Closed sign, nursing home
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The supply of federally certified nursing homes has dropped 5% since 2014, according to new data compiled by KFF’s healthcare research arm.
In the same 10-year period, the number of deficiencies assessed by nursing home surveyors — especially those alleging serious violations — has skyrocketed.
KFF said the explosion of penalties “could reflect increased oversight and lower staffing levels.” Using data from the Centers for Medicare & Medicaid Services, KFF also found that the average daily nursing care provided per resident declined by 8%, from 4.13 hours to 3.8 hours.
Nationally, the number of nursing homes certified by CMS fell from 15,648 in 2015 to 14,827 this year.
“What policymakers need to take away from this report is that America’s nursing homes need their support. The increase in nursing home closures, accelerated by the growing caregiver shortage, should be a grave concern for lawmakers given our aging population,” said Rachel Reeves, a spokeswoman for the American Health Care Association/National Center for Assisted Living.
“It means countless seniors and their families will be desperately searching for care,” she told McKnight’s Long-Term Care News. “Nursing homes are also committed to quality and compliance, but we need to foster a shared responsibility with government officials to ensure our residents receive the care they deserve. We need policymakers to invest in growing our workforce, incentivize improvement over excessive penalties, and focus on the metrics that matter for our residents to help drive meaningful change.”
The American Health Care Association reported in August that nearly 800 nursing homes closed between February 2020 and July 2024, displacing nearly 30,000 residents. In its Access to Care report, AHCA highlighted the devastating consequences to rural communities in particular.
Local closures add up
As KFF notes, the pandemic has had a lasting effect on both patient demand for services and the level of staffing needed to accommodate more residents. Its new report includes the ability to track declines by state and shows the impact to particular states and regions.
In Nebraska, one of the rural states most affected by staff shortages, the number of facilities has shrunk from 219 to 184. Illinois dipped from 762 in 2015 to 682 this July.
In Maine — the oldest state in the nation, with more than 23% of residents over the age of 65 — providers have been challenged by reimbursement rates and a high cost of living that makes it hard to recruit needed staff. Since 2015, the number of nursing facilities has fallen from 103 to 81.
Katie Smith Sloan, president and CEO of LeadingAge, told McKnight’s Monday that the availability of quality care and staffing are “tightly connected.”
“Workforce challenges in our sector are chronic and unrelenting. The reasons for them are varied – from a tight labor market and a shrinking labor pool due to retirements or employees quitting the sector for other jobs, to America’s insufficient financing of and patchwork approach to delivering long-term services and supports,” she said.
“Without the nurse aides, registered nurses, licensed practical nurses and others who serve nursing home residents, there simply is no care. Staffing concerns force our nonprofit and mission-driven members to make hard choices, such as paring back admissions, taking beds off line and — in the most extreme cases — closing.”
KFF noted that declines in the number of skilled nursing facilities and daily care hours have come as patient needs have increased. The slide in overall direct care hours has been fueled by a 21% decline in registered nurse hours and an 8% decline in nurse aide hours. Licensed practical nurse hours, however, increased by 6% in this same time period — a factor not given much consideration in the new federal staffing mandate.
The Biden administration rule calls for a 3.48-hour daily nursing requirement dependent mostly on RNs and CNAs. CMS has estimated that increasing daily care and bringing on round-the-clock RNs would cost nursing homes an additional $4.3 billion annually; AHCA puts that figure at $6.8 billion.
But the latest KFF data shows the majority (63%) of patient care continues to be funded by Medicaid, which a recent study showed covered only an average of 82 cents of every dollar that nursing homes spent providing beneficiary care.
LeadingAge Monday called for targeted federal investments “to ensure that older adults and families can access the unique, 24/7 care that nursing homes provide.”
In the last 10 years, though, funding has received far less attention from policymakers than regulation.
The KFF data reveals that the average number of deficiencies per survey steadily increased from 6.8 to 9.5 — an increase of 40% — between 2015 and 2024. The only exception was during a two-year pandemic period when survey were initially paused and then highly focused on infection control.
Meanwhile, the share of facilities cited for serious deficiencies, including serious harm or Immediate Jeopardy, climbed from 17% to 28%. KFF cited a CMS-commissioned staffing study by Abt Associates that connected better-staffed nursing homes with fewer cited deficiencies.
But providers point to the subjective nature of surveys, their lack of educational support for caregiving organizatons and major lags between annual recertification inspections. Those lags have persisted well beyond the public health emergency, exposing nurisng homes to the potential of added citations and fines later.