WHO IS WATCHING THE NURSING HOMES?
America Cannot Keep Writing Checks While Our Most Vulnerable Citizens Are Left Waiting for Care
An Investigative Op-Ed by Craig Bushon Media Team
About 1.24 million people live in 14,742 CMS-certified nursing facilities across the United States, according to KFF’s analysis of federal Nursing Home Compare and CASPER data as of July 2025. The number of certified facilities has fallen 6 percent since 2015 and continues to decline, while the resident population has climbed back from a pandemic low of 1.10 million in 2021. Those residents are cared for largely behind closed doors, frequently by workforces stretched thinner than the public understands, and their families sometimes discover that something has gone wrong only after a loved one has already deteriorated. The entire arrangement rests on an assumption most families never examine until circumstances force them to, which is that somebody is watching. It is worth asking who.
This column is not a prosecution of one nursing home, one administrator, one nurse or one corporation. The problem appears to be considerably larger than any single building, and the evidence for that comes overwhelmingly from the government’s own auditors, inspectors and prosecutors.
Start with what the government says about itself. The HHS Office of Inspector General states plainly on its own nursing-home oversight page that decades of its audits, evaluations and investigations have uncovered widespread challenges in providing safe, high-quality care, and that this work has raised concerns about staffing levels, employee background checks, the reporting of adverse events experienced by residents, and other issues. That is the federal government’s own inspector general characterizing the results of decades of its own oversight work.
Tennessee’s Numbers Deserve a Closer Look
Consider what regulators documented in Tennessee. The Health Facilities Commission’s most recent published inspection and enforcement report, submitted to the General Assembly in February 2025 and covering calendar year 2024, records that 3,703 nursing-home complaints were triaged by intake staff, that 1,618 of them — 44 percent — were triaged as immediate jeopardy or non-immediate-jeopardy high priority, and that of the 2,353 complaints investigated by survey staff, 1,273, or 54 percent, were substantiated. Two hundred ninety-four of Tennessee’s roughly 304 CMS-certified nursing homes received at least one complaint that year. One hundred twenty-eight of them accumulated more than ten.
Those numbers deserve context before anyone draws conclusions from them, and the Commission’s own reporting supplies most of it. The Commission defines a substantiated complaint as one found to be “substantiated in some way, meaning there was at least some validity to the complaint,” which is a considerably lower threshold than a finding of serious harm. The rise in complaint volume is also partly a reporting artifact: CMS modified Chapter 5 of its State Operations Manual effective October 24, 2022, changing what facilities must report and, in the Commission’s words, drastically increasing the number of complaints. More complaints entering the system does not by itself prove that more harm is occurring. And the Commission reports something that cuts directly against the alarm: total nursing-home federal citations have decreased since 2022, with 1,320 federal citations issued across all 2024 surveys.
None of that context makes the underlying picture comfortable. The most frequently cited health deficiency in Tennessee nursing homes in 2024 was infection prevention and control, followed by failure to keep residents free of accident hazards and provide adequate supervision, with failure to keep residents free from abuse and neglect ranking fourth. One hundred of the 2024 citations, 7.6 percent, were classified at the immediate jeopardy level. Eight Tennessee nursing homes were decertified by CMS between July 1, 2022 and December 31, 2024, and the Commission issued nineteen suspensions of admissions over that same period.
The Watchers Are Years Behind
Here the question in this article’s title stops being rhetorical, because Tennessee has an audited answer to it.
On October 14, 2025, the Comptroller of the Treasury published the first performance audit of the Health Facilities Commission since the agency was created in 2022, covering July 2022 through May 2025. State and federal law require every nursing home and assisted-care living facility to be surveyed within fifteen months of its last inspection. Auditors examined all 670 such facilities active during the period and found that 341 of them — 51 percent — had not been surveyed within that window. Twenty-two providers had gone at least sixty months without an inspection. The Commission inherited a backlog of 176 overdue federal nursing-home surveys when it took over in July 2022; by April 2025 that backlog had grown to 192. CMS ranked Tennessee thirty-ninth out of fifty-two states and territories for late surveys in federal fiscal year 2025.
The complaint findings are worse. Between July 1, 2022 and April 17, 2025, the Commission received 13,096 complaints involving nursing homes and assisted-care living facilities, and did not begin investigating 5,534 of them — 42 percent — within the federally required timeframes. Every one of those late investigations involved a complaint that intake staff had already classified as immediate jeopardy, high risk, or medium risk. Federal rules require an immediate-jeopardy complaint, meaning one alleging conduct that has caused or is likely to cause serious injury or death, to be investigated within two business days. In Tennessee, 778 immediate-jeopardy nursing-home complaints were opened late, by an average of 118 days, with the worst running 897 days behind. Another 1,976 high-risk nursing-home complaints were late by an average of 137 days. As of April 2025, 4,756 complaints had not been investigated at all.
