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Note: Abuse citations include violations for failing to investigate and report potential abuse. At homes whose five stars masked serious problems, residents developed bed sores so severe that their bones were exposed. Others lost the ability to move. But the most important impact may be that the nursing home industry was ill equipped for the pandemic. The rating system allowed facilities to score high grades without upgrading the care they provided. “They were working to improve their ratings, but not their quality,” said Charlene Harrington, who sits on a board that advises C.M.S. on the ratings system. “The problems with the five-star system left these homes less prepared in the pandemic,” she said. “They were allowed to not have enough staffing, and they were allowed to ignore infection-control deficiencies, so they had poorer quality than the public knew about, and they were in the worst position to manage Covid.”

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