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The Nursing Home Reform Law (1987) established the federal standards for nurse staffing in nursing facilities: registered nurses eight consecutive hours per day; licensed nurses 24 hours per day; and “sufficient” nursing staff to meet residents’ needs.[1]

Most nursing facilities do not have sufficient numbers of nurses to provide the care that residents need.  The result is poor care outcomes for residents – avoidable pressure ulcers, medication errors, inappropriate use of psychotropic medications, failure to assist residents with activities of daily living, avoidable weight loss, falls, and more.  

In 2014, the Center for Medicare Advocacy looked at nurse staffing deficiencies that the Centers for Medicare & Medicaid Services (CMS) cited in the four-year period 2010-2013.  In an Alert entitled “Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned,” the Center reported that CMS cited few staffing deficiencies and that financial penalties for even the most serious deficiencies – those labeled “immediate jeopardy” – were infrequent.[2]

In December 2018, the Center again reviewed deficiencies cited by CMS for insufficient nurse staffing, this time, between November 28, 2017 (the effective date of the new, uniform federal survey process) and December 18, 2018.[3]  While CMS cited more staffing deficiencies than it did in the Center’s earlier review, it continued to classify most of them as “no-harm” and to impose few enforcement actions for those it labeled “actual harm” or “immediate jeopardy.”

The overwhelming majority of the 781 deficiencies (96.8%) were cited as “no harm,” a level of noncompliance that CMS generally does not sanction with financial penalties.

Staffing Deficiencies, Nov. 28, 2017-Dec. 18, 2018
Total: 781 Deficiencies

Level of staffing deficiency

Number of facilities cited with deficiency at this level

Percentage of total staffing deficiencies cited at this level

Immediate jeopardy



Actual harm



No harm



Substantial compliance



CMS imposed few remedies on the 23 facilities whose staffing deficiencies it called jeopardy or actual harm.

  • CMS did not impose a civil money penalty (CMP) or denial of payment for new admissions (DPNA) on 10 of the 17 facilities that it cited with immediate jeopardy deficiencies.  CMS imposed DPNA only on one facility and CMPs on six facilities.  Only two facilities with an immediate jeopardy staffing deficiency had a CMP of more than $100,000.  (It is possible that CMS imposed CMPs against additional facilities.  However, if a facility appeals the CMP, CMS does not publicly post the CMP while the appeal is pending.)
  • CMS did not impose a CMP or DNPA on two of the six facilities that it cited with actual harm deficiencies.  It imposed DPNA-only on two facilities and CMPs-only on two other facilities.  The CMPs for the two facilities averaged $28,586.

The federal survey reports were similar to each other, whether the staffing deficiency was cited as immediate jeopardy or no-harm. Surveyors follow the federal survey protocol that directs them in how to identify and cite deficiencies. Nevertheless, and even though the Center reviewed only a small number of survey reports, what is most striking is how similar the evidence appears in the survey reports, regardless of the level of noncompliance identified.Surveyors describe the failures of care through multiple examples of: poor resident outcomes, resident complaints about insufficient staffing, staff admissions that the facility is not adequately staffed to meet residents’ needs, and documentation from facility records that the facility does not have enough staff (according to its own staffing standards). Surveyors appeared more likely to cite immediate jeopardy in staffing when they cited additional jeopardy-level deficiencies. In these cases, they included additional details and examples about the staffing deficiency. However, as a general matter, the evidence that surveyors cite appears to be the same, whether the deficiency is called jeopardy or no-harm.

For the Center’s full report, including descriptions of nurse staffing deficiencies at eight nursing facilities, and recommendations to strengthen the federal oversight system to protect residents, see:

January 10, 2019 – T. Edelman

[1] 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)), Medicare and Medicaid, respectively.
[2] “Staffing Deficiencies in Nursing Facilities: Rarely Cited, Seldom Sanctioned,” (CMA Alert, Mar. 7, 2014),
[3] For information on deficiencies between 2013 and 2017, see the Long Term Care Community Coalition’s reports of deficiencies cited between 2014 and 2017, by state, at Note: The Coalition’s state deficiency reports include all health deficiency citations. Insufficient staffing deficiencies are identified as F-353.




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