Fairness requires the rest of the record. Commission management concurred with the finding rather than disputing it, and pointed to steps that are real: reclassifying positions to widen the hiring pool, creating a high-priority complaint intake unit for long-term care, consolidating regional offices, and cutting the surveyor vacancy rate from 28 percent in July 2022 to 5.8 percent by January 2025. The complaint surge that overwhelmed them was created by a federal rule change, not by anything they did. The legislature has now required every Tennessee nursing home to receive a current survey by December 31, 2026, and management says it expects to meet that deadline. The auditors also flagged that because the Commission cannot reconcile its two tracking systems, they rated the completeness of the underlying data as undetermined — a caution that applies to the numbers above as much as to the agency’s own reporting.
But the structural fact survives every caveat. For roughly three years, the agency Tennessee families are told to call has been unable to answer half its complaints on time, including the ones alleging that someone is about to die.
It also does not mean every Tennessee nursing home is failing, or that every complaint reflects catastrophic neglect. There are dedicated nurses, certified nursing assistants, therapists, physicians and administrators working extraordinarily difficult jobs under real pressure, and they deserve our respect rather than our suspicion. But good employees cannot indefinitely compensate for a system that assigns them more residents than any human being can reasonably care for. When that happens, something eventually gives — a call light waits, a resident is not repositioned, water is not offered often enough, a change in mental status goes unnoticed, a wound progresses, an infection spreads. A family assumes someone is watching, and sometimes nobody realizes how serious things have become until an ambulance is on its way to the hospital. every Tennessee nursing home is failing, or that every complaint reflects catastrophic neglect. There are dedicated nurses, certified nursing assistants, therapists, physicians and administrators working extraordinarily difficult jobs under real pressure, and they deserve our respect rather than our suspicion. But good employees cannot indefinitely compensate for a system that assigns them more residents than any human being can reasonably care for. When that happens, something eventually gives — a call light waits, a resident is not repositioned, water is not offered often enough, a change in mental status goes unnoticed, a wound progresses, an infection spreads. A family assumes someone is watching, and sometimes nobody realizes how serious things have become until an ambulance is on its way to the hospital.
The Federal Data Is Not Anecdotal
In September 2025, the HHS Office of Inspector General published a data snapshot examining serious falls among Medicare-enrolled nursing-home residents over the one-year period from July 1, 2022 through June 30, 2023. Residents experienced 42,864 falls involving major injury and hospitalization during that single year. Of those residents, 1,911 died while hospitalized. Medicare and its beneficiaries paid more than $800 million for the resulting hospital care. Most of the residents who fell had already been identified by their nursing homes as being at risk, primarily for balance problems and psychotropic medication use.
The finding most relevant to this discussion is the one connecting outcomes to resources: OIG reported that nursing homes with lower nurse staffing levels and lower quality ratings had higher fall rates. That is a correlation drawn from federal claims and assessment data, not a controlled study establishing causation, and it should be read that way. But it points in an unmistakable direction.
A companion OIG report released the same month found something arguably more troubling. Nursing homes failed to report 43 percent of falls with major injury and hospitalization — 18,369 of 42,236 such falls — in the Minimum Data Set assessments federal rules require them to complete. Underreporting was most common among for-profit facilities, chain-affiliated facilities and larger facilities, and it varied enormously by state, ranging from 21 percent in South Dakota to 64 percent in the District of Columbia. OIG found that the nursing homes showing the lowest fall rates on Medicare’s Care Compare website were the least likely to report the falls that actually occurred, which suggests their favorable public numbers reflect reporting behavior rather than resident safety.
That finding has a practical consequence for families. Care Compare is the tool the federal government tells consumers to use, and OIG has now documented that one of its quality measures may substantially understate how often residents fall. If the data families rely on to make one of the most consequential decisions of their lives is itself incomplete, the informed choice we are all told to make becomes considerably harder to make.
The broader inspection record has been moving in one direction for a decade. As of July 2025, the average certified nursing facility received 9.5 deficiencies over the course of a survey cycle, up from 6.8 in 2015, an increase of 40 percent. The share of facilities cited for serious deficiencies — those graded as actual harm or immediate jeopardy, meaning a resident was harmed or was likely to suffer serious injury or death — rose from 17 percent to 27 percent over the same ten years. More than a quarter of American nursing facilities now receive a citation at that severity level in a given survey cycle. Some of that increase may reflect more aggressive inspection rather than worse care, and KFF says as much. A 2023 CMS-commissioned staffing study by Abt Associates points toward the other explanation, finding that better-staffed facilities are typically cited for fewer deficiencies.
These Problems Predate the Pandemic
The Government Accountability Office examined infection-control deficiencies in nursing homes and published its findings in May 2020, drawing on CMS survey data from 2013 through 2017. GAO found that infection prevention and control deficiencies were the single most common type of deficiency cited, that 13,299 nursing homes — 82 percent of all surveyed homes — were cited for such a deficiency in at least one year during that period, and that 6,427 of those homes, or 48 percent, were cited in multiple consecutive years. In each individual year, roughly 40 percent of surveyed homes had an infection-control deficiency, and that pattern continued through 2018 and 2019.
Here is where the picture becomes genuinely complicated, and where the industry has a fair point that this column will not pretend away. GAO also found that in each year from 2013 through 2017, approximately 99 percent of those infection-control deficiencies were classified by surveyors as not severe, meaning the surveyor determined that residents were not harmed. A reader could reasonably conclude from that figure alone that the 82 percent number describes routine paperwork and hand-hygiene citations rather than a systemic safety failure, and in many individual cases that is probably accurate.
