A Look at Nursing Facility Characteristics Between 2015 and 2024
Nursing facilities provide medical and personal care services for nearly 1.2 million Americans. In response to high mortality rates during the COVID-19 pandemic and long-standing staffing shortages, the Centers for Medicare and Medicaid Services (CMS) released a highly-anticipated final rule that established minimum staffing standards for nursing facilities. These standards were part of the Biden Administration’s broader strategy to increase the quality of and access to Medicaid services and long-term care. Several lawsuits have been filed in opposition to the final rule, including lawsuits filed by nursing home industry groups, Texas’ attorney general, and a group of Republican state attorneys general. With President-elect Trump returning to the presidency, the staffing rule’s future is unknown. It is not clear whether the incoming Administration will defend the nursing home staffing final rule in court, support the litigation in opposition to the rule, or issue new regulations to scale back the provisions in the staffing rule. Additionally, during President Trump’s first term, the Administration issued regulations to relax oversight for nursing facilities, which included reducing the frequency of facility assessments, removing the requirement that an infection preventionist work at a facility part-time, and removing the 14-day prescription limit for psychotropic drugs.
This data note examines the characteristics of nursing facilities and the people living in them with data from Nursing Home Compare, a publicly available dataset that provides a snapshot of information on quality of care in each nursing facility, and CASPER (Certification and Survey Provider Enhanced Reports), a dataset that includes detailed metrics collected by surveyors during nursing facility inspections. State-level data are also available on State Health Facts, KFF’s data repository with downloadable health indicators. Key takeaways include:
- The number of nursing facilities certified by CMS decreased by 5% between July 2015 and July 2024.
- Over that same period, the average number of hours of nursing care that residents receive per day declined by 8% (from 4.13 to 3.80), despite generally increasing health needs of nursing facility residents.
- The average number of deficiencies per facility increased during this time period as did the share of facilities with serious deficiencies, from 17% to 28%.
The number of nursing facilities certified by CMS decreased by 5% between July 2015 and July 2024 (Figure 1). In order to receive payment under the Medicare and/or Medicaid programs, nursing facilities are required to follow certain regulations and be certified by CMS. The decreased number of nursing facilities reflects the net change in the number of certified facilities after accounting for newly-certified facilities and facilities that are no longer certified, including facilities that closed.
Between 2015 and 2024, the number of residents living in nursing facilities decreased by 10%, with a steep decline between 2020 and 2021 reflecting the effects of the COVID-19 pandemic (Figure 1). Since the steep drop in 2021, resident counts have slowly started to rise but are still well below pre-pandemic levels. Prior to the pandemic, the number of residents was declining more slowly, which reflects a longer-term trend of people increasingly receiving care in home and community-based settings (HCBS) rather than institutional settings. COVID-19 exacerbated the decrease in nursing facility residents—in part because nursing facility residents and staff incurred so many deaths during the pandemic.
Between July 2015 and July 2024, the average hours of care from registered nurses, licensed practical nurses, and nurse aides that nursing facility residents received declined by 8%, from 4.13 hours to 3.80 hours per resident each day (Figure 2). The decrease was driven by a 21% decline in registered nurse (RN) hours and an 8% decline in nurse aide hours. Licensed practical nurse (LPN) hours increased by 6% in this same time period. The 2024 rule on nursing facility staffing requires nursing facilities to meet minimum standards in staff hours for RNs and nurse aides but does not include any requirements for LPNs. The growing use of LPNs and declining number of RNs and nurse aide hours is one reason that fewer than 1 in 5 nursing facilities had staffing levels sufficient to meet the rule’s requirements as of April 2024, according to KFF analysis. The total hours from nursing staff decreased between 2015 and 2024, but the number of hours of care per resident rose briefly in 2021. The relatively higher staffing hours in 2021 reflected the fact that the number of residents declined more quickly than the number of staff hours did between 2020 and 2021. In 2021, the number of staffing hours was 12% lower than in 2020 (data not shown). These lower staffing levels in the last several years align with data as of March 2024 showing that the number of workers employed at long-term care facilities continues to remain below pre-pandemic levels.
Box 1: Direct Care Staff in Nursing Facilities |
| Registered Nurse (RN): Registered nurses (RNs) are responsible for the overall delivery of care to the residents and assess needs of nursing facility residents. RNs are typically required to have between two and six years of education.
Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN): LPNs/LVNs provide care under the direction of an RN. Together, RNs and LPNs/LVNs make sure each resident’s plan of care is being followed and their needs are being met. LPNs/LVNs typically have one year of training. Certified Nurse Aides/Assistants (CNAs): CNAs work under the direction of a licensed nurse to assist residents with activities of daily living such as eating, bathing, dressing, assisting with walking/exercise, and using the bathroom. All CNAs must have completed a nurse aide training and competency evaluation program within 4 months of their employment. They must also pursue continuing education each year. |
Both the average number of deficiencies and the share of facilities with serious deficiencies has increased over time, which could reflect increased oversight and lower staffing levels (Figure 3, Box 2). Between 2015 and 2024, the average count of deficiencies increased from 6.8 to 9.5, an increase of 40%. The increase was generally steady overtime, except for a stable period between 2020 and 2022. The share of facilities reporting serious deficiencies between 2015 and 2024 increased from 17% to 28%. The Nursing Home Staffing Study report by Abt Associates from June 2023 found that better-staffed nursing homes are typically cited for fewer deficiencies or violations of federal regulations, suggesting there may be a relationship between the increase in deficiencies and the decrease in staffing levels over the same time period.
Box 2: Deficiencies in Nursing Facilities |
| Nursing facilities receive deficiencies when they fail to meet the requirements necessary to receive federal funding. Deficiencies are often given for problems which may have negative effects on the health and safety of residents. Commonly cited deficiencies include a failure to provide necessary care, failure to report abuse or neglect, and violation of infection control requirements. Each of these categories has specific regulations that state surveyors review to determine whether or not facilities have met the standards.
Deficiencies are characterized by their level of severity: Deficiencies for “actual harm” or “immediate jeopardy” are the most severe and are grouped together under the term, “serious deficiencies.” CMS defines “actual harm” as a “deficiency that results in a negative outcome that has negatively affected the resident’s ability to achieve the individual’s highest functional status.” “Immediate jeopardy” is defined as a deficiency that “has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the nursing facility.” |
The share of residents by primary payer stayed relatively stable over time (Figure 4). As of July 2024, Medicaid was the primary payer for 63% of nursing facility residents; Medicare for 13% of residents; and the remaining 24% of residents had another primary payer (ex. private insurance, out-of-pocket, etc.) (Figure 4). Medicare does not generally cover long-term care but does cover up to 100 days of skilled nursing facility care following a qualifying hospital stay. KFF polling shows that four in ten adults overall incorrectly believe that Medicare is the primary source of insurance coverage for low-income people who need nursing facility care.
The share of facilities by ownership type also stayed relatively stable over time (Figure 4), but there was increasing scrutiny over the 72% of facilities that are for profit during the prior Administration. Despite little change in the type of ownership, there have been reports of private equity firms purchasing nursing facilities and changing operations to increase profits, resulting in lower-quality care. Currently available data do not reliably identify whether facilities are owned by a private equity company, though the GAO estimates that about 5% of nursing facilities had private equity ownership in 2022. The Biden Administration issued a final rule (effective as of January 2024) that requires nursing homes enrolled in Medicare or Medicaid to disclose detailed information regarding their owners, operators, and management, including:
- Anyone who exercises any financial control over the facility;
- Anyone who leases or subleases property to the facility, including anyone who owns 5% or more of the total value of the property; and
- Anyone who provides administrative services, clinical consulting services, accounting or financial services, policies or procedures on operations, or cash management services for the facilities.
Facilities must also disclose whether any of the owning or managing entities are a private equity company or real estate investment trust. It is unknown whether the income Administration will eliminate, strengthen, or maintain those requirements.