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Jimmy Carter, on Death
Jimmy Carter brought up death — specifically, his own — at what turned out to be the last Sunday school class he would teach at Maranatha Baptist Church. It was November 2019. He’d recently fallen and fractured his pelvis, a setback that followed a string of illnesses and injuries that reminded everyone around him — and himself, it seems — that despite his mental acuity and physical vigor, he was 95 and would not live forever.
Mr. Carter’s death on Sunday at 100, has spurred an examination of a sprawling legacy: the successes and failures of his presidency; his work to eradicate diseases and bolster free and fair elections; his involvement with nonprofits like Habitat for Humanity.
Here is something else he left behind: In a culture where death as a subject is often taboo and engulfed in an aura of fear, he amassed over the years — across writing, public comments and Sunday school lessons — a compilation of observations that amounted to a candid, cleareyed, evolving exploration of the end.
He wrote about death in books — and he wrote more books than any other American president. He discussed it in speeches and in correspondence with friends.
Those observations were a product of his Christian faith. His perspective also grew out of experience, a fluency with death that came from seeing many of his closest family members, including all of his younger siblings, die before him.
His views were also shaped by his own advancing age. He described the sense of the inevitable looming over him and the health challenges that had piled up, including cancer that had spread to his brain.
At Sunday school that morning in 2019, he said that he did not think he would survive for long after his cancer diagnosis. “I assumed, naturally, I was going to die very quickly,” he told the packed church. He lived nine more years.
Mr. Carter atop his Shetland pony named Lady in 1928.
“By the time I was 12 or 13 years old, my anxiety about this became so intense that at the end of every prayer, until after I was an adult, before Amen I added the words ‘And, God, please help me believe in the resurrection.’”
“Living Faith,” 1996
Mr. Carter recalled the worries he had as a young person, stirred by learning in church about Jesus Christ’s crucifixion and resurrection and by the pastor’s sermons about how “all believers,” as he put it, “would someday enjoy a similar resurrection.”
“As I grew older,” Mr. Carter wrote, “I began to wonder whether this could be true.”
He was concerned as a boy that even an iota of doubt could lead him to a different fate, relegating him to an eternity separated from his family, particularly his parents. “These two people were the core of my existence,” he wrote, “and I couldn’t bear the idea that I would not be with them forever.”
Mr. Carter prayed before teaching a Sunday school in Plains, Ga.
“I realize that my physical strength and endurance are steadily declining, and I am having to learn how to conserve them, but I have found with relief and gratitude — even when facing the prospect of an early death from cancer in my liver and brain — that my faith as a Christian is still unwavering and sustaining.”
“Faith: A Journey for All,” published in 2018
As he matured, Mr. Carter’s faith firmed and came to define his approach to life — and death.
He considered himself a born-again Christian. In a 2012 interview with an influential evangelical theologian, Mr. Carter said his aim had been to “pattern my life and my own fallible human ways after Jesus’s life.”
“Faith in something,” he has written in several books, “is an inducement not to dormancy but to action.”
Mr. Carter spoke to a Sunday school class at Maranatha Baptist Church.
“If I were an amputee, for instance, my prayer would not be to restore my leg but to help me make the best of my condition, and to be thankful for life and opportunities to be a blessing to others. At the moment, we are monitoring the status of my cancer, and my prayers about my own health are similar to this.”
“Faith: A Journey for All”
In 2015, Mr. Carter said he was feeling unwell while monitoring elections in Guyana. When he returned to Georgia, doctors found a small mass on his liver, which turned out to be malignant.
After the mass was removed, doctors discovered that the cancer had spread to his brain.
The prognosis was grim, particularly given his age at the time, 90. But he began an aggressive treatment regimen for metastatic melanoma that included a drug that had been approved only months before he started on it.
Four months later, he announced at Sunday school that scans showed he was free of the disease.
Mr. Carter with his mother, Lillian Carter, in 1976.
“When other members of my family realized that they had a terminal illness, the finest medical care was available to them. But each chose to forgo elaborate artificial life-support systems and, with a few friends and family members at their bedside, they died peacefully.”
“The Virtues of Aging,” published in 1998
Mr. Carter’s understanding of mortality was anything but abstract.
His father, brother and two sisters died of pancreatic cancer. His mother, Lillian Carter, died of breast cancer. She was 85 when she died, but Mr. Carter noted that the others had died at relatively young ages — his father, James Carter Sr., was 59; his sister Gloria was 64; his sister Ruth was 54; and his brother, Billy, was 51.
His grandson, Jeremy, died in 2015 of a heart attack at the age of 28.
Mr. Carter recounted how his brother and mother kept their sense of humor, even as they suffered. He also admired the unflagging faith of his sister Ruth, an evangelist and spiritual healer.
Mr. Carter, center, at a funeral service at Arlington National Cemetery in 1996.
“If our doctors tell us that we have a terminal illness and can expect to live only another year, or five years, how would we respond? In fact, we confront exactly the same question if we are still healthy and have a life expectancy of fifteen or twenty more years.”
“The Virtues of Aging”
In his final years, Mr. Carter had become a source of inspiration to many — and of frustration and worry for those closest to him — for the stubbornness in how he pressed ahead with his work, despite his illness and age.
In 2019, he was bruised and bandaged with a black eye after a fall at home, yet hours after the fall, he was in Nashville, helping to assemble porches on homes being built by Habitat for Humanity. A few weeks later, after fracturing his pelvis in another fall, family members and aides were adamant that he should cancel his Sunday school lesson. He perched himself before the congregation and did it anyway.
That resilience was apparent again after the Carter Center announced in February 2023 that he had entered hospice care. Many believed the end was rapidly approaching. Yet, once again, Mr. Carter defied others’ expectations. He celebrated another anniversary with his wife, Rosalynn, in July of that year, and his 99th birthday in October.
When Mrs. Carter died in November 2023 at the age of 96, Mr. Carter attended her funeral services, which was a display of his frailty as well as the strength of his devotion to his wife and his resolve to be there for her.
Mr. Carter at a prayer service at Washington National Cathedral in 1979.
“Perhaps the most troubling aspect of our later years is the need to face the inevitability of our own impending physical death. For some people, this fact becomes a cause of great distress, sometimes with attendant resentment against God or even those around us.”
“The Virtues of Aging”
Aging is difficult. That’s true even for a former president with access to the best medical care and the constant support of staff.
Well into his 90s, Mr. Carter continued trotting around the world, teaching, writing and keeping up with his hobbies, including bird watching. But eventually, time caught up with him. The coronavirus pandemic pinned him down even more. He spent his final years with Mrs. Carter in the same modest home where he’d lived for decades.
In Plains, the tiny Georgia town where Mr. Carter’s house was just off the main road, his death was the cause of deep sadness. But there was a twinge of another sentiment, not quite relief but something close to it — a feeling that after such a long, productive and varied life, he had earned his rest.
His death created a void in the world, in his community, in his family, according to many who knew him and many others connected to him only through his legacy. Despite that, many in Plains also believed that his death was not an end but a transition to the eternal life that he remembered the pastor preaching about.
That’s what he believed, too.
Leslie Adams holds a photo of his mother, Shirley, who died after developing infected bedsores at a rehabilitation center, according to a lawsuit he filed. A court awarded the family $17 million, but they are still trying to collect it.
Taylor Glascock for KFF Health News
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Taylor Glascock for KFF Health News
By the time she was hospitalized in 2020, Pearlene Darby, a retired teacher, had suffered open sores on both legs, both hips, and both heels, as well as a five-inch-long gash on her tailbone. She died two weeks later at age 81 from infections and bedsores, according to her death certificate. Her daughter sued the nursing home, alleging it had left Darby sitting in her own feces and urine time and again.
The lawsuit, settled on confidential terms last year, blamed not only the managers of City Creek Post-Acute and Assisted Living but also the building’s owner, a real estate investment trust, or REIT. In the year Darby died, City Creek paid CareTrust REIT more than $1 million in rent, while the Sacramento, California, nursing home ran a deficit, court records show.
Federal tax rules ban REITs from running health care facilities, but CareTrust was not an absentee landlord either, according to internal records filed in the case. It chose the nursing home’s management company and required through the lease that the home keep at least 80% of beds occupied. CareTrust granularly tracked how well the home kept to its financial plan, down to the money spent monthly on nurses and food, the records said. And the documents showed that the real estate company kept tabs on government safety inspection findings and Medicare quality ratings.
Both CareTrust and the nursing home operator denied liability for Darby’s death. CareTrust officials said in court papers that it is not involved in day-to-day nursing home decisions or patient care, and that it monitors facilities to ensure nothing jeopardizes rent payments.
In a written statement, CareTrust Corporate Counsel Joseph Layne told KFF Health News: “We are the property owners, not the operators.”
Pearlene Darby, pictured here with her grandson Caleb Darby, was a resident of a Sacramento, California, nursing home. She died two weeks after being hospitalized for bedsores and an infection. The home denied liability and the case was settled out of court.
Shirlene Darby
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Shirlene Darby
Landlords with influence
Over the past decade, real estate investment trusts have bought thousands of buildings that house nursing homes, hospitals, assisted living facilities, and medical offices. A KFF Health News examination of court filings and corporate records shows that these landlords have more influence than the health care facilities publicly acknowledge.
The documents reveal REITs often select the management who oversee the operations and leave them in place even when they are aware of threadbare staffing, floundering governance, repeated safety violations, or other problems that hamper quality of care. A California jury in March awarded $92 million in punitive damages against a former REIT over the death of a 100-year-old resident with dementia who froze to death outside her assisted living facility.
“The REITs are in charge,” said Laraclay Parker, one of the lawyers who represent Darby’s daughter.
Absence of oversight
Despite their ubiquity, REITs remain invisible to state and federal health regulators. Hospitals and nursing homes are not required to disclose rent payments or landlord identities in the annual reports they submit to Medicare.
Under President Donald Trump, the Centers for Medicare & Medicaid Services indefinitely suspended a Biden-era requirement that nursing homes disclose REIT involvement. Catherine Howden, a CMS spokesperson, said in a statement that the agency does not regulate facilities based on their tax status or corporate form and instead focuses on the quality of the care they provide.
REITs now own a fifth of the nation’s senior housing, which includes assisted living, memory care, and independent living, according to an industry analysis. REITs also hold investments in 1 in 6 nursing homes. Publicly traded REITs that focus on health care are now worth nearly a quarter of a trillion dollars, according to Nareit, an industry association.
While one research study found REIT investments were associated with higher spending on nursing wages, another concluded that after being bought by REITs, nursing homes frequently replaced registered nurses with less skilled nurses and aides. A third analysis concluded that health inspection results were worse after REIT investment.
Researchers also found that investor-owned hospital chains that sold buildings to REITs were more likely to close or go bankrupt, as happened in 2024 with Steward Health Care. Often, private equity investors kept the sale proceeds as profits while the hospitals were burdened with new rent costs. “There were no improvements in clinical outcomes,” said Thomas Tsai, an associate professor at the Harvard T.H. Chan School of Public Health.
REITs are required to distribute most of their income and don’t have to pay the 21% federal corporate income tax on it. There is a catch: A REIT that “directly or indirectly operates or manages” a health care facility loses the tax break for five years. Typically, a REIT leases the property to another company that runs the nursing home or assisted living facility and maintains its tax break. Nareit said health care REITs distributed more than $7 billion in dividends in 2024.
Michael Stroyeck, head of health care analysis at Green Street, a real estate research company, said “there’s definitely a symbiotic relationship” between REITs and facility managers because they have the same goals. He said he has seen REITs replace operators that are having difficulties or go bankrupt.
John Kane, a senior vice president at the American Health Care Association and the National Center for Assisted Living, an industry group that represents nursing homes, said in a statement: “Given government funding often falls short, REITs have been valuable partners in helping to invest in long term care without influencing daily operations.”
Low staffing at a chain
Strawberry Fields REIT, which like CareTrust trades on the New York Stock Exchange, owns or controls the buildings of 131 nursing home facilities. The nursing home operations inside 66 of those facilities are owned by Moishe Gubin, Strawberry Fields’ chief executive, and Michael Blisko, one of its directors, according to Strawberry Fields’ annual report for last year.
Gubin and Blisko also jointly own Infinity Healthcare Management, which manages their nursing homes; Blisko is Infinity’s CEO. On average, Infinity-affiliated nursing homes provided an hour and a quarter less nursing care per resident per day than the national average of four hours, a KFF Health News analysis of federal records found.
Infinity and several of its nursing homes have recently settled 30 death and injury lawsuits in Cook County, Illinois, totaling more than $4 million, said Margaret Battersby Black, a Chicago lawyer. A jury last year awarded $12 million in a lawsuit brought against Infinity and one of its Chicago nursing homes over the 2023 death of Shirley Adams. A retired candy factory worker, Adams died after developing infected bedsores at Lakeview Rehabilitation and Nursing Center, according to the lawsuit.
“She had wounds that no one could explain,” one of her adult children, Leslie Adams, testified at trial. Medicare gives Lakeview its lowest quality rating, one star out of five.
Leslie Adams lost his mother, Shirley, who died after developing infected bedsores at Lakeview Rehabilitation and Nursing Center, according to a lawsuit he filed. “She had wounds that no one could explain,” he testified. (Taylor Glascock for KFF Health News)
Taylor Glascock for KFF Health News
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Taylor Glascock for KFF Health News
Paul Connery, a lawyer for Adams’ family, said they are still trying to collect on the judgment against the nursing home and management company, which now totals $17 million with interest and attorney fees.
“If I get caught speeding and I went to court, they issue me a ticket and I’ve got a fine to pay,” Adams said in an interview. “How are they able to still continue to move on with business like nothing has happened?”
In a phone interview and an email, Gubin said Strawberry Fields, Infinity, and the nursing homes are all legally distinct and that he has not played an active role in Infinity in more than a decade. He said nursing homes get sued all the time but that the verdict against Lakeview is so large that it will force the home to declare bankruptcy or shut down.
The owners and operators of Lakeview Rehabilitation and Nursing Center in Chicago also are directors of the real estate investment trust that owns the building, a securities filing shows.
Taylor Glascock for KFF Health News
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Taylor Glascock for KFF Health News
“The whole thing is unfortunate,” Gubin said by phone. “For 15 years they were a perfectly good guardian” and “a well-run building,” he said. “You wouldn’t think it was fair to be judged on your worst day.”
Blisko and an Infinity lawyer did not respond to requests for comment.
Strawberry Fields, which owns 10 assisted living facilities and two long-term care hospitals in addition to the nursing homes, earned net income last year of $33 million from $155 million in rent, a 21% profit margin, securities filings show. Gubin said those weren’t excessive returns.
A $110 million verdict
Traditionally, REIT leases make the operating companies responsible for paying property taxes, insurance premiums, and maintenance costs. In 2008, Congress gave health care REITs a new option to make money: On top of collecting rents, they could set up subsidiaries and take profits directly from health care businesses. They still must have independent management overseeing care decisions. Many REITs have embraced the role even though the subsidiaries must pay corporate taxes and risk losing money if the businesses do poorly.
Colony Capital was a REIT that through layers of shell corporations owned both the building and the operation of Greenhaven Estates, a Sacramento assisted living and memory care facility. In 2018 Greenhaven paid Colony $1.4 million in rent, nearly a third of its $4.5 million in revenue that year, according to financial records filed in court.
Greenhaven also was on the verge of losing its license, according to a revocation notice filed in November 2018 by the California Department of Social Services. Greenhaven had racked up years of health violations, including from letting untrained workers administer medications, lacking enough employees to care for people with dementia, and neglecting a resident who smeared feces over his body, bed, floor, and bathroom, the notice said.
In February 2019, a few weeks after celebrating her 100th birthday, Mildred Hernandez, a resident with Alzheimer’s, wandered out of Greenhaven in the middle of the night. Her assisted living wing had no exit door alarms even though it housed several residents with dementia, court records showed. Berta Lepe, one of Greenhaven’s caregivers, found Hernandez under a bush, wearing only a shirt and underwear. The temperature was in the 30s.
Mildred Hernandez was 100 when she died of hypothermia after wandering out of her assisted living facility in the middle of the night. A jury awarded $92 million in punitive damages against the owner of the home.
Ric Tapia
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Ric Tapia
“She was talking, but I couldn’t understand what she was saying,” Lepe testified at trial over a lawsuit from Hernandez’s family. Hernandez died of hypothermia a few hours later, according to her death certificate.
Frontier Management, the company that Colony had hired to manage Greenhaven, denied liability and settled the lawsuit on undisclosed terms.
Since the lawsuit, Colony has changed its name to DigitalBridge, which no longer owns Greenhaven and gave up its REIT status. At trial earlier this year, DigitalBridge said resident care was the responsibility of Frontier and that Colony “encouraged” Frontier to address problems. Richard Welch, a former Colony executive, testified that replacing management is disruptive. “I viewed it as a last resort,” he said.
In March, a jury awarded Hernandez’s family a total of $110 million: $10 million in compensatory damages, $92 million in punitive damages against DigitalBridge, and $8 million in punitive damages against Formation Capital, an asset management company.
“REIT money is very detached from knowing about or caring about patient or resident outcomes, because it’s not in their business model,” Ed Dudensing, a lawyer for the family, said in an interview. “Their allegiance is to their investors.”
DigitalBridge has asked the judge to delay finalizing the judgment while its legal challenges to the lawsuit and the verdict are evaluated. A DigitalBridge attorney and a corporate spokesperson did not respond to requests for comment, a Formation attorney declined comment, and a Frontier attorney and a spokesman did not respond to a request for comment.
‘Wet from head to toe’
When CareTrust bought City Creek Post-Acute and Assisted Living in 2019, the Sacramento nursing home where Pearlene Darby lived had a one-star Medicare rating and was losing money. CareTrust leased the building to a management company called Kalesta Healthcare Group based on the business plan Kalesta submitted.
While CareTrust was not the operator, it held periodic phone calls with Kalesta, which provided “a full update of what’s happening at the facility,” including changes in leadership, financial progress, and health inspection survey results, according to deposition testimony by Ryan Williams, a Kalesta co-founder.
According to a state inspection report, in 2020, the year Darby died, City Creek left a resident in soiled linens “wet from head to toe lying in bed” for more than eight hours. During a different visit, a health inspector cited the home after watching a nurse put a dirty diaper back onto a resident after caring for a wound. “It was just a small stool and it is far from where the wound is,” the nurse told the inspector, according to the report.
James Callister, CareTrust’s chief investment officer, said in his deposition that CareTrust officials “review results of regulatory surveys provided to us by the tenant. We review the five-star rating.” He said, “We evaluate results of care, but we do not evaluate types of care given or how or when, no.”
Darby had been living in City Creek since 2011 after a stroke left her in a wheelchair. She needed help getting in and out of bed. From September through November 2020, Darby lost 30 pounds, her family’s lawsuit alleged. During those months, employees dropped her three times as one worker rather than the required two operated the mechanical lift, the lawsuit said.
The suit alleged City Creek failed to reposition her every two hours in bed or her wheelchair, which is the clinical standard for people at risk of bedsores, and to promptly order devices to protect her skin.
In November, the nursing home sent Darby to the hospital. A blood test found bacteria had entered her bloodstream from her feces’ touching open skin wounds, according to the lawsuit. The hospital diagnosed her with sepsis. A surgeon said she needed an operation to redirect fecal waste from her intestines but concluded she wasn’t medically stable enough for surgery, the suit said.
Darby began receiving comfort care measures and was sent back to City Creek. She died two weeks later. In court filings, CareTrust and Kalesta denied the allegations.
In a phone interview, Williams, the Kalesta co-founder, said Darby’s death occurred during the most challenging point of the covid pandemic, when California rules required any nurses testing positive for the virus to be sent home and nurses were quitting out of fear for their health. “It was the most herculean of professional efforts to secure enough staff,” he said.
While expressing sympathy for Darby and her family, he said it was “unconscionable” that personal injury lawyers sued nursing homes over care failures during “the worst of times.”
In court, CareTrust petitioned Judge Richard Miadich to dismiss it from the lawsuit before trial. “This case does not concern a property condition,” CareTrust’s lawyers wrote. “CareTrust is simply a landlord.” But the judge ruled last year a jury should decide whether CareTrust “exercised actual control over City Creek.”
The case was settled out of court a few months later. All parties declined to reveal the settlement terms.
A 67% Profit
As recently as November 2023 — four years after its acquisition — City Creek earned one star from Medicare. It was cited for failing to have the minimum nursing home staffing required by California law during five of 24 randomly selected days in 2022, according to an inspection report. Williams said in the interview that Kalesta had increased spending on nursing over the course of its ownership, including boosting wages, but that it takes a year or two to turn around a troubled nursing home. He said the home’s star rating in 2023 was dragged down by its poor inspection history from before Kalesta took over.
City Creek’s rating has climbed in the past two years, and it now has the top overall rating of five, according to Medicare. Medicare rates City Creek’s current staffing levels as average. That’s better than most nursing homes in more than 200 buildings CareTrust bought before 2025, according to a KFF Health News analysis of federal data. On average, CareTrust nursing homes provided a half hour less nursing care per resident per day than the national average of four hours.
In its statement to KFF Health News, CareTrust’s counsel Layne said the REIT worked to “identify quality operators as tenants,” and that the homes the REIT rents out have more nurses and aides than the minimum required for nursing homes by their state governments. “The operators are licensed by state regulators and retain sole responsibility for operations,” the statement said.
CareTrust, which now owns more than 500 senior housing and nursing home buildings, reported net income last year of $320 million from $476 million in rents and other revenue — a 67% profit margin. As one point of comparison, HCA Healthcare, one of the nation’s largest for-profit hospital and health care chains, reported a 10% profit margin for last year.
Lesley Ann Clement, one of Darby’s lawyers, said cases like hers show the nursing home industry is wrong to complain it lacks financial resources for more staffing.
“There’s plenty of money,” Clement said. “They’re just not spending it on patient care.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
The US is planning to board and seize Iran-linked oil tankers and commercial ships in the coming days, according to a Saturday report by The Wall Street Journal.
The report noted that these actions would take place in international waters, potentially outside of the Middle East.
The US “will actively pursue any Iranian-flagged vessel or any vessel attempting to provide material support to Iran,” US Chairman of the Joint Chiefs of Staff Gen. Dan Caine said. “This includes dark fleet vessels carrying Iranian oil.”
“As most of you know, dark fleet vessels are those illicit or illegal ships evading international regulations, sanctions, or insurance requirements,” Caine continued.
Caine was further quoted as saying that the new campaign, which would be operated in part by the US Indo-Pacific Command, would be part of a broader US President Donald Trump-led campaign against Iran, known as “Economic Fury.”
White House spokeswoman Anna Kelly told the WSJ that Trump was “optimistic” that the new measures would lead to a peace deal.
The potential US military action comes as Iran tightens its grip on the Strait of Hormuz, including attacking several ships earlier on Saturday, the WSJ reported.
The report cited CENTCOM as saying that the US has already turned back 23 ships trying to leave Iranian ports since the start of its blockade on the Strait.
The expansion of naval action beyond the Middle East will provide the US with further leverage against Iran by allowing it to take control of a greater number of ships loaded with oil or weapons bound for Iran, the report noted.
“It’s a maximalist approach,” said associate professor of law at Emory University Law School Mark Nevitt. “If you want to put the screws down on Iran, you want to use every single legal authority you have to do that.”
Iran claimed earlier on Saturday that it had regained military control over the Strait, intending to hold it until the US guarantees full freedom of movement for ships traveling to and from Iran.
“As long as the United States does not ensure full freedom of navigation for vessels traveling to and from Iran, the situation in the Strait of Hormuz will remain tightly controlled,” the Iranian military stated.
In addition, Iranian Supreme Leader Mojtaba Khamenei declared on Saturday in an apparent message on his Telegram channel that the Iranian navy is prepared to inflict “new bitter defeats” on its enemies.
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