But GAO reported a second number alongside it, and the two together tell a story neither tells alone: over that same five-year span, CMS implemented enforcement actions for one percent of the infection-control deficiencies classified as not severe. So the deficiencies were nearly universal, frequently persistent across consecutive years at the same facilities, almost always graded as harmless, and almost never enforced. Whether that reflects appropriate regulatory restraint or a severity classification system that made a widespread problem look manageable is exactly the question Congress has never seriously examined. GAO itself flagged the classification of these deficiencies as a subject for future review. Whatever COVID-19 did to American nursing homes in 2020, it did to a system that had already been carrying this problem for years.
The Staffing Question Washington Abandoned
Federal law requires nursing homes participating in Medicare and Medicaid to provide nursing services sufficient to meet the needs of their residents, to maintain 24-hour licensed nursing services, and to employ a registered nurse for at least eight consecutive hours per day, seven days per week. What federal law has never established is a minimum number of nursing hours per resident per day. Some states set their own stricter ratios; most of the country operates on the word “sufficient.”
In 2024, CMS finalized a rule intended to change that. It would have required at least 3.48 total nurse staffing hours per resident day, including 0.55 hours from registered nurses and 2.45 hours from nurse aides, along with a registered nurse on site twenty-four hours a day, seven days a week, phased in through May 2029.
The industry fought it hard, and its central argument deserves to be stated fairly rather than dismissed. The American Health Care Association and LeadingAge argued that a rigid federal staffing floor would collide with a workforce shortage the rule did nothing to solve, that rural facilities in particular could not hire registered nurses who simply were not available at any wage in their markets, and that the practical result would be reduced bed capacity or outright closures, displacing the very residents the rule was meant to protect. A peer-reviewed analysis published in Health Affairs Scholar in August 2025 found that nursing homes in eleven states had staffing levels below the new federal minimum and that compliance rates ranged from 31 percent in states with the lowest existing requirements to 65 percent in states with the highest, which suggests the transition costs would have been real and unevenly distributed.
What happened next resolved the dispute without resolving the question. On April 7, 2025, Judge Matthew J. Kacsmaryk of the U.S. District Court for the Northern District of Texas vacated the 24/7 registered nurse requirement and the hours-per-resident-day requirement, holding that CMS lacked authority to replace Congress’s chosen minimum with its own. On June 18, 2025, Judge Leonard T. Strand of the Northern District of Iowa vacated the same two provisions in Kansas v. Kennedy, a case brought by twenty states, seventeen LeadingAge affiliates and two Kansas nursing homes. On July 4, 2025, section 71111 of Public Law 119-21 barred CMS from implementing, administering or enforcing the provisions until September 30, 2034. CMS then published a repeal rule on December 3, 2025, effective February 2, 2026, citing the statutory bar, the court vacaturs, and the absence of any regulated entity currently relying on the requirements. The Justice Department’s appeal of the Texas ruling remains pending before the Fifth Circuit.
Where staffing actually stands is worth knowing before anyone concludes the mandate was either unnecessary or unattainable. As of July 2025, residents received an average of 3.85 nursing hours per day, composed of 0.68 hours of registered nurse care, 0.87 hours of licensed practical nurse care and 2.30 hours of nurse aide care. That average has declined 7 percent since 2015, when it was 4.13 hours, with the drop driven by a 19 percent fall in registered nurse hours and a 7 percent fall in aide hours. The comparison to the vacated rule is instructive in both directions. The national average of 3.85 total hours comfortably exceeds the rule’s 3.48-hour floor, and average RN time of 0.68 hours exceeds the 0.55 required. Average nurse aide time of 2.30 hours falls short of the 2.45 the rule required, and averages conceal the facilities at the bottom of the distribution in any case. KFF’s analysis at the time of the rule’s passage found that only 19 percent of facilities met its standards.
So the country now stands where it stood in 2023, with a legal requirement that nursing homes provide sufficient staffing and no national agreement about what sufficient means. The dispute is less ideological than arithmetic. If a single caregiver physically cannot provide hydration, hygiene, toileting, repositioning, feeding assistance, medication administration, wound care, documentation and observation to the number of medically fragile residents assigned to that caregiver on a given shift, instructing the facility to provide sufficient staffing does not produce another pair of hands. Congress has now guaranteed itself nine years without having to answer that question.
Follow the Money, and Follow the Care
Medicare and Medicaid move enormous sums of taxpayer money through this system, which creates obligations running in both directions. Facilities should be paid enough to recruit, train and retain competent caregivers, and reimbursement rates that make adequate staffing financially impossible are a legitimate grievance rather than an excuse. Taxpayers, in turn, are entitled to know how much of that money reaches the bedside, how much goes to nurses and aides, how much goes to administrative overhead, and how much flows through management companies, real-estate entities and related corporate structures before it reaches a resident’s room. Those are accountability questions rather than anti-business ones, and no honest operator should fear them.
