- The video discusses the issues surrounding nursing homes and long-term care.
- It highlights the disparity between upscale retirement communities for the wealthy and the majority of people who receive long-term care at home, often provided by unpaid family caregivers.
- The COVID-19 pandemic has exposed the neglect and abuse that occurs in many long-term care facilities.
- Nursing homes are often understaffed and have persistent problems with infection prevention and control.
- Nursing assistants are overworked and underpaid, with a median national salary of $30,000 per year.
- Nearly 70% of nursing homes are for-profit institutions, charging high fees while not fully covering costs through Medicare.
- Medicaid, the government program for the poor, reimburses nursing homes at a much lower rate.
- There have been cases of fraudulent Medicare billing practices and inappropriate discharge of Medicaid patients.
- The video calls for a discussion on how the long-term care industry is structured and suggests potential solutions for improvement.

- The Avalon Villa Care Center disputes allegations of inappropriately discharging patients
- The practice of "resident dumping" is considered unethical and unacceptable
- The federal government's list of problem nursing homes is capped at 88, despite acknowledging that 400 more facilities qualify for the program
- Nursing home ratings are based on self-reported statistics, which can be inaccurate and misleading
- Assisted Living Facilities (ALFs) are less regulated and can be started by anyone
- Some ALFs have been targeting dementia patients for memory care programs
- Training for ALF workers may be inadequate, leading to potential safety issues
- A resident at a Brookdale facility died after leaving unnoticed and being attacked by an alligator
- Increased oversight and enforcement are needed in the long-term care industry.

- Many elderly people want to stay in their homes, but Medicaid only provides entitlement to nursing home care, not home-based care.
- Some states, like Washington, allocate a significant portion of Medicaid money to home and community-based services.
- However, other states have long waiting lists for home-based care, resulting in many people dying before receiving the support they need.
- There is a discussion draft of a bill that aims to make home and community-based care an entitlement under Medicaid.
- Biden's infrastructure plan includes $400 billion for these services.
- Proper oversight and regulations are necessary to prevent misspending and ensure quality care.
- It is crucial to prioritize the well-being of the elderly and people with disabilities in the country.
- Ignoring this issue will only worsen the situation, as the current industry is failing to adequately care for its clients.

The video discusses the issues surrounding nursing homes and long-term care, highlighting the disparities between upscale retirement communities and the majority of people who receive care at home. The COVID-19 pandemic has exposed neglect and abuse in many long-term care facilities. Nursing homes are often understaffed and have problems with infection control. Nursing assistants are overworked and underpaid. Many nursing homes are for-profit and rely on high fees, while Medicaid reimburses at a lower rate. There have been cases of fraudulent billing and inappropriate discharge of patients. The video calls for a discussion on improving the long-term care industry. Assisted Living Facilities (ALFs) are less regulated, and some target dementia patients. Increased oversight and enforcement are needed. Many elderly people want to stay in their homes, but Medicaid only covers nursing home care. Some states allocate more Medicaid money to home-based care, while others have long waiting lists. There is a bill draft to make home-based care an entitlement under Medicaid. Biden's infrastructure plan includes funding for these services. Proper oversight and regulations are necessary to ensure quality care and prioritize the well-being of the elderly and people with disabilities. Ignoring the issue will worsen the situation.

John Oliver explains the industry behind nursing homes and assisted living facilities, and why long-term care needs fixing. 

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Our main story tonight concerns nursing homes.

The absolute last thing you want Andrew Cuomo to be handling, tied comfortably with literally anything else.

Nursing homes and long-term care in general are something that we tend to try to avoid thinking about.

But the truth is, whether due to old age or disability, many of us do or will require help with daily living.

The number of Americans 65 and older is projected to nearly double over the next 40 years.

And 1 study estimated over two-thirds of Americans who reach 65 will need long-term care at some point in their lives.

And the good news is, for the rich, there are plenty of options.

There are multiple upscale retirement communities where residents can transition, if needed, into full-time nursing care, like this 1, taught in exquisite fashion by 2 Chainz.

