’re a 50-bed rural facility out West or in the Dakotas,” she said, “you don’t have the resources to get everything done from A to Z.”

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