One figure from the repeal proceeding is worth sitting with. In justifying the rollback, CMS estimated that removing the 24/7 registered nurse requirement and the minimum staffing levels would produce annualized monetized benefits of roughly $5.4 billion at a three percent discount rate over the 2025 through 2034 period. That number represents the compliance cost the industry will not bear. It is also, viewed from the other direction, a reasonable federal estimate of what it would have cost to staff American nursing homes at the level CMS believed was safe.
When care falls far enough, the federal government does act, though the mechanism is a billing statute rather than a safety one. On March 30, 2026, United States Attorney Braden H. Boucek for the Middle District of Tennessee announced that American Health Companies, LLC, doing business as American Health Partners, agreed to pay $2,090,309 to the United States and Tennessee to resolve False Claims Act allegations involving AHC Lewis County, a 131-bed facility in Hohenwald that operated as a subsidiary of the company between 2019 and 2024. The government alleged the facility billed Medicare and TennCare for grossly substandard or worthless nursing-home services, including failures in wound care, infection control, fall prevention and nutrition, along with overprescribing of antipsychotic medications. Tennessee regulators had temporarily suspended new admissions to the facility in 2023. Fairness requires two additions: these were allegations resolved by civil settlement with no determination of liability, and the company has since sold its nursing homes, with the facility now operating under different ownership.
This is not the first such case in Tennessee. On February 27, 2019, the Justice Department announced that Brentwood-based Vanguard Healthcare LLC and related entities agreed to more than $18 million in allowed claims — described at the time as the largest worthless-services resolution in Tennessee history — to resolve allegations that five Vanguard-owned facilities billed Medicare and Medicaid for grossly substandard services between 2010 and 2015. The government alleged failures to administer medications as prescribed, failures in infection control that resulted in urinary tract and wound infections, failures to provide ordered wound care, failures to reposition residents to prevent pressure ulcers, unnecessary use of physical restraints, and failures to meet basic nutrition and hygiene requirements, along with hundreds of TennCare preadmission forms bearing forged nurse or physician signatures. Those claims were also allegations only, with no determination of liability, and the settlement included a five-year corporate integrity agreement with an independent quality-of-care monitor.
What both cases establish is that care in this country can deteriorate to the point where the government concludes that billing taxpayers for it raises False Claims Act exposure. That threshold should concern every taxpayer regardless of party.
Where the Money Actually Goes
The industry’s central argument against staffing mandates is that facilities cannot afford more nurses and aides. Evaluating that claim requires knowing what nursing homes actually do with the money they receive, and the honest answer is that the public financial record makes this remarkably hard to determine.
The structure of the sector frames the question. As of July 2025, 73 percent of certified nursing facilities were for-profit, 20 percent were non-profit and 7 percent were government-owned, and Medicaid was the primary payer for 63 percent of residents, with Medicare covering 14 percent and other sources, including out-of-pocket spending, covering the remaining 23 percent. This is a predominantly investor-owned industry funded predominantly by taxpayers, which is precisely the arrangement that makes financial transparency a public question rather than a private one.
A study published in December 2023 by Charlene Harrington, Richard Mollot, Robert Tyler Braun and Dunc Williams Jr. examined 2019 Medicare cost reports for 11,752 freestanding nursing homes. Those facilities reported total net revenues of $126 billion and a profit of $730 million, a margin of 0.58 percent. Excluding $6.4 billion in disallowed costs and $3.9 billion in non-cash depreciation, the margin rose to 8.84 percent. About 77 percent of the facilities reported payments to related-party organizations — companies owned or controlled by the same people who own the nursing home — totaling $11 billion, or 9.54 percent of net revenues. Direct care accounted for 66 percent of net revenues, with 27 percent going to nursing, while 34 percent went to administration, capital, other costs and profit. Facilities reported $1.95 billion in disallowed related-party expenses because the payments exceeded the fair market value of comparable goods and services.
Related-party arrangements are legal, common across many industries, and in some cases operationally sensible. A facility that owns its own supply or therapy company may get faster service at better prices. The concern is not that the arrangements exist but that the reported price is set by the buyer and the seller at the same time, and that Medicare cost reports do not require detailed reporting on related-party service expenses, profits, losses or administrative costs that would allow anyone to verify whether the price was fair.
Economists Ashvin Gandhi of UCLA and Andrew Olenski of Lehigh University examined that question using Illinois regulatory filings covering all Illinois nursing facilities from 2000 through 2021, a state that has long required detailed related-party reporting. They found that 77 percent of facilities began transacting with related parties for real estate or management services, that facilities contracting out real estate reported an average 20 percent jump in total costs afterward, and that management contracts raised costs by about 25 percent, with no corresponding increase in the quantity or quality of services delivered. Their estimate is that in 2019, roughly 63 percent of Illinois nursing home profits were shifted to related parties through inflated transfer prices, a practice they call tunneling; a working-paper version of their estimate puts the figure at 68 percent. Because about a third of facilities had no related-party profits at all, the facilities that did use related vendors reported less than 37 percent of their actual profits.
Gandhi has been explicit about the limits of his own finding, and the caution belongs alongside the number. He has said the paper should not be read to mean that all related-party transactions are made in bad faith, that investors need to earn returns for capital to flow into the sector at all, and that the correct takeaway is narrower: industry profits are higher than publicly available data suggest. The scope limit matters too, because the estimate rests on one state’s filings. Federal cost report data indicates that 77 percent of nursing homes nationally transact with related parties, which makes the pattern plausible elsewhere, but the tunneling percentage itself has not been reproduced at national scale.
