Federal oversight of nursing homes is changing as inspection data show an association between short staffing and serious harm to residents, according to a July KFF analysis.
The report examined deficiency data for the nation’s roughly 14,700 nursing homes, home to about 1.2 million older adults and people with disabilities. It found that facilities with lower staffing levels are far more likely to be cited for violations that caused actual harm or put residents in immediate danger.
Why this matters
One rule that’s been paused is ownership disclosure, a change that advocates say will increase uncertainty about harm and neglect for thousands of residents and make it more challenging for companies or people to be held accountable.
Nursing home ownership structures, including private equity ownership and multi-facility chains, have been the subject of research linking complex ownership structures to quality problems and reduced accountability. A study from Weill Cornell Medicine associated private equity acquisition with more emergency room visits, more hospitalizations and higher Medicare costs among long-stay residents.
A National Bureau of Economic Research-linked study found an 11% increase in short-term mortality at private-equity-owned facilities. With the disclosure deadline suspended, that information will be harder to obtain in the near term.
The changes shift more of the burden for catching problems onto residents and their families, at a time when inspections are already falling behind schedule in a significant share of facilities.
This is an opportunity for journalists to track their local nursing facilities, use available data to examine hospitalizations and costs, track ownership and question those in charge about staffing, emergency room visits, quality of care and patient safety.
What inspectors found
Homes with low staffing had level 3 or level 4 deficiencies — the most serious categories — at nearly double and triple the rate of well-staffed homes, respectively. Those deficiencies include falls resulting in fractures, delayed treatment for conditions like pneumonia, and failures to follow basic protocols for feeding residents at risk of choking.
The findings come as the Trump administration has scaled back several oversight mechanisms. It rescinded the Biden-era rule requiring nursing homes to meet a minimum staffing level. CMS has also moved to prioritize complaint-driven surveys over routine, scheduled ones.
The agency also suspended a deadline for nursing homes to disclose detailed ownership information. The current administration cited cost and workforce concerns raised by the nursing home industry, which argued the requirement was unachievable given existing labor shortages, particularly in rural areas.
Nursing homes are required by law to receive a standard inspection every nine to 15 months. However, KFF found that about 13% of homes are going longer than that, and that 3% hadn’t been inspected since before January 2024. The staffing findings are consistent with years of prior research linking inadequate staffing to poor outcomes in long-term care, a connection that prompted the Biden administration to finalize minimum staffing standards in 2024.
One in four deficiencies nationally is now identified through a complaint survey rather than a routine one — meaning a resident, family member, or staffer had to flag a problem before regulators investigated.
From deficiencies to harm
Most deficiencies, KFF found, don’t involve actual harm. About 93% are classified as level 2 — no harm yet, but the potential for it. Examples cited in the report include unanswered call bells, late medication deliveries and expired food not thrown away.
The remaining 5% are level 3 or 4. These categories are tied to actual harm or immediate jeopardy. In the most recent survey cycle, about 6,700 deficiencies fell into those categories, and 28% of nursing homes had at least one.
Inspection reports reviewed by KFF included a case where a facility failed to raise a resident’s bed rail, resulting in a fall and a fractured femur, and another where a resident’s worsening condition went unaddressed until the resident arranged their own transport to a hospital, where they were diagnosed with pneumonia and influenza.
Critics of the repeal, including resident advocacy groups, have argued that removing the requirement eliminates one of the best tools regulators had for addressing the root cause of many serious deficiencies. The National Consumer Voice for Quality Long-Term Care called the staffing rule “the most significant increase in protections for nursing home residents in decades” and said it “strongly condemns” the rollback.
KFF’s analysis draws on Nursing Home Compare, filtered to approximately 137,000 deficiencies from each facility’s most recent inspection. The deficiency examples were drawn from a review of 70 inspection reports across six states: Maryland, New Jersey, Pennsylvania, California, Tennessee and Washington.
Note: The report was supported in part by the John A. Hartford Foundation, which also supports the aging health beat. KFF said it retained full editorial control over the analysis.
Resources
- Nursing home staffing data, Long Term Care Community Coalition
- Nursing home compare, Centers for Medicare and Medicaid
- How to Find the Long-Term Care Ombudsman in Every State, AARP
- Nursing home inspect, ProPublica
- State health facts: nursing homes, KFF