All right, so the name of this episode is called The Most Expensive Retirement, right?

And so this is the most upscale, luxurious retirement homes that I've ever seen and ever heard about.

The building itself costs $100 million to build.

Oh, yeah ♪ the marble, it's from Italy.

Okay, extravagance of that place aside, let's all just agree, that $195 plate sucks shit.

If you're gonna spend that kind of money on a plate, it better be really big, really fun, or really, really hot.

That plate, look at me, put your phone down and look at me when I'm talking to you.

But the fact is, most of us aren't ending up in that place.

In fact, the vast majority of people receive long-term care at home, and around 80 percent of that care is provided by unpaid caregivers, often family members who want to keep their loved ones out of institutional care, like this wife and daughter.

Cheryl and Kristen are among the 42 million Americans caring for loved ones at home.

And the tasks they perform have become increasingly complex.

When we have to flush his PICC line, or clean his PEG tube, or take his blood glucose, or his blood pressure, you know, none of us went to school for that.

I don't feel like I had enough training at all for this.

And there are certain things you kind of expect to do by trial and error.

Solving a puzzle, learning to pronounce the name of Tambourine Saturday, or choosing a haircut.

And for the record, error, error, error, and...

But providing essential medical care should not be 1 of those things.

Taking care of someone at home can be an incredibly complicated, full-time job that is almost always unpaid.

In fact, in terms of lost wages, the labor of family caregivers totals about 67 billion dollars annually.

That's a workforce that, if it were paid, would rival the entire GDP of Bulgaria.

But for those who cannot afford to eat off unfuckable plates, or whose loved ones are unable to help them at home.

Many wind up in long-term care facilities.

There are 2000000 people in them in the United States.

And as we've seen during the COVID crisis, they can be far from ideal.

Residents and staff in them make up less than 1 percent of the population, but currently account for around a third of COVID deaths.

The pandemic pushed an already heavily strained system to the absolute brink, with conditions getting so bad that we're near constant local news stories like this 1.

1 resident here says her calls for help were ignored because there wasn't enough staff to respond.

I was screaming, get me out of here, get me out of here, get me out of this pain.

I was in terrible pain, and they didn't come for me.

Penny Shaw was in pain as she lay helpless in her bed at Braintree Manor nursing home in the midst of the COVID-19 pandemic.

She became so desperate, she even called Bain Street police for help.

I can't lay in bed for hours and hours, you know, in pain like that.

Now, I have to tell you, we contacted that facility, which chose not to address its staffing levels back then in its response to us.

But that is pretty fucking hard to believe when they're calling the police for help.

There are only 2 instances where lying in bed for hours, screaming in pain is to be expected, and that's if you're giving birth or you're digesting a Crunchwrap Supreme.

And the truth is, COVID just exposed what we've basically known for years.

That the way the elderly and disabled are treated in far too many of these facilities is with, at best, indifference, and at worst, abuse and neglect.

So tonight, let's talk about long-term care.

How the industry is structured, how that structure creates bad incentives, and what we can do going forward.

And we're gonna focus on the 2 main types of long-term care facilities, nursing homes and assisted living.

Nursing homes are medical facilities overseen by registered nurses and largely staffed by low-paid nursing assistants.

And there have long been issues with nursing home care.

A GAO report covering a five-year period before the pandemic found that 82 percent of homes had been cited for infection prevention and control deficiencies, and about half had persistent problems that had been cited across multiple years.

And a big reason for that may be because understaffing is a huge problem, with employees often tasked with taking care of way too many residents, as these nursing assistants pointed out just last year.

People falling to where they fell out of their wheelchairs.

Most days that's for 1 person to wash, dress, get up, 2 meals, and they're being neglected because you can't get to everybody.

I told the administrator, I'm embarrassed of my work, my work process,

because I can't do what I was trained to do on how to take care of these residents.

Do you have any idea how bad things need to get for you to tell your boss you're embarrassed by your work?

I'm not even embarrassed by my work, and just 3 minutes ago, I joked about fucking a plate.

And nursing assistants aren't just overworked.

The median national salary for that job is barely $30,000 a year.

And 1 reason is that nearly 70 percent of nursing homes are now for-profit institutions.

And there is a lot of profit for them to make because they don't pay staff much, but they charge you a lot.

The average per-person cost for a private room is $100,000 per year.

And if you're thinking, well, yeah, that is expensive, but doesn't a Medicare program that I've paid into all my life cover that?

Medicare only fully covers the first 20 days of nursing home care after an eligible hospital visit, then partially pays for up to 100 days.

But after that, you are on the hook for all costs.

The only other way to access taxpayer help to live in a nursing home is to almost completely impoverish yourself.

To basically spend your way down to the point that you qualify for Medicaid, the government program for the poor, which crucially, reimburses nursing homes at less than half the average daily rate paid by Medicare.

And while you would like to think that nursing homes would treat all patients the same, whether they're on Medicare or Medicaid, The truth is, you might get 2 very different experiences.

Because if you're on Medicare, you could wind up getting too much attention.

Just listen to an assistant manager at 1 nursing home chain.

Describe how Medicare patients there were treated.

What percentage of the therapy that you were being told to administer do you think was not necessary?

I would say probably, as time went on, about 40 percent.

40 percent of the work that you were doing?

Was not reasonable and not necessary under Medicare guidelines.

At another facility, the entire rehab staff signed a letter to their boss.

It reads, we've been encouraged to maximize reimbursement even when clinically inappropriate.

The DOJ actually filed a lawsuit claiming that the chain that that woman worked for, Life Care Centers of America, which runs over 200 nursing homes, was subjecting his patients to therapy even as they were on their deathbeds.

It alleged 1 92-year-old, who was dying of metastatic cancer, was recorded as having had 48 minutes of physical therapy, 47 minutes of occupational therapy, and 30 minutes of speech therapy, just 2 days before his death, on a day he was spitting up blood.

Residents should be getting proper nursing care, not shit tons of expensive therapeutic treatments that are clinically inappropriate.

Which, by the way, I'm pretty sure was the original slogan of Goop.

Now, Life Care denied wrongdoing, but agreed to pay $145 million to resolve that lawsuit.

Over the past decade, multiple other large nursing home chains have been charged with fraudulent Medicare billing practices and denied wrongdoing while paying tens of millions of dollars to settle their cases.

You know, like you do when you are totally innocent.

So, to recap here, If Medicare is paying, the risk is that you could be billed for unnecessary treatments.

But if Medicaid is paying, which remember, reimburses nursing homes at less than half the average daily rate, things could get much worse.

Because if facilities want to open up a bed to a more lucrative patient, They can take drastic action.

Ronald, who was 51 and homeless, got rehab at the nursing home, where he lived for more than a year.

Then 1 night, around 10 p.m., he says an administrator came into his room.

And they just bundled me into a van and just dropped me off here on the sidewalk.

The Avalon Villa Care Center, through its lawyers, told NBC News it strongly disputes that it has inappropriately discharged any patients.

The homeless shelter where Ronald's living now says it's seen cases like this before.

Experts even have a term for it, resident dumping.

Resident dumping is a completely unacceptable practice.

I don't even like it when residents are dumped on Grey's Anatomy at the altar, Burke.

You dump that resident at the fucking altar?

And you would hope regulators would punish nursing homes for doing things like that, but the oversight here has some massive gaps.

For instance, the federal government keeps a list of so-called special focus facilities, homes that have a pattern of serious problems over a long period of time, and therefore, receive extra inspections.

But interestingly, not because there are only 88 homes that deserve to be, it's because due to limited resources, the government has capped the list at that exact number, despite the fact they fully acknowledge an additional 400 facilities qualify for the program.

And look, I'm not saying every list should go on forever.

If a list of cutest otters was capped at 88, that'd be a perfectly fine list.

But if there were 400 other cute otters that were also abusing the elderly, I'd really like to know who all of them are.

And if you're thinking, well, look, that is good to know, that's good information.