Federal auditors have looked at the reporting itself and found it wanting. In a 2024 audit, the HHS Office of Inspector General examined a nonstatistical sample of 14 skilled nursing facilities and found that 3 did not properly disclose one or more related parties on their Medicare cost reports, and that 7 did not properly adjust related-party costs to Medicare-allowable levels, resulting in more than $1.7 million in overstated costs. Fourteen facilities cannot support a national estimate, and OIG did not offer one. The structural finding is the more important one: OIG determined that Medicare administrative contractors were not reviewing related-party disclosure or costs as part of their normal oversight, and that CMS had not given facilities sufficient guidance on how to calculate allowable related-party costs. OIG has an open Work Plan item examining whether facilities report related-party costs as federal regulations require and whether overhead allocations have risen while allocations for patient care have fallen.
State investigators have found what happens when nobody is checking. On December 10, 2025, the New Jersey Office of the State Comptroller reported that the owners of two facilities, Hammonton Center for Rehabilitation and Healthcare and Deptford Center for Rehabilitation and Healthcare, received $134.8 million in Medicaid funds between 2019 and mid-2024 and routed $92 million of it to nine related entities they or their relatives owned. On their state and federal cost reports, those same facilities disclosed related-party payments of $882,666. The Comptroller found that $27.8 million went directly into personal and affiliated accounts, that both facilities failed to meet minimum staffing requirements on all but two of the 146 days reviewed, and that CMS had repeatedly designated both as special focus facilities. The office is seeking approximately $123.9 million in overpayments, $87 million of it attributed to staffing violations. The owners declined to be interviewed, invoking the Fifth Amendment, and the investigation remains open. These are the Comptroller’s findings and demands rather than adjudicated conclusions, and no court has ruled on them.
The gap between $882,666 disclosed and $92 million paid is the whole problem in one number. Taxpayers fund this system through Medicare and Medicaid, and they are entitled to know how much of every dollar reaches a resident’s bedside. At present, the reporting system is not built to tell them.
The Answer Is Not More Paperwork
There is a real risk that Washington responds to all of this by doing the easiest thing available to it, which is generating documentation requirements. That would make the underlying problem worse. Regulation without staffing accomplishes very little, because a compliance binder does not answer a call light and a completed assessment form does not turn a resident who needs turning. Every hour a nurse spends satisfying a new reporting mandate is an hour not spent at a bedside.
If Congress wants better care, it should examine the entire economic chain rather than the paperwork at the end of it: Medicaid reimbursement rates, Medicare payment structures, workforce pipelines, caregiver compensation, training requirements, ownership and related-party transactions, inspection capacity and enforcement follow-through. It is entirely possible that some facilities genuinely cannot find qualified workers, that reimbursement in some markets is inadequate, that state survey agencies lack the inspectors to do the job Congress assigned them, and that some operators are performing well under impossible conditions. It is also possible that in other cases money intended to support bedside care is not arriving there. All of those propositions can be true simultaneously, and the only way to sort out which applies where is to investigate all of it.
What Congress Should Actually Do
Congress and the state legislatures should convene serious bipartisan hearings on the nursing-home and post-acute rehabilitation system, and those hearings should hear from families, floor nurses, certified nursing assistants, physicians, long-term care ombudsmen, state survey agency staff, facility operators, and Medicare and Medicaid officials. They should also subpoena the financial records, because ownership structures and related-party transactions cannot be evaluated from testimony alone.
From there, the agenda writes itself. Increase the resources available for unannounced inspections and complaint investigations, given that a system relying on state survey agencies has been documented by OIG as having shortcomings in effectiveness. Require meaningful transparency about staffing and ownership, including independently audited consolidated cost reports covering every entity related to a facility’s operation, which is the reform the New Jersey Comptroller has now recommended twice. Determine empirically whether current reimbursement supports adequate bedside staffing, and adjust it where it does not. Establish consequences for repeated serious deficiencies that operators actually notice, given GAO’s finding that enforcement followed one percent of non-severe infection-control citations. Strengthen whistleblower protections for the aides and nurses who see problems first and have the most to lose by reporting them. Give families direct access to complaint histories, staffing data and enforcement records without requiring them to file records requests during a medical crisis. And address the reporting integrity problem OIG identified, because a public quality database that facilities can improve by not reporting is worse than no database at all.
Above all, Congress should return to the staffing question it has now deferred until 2034 rather than waiting for the next crisis to force the issue.
Until Then, Families Are the Inspectors
Until the system improves, families cannot assume that a well-appointed lobby indicates well-delivered care. Visit unannounced, and visit at night and on weekends when staffing typically thins. Ask directly how many residents each aide is responsible for on each shift, and treat an evasive answer as an answer. Check Medicare’s Care Compare, while understanding from OIG’s own findings that its fall data may understate reality. Read the actual inspection reports rather than the summary star rating.
