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Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2014

Charlene Harrington and Helen Carrillo are with The University of California San Francisco and Rachel Garfield is with the Kaiser Family Foundation.

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. In addition, the quality of care provided in nursing facilities has been a longstanding policy challenge. Several federal and state regulations, including new regulations proposed in July 2015, aim to address longstanding quality and safety issues. As the demand for long term care continues to increase, 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 Certification and Survey Provider Enhanced Reports (CASPER), to provide information on nursing facility characteristics, resident characteristics, facility staffing, and deficiencies by state from 2009 through 2014. Additional detail on the survey and methods underlying the data in this report are provided in the Appendix at the end of the report. This data 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 concern for current and future policymaking.



Facility characteristics provide a picture of who provides nursing facility care in the United States, including the number and capacity of facilities, certification and ownership, and revenue sources. The number of nursing facility beds has declined slightly since 2009, reaching 1.6 million certified beds in 2014 (with an average of 109 beds per facility). In addition, nursing facility occupancy rates declined slightly from 2009 to 2014, from 83.7 percent in 2009 to 82.3 percent in 2014. States vary in their average facility size and occupancy rates, with states in the East generally having larger facilities and higher occupancy rates.

Over the 2009 to 2014 period, share of nursing facilities that were for-profit increased slightly, from 67% in 2009 to 69% in 201, while the share that were non-profit declined slightly from 26% in 2009 to 24% in 2014 (the remainder, about 6% over time, were government-owned). Ownership patterns vary widely across states, with states in the South and West having higher shares of facilities that are for-profit. In addition, more than half of facilities over this period were owned or leased by multi-facility organizations (chains that have two or more facilities), though the share of nursing facilities that are chain-owned varies by state.

Medicaid is the primary payer source for most certified nursing facility residents, with more than six in ten (63%) of residents having Medicaid as their primary payer in 2014. States in the East, particularly the Southeast, have higher shares of residents with Medicaid as their primary payer than other states (Figure ES-1).

Figure ES-1: Share of Nursing Facility Residents with Medicaid as Primary Payer by State, 2014

Figure ES-1: Share of Nursing Facility Residents with Medicaid as Primary Payer by State, 2014


Resident characteristics affect the environment of the facility and also require different levels and types of staff resources. While nearly all residents in a nursing facility require some level of assistance, some facilities may have residents with a greater level of need. On average, in 2014 residents’ level of need for assistance with activities of daily living scored 5.8 on a scale from 3 to 9, and levels of need have been fairly stable since 2009. Residents commonly have mobility impairments, which range from difficulty walking to inability to get oneself out of bed. While relatively few (4%) residents were bed-bound in 2014, nearly three quarters (64.3%) of residents depend on a wheelchair for mobility or are unable to walk without extensive or constant support from others. Another common health care need of nursing facility residents is treatments related to gastrointestinal issues such as bladder or bowel incontinence. However, there is still a notable discrepancy between the high percentage of residents with incontinence problems and the low percentage of residents in training programs to address these problems.

Cognitive and behavioral health is of particular concern for nursing facility residents. Nearly half (46%) of residents had a dementia diagnosis in 2014, and 31% had other psychiatric conditions such as schizophrenia, mood disorders, or other diagnoses. In addition, nearly two-thirds of residents received psychoactive medications, including anti-depressants, anti-anxiety drugs, sedatives and hypnotics, and anti-psychotics, in 2014. Over-use of antipsychotic medications has been the focus of recent policy attention, particularly their use among residents with dementia, and is the subject of recent proposed regulations for nursing facility care. Use of physical restraints is another area of concern for residents with cognitive problems. Federal law and ongoing education about the negative effects of restraint have led to a decline in their use over time, and in the share of residents with physical restraints was just 2 percent in 2014.


Over the past 25 years, numerous research studies have documented a significant relationship between higher nurse staffing levels, particularly RN staffing, and the better outcomes of care. Though several recommendations for minimum staffing levels have been put forth, there are not federal requirements for specific nurse staffing levels (though some states do have their own minimum staffing requirements). In 2014, total nursing hours (including RNs, LPN/LVNs, and NAs) averaged 4.0 hours per resident day in 2014, an increase from 3.9 in 2009, but there was wide state variation in average nursing hours per resident day. Nationwide, many of these hours are accounted for by non-licensed nursing care (such as nursing assistants).


Nursing facilities provide care to prevent problems and to address the needs of residents, but sometimes care does not meet established standards. State surveyors assess both the process and the outcomes of nursing facility care for 175 individual requirements across eight major areas. Where a facility fails to meet a requirement, a deficiency or citation is given to the facility for that individual requirement. Between 2009 and 2014, the average number of deficiencies per facility declined from 9.33 to 7.96, and the share of facilities with no deficiencies has increased slightly. In 2014, the most common deficiencies were given for failures in infection control, accident environment, food sanitation, quality of care, and unnecessary drugs. Of particular concern are deficiencies that cause harm or immediate jeopardy to residents. In 2014, more than one in five facilities received a deficiency for actual harm or jeopardy. As with other outcomes, there was wide variation across states in these outcomes; however, some states had high rates across all top ten deficiencies.


Recent trends in facility characteristics can help policymakers spot potential areas of concern and plan for future system needs. For example, while nursing facility capacity has remained fairly flat from 2009 to 2014, occupancy rates have declined, perhaps reflecting a shift from institutional to community-based long-term care. Still, overall demand for long-term care services will increase in coming years as the “baby boom” generation ages, and states and policy makers can use this information to determine sufficient capacity to accommodate long-term care user choice in both institutional and community-based settings. In addition, continuing a trend that started before 2009, the share of nursing facilities that are for-profit or chain-owned continued to grow slightly from 2009 to 2014. These facility characteristics are important to policy makers and consumers because of their link to poorer quality of care, and continued monitoring of facility ownership by states can help to ensure that a high quality of care is provided at these facilities. With Medicaid as the primary payer for most nursing facility residents, policy and payment for nursing facility care is a priority policy area for state and federal governments that finance it.

Notable shares of nursing facility residents have extensive behavioral or physical health needs, and facilities’ ability to meet these needs is the subject of ongoing policy attention. Nursing assistants who provide most of the care to these individuals often have limited training in working with this population. Some may interpret residents’ behavior as aggressive or have difficulty managing these residents’ needs. Despite regulations to limit the use of psycho-active medication, relatively high shares of residents still receive these medications, indicating an ongoing problem with chemical restraint. This pattern may be indicative of nursing facilities lacking systematic plans to address the needs of residents with dementia or other cognitive impairments. Recently proposed regulations would implement ACA requirements to improve the quality of care for residents with cognitive impairments and further restrict the use of psychotropic agents.

Last, the data show that nursing facility deficiencies have declined between 2009 and 2014, though there is still much state variation in rates of deficiencies. While voluntary guidelines for compliance programs have been in place for many years, the ACA authorized new, mandatory compliance programs to improve quality of care. Regulations proposed in July 2015 implement these requirements, building on existing requirements for quality assessment and assurance programs to address quality deficiencies. Moving forward, it will be important to continue to monitor deficiency reports to understand whether and how new requirements are affecting care and outcomes and to identify additional areas of concern for future policy changes.


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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.