The plan was simple: acquire 18 nursing homes in Ohio.
The private equity firm put together a 56-page proposal with bullish projections and minimal costs, including spending just $6 per day for food for each resident.
The figure astounded Sam Brooks.
“They were talking about cutting costs and saying, ‘We’ll feed them on $6 a day,’ if you can imagine that,” said Brooks, a national advocate for residents in long-term care.
Brooks said he has watched as money has become the driving force at nursing homes, once largely run by small businesses, religious groups and nonprofits.
Perhaps nowhere is that change more easily noticed than on the dinner menu.
There are no federal or state regulations on spending for food. It’s an easy, overlooked corner to cut.
And so you end up with: One ravioli.
That was all that was being served during a meal at one Oregon long-term care facility rated 2-stars or “below average” on the federal government’s 5-star nursing home grading system, recalled an assistant nursing supervisor there. That’s according to a 2023 health inspection report sparked by complaints that residents weren’t getting enough to eat.
The Oregon nursing home inspection report that alleged a single ravioli was served for dinner. Centers for Medicare & Medicaid Services
In Georgia, inspectors at a 1-star or “much below average” nursing home, questioned whether residents were being shortchanged on a meal of chicken-and-dumplings after they saw it being dished out with small ladles. A surveyor who tasted food from a dinner tray that included stuffed cabbage soup pronounced it “not edible,” a March 2024 inspection report noted.
In a first-of-its-kind analysis, reporters reviewed thousands of federal cost reports filed with the Centers for Medicare and Medicaid, or CMS. Aided by academics at Rutgers University and data experts, the investigation found:
Nationwide more than a quarter of all nursing home operators spent under $10 a day to feed their residents — less than what it costs to buy a Quarter Pounder with cheese, fries and a Coke at many McDonald’s.From 2021 through 2024, the number of nursing homes written up for food-related shortcomings nearly tripled, federal data shows.The number of dietary complaints to ombudsman offices around the country increased from 5,620 in 2020 to 8,485 in 2023, a jump of more than 50%.Outbreaks of foodborne illnesses tied to nursing home kitchens are on the rise, according to data compiled by the Centers for Disease Control and Prevention.Residents in numerous interviews repeatedly complained about being unable to find something appetizing on the menu, even when their meals did meet all standards for quantity and nutritional value.
While rarely the focus of public attention, malnutrition and food deprivation have long been a major concern in nursing homes, said Fred Steele, Oregon’s long-term care ombudsman.
“There are plenty of pictures of food I have seen where it’s ‘a guess-what-is-on-the-plate scenario,’” he said. “We have seen scenarios of residents being limited to 4 oz. of milk a day in a tiny glass.”
From 2021 through 2024, the number of nursing homes written up for food-related shortcomings nearly tripled, federal data shows. Advance Local
In hundreds of inspection reports reviewed by reporters, complaints of rancid meat, spoiled vegetables, moldy fruit and meals, at times prepared in filthy conditions, were not uncommon.
“We had better food in prison,” one nursing home resident, who had served time behind bars, told Elizabeth Speidel, the director of community engagement for the New Jersey Long-Term Care Ombudsman.
“They receive the lowest grade meats and no fresh fruits or vegetables,” Speidel said.
That’s not what family members have in mind when sending parents or grandparents to a home that can cost upwards of $104,000 a year. That’s the median annual cost of a semi-private room, according to Genworth, a long-term care insurer. That means half cost more than that.
Industry officials say the nursing home sector is “deeply committed to providing quality care to residents, including ensuring dietary standards are upheld.” At the same time, they argue that state and federal inspectors don’t make things better, operating in a system that encourages them to “cite and penalize nursing homes, rather than offering support to help improve care.”
Food concerns by residents themselves, though, are not uncommon, said Brooks, the policy director for National Consumer Voice for Quality Long-Term Care in Washington D.C. that seeks nursing home reform.
“Besides staffing, I think food is one of the complaints we hear most. We get that firsthand from residents talking about how disgusting the food is,” he said.
‘A day without food’
For decades, researchers have documented the widespread prevalence of food-related issues in nursing homes. The rates of malnutrition and dehydration range from 30% to 85% of residents, according to a review of medical studies by the Journal of the American Dietetic Association.
“We are hearing from ombudsman programs that food is running out or it’s inadequate,” said Amity Overall-Laib, the director of the National Ombudsman Resource Center, which provides support for the 53 long-term care ombudsman programs across the country. “The residents are literally getting sandwiches and bread.”
Half of all nursing homes in the country spent less than $12.03 for three meals a day, according to the Advance Local analysis of federal data on food spending, according to 2023 data — the most current available. And more than a quarter spent under $10. Some well under $10.
“That’s appallingly low. You can’t feed anyone on less than $10 a day,” said David C. Grabowski, a professor of health care policy at Harvard Medical School who studies nursing homes.
Those numbers, though, were no surprise to Steele, the long-term care ombudsman in Oregon. He recalled a 2017 conference that featured a panel of dietary specialists at three different facilities. Asked how much was spent per day per resident, one said it hovered around $4 per day. Another said $5. The third gave a figure of $8.50.
“The first two wondered — how did you get that much?” Steele said. “I thought that was horrifying.”
The implications are serious, said Grabowski, as the lack of fresh food with healthy ingredients leads to malnourishment and even early death. “I’ve long thought it an issue not receiving the attention it deserves,” he said, noting that there is no incentive for nursing homes to pay for quality meals.
State and federal watchdogs may not even be aware of what is happening related to food, he suggested. A study he co-authored on staffing regulations found that when the government requires nursing home operators to add staff, they cut costs in areas not scrutinized by regulators, such as housekeeping. And, he suspects, food as well.
“It’s kind of under the surface, but super important,” he said.
In hundreds of inspection reports, complaints of rancid meat, spoiled vegetable, moldy fruit and meals, at times prepared in shockingly filthy conditions. Illustration by Andrea Levy
CMS officials say there are no requirements for how much money is spent on food, but there are standards for prep and nutrition. A spokesman said: “Multiple aspects of food safety, nutrition, preparation, storage, and the distribution of food are reviewed during the kitchen tour and food service observation portion of every facility survey to make sure CMS’s requirements are being met.”
Holly Harmon is a senior vice president for the American Health Care Association and National Center for Assisted Living, which represents more than 14,000 nursing homes and long-term care facilities across the country. She noted that facilities comply with stringent food safety regulations.
An examination of federal and state inspection reports, she said, shows that “the vast majority of food-related issues identified during inspections are corrected” and were rated by state and federal officials as unlikely to put anyone’s health at immediate risk.
“We all know nursing homes are woefully underfunded, and soaring inflation in recent years has impacted the cost of food not just for everyday Americans, but nursing homes as well,” Harmon said.
According to interviews with numerous residents across multiple homes, often the issue is about not getting enough to eat.
During a group interview on Zoom, NJ.com spoke to eight residents of seven different nursing homes about meals.
“Have any of you ever gone a day without food?”
They all raised their hands.
No bananas
Theresa Dante worked as a cook at a nursing home in South Dakota, where the financial collapse of the parent company that operated the facility led to abrupt changes in the menu — and to her health insurance, which was no longer being paid by the operator of the long-term care facility. That’s according to a federal lawsuit alleging fraud that she filed with other workers.
Old standbys like chicken with green beans and mashed potatoes were gone overnight, she said. Instead, residents got a plain bowl of Campbell’s tomato soup accompanied by a dry sandwich.
“Soup and a sammie,” she said. “And the spec on the sandwich was one slice of bologna and one slice of cheese — not enough calories to sustain anyone.”
“Soup and a sammie,” said Theresa Dante of the food served at a financially troubled South Dakota nursing home where she once worked.. “And the spec on the sandwich was one slice of bologna and one slice of cheese — not enough calories to sustain anyone.” Rapid City Journal
And if that wasn’t bad enough, she said, for those on special low sodium or low sugar diets, the instructions were to simply eliminate the meat and cheese.
“So what were we supposed to give them?” asked Dante. “A slice of Wonder Bread?”