Ask specific operational questions, because specific questions are harder to deflect than general ones. Ask how hydration and nutrition are documented and who reviews that documentation. Ask how often immobile residents are repositioned and how that is verified. Ask who provides oral hygiene and how frequently. Ask what the average call-light response time is and whether anyone measures it. Then watch what actually happens rather than what you are told happens. Look at your loved one’s skin, watch their alertness, pay attention to sudden weight loss, and ask questions whenever medications change.
Document your conversations, note who you spoke with and when, and keep your own records. If something does not add up, escalate it in order: the facility administrator, then the Tennessee Health Facilities Commission or your state’s equivalent regulatory agency, then the Long-Term Care Ombudsman program. Where circumstances warrant, involve law enforcement, Medicare, an attorney, your state legislators and your congressional delegation. Families are frequently made to feel that raising concerns is impolite, when in fact a family member is the only oversight mechanism guaranteed to be present in the building every time you are.
This Is the Warning Shot
America is aging, and millions of families who have never given nursing homes a moment’s thought eventually will. Most of them will not get months to research the decision. A stroke, a cancer diagnosis, a fall, a surgery, or a hospital discharge deadline will compress one of the most consequential decisions of their lives into a matter of days. They will sign paperwork they do not have time to read, hand over someone they love, and assume the system is watching.
That assumption is the reason this question deserves attention now rather than after the next enforcement action makes headlines. Not every nursing home is failing, not every operator is indifferent, and not every bad outcome is neglect — residents in these facilities are old, frail and often seriously ill, and adverse outcomes can and do occur in facilities providing genuinely excellent care. But federal watchdogs have documented systemic problems across two decades and multiple administrations, the enforcement response has been thin, Congress has now shelved the central staffing question until 2034, and families deserve to know whether the people entrusted with America’s most vulnerable citizens have both the resources and the accountability necessary to keep them safe.
None of that is Republican or Democratic. The person in that bed will eventually be someone’s mother or father, someone’s husband or wife, and eventually it will be one of us. We can argue in good faith about how to fix this system. What we can no longer responsibly argue about is whether it deserves our attention.
SOURCES
A note on data currency. Every figure in this article is the most recent published by its source as of September 2026, and the reporting cycles behind them vary. National facility, staffing and deficiency data comes from KFF’s December 2025 analysis of July 2025 federal data; the next annual edition is expected in December 2026. Tennessee complaint and enforcement figures come from the Health Facilities Commission’s February 2025 report covering calendar year 2024. Several findings have not been refreshed because no agency has revisited them: GAO’s infection-control analysis, published in 2020, remains the most recent national study of its kind and uses 2013–2017 survey data, and OIG’s falls reports cover July 2022 through June 2023 because that is the period OIG examined. Where a figure is old, it is old because the government has not produced a newer one, not because a newer one went unexamined.
1. HHS Office of Inspector General — Nursing Homes (featured topic page, last updated March 23, 2026) OIG states that decades of its work on nursing homes has uncovered widespread challenges in providing safe, high-quality care, with concerns regarding staffing levels, employee background checks, and reporting of adverse events. https://oig.hhs.gov/reports/featured/nursing-homes/
1a. KFF — “A Look at Nursing Facility Characteristics in 2025” (published December 17, 2025; July 2025 data) Source for all current national figures in this article. 14,742 CMS-certified nursing facilities, down 6% since July 2015; about 1.24 million residents, up from 1.10 million in 2021 and down 9% since 2015. Average 3.85 nursing hours per resident day (0.68 RN, 0.87 LPN, 2.30 nurse aide), down 7% from 4.13 in 2015, with RN hours down 19%. Average 9.5 deficiencies per survey cycle, up from 6.8 in 2015; 27% of facilities cited for serious deficiencies (actual harm or immediate jeopardy), up from 17% in 2015. Medicaid primary payer for 63% of residents, Medicare 14%, other 23%. 73% of facilities for-profit, 20% non-profit, 7% government-owned. KFF’s earlier analysis found 19% of facilities met the 2024 staffing rule’s standards at passage. Drawn from CMS Nursing Home Compare and CASPER data. Note: KFF’s own text gives the Texas ruling date as April 2025 in one place and May 2025 in another; the correct date is April 7, 2025. https://www.kff.org/medicaid/a-look-at-nursing-facility-characteristics/
1b. Abt Associates — Nursing Home Staffing Study, final report appendix (CMS, June 2023) Finding that better-staffed nursing homes are typically cited for fewer deficiencies. https://www.cms.gov/files/document/nursing-home-staffing-study-final-report-appendix-june-2023.pdf
