A Look at Nursing Facility Characteristics Between 2015 and 2023

As of mid-December 2023, over 170,000 people living in nursing facilities have died due to COVID-19, highlighting long-standing issues in nursing facilities. In response to the high mortality rate among residents and long-standing staffing shortages in nursing facilities, the Centers for Medicare and Medicaid Services (CMS) released a highly-anticipated proposed rule earlier this year that would create new requirements for staffing levels in nursing facilities, which provide medical and personal care services for nearly 1.2 million Americans. KFF analysis finds that 19% of facilities currently meet the required number of hours for registered nurses and nurse aides, with much lower rates among for-profit facilities (10%) when compared with non-profit and government facilities (40%). Under the proposed rule, facilities would have several years to come into compliance and may qualify for hardship exemptions.

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 dropped by 4% between 2015 and 2023, and the number of nursing facility residents dropped by 12%.
• Over that same period, the average number of hours of nursing care that residents receive per day has declined by 9% (from 4.13 to 3.77), in spite of the generally increasing acuity levels of nursing facility residents.
• The average number of deficiencies and the share of facilities with serious deficiencies has increased over time, which may partly be the result of decreasing staffing levels. Between 2015 and 2023, the share of facilities with a serious deficiency increased from 17% to 26%.

The number of nursing facilities certified by CMS decreased by 4% between July 2015 and July 2023, dropping from 15,648 facilities in 2015 to 15,003 facilities in 2023 (Figure 2). 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 2023, the number of residents living in nursing facilities decreased by 12%, from 1.37 million in July 2015 to approximately 1.2 million in July 2023 (Figure 2). Decreasing resident counts reflect longer-term trends as people increasingly opt to receive care in home and community-based settings (HCBS) over institutional settings, and the increased availability of HCBS resulting from the Supreme Court’s Olmstead decision, which ruled that people with disabilities are to be served in the most integrated setting that is appropriate. 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 2023, the average hours of care that nursing facility residents received declined by 9%, from 4.13 hours to 3.77 hours (Figure 3). The decrease was driven by a 21% decline in registered nurse (RN) hours and a 10% decline in nurse aide hours. Licensed practical nurse (LPN) hours increased by 7% in this same time period. The decline occurred over the entire period but the number of hours of care per resident increased briefly in the year 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 October 2023 showing that the number of workers employed at long-term care facilities continues to remain below pre-pandemic levels.

The proposed new staffing rule proposes a minimum of 0.55 RN and 2.45 nurse aide hours per resident day and does not include proposed minimums for LPNs. This would be somewhat lower than the average hours per resident day in 2023 for RNs, but higher than the average hours for nurse aides. See Box 1 for a description of direct care staff working in nursing facilities.

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 may reflect lower staffing levels (Figure 4, Box 2). Between 2015 and 2023, the average count of deficiencies increased from 6.8 to 8.9, an increase of 31%. Additionally, the share of facilities reporting a serious deficiency increased from 17% to 26%. The recent Nursing Home Staffing Study report by Abt Associates 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. The Biden Administration requested increased funding in the president’s budget for survey and certification of nursing facilities in FY 2024, citing that “CMS has seen an increase in the overall number of nursing home complaints since 2015, requiring additional survey resources during a time when enacted funding has generally been held constant.”

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.”

Some key nursing facility characteristics, such as the share of residents by primary payer and share of facilities by ownership type stayed relatively stable over time (Figure 5). As of July 2023, Medicaid was the primary payer for 62% of nursing facility residents; Medicare for 13% of residents; and the remaining 25% of residents had another primary payer (ex. private insurance, out-of-pocket, etc.) (Figure 5). Medicare provides up to 100 days of skilled nursing facility care under specific circumstances, but the Medicare benefit is considered “post-acute” care and generally not available for people needing nursing facility services on an ongoing basis. Similarly, the share of facilities by type of owner has not changed notably overtime. As of July 2023, 71% of facilities were for-profit, 22% were non-profit, and 6% were government owned (Figure 5).

The Biden Administration released two recent proposed rules intended to address the LTSS workforce and access to services. To address workforce shortages in nursing facilities, the Administration proposed a rule that would create new staffing requirements in nursing facilities, require state Medicaid agencies to report on the percent of Medicaid payments for institutional long-term services and supports (LTSS) that are spent on compensation for direct care workers and support staff, and provide funding for individuals to enter careers in nursing facilities. The Administration also released a proposed rule aimed at ensuring access to Medicaid services, which included several notable provisions aimed specifically at LTSS provided in people’s homes and the community. For certain LTSS, states would be required to report payment rates, demonstrate that payment rates are “adequate” to provide the level of services in enrollees’ personalized care plans, and to ensure at least 80% of Medicaid payments are passed through to worker compensation.

The Biden administration also finalized a rule in November 2023 requiring facilities to report private equity ownership. Nursing home ownership has drawn attention in recent years as private equity ownership of facilities has become more common. 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 new rule 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;
• Anyone who provides administrative services, clinical consulting services, accounting or financial services, policies or procedures on operations, or cash management services for the facilities; and
• Whether any of the owning or managing entities are a private equity company or real estate investment trust, which the final rule also defines.

While there is ample evidence that higher levels of staffing are associated with better quality and fewer deficiencies in care, there are ongoing questions about how such care will be financed and whether there are sufficient workers to meet the needs of an aging population, in nursing facilities and in other settings. In addition to federal action, many states have adopted widespread payment rate increases for nursing facilities and HCBS providers with the goal of boosting staffing levels as reported to KFF in a 2023 survey; however, employment levels in the LTSS sector were still 10% below pre-pandemic levels in October 2023. Immigrants could help fill some positions but a backlog of green card petitions prompted the State Department to cutoff eligibility for anyone who applied after June 1, 2022. There are concerns that the freeze on green card petitions will further exacerbate nursing shortages across both health and long-term care sectors. As the primary payer of LTSS, pressure to further increase staffing and raise reimbursement rates may fall disproportionately to Medicaid where financing is shared between states and federal government.