Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016


Nursing facilities are a major provider of long-term care services in the United States. These facilities provide medical, skilled nursing, and rehabilitative services on an inpatient basis to individuals who need assistance performing activities of daily living, such as bathing and dressing. Nursing facilities are one part of the long-term care delivery system that also includes home and community based services, but their relatively high cost has led them to be the focus of much attention from policymakers. Medicaid plays a major role in financing nursing facility care in the United States, and policy proposals to limit federal financing for Medicaid may lead to cuts in eligibility or scope of coverage for long-term care services. In addition, regulations effective November 2016 aimed to address longstanding challenges in quality and safety in nursing facilities. As the demand for long term care continues to increase and policy proposals and regulations unfold, the characteristics, capacity, and care quality of facilities remain subjects of concern among consumers and policy makers.

This report provides information on recent trends in nursing facilities in the United States, drawing on data from the federal On-line Survey, Certification, and Reporting system (OSCAR) and more recent Certification and Survey Provider Enhanced Reports (CASPER). We use these databases to provide information on nursing facility characteristics, resident characteristics, facility staffing, and deficiencies by state from 2009 through 2016. This information enables policymakers and the public to monitor and understand recent changes in nursing facility care in the United States and help highlight areas of ongoing interest for current and future policymaking.


Long-term care includes medical and personal care assistance that people may need – for weeks, months, or years – when they experience difficulty completing self-care tasks as a result of aging, chronic illness, or disability. While many people’s long-term care service needs can be met in the community, some may choose or require care in facilities. Nursing facility care is costly: a year of care typically costs over $82,000,1 and national spending on nursing facilities across all payers totaled $162.7 billion in 2016.2 Much of the cost of nursing facility care is publicly-financed through Medicaid, making it a high priority for state and federal policymakers.

In addition, a particular concern to consumers, professionals, and policy-makers is the quality of care provided in nursing facilities. In response to a request from Congress, the Institute of Medicine (IOM) completed a Study on Nursing Home Regulation in 19863 that reported widespread quality of care and oversight problems and recommended the strengthening of federal regulations for nursing homes.4  The IOM Committee recommendations and the active efforts of many consumer advocates resulted in Congress passing Nursing Home Reform Legislation as part of the Omnibus Budget Reconciliation Act (OBRA) in 1987.5

OBRA 1987, implemented by federal regulations in 1990 and in 1995, mandated a number of changes. The regulations eliminated the priority hierarchy of conditions, standards, and elements that were in the prior regulations. The merger of Medicare and Medicaid standards and processes raised standards for Medicaid-participating facilities. The Act also mandated more rigorous inspection procedures and the use of intermediate sanctions for regulatory violations and required surveyors to focus on quality outcomes.6 The federal law also required comprehensive assessments of all nursing facility residents to determine their care needs and to use this information in the care planning process.7 The law specifically required nursing facilities to provide sufficient nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status of residents. The law focused on outcomes of care (such as incontinence, immobility, and pressure ulcers) as well as the protection of residents’ rights and the establishment of quality of life requirements. The provisions of the law were implemented by the Centers for Medicare & Medicaid Services (CMS) over a ten-year period.

The 2010 Affordable Care Act (ACA) further expanded quality of care requirements for nursing facilities that participate in Medicare and Medicaid.8 The ACA incorporates the Nursing Home Transparency and Improvement Act of 2009, introduced because complex ownership, management, and financing structures were inhibiting regulators’ ability to hold providers accountable for compliance with federal requirements. The ACA also incorporates the Elder Justice Act and the Patient Safety and Abuse Prevention Act, which include provisions to protect nursing facility residents from abuse and other crimes. Under these laws, nursing facilities face standards regarding disclosing financial relationships and costs; reporting requirements for nurse staffing; and improvements to compliance and ethics programs. There are also rules regarding monetary penalties for lack of compliance with federal regulations; notification requirements when a facility closes; additional staff training on dementia care; and provisions for background checks and reporting criminal activity. While implementation of many nursing facility provisions in the ACA was delayed, comprehensive regulations effective November 2016 implement these and other changes to both improve patient care and safety and reduce reporting and procedural burden on facilities.9

Since 1998, CMS has published limited information on nursing facilities through its Nursing Home Compare website. In 2008, CMS added the Nursing Home Five-Star Quality Rating System, which provides individual and composite ratings for nursing facilities based on health inspections, nurse staffing hours, and selected quality measures. ACA requirements led CMS to update and improve the Nursing Home Compare website, and over time, CMS has added new indicators and information about complaints and modified its star rating system to make it more difficult to achieve a better star rating.10,11

This report provides information on nursing facility characteristics, resident characteristics, facility staffing, and deficiencies by state from 2009 through 2016. The deficiency data include all deficiencies from the annual survey and any complaint surveys during each calendar year. The data source, originally the federal On-line Survey, Certification, and Reporting system (OSCAR), was converted to the Certification and Survey Provider Enhanced Reports (CASPER) in 2012.12 Because OSCAR/CASPER data changes frequently throughout the year as facilities add new data (and older ones are deleted), our analysis may have slightly different exact figures than those reported elsewhere. Additional details on the survey and methods underlying the data in this report are provided in the Appendix at the end of the report.

Executive Summary Facility Characteristics

KFF Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270 | Email Alerts: | |

The independent source for health policy research, polling, and news, KFF is a nonprofit organization based in San Francisco, California.