2. Tennessee Health Facilities Commission — Annual Nursing Home Inspection and Enforcement Report (submitted February 2025, covering calendar year 2024) 3,703 complaints triaged; 1,618 (44%) triaged as immediate jeopardy or non-IJ high; 2,353 investigated; 1,273 (54%) substantiated; 294 nursing homes with at least one complaint, 128 with more than ten; 1,320 total federal citations, of which 100 (7.6%) were immediate jeopardy; 308 nursing homes operating in Tennessee, 304 CMS-certified; eight decertifications and nineteen suspensions of admissions between July 1, 2022 and December 31, 2024; surveyor vacancy rate down from 28% to 5.8%. The Commission states total federal citations have decreased since 2022. https://www.tn.gov/content/dam/tn/hfc/documents/Annual%20Nursing%20Home%20Inspection%20and%20Enforcement%20Report-2025.pdf
2a. Tennessee Comptroller of the Treasury, Division of State Audit — Health Facilities Commission performance audit (October 14, 2025; audit period July 1, 2022 – May 31, 2025) 341 of 670 facilities (51%) not surveyed within the required 15-month window; 22 providers not surveyed in at least 60 months; federal nursing-home survey backlog grew from 176 to 192 between July 2022 and April 2025; Tennessee ranked 39th of 52 jurisdictions for late surveys in FY2025. Of 13,096 complaints received July 1, 2022 – April 17, 2025, 5,534 (42%) were not investigated within federal timeframes, all classified immediate jeopardy, high or medium risk; 778 immediate-jeopardy nursing-home investigations began late by an average of 118 days (range 3–897); 1,976 high-risk late by an average of 137 days; 4,756 complaints not yet begun as of April 17, 2025. Management concurred. Chapter 263 of the Public Acts of 2025 requires all nursing homes surveyed by December 31, 2026. Auditors rated the completeness of the underlying survey and complaint data as of undetermined reliability. Published at comptroller.tn.gov; copy at https://www.wkrn.com/wp-content/uploads/sites/73/2025/10/Health-Facilities-Commission-Oct.-2025-Audit-from-the-TN-Comptrollers-Office.pdf
2b. Prior-year Tennessee report (calendar year 2023), retained for trend comparison 4,037 complaints triaged, 2,536 investigated, 1,354 (53.3%) substantiated. Note that this report is internally inconsistent, listing 4,070 triaged complaints in its key findings and 4,037 in its statistical findings, and that it attributes a 537% complaint increase to the October 2022 State Operations Manual change while the CY2024 report describes a 50% increase in complaints triaged for the calendar year. The two reports are measuring over different baselines. https://www.tn.gov/content/dam/tn/hfc/documents/Annual%20Nursing%20Home%20Inspection%20and%20Enforcement%20Report%202024.pdf
3. HHS OIG — Serious Falls Resulting in Hospitalization Among Medicare-Enrolled Nursing Home Residents, July 2022–June 2023 (OEI-05-24-00181, September 2025) 42,864 falls with major injury and hospitalization; 1,911 residents died while hospitalized; more than $800 million paid by Medicare and enrollees; nursing homes with lower nurse staffing levels and lower quality ratings had higher fall rates. https://oig.hhs.gov/reports/all/2025/serious-falls-resulting-in-hospitalization-among-medicare-enrolled-nursing-home-residents-july-2022-june-2023/
4. HHS OIG — Nursing Homes Failed to Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled Residents (OEI-05-24-00180, September 2025) 18,369 of 42,236 falls with major injury and hospitalization went unreported in Minimum Data Set assessments; underreporting highest among for-profit, chain-affiliated and larger facilities; state range from 21% (South Dakota) to 64% (District of Columbia); homes with the lowest reported Care Compare fall rates were least likely to report actual falls. This is a separate report from source 3, with a different denominator. https://oig.hhs.gov/documents/evaluation/10955/OEI-05-24-00181.pdf
5. GAO — Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic (GAO-20-576R, May 20, 2020) 13,299 nursing homes (82% of surveyed homes) cited for an infection prevention and control deficiency in one or more years from 2013 through 2017; 6,427 of those 13,299 (48%) cited in multiple consecutive years; approximately 99% of such deficiencies classified as not severe in each year; CMS implemented enforcement actions for 1% of the not-severe deficiencies. https://www.gao.gov/products/gao-20-576r
6. Federal nursing-home staffing requirements (42 U.S.C. 1395i-3; 42 CFR 483.35) Federal law requires 24-hour licensed nursing services sufficient to meet residents’ needs and a registered nurse for at least 8 consecutive hours per day, 7 days per week. No federal hours-per-resident-day minimum is currently in effect. CMS’s own description of these baseline requirements is at: https://www.cms.gov/blog/centers-medicare-medicaid-services-staffing-study-inform-minimum-staffing-requirements-nursing-homes
7. CMS 2024 Minimum Staffing Rule 3.48 total nurse staffing hours per resident day, including 0.55 RN HPRD and 2.45 nurse-aide HPRD, plus 24/7 RN coverage, with phased implementation through May 10, 2029. https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid-0
8. Court vacaturs of the staffing rule American Health Care Association, et al. v. Kennedy, et al., Nos. 2:24-cv-00114-Z-BR and 2:24-cv-171-Z (N.D. Tex.), decided April 7, 2025 (Kacsmaryk, J.); Kansas v. Kennedy, No. 1:24-cv-00110-LTS-KEM (N.D. Iowa), decided June 18, 2025 (Strand, J.). DOJ’s appeal of the Texas decision is pending in the Fifth Circuit.