If I need to move a loved 1 into a nursing home, I'm definitely gonna look online and make sure it's a good 1.

Because while the government does have a website where nursing homes are rated from 1 to 5 stars, it has an absolutely massive loophole.

Of the 3 factors that determine an overall rating, only the health inspections are conducted independently.

The other statistics, staffing and quality measures, are self-reported by the nursing home.

These self-reported statistics can boost a three-star rating into a five-star rating overall.

The problem is, you know, it's garbage in, garbage out.

So whatever they're telling the feds, the feds are not...

The federal government isn't going in and double-checking that their numbers are accurate.

Something as important as our nursing home rating system should not follow the same rule as every recipe on Velveeta's website.

Because there is just no way any of those are any good.

If you're making a recipe that calls for a puddle of Lorax jizz, then don't be surprised when the finished product is equally repulsive.

So given everything that you've seen so far, it's hardly surprising that for reasons of cost or conditions, many might want to avoid a nursing home altogether.

Which brings us to Assisted Living Facilities, or ALFs.

Around a third of people in long-term care facilities are in 1 of these, and they do cost far less than a nursing home, typically around $50,000 a year.

ALF started out as an alternative for those who needed help with key activities like dressing, toileting, taking medicines, and eating, but only needed limited medical support.

Just as with nursing homes, the vast majority of ALFs are for profit.

ALFs are largely paid for out of pocket, and they are far less regulated, making it easy for basically anyone to start 1, and I do mean anyone.

By the age of 30, she owned 6 small ALFs in Southern California and had made a lot of money from them.

Enough to qualify her to appear in an episode of The Millionaire Matchmaker.

My name is Stephanie and I'm 30 years old and I own a chain of elderly care facilities.

I've always had this thing of taking care of older people, like, sick people that are dying.

So, I couldn't wait to graduate college and start my own business doing assisted living facilities like nursing homes.

There are a lot of unfair reasons that I inherently don't trust Stephanie Costa, from her driving a douchey Ferrari, to the fact that she looks like an uncredited extra from an entourage party scene, to that voice, which sounds like a mouse who wouldn't dress Cinderella because it had better things to do.

But it turns out, that gut feeling is actually entirely valid, because Costa treated her employees and residents so terribly, that after multiple health and safety violations, California banned her from the industry for life and ordered her and her company to pay about $1.6 million for unpaid wages and penalties.

But if you think that that gave her accountability, you're gonna want to think again.

She kept this home after filing for bankruptcy and settled with workers for a fraction of what she owed.

Her 6 care homes are now owned by a property investment company registered by her father.

As recently as last year, she was still listed as that company's CEO.

So the state of California really taught Stephanie Costa a lesson there.

Specifically, the lesson that you can treat your elder care workers like absolute shit, avoid any real consequences, and just keep living your life in the single ugliest home in Beverly Hills.

Although it's legitimately hard to tell whether that is actually a home or just an abandoned white castle.

But it's not just individuals involved here.

There are also big corporations running ALFs who've been working hard to fill up beds.

And despite the fact that ALFs, remember, are supposed to be for people who require less medical attention, recently, some have been aggressively courting dementia patients for memory care programs, as seen in this advertisement for Brookdale, the largest ALF provider in the country.

This is a compassionate place that helps families through very difficult stages of dementia in a safe and comfortable setting.

And I have peace of mind knowing there's staff fully trained 24 hours a day, 7 days a week.

I can't believe how much my mom's quality of life has improved since coming here.

I'm seeing her smiling and laughing again.

We help them maintain their abilities and encourage the use of their current skills in a warm, engaging environment.

This is a special place, and every day is a new beginning with lots of smiles and memories.

Okay, I get that a senior living commercial might want to have at least 1 staffer with their arms around a resident's shoulders.

It's kind of nice, trustworthy, makes you feel safe.

But immediately cutting to another 1 feels like a bit much.

And then a third starts to make me feel a little nervous.

And when that fourth 1 hits, as a British person, I've got to say, that is just too much physical contact.

That said, even I will admit, an ALF that offered all that that commercial claims to, but with significantly less touching, would really be great.

Unfortunately, a woman who worked at a Brookdale facility in South Carolina painted a pretty worrying picture of how staffers are trained to work with dementia patients.

When you first start, they have you set through a series of...

But once they put you out on the floor, they don't...

Because it's hard to retain important information just by watching a video.

Sure, a few random facts about the long-term care industry that you'll probably immediately forget.

But if you're honest, you've mainly learned that it's possible to want to fuck a plate.

And that's a lesson you will never forget.

And look, Brookdale insists that it offers ongoing training for its workers, and that its training program for dementia care workers meets or exceeds state guidelines.

As some states require only 2 to 30 hours of specialized training.

And South Carolina, where that facility is located, requires training, but doesn't set a minimum number of hours.

And by the way, if you're wondering about why there were a bunch of shots of a pond in that story, the answer is completely horrifying.

Because a 90-year-old resident there, who was supposed to be under constant supervision before being transferred to a memory care unit, died after leaving a facility unnoticed in the middle of the night.

There are signs out here warning people about alligators.

It says, Alligators may live here, be gators safe.

In this case, the signs probably would not have made a difference according to authorities.

We are told the victim likely slipped or fell down a steep embankment and landed in the water, attracting the gator's attention.

I honestly don't even know where to begin there, but I guess I'd start with, why would anyone put an assisted living facility next to a fucking alligator pond.

That seems like the sort of detail that really has to be included at the end of 1 of Brookdale's heartwarming ads.

Also, 1 of our residents was eaten by an alligator.

And that's important information for people to know, Brookdale.

And look, obviously, that is an appalling story.

But to be fair, it's hard to talk about long-term care without showing you at least 1 of those.

Just be grateful I didn't show you the story where a resident jumped from a fourth-story window of an ALF, or the 1 about a nursing home resident who set herself on fire, or the 1 about a 91-year-old suffering from Alzheimer's who froze to death on Christmas Day, which, by the way, sounds like a holiday album written by fucking Bjork.

Well, obviously, increased oversight and enforcement are badly needed.

That facility with the alligators was eventually fined by the state for 11 violations, including...

And it feels like if you lost a loved 1 in such a horrific way, you would want more accountability than just, don't worry, someone decided their life was worth the price of a 2013 Chrysler Motown.

And the fact is, there are lots of ideas on how to force facilities to improve.

Mandating a certain level of money has to go to patient care, for instance, or that residents have access to a minimum amount of care per day.

But the bigger fix here might be to try and make it easier for as many people as possible not to end up in these institutions in the first place, and instead, receive whatever support they need at home.

Nearly 90 percent of people over 65 apparently want to stay in their home for as long as possible, which does make sense.

The problem is, right now, many of them can't.

Because under Medicaid, nursing home care is an entitlement, but home-based care is not.

To access long-term services and support through Medicaid in your home, you need a waiver from your state.

And to be fair, some, like Washington, do that pretty well.

More than 70 percent of the Medicaid money they spend on long-term care for older people and adults with disabilities is spent on home and community-based services.

That's things like skilled nursing visits, home care aides who can help with daily tasks, and even the ability to pay family caregivers.

You know, People like those 2 women that you saw earlier.

The problem is, other states have waiting lists that can be many years long, by which point, seniors trying to access that care can be dead, because sadly, that is how time works.

Nationwide, more than 800,000 people are on these kinds of waiting lists.

What we need is reform at a national level.

And there are actually some promising developments here.

A discussion draft of a bill was recently introduced that would make home and community-based care an entitlement under Medicaid.

And Biden's proposed infrastructure plan actually calls for $400 billion to be spent on those exact services, and that would be a really big deal.

And look, any aggressive transition to home-based care is going to need rigorous guardrails and oversight to make sure that money is not misspent just in a different way.

The last thing I want is 5 years from now to be having to do a show on the evils of new for-profit home care agencies who've somehow been destroying people's lives in their own homes.

And if you're thinking, wait, hold on, 5 years from now, you'll still be doing shows in the void?

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