The food shortages at the South Dakota nursing home were not just a matter of hunger. Dante said one resident who had suffered a stroke was on a medication that drained her of potassium. Each day, she was supposed to get a whole banana, which is high in potassium.
“We had no bananas,” said the former nursing home worker. “The resident was really upset. She thought she wasn’t communicating with me because of her stroke.”
Concerns over food there were later raised by state regulators in South Dakota.
In a series of emails to state health officials, nursing home administrators warned of electric and water services being shut off. Those emails by the administrators, included in a 2022 complaint filed by the state’s attorney general, said they feared they would soon run out of food for more than 900 residents.
“I NEED HELP!!!!!” wrote the local vice president of operations for the nursing home managing the South Dakota homes.
But if some nursing home operators aren’t spending much money on food, what are they spending it on?
“If you want to look at nursing home food,” said Charlene Harrington, a professor emeritus at University of California San Francisco who studies skilled nursing facilities, “you need to look at where the money is going.”
In the case of Dante’s nursing home, it was going into the pocket of the owner, according to court records.
The Redfield Care and Rehab Center in South Dakota where Dante worked had been part of a New Jersey-based nationwide empire, known as Skyline Healthcare, operated by Joseph Schwartz before its collapse between 2018 and 2019. In court depositions, Schwartz talked about being “the largest nursing home chain operator in the country,” with a presence in 11 states.
However, Schwartz was later accused in a string of criminal charges and civil lawsuits, with allegations that included skimming profits through a string of related companies. Court filings claimed Skyline Healthcare “had a habit of not paying bills to vendors, utilities, and landlords, or wages to its staff.”
Joseph Schwartz, who headed Skyline Healthcare before the nursing home operator collapsed, during a video deposition from his home in New York. Exhibit filed with Circuit Court of Pulaski County
Schwartz pleaded guilty in U.S. District Court this past November to a $38 million tax fraud scheme and many of his nursing homes were taken over by state regulators. In April, he was sentenced to three years in federal prison and hit with a $100,000 fine, according to the U.S. Attorney’s office in New Jersey. He also is on the hook for $5 million in restitution.
A lawyer for the former nursing home mogul said he is not a bad guy, as he has been portrayed.
“He has remorse and accepted responsibility for what he did,” said attorney Kevin Marino. “The reality is he became involved in a business that was unfamiliar to him and got in over his head.”
Nora Mikkelsen, a former resident of Princeton Care Center in New Jersey, also said that she saw how financial troubles affected the menu. Mikkelsen and 70 others were forced out the door with little notice in September 2023 after owners said they couldn’t meet payroll, but she had already noticed a change.
Milk was no longer provided in sealed cartons, she said. Instead, it was being poured into plastic cups, as if it was being rationed. “You had to be blind not to notice what was going on,” said Mikkelsen.
“You had to be blind not to notice what was going on,” said Nora Mikkelsen, a former resident of the now-closed Princeton Care Center. Patti Sapone | NJ Advance Media for NJ.com
An attorney for Princeton Care Center, which is now being sued by 11 former residents, including Mikkelsen, said he spoke to the former food director about the allegations of cuts in dietary spending.
“She stated there was always an ample food supply for the residents,” said Avram Frisch. Asked specifically about milk served in small plastic cups, which Mikkelsen called “tell-tale signs of cutbacks,” the lawyer offered no further comment.
Bad food
Rotting cucumbers and moldy strawberries sat on a shelf in the refrigerator at a nursing home in Michigan, according to an August 2022 inspection report. Yet even after the spoiled produce was pointed out, a survey team found it still on the shelves the following day, the report stated.
Asked when the last “deep cleaning” of the kitchen had occurred, the facility’s dietary manager replied, “Probably before I got here, three months ago,” the manager told an inspector, according to the report.
Officials there did not respond to requests for comment.
Rotting cucumbers and moldy strawberries sat on a shelf in the refrigerator at a nursing home in Michigan, according to an August 2022 inspection report. Illustration by Andrea Levy
At a long-term care facility in Florida with a history of quality issues, a dietician gasped as state inspectors opened an oozing plastic bag. “Uuuggghh,” she exclaimed, according to a December 2023 inspection report reviewed by reporters.
“Those are baked potatoes,” a staff cook told the inspectors, they wrote in the report. “We just had those.”
State inspectors also found an unlabeled pasta salad that was covered with a “fuzzy, green bio growth.” Inspectors cited the nursing home for expired food, inappropriate cooking temperatures, and unsanitary preparation of meals — problems deemed so egregious they were classified as an immediate threat to the health and safety of residents.
The facility did not respond to requests for comment.
Richard J. Mollot is the executive director of the Long Term Care Community Coalition, a national nonprofit research and advocacy group. He called such inspection reports pretty revolting.
“Unlike customers in a restaurant, nursing home residents cannot walk out if the food is bad and go home and make a sandwich,” he said. “The nursing home is their home and, generally speaking, they eat what the facility serves or nothing at all.”
Food-related citations by federal and state inspectors are on the rise nationwide, according to an analysis of deficiency reports filed with CMS.
In 2024, inspectors issued 9,484 citations for various food deficiencies across the country, ranging from inappropriate meals for people with restricted diets to filthy prep areas. That was up from 7,463 in 2022 and just 3,391 in 2021.
Nursing homes that spent more to feed residents saw higher rankings Advance Local
Separately, CDC data shows growing numbers of foodborne illness outbreaks in long-term care facilities that have led to hospitalizations and deaths. In 2022, the most recent data available, there were 1,127 outbreaks across the country that sickened 26,268 people. Of those, 555 required hospitalization and 50 nursing home residents died.
The previous year, there were just 568 foodborne outbreaks that led to 11,909 people getting sick and 225 being hospitalized. Twenty-nine people died.
The CDC noted that the reporting of outbreaks was voluntary and “historically underreported.”
Indeed, even when the meals met basic standards for quantity and nutritional value, residents in numerous interviews complained often about being unable to find something they wanted to eat.
At the New Jersey nursing home where Mike Howland is rehabbing, he said they too often don’t have anything he wants to eat. “We get the food tray and open it up and sometimes we are not sure what we are eating. It is unidentifiable.”
Daryle Geter, who complains the food in his nursing home is “horrible,” says he keeps a stash of canned food that he prefers in his room. Patti Sapone | NJ Advance Media for NJ.com
Daryle Geter, 54, who lives at the same facility, said “the food here is horrible.”
He even complained about the coffee. “I have to go out and buy my own coffee, instant coffee. The coffee is like water,” he said. He keeps a stash of canned food that he prefers in his room.
Glenn Osborne, a 70-year-old Marine Corps veteran with ALS at a nursing home in Bergen County said he often doesn’t know what his next meal will bring.
“We just want to be treated with dignity, with respect and want to enjoy what little time we have left,” said Glenn Osborne, a Marine Corps veteran with ALS. “And that means the quality of the food…” NJ Department of Military and Veterans Affairs
“We just want to be treated with dignity, with respect and want to enjoy what little time we have left,” he said. “And that means the quality of the food.”
Residents in jeopardy
Sometimes poor conditions can be a health threat, inspection reports revealed.
At a nursing home in Alabama, the main entrée could have literally killed someone. Featured was a simple meal of cubed pork over noodles. But for nearly two dozen aging residents on restricted “soft” diets because they could not easily swallow, the thick chunks of meat represented a deadly threat. That soon became clear as one of those being fed by a nursing aide began choking.
An inspection team issued an emergency red-flag classification of “immediate jeopardy” to those living there, according to an August 2023 report of the incident. The assistant director of nursing responded that the kitchen staff was “used to country cooking.”
In a December 2023 federal enforcement action resulting from the immediate jeopardy finding, the nursing home was found to be out of substantial compliance with program requirements and hit with tens of thousands in penalties, documents show. The facility has since been taken over by new owners, according to filings with the Alabama State Health Planning & Development Agency.
“We are hearing from ombudsman programs that food is running out or it’s inadequate, the residents literally getting sandwiches and bread…” Illustration by Andrea Levy
In Illinois, Danielle Combs is suing River Crossing of Edwardsville, a half-hour drive from St. Louis, claiming the facility failed to assist her father Guy Combs when it knew that he was unable, or ill-equipped, to feed himself after having a stroke and losing some use of his arms.
Each day, someone dropped off a tray of food in his room. Unable to feed himself, he could do little more than stare at the plate they had left for him, said his daughter.
The lawsuit alleged that Combs “lost considerable amounts of weight due to the lack of nutrient intake. Placing the food in his room was the equivalent of torture” to him.
“He didn’t eat unless I was there,” said his daughter in an interview.
The facility is now under different ownership. An attorney for River Crossing did not respond to calls or emails seeking comment. But in filings with the court, the nursing home sought dismissal of parts of the complaint related to allegations of negligent care, arguing that there was no affidavit or report by a health professional in support of those claims.
“Distributing meals can take an hour or two. By the time it arrives, it is often cold and less than palatable…” Illustration by Andrea Levy
Sandy, who asked to be identified only by her first name, has worked in nursing homes in northern New Jersey for 20 years. She has seen not only a decline in the food she serves, but also an increased workload because of short staffing that is a common complaint at nursing homes across the country. She has worked alone taking care of 43 residents at times.
That, too, affects the feeding of those who are being cared for there. Distributing meals can take an hour or two. By the time it arrives, it is often cold and less than palatable. About half of the residents need assistance eating.
“You take care of those residents first, as fast as you can. It depends on the condition of the resident, but it can take 15-20 minutes,” she said. “There are cases of dehydration. Sometimes people have to be sent to the hospital.”
Grabowski at Harvard said the lack of proper nutrition contributes to a lot of health issues for nursing home residents.
“If ever a group needed healthy food,” he said, it’s the frail, living in congregate settings such as residential care facilities.
“It’s a pretty simple thing,” he continued. “Most hotel breakfasts have bananas. It’s telling they are unwilling to do even that.”
“When I talk to people about nursing homes this issue comes up a lot,” Grabowski said of food issue. “My own aunt is in a nursing home in Pennsylvania and I recently got a call from her. The complaint wasn’t about staffing or conditions. It was about the food being inedible.”
On the hunt for food
Even in nursing homes without a history of serious food deficiencies, residents still take it upon themselves to hunt for something they find palatable.
John Bodnar, a 59-year-old resident of Advanced Center for Nursing & Rehabilitation in Connecticut, can often be seen scooting around the streets of downtown New Haven looking for something good to eat.
“The weakest link in our building is the kitchen,” said John Bodnar. Jessica Hill | For NJ Advance Media
“I love the location — I’m a mile from Yale — and the staff are great. The weakest link in our building is the kitchen,” he said. “We get one good meal a year and that is Thanksgiving.”
Indeed, if not for his prime location near the center of everything in New Haven, he said he would be stuck eating unsavory chicken on the bone and vegetables he finds overcooked.
State inspectors over the past two years investigated two food-related complaints at his nursing home, which has a 2-star or “below average” rating, according to public records. In one case, the facility was cited for failing to ensure a resident’s significant weight loss was addressed.
The facility in Connecticut did not reply for comment.
Bodnar, who has testified before the state legislature about nursing home regulation in the past, makes the best of his situation. He has wheels and an appetite, so he heads out the door in his motorized wheelchair. He is a regular customer at Jon’s Lunch, his favorite food truck. Bodnar sticks with an Atkins salad on this day’s trip with a photographer.
“One bodega around the block sells four wings for three bucks,” he boasted. “You can’t beat that.”
Laurie Facciarossa Brewer, the ombudsman for long-term care in New Jersey, said the thing about food in a nursing home is as residents are getting older, their world is getting smaller.
“Things like food become more and more important as a bright spot in their day,” she said. “It’s important not only for health but mental health.”
But, she added: “Everyone agrees that recreational activities and food are the easiest place for a company to cut corners.”
John Bodnar, left, leaves his nursing home and heads out to his to get lunch at his favorite food truck. Jessica Hill | For NJ Advance Media