9. Statutory bar and repeal Public Law 119-21, § 71111 (July 4, 2025) precludes CMS from implementing, administering or enforcing the specified staffing provisions until September 30, 2034. CMS’s repeal rule was published December 3, 2025 (90 Fed. Reg. 55687), effective February 2, 2026. CMS estimated annualized monetized benefits of approximately $5,412 million at a 3% discount rate over 2025–2034. https://www.gao.gov/products/b-337945
10. Health Affairs Scholar — state variation in nursing home staffing (August 4, 2025) Nursing homes in 11 states had staffing levels below the 2024 federal minimum; compliance ranged from 31% in states with the lowest existing staffing requirements to 65% in states with the highest. DOI: 10.1093/haschl/qxaf154
11. DOJ, Middle District of Tennessee — American Health Companies settlement (March 30, 2026) $2,090,309 paid to the United States and Tennessee to resolve False Claims Act allegations involving AHC Lewis County, a 131-bed facility in Hohenwald operated as a subsidiary of American Health Partners between 2019 and 2024. The claims were allegations only, with no determination of liability. The company has since sold its nursing homes. https://www.justice.gov/usao-mdtn/pr/american-health-companies-dba-american-health-partners-agrees-pay-over-two-million
12. DOJ — Vanguard Healthcare settlement (February 27, 2019) More than $18 million in allowed claims resolving allegations of grossly substandard services at five Tennessee facilities between 2010 and 2015, plus forged TennCare preadmission forms from 2012 to 2014. Described by DOJ as the largest worthless-services resolution in Tennessee’s history. Includes a five-year corporate integrity agreement with a government-selected quality-of-care monitor. Claims were allegations only, with no determination of liability. United States v. Vanguard Healthcare, LLC, et al., No. 3:16-cv-02380 (M.D. Tenn.). https://www.justice.gov/archives/opa/pr/vanguard-healthcare-agrees-resolve-federal-and-state-false-claims-act-liability
13. Harrington, Mollot, Braun & Williams — “United States’ Nursing Home Finances: Spending, Profitability, and Capital Structure” (Sage, December 19, 2023) 2019 Medicare cost reports for 11,752 freestanding nursing homes; $126 billion net revenues; $730 million profit (0.58%), rising to an 8.84% margin when $6.4 billion in disallowed costs and $3.9 billion in depreciation are excluded; 77% reported $11 billion in related-party payments (9.54% of net revenues); $1.95 billion in disallowed related-party expenses; 66% of net revenues to direct care, 27% to nursing, 34% to administration, capital, other and profit. DOI: 10.1177/27551938231221509 https://journals.sagepub.com/doi/10.1177/27551938231221509
14. Gandhi & Olenski — “Tunneling and Hidden Profits in Health Care” (NBER Working Paper 32258, 2024) Illinois regulatory filings, all Illinois nursing facilities, 2000–2021. 77% began transacting with related parties for real estate or management services; real estate contracts raised total costs ~20%, management contracts ~25%, without corresponding service increases; estimated 63% of 2019 Illinois nursing home profits tunneled to related parties (the SSRN abstract states 68%). Gandhi’s published caveat against reading the finding as proof of universal bad faith is in McKnight’s Long-Term Care News, April 18, 2024. https://www.nber.org/system/files/working_papers/w32258/w32258.pdf https://anderson-review.ucla.edu/nursing-home-industry-profits-obscured-by-related-party-transactions
15. HHS OIG — “Some Selected Skilled Nursing Facilities Did Not Comply With Medicare Requirements for Reporting Related-Party Costs” (A-07-21-02836, 2024) Nonstatistical sample of 14 SNFs: 3 failed to properly disclose one or more related parties; 7 failed to properly adjust related-party costs, resulting in more than $1.7 million in overstated costs. MACs were not reviewing related-party disclosure or costs in normal oversight; CMS had not provided sufficient guidance on allowable related-party costs. https://oig.hhs.gov/reports/all/2024/some-selected-skilled-nursing-facilities-did-not-comply-with-medicare-requirements-for-reporting-related-party-costs
16. HHS OIG Work Plan — Skilled Nursing Facilities’ Medicare Payments to Related Parties (W-00-24-35887, announced February 16, 2021; last modified December 18, 2024) Open review of whether SNFs report related-party costs in accordance with federal regulations and whether allocation of Medicare funds could affect beneficiary care, including whether overhead costs increased while patient care allocations decreased. https://oig.hhs.gov/reports/work-plan/browse-work-plan-projects/w-00-24-35887/
17. New Jersey Office of the State Comptroller — Hammonton and Deptford investigation (December 10, 2025) $134.8 million in Medicaid funds received 2019 through mid-2024; $92 million routed to nine related entities; $882,666 disclosed on state and federal cost reports; $27.8 million into personal and affiliated accounts; minimum staffing requirements missed on all but two of 146 days reviewed; both facilities repeatedly designated special focus facilities; approximately $123.9 million sought in overpayments, $87 million attributed to staffing violations; owners invoked the Fifth Amendment; investigation ongoing. These are OSC findings and demands, not adjudicated conclusions. https://www.nj.gov/comptroller/news/2025/approved/20251210.shtml
18. Tennessee complaint and ombudsman resources https://www.tn.gov/content/tn/hfc/division-of-licensure-and-regulation/filing-a-complaint.html https://www.tn.gov/disability-and-aging/disability-aging-programs/long-term-care-ombudsman.html
EDITORIAL & LEGAL DISCLAIMER
This article is opinion and investigative commentary intended to encourage public discussion, governmