Quality in Skilled Nursing Facilities


Nursing facilities provide long-term services and supports (LTSS), as well as short-term rehabilitation and postacute care following hospitalizations to people of all ages. Although younger people do use nursing facilities, 83.5 percent of nursing facility residents are age 65 and older. Those older residents make up an even higher percentage of long-stay residents receiving LTSS (see also End-of-Life Care and Medicaid for more information). 

Federal Requirements: The Nursing Home Reform Act of 1987 seeks to guarantee all nursing home residents receive quality care by: 

  • setting quality standards for nursing facilities nationwide, 
  • establishing the rights of nursing facility residents, 
  • defining the state survey and certification process to enforce the standards, 
  • mandating comprehensive assessments of residents, and 
  • prohibiting nursing facilities from inappropriately admitting and keeping people with mental disabilities unless they can provide or arrange appropriate care. 

Nursing facilities that want to be reimbursed by Medicare and Medicaid must meet all federal requirements. 

The act includes significant provisions regarding the rights of nursing facility residents and the responsibilities of ombudsmen. Its residents’ bill of rights includes the right to self-determination, personal and privacy rights, transfer and discharge rights, protections against misuse of personal funds and Medicaid discrimination, and the right to be free of physical and chemical restraints. 

Nursing facilities have reduced the use of physical restraints. But research indicates that the use of antipsychotic medications remains high, particularly in the Northwest and Midwest. The extent to which nursing home management may have falsified diagnoses to justify the inappropriate use of these drugs as a chemical restraint is relatively unknown. Many facilities continue to use these potentially dangerous drugs—in lieu of proper staffing—which has the potential to harm hundreds of thousands of patients. 

The Nursing Home Reform Act is implemented through the requirements of participation for Long-Term Care Facilities. 

The act also establishes a resident’s right to unrestricted access to visitors who are family members and the right of access to other visitors, subject only to reasonable restrictions by the facility. The law also requires each nursing facility to “care for its residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident.” 

Staffing levels: The Nursing Home Reform Act requires that, at minimum, nursing facilities provide eight hours of registered nurse (RN) coverage and 24 hours of licensed practical nurse (LPN) coverage per day. In addition, the law requires nursing facilities to provide the scope of care and services (including sufficient qualified staff) that will ensure that each resident can attain or maintain their “highest practicable physical, mental, and psychosocial well-being.” 

In 2016, the Centers for Medicare and Medicaid Services (CMS) issued new requirements for nursing and skilled-nursing facilities to participate in Medicare and Medicaid. However, CMS has never issued minimum staffing standards based on the resident census. Some states have done so. 

Research shows that RN staff hours are correlated with better quality outcomes. This includes reduced incidence of pressure sores, lower use of physical restraints, and fewer hospital admissions. Certified nursing assistants (CNAs) provide the majority of direct care in nursing facilities. However, while adequate LPN and CNA staffing is essential, it is not a substitute for RN staffing. In public health emergencies, states can provide temporary “surge teams” to help affected facilities implement new policies to care for critically ill residents, reduce the incidence of infections, and maintain appropriate staffing levels and quality of care. 

Federal law requires that state-approved nurse aide training programs have at least 75 hours of classroom and clinical instruction and that nurse aides pass a competency test within four months of providing direct care to residents. Many states require more than 75 hours of training, believing that the federal standard is inadequate to protect residents’ welfare and workers’ safety. As of 2014, 19 states required only the federal minimum of 75 hours of training, and 18 states reported that their nurse aide training programs exceeded the federal requirement of 75 hours. Fourteen states required between 76 and 100 hours, and 14 states and the District of Columbia required more than 100 hours. Maine had the highest requirement of 180 hours. 

Nursing facilities may hire feeding assistants to feed and hydrate residents who are unable to eat or drink without help. Feeding assistants are required to complete a state-approved training program and must be properly supervised. Skilled-nursing facilities can use paid feeding assistants if allowed under state law. 

Quality measures: The Department of Health and Human Services Nursing Home Quality Initiative emphasizes the provision of consumer information and the use of consultants to help nursing facilities improve care. A key component of the program is the Care Compare website, which includes the former Nursing Home Compare website. It provides information about the quality of care in individual nursing facilities. It reports measures of key quality factors, such as preventable bedsores and the use of restraints. The ratings are risk-adjusted, so facilities with sicker and more impaired residents do not receive unfairly low scores. Ratings can be compared across all nursing facilities. The website also features an overall five-star rating system based on health inspections, staffing, and quality measures. 

Prior to the COVID-19 pandemic, about 40 percent of nursing homes were cited each year for inadequate infection prevention control., From 2013–2017, 82 percent of all surveyed nursing homes had an infection prevention and control deficiency cited in one or more years. The pandemic has highlighted the importance of data reporting in LTSS settings. This reporting is regulated by states except for some federal requirements for nursing homes. Reporting data is not currently uniform, transparent, or easily available to the public. Data should be collected and reported using variables that are most helpful to public health officials and the public. For example, staff and resident deaths should be reported separately. And hospital deaths for patients hospitalized directly from an LTSS facility should be reported uniformly across the states. In LTSS data reporting, care should be taken to report data by race and ethnicity accurately and in uniform ways. This way, disparities in health outcomes by race and ethnicity can be identified readily. The same is true for collecting data on sexual orientation and gender identity. Patient privacy should also be protected. 

Direct-Care Payment Ratio: Several states have adopted policies requiring all nursing facility providers to spend a specific share of revenue—referred to as the direct payment ratio—on improving direct care of residents. The goal is to improve overall quality of care. The concept is similar to a medical loss ratio in insurance used to create greater transparency and accountability for health insurers. A few states have enacted these ratios. The floor required in these states is 70 to 90 percent of revenue spent on patient care. 

Nursing facility inspections: State governments oversee the licensing of nursing facilities and have contracts with CMS to monitor nursing facilities that want to provide care to Medicare and Medicaid participants. (The federal government decides whether to certify a facility for Medicare/Medicaid.) Each state with a contract must conduct on-site inspections, known as surveys, which determine whether nursing facilities meet the minimum Medicare and Medicaid quality and performance standards. Surveys are conducted on a 9- to 15-month cycle with a state-average time of 12 months. State inspections may occur more frequently if a nursing facility is performing poorly. Research shows variability in how surveys are conducted across states and regions. Care should be taken to ensure that surveyor characteristics better reflect the demographic makeup of the increasingly diverse nursing home resident and receive needed cultural sensitivity training. 

Investigation of residents’ deaths: No national policy requires that deaths of nursing facility residents be investigated to determine whether abuse or neglect played a role. Arkansas and Missouri are the only two states that require coroner investigations of all deaths in nursing facilities. Coroners who find reasonable cause that the death is due to neglect or other maltreatment report their findings to the state survey agency and the state Medicaid Fraud Control Unit. Referrals may also go to a local city or county prosecutor. The state survey agency treats the coroner referrals as complaints and investigates them accordingly. 

Swing beds: Hospital swing beds can be converted temporarily from acute care to postacute and rehabilitative care. They can improve access to care for people living in rural areas with severe shortages of nursing facility beds. 

Nursing facility transparency and improvement: Provisions in the Affordable Care Act (ACA) help consumers obtain more complete nursing facility information. Publicly available data include nursing facility ownership and staffing information based on payroll data instead of data self-reported by facilities. Consumers can have access to their complaints, inspection reports, and other information. The law also modifies civil monetary penalties for nursing facilities. It allows penalties to be collected and held in an escrow account, improves notice in the case of facility closure, and improves staff training, among other provisions. 

Nursing facility ownership and management: In 2010, the Government Accountability Office (GAO) found that private investment firms acquired 1,876 nursing facilities from 1998 through 2008. Ten firms accounted for 89 percent of these nursing facility acquisitions during this period. According to GAO, the CMS system for tracking information about nursing facility ownership was confusing. Congress included enhanced reporting requirements for nursing facilities in the ACA. The ACA requires a nursing facility to disclose extensive information regarding the people and entities that own, control, or manage the facility. The disclosure must address corporate structures by including organizational information on the legal relationships between the entities and people who own or manage the facilities. 



Monitoring and enforcement

Federal and state governments should monitor compliance with the Nursing Home Reform Act and other laws and regulations affecting nursing facilities. They should enforce regulations as mandated by the quality reform provisions of these laws. 

The federal government should maintain strong federal nursing facility quality standards. The nursing facility industry should not be deregulated. And the survey system should not be changed in ways that could hamper states’ ability to enforce standards and impose sanctions against poor-quality providers. 

Federal and state governments should provide effective oversight of nursing facilities. Strong sanctions for violations of health and safety standards and residents’ rights should be created. 

The Centers for Medicare & Medicaid Services (CMS) should not allow surveyors to also serve in a consultant role to nursing homes. This presents a conflict of interest. 

The Department of Health and Human Services should ensure that accurate and comprehensive data on the finances, operations, and ownership of all nursing homes are available in a real-time, readily usable, and searchable database so that it is possible to: 

  • track the percentage of funds that directly support residents rather than administrative or other costs, 
  • evaluate and track the quality of care for facilities with common ownership or management company, and 
  • assess the impact of nursing home real-estate ownership models and related-party transactions on the quality of care. 

An independent third party should obtain feedback from residents to ensure that complete and accurate information is obtained. 

Federal and state governments should provide the necessary funding to carry out the provisions of the Nursing Home Reform Act. This includes giving residents the right to immediate and unrestricted access to family members and others with whom they have established relationships. Such access can be subject to reasonable and nondiscriminatory restrictions that the facility may adopt for residents’ health and safety and the facility’s security. 

The Act’s requirement that facilities ensure each resident attains or maintains their “highest practicable physical, mental, and psychosocial well-being” should be vigorously enforced. 

Inspections should be unannounced. The current interval between nursing facility inspections should not be changed. 

States should require surveyors to interview residents in private when inspecting facilities and to conduct private interviews with family members and independent family councils requesting an interview. 

Federal and state regulations should require coroners to report nursing facility residents’ deaths suspected of having been caused by abuse, neglect, or other maltreatment. They should be reported to the state survey agency and referred to a local city or county prosecutor to investigate the death. 

When an investigation uncovers abuse, neglect, or noncompliance associated with the resident’s death, the nursing facility should be penalized. 

Policymakers should encourage nursing homes to pilot smaller units within a facility with staff dedicated to particular units and assess the outcomes, particularly on infection control. 

Rights of residents and applicants

Facilities should be required to post a residents’ bill of rights in prominent places accessible to residents and families. States should require that facilities give the bill of rights to prospective residents, their families, and their representatives and provide translations for people who do not speak English. 

The federal government and the states should prohibit facilities from blocking the formation of a resident or family council or interfering with their meetings or promotion. New residents should be informed of their right to form or participate in an existing council. This should continue to apply during a public health emergency to the extent it is safe and practical. If possible, the facility should facilitate virtual meetings. 

Medicare-Medicaid beds

States should require that all beds in a nursing facility be certified for Medicaid and Medicare as a condition for the facility’s participation in Medicaid. 

Federal and state governments should enforce quality standards similar to those for freestanding nursing facilities in order to protect against improper use of hospital swing beds. 

Adequate staffing

States should require adequate numbers of appropriately trained staff to ensure a high quality of care. Minimum staffing requirements should aim to increase staffing thresholds at least to levels necessary to ensure adequate care. 

Nursing facilities should be required to have at least one registered nurse or Advanced Practice Registered Nurse (e.g., a gerontological nurse-practitioner), with clinical responsibilities on duty 24 hours a day, seven days a week. 

Federal and state governments should enact regulations that go beyond the Nursing Home Reform Act’s standard of eight hours of registered nurse (RN) time per nursing facility per day, recognizing that increased RN staffing hours correlate with better quality outcomes. 

Federal and state governments should establish and enforce minimum staffing levels no lower than the minimum thresholds identified by the CMS. 

Minimum thresholds include: 

  • 2.8 hours for nurse aides per resident per day; 
  • 1.3 hours for RNs and licensed practical nurses, combined, per resident per day; and 
  • 0.75 hours for RNs per resident per day. 

Federal and state regulations should require that all long-term services and supports providers monitor staff levels to ensure that individual needs are being met. Staffing levels should be adjusted to maintain this standard. 

States should require that facilities exceed the absolute minimum number of staff, as determined by CMS. This will ensure that each resident can attain or maintain their “highest practicable physical, mental, and psychosocial well-being,” as required by the act. 

States should create incentives encouraging providers to hire as many permanent workers as possible. Extensive use of temporary workers is a disincentive to staff recruitment and retention. 

States should create incentives to minimize sharing of direct-care staff across multiple nursing facilities. 

The required minimum certified nursing assistant training should be increased to at least 120 hours. Staff should continue to be required to complete a competency-based assessment in practice before providing care, in addition to passing a state exam that includes a written or oral component. 

CMS should establish minimum education and national competency requirements for nursing facility staff, including continuing competence. Training for continuing competence, as well as initial education for students preparing for health professions, should follow best practices and evolving knowledge and understanding. It should ensure nursing facility staff support and advance health equity outcomes in their interactions with residents and provide high-quality care to all older adults. 

Federal minimum requirements for supervised hands-on training should be increased beyond the 16 hours that are currently required. 

Federal and state policymakers and the private sector should develop and implement competency-based training and evaluation. This could potentially replace some classroom hours. States should encourage employers to pay for staff training through various methods. This could include, but not be limited to, tuition reimbursement to help defray the training cost for employees, as many employers already do for continuing education requirements. 

Federal and state minimum requirements for staff training should permit some or all of the hours performed for work in one long-term services and supports (LTSS) setting or level of care (and directly relevant to other settings) to be portable. These hours should count toward training requirements for other settings. 

Federal and state governments should work across agencies to support building and retaining a robust and diverse LTSS workforce. They should encourage diversity in hiring across the staff hierarchy, from direct-care workers to administrators. 

Providers should be held accountable for failing to meet cultural competency standards. 

Training in communication, problem solving, cultural competency, and recognition and reporting of abuse and neglect should be added to certified nursing assistant (CNA) curriculum requirements. 

Federal and state governments should require that nursing facility staff be trained and demonstrate needed skills before implementing new technology or equipment for residents. 

States should establish continuing education requirements for registered nurses, licensed practical nurses, and CNAs. They should also require employer-provided paid leave for this purpose. Employers should be encouraged to pay tuition and fees for continuing education. 

States should ensure that social workers and other mental health professionals who work in nursing facilities or under contract to nursing facilities have training in the special needs of older people and people with all types of physical and mental disabilities(see also Adequate and Well-Trained Workforce for Long-term Services and Supports in this chapter). 

Additional research that will advance the understanding of the relationship between staffing levels and quality of care should be encouraged. 

Federal and state governments should consider evidence-based solutions and practices for training, and empowering direct-care workers from culture of change models such as Green House. 

CMS should complete, in a timely manner, research to determine the staffing levels needed to ensure adequate care and to develop methods of adjusting staffing levels based on case-mix and residents’ needs. 

During a public health emergency, surge teams should be made available to nursing homes and other long-term care facilities or congregate care settings experiencing an outbreak. 

Additional quality policies

Quality measures: Participant preferences and satisfaction should be used as key quality measures. These measures should evaluate whether a participant is receiving all the services in their service plan and whether there are unmet needs. 

Direct-Care Payment Ratio: The federal government and states should set a floor on the total amount of revenue (including Medicaid, Medicare, and private pay) that every nursing home must spend on direct resident care, referred to as a direct-care payment ratio. This would ensure greater transparency and accountability. Proposals for direct-care payment ratios will be evaluated based on several factors, including the payment sources included, the portion of dollars allocated to direct care, and the definition of direct-care. 

Palliative care: Federal and state policymakers should support unbiased assessment of palliative care needs as well as improved access to palliative care services regardless of setting (e.g., hospital, nursing home, or home). Palliative care should be available in the care setting that the person prefers. States should require facilities to establish ethics committees to help staff, residents, and families deal with end-of-life treatment decisions, such as refusal of nutrition and hydration and do-not-resuscitate orders. 

Use of physical or chemical restraints: States should establish and enforce standards to eliminate the unnecessary use of physical and chemical restraints. Antipsychotic drugs should not be used to sedate residents. 

States should ensure that physicians, nursing facility staff, and families are educated about the negative effects of restraints and alternatives to their use. Medical professionals should be held accountable for inappropriate prescribing. 

Providers should only use physical restraints in an emergency and under a physician’s order. The order should not last more than 12 hours. During the 12 hours, residents must be checked on a schedule specified in the Nursing Home Reform Act. An “emergency” should be defined as an unanticipated and rarely occurring situation that poses an immediate and serious danger to the resident or other individuals in the facility. 

States should require that when restraints are applied, residents are checked on a schedule at least as strict as that required by CMS under the Nursing Home Reform Act. 

Disclosure of ownership

Federal and state governments should work closely with consumer groups to develop and implement a standardized format for nursing facilities to disclose the names of all parties with ownership control or lease, financial, or operational interest in the facility. This data should be submitted to federal and state governments, the state long-term care ombudsman, and the public. Federal and state governments should notify the public of the availability of this information and make it readily accessible to the public. 

Nursing facilities should be required to notify prospective and current residents, their families, and resident councils of the availability of ownership information and provide them with this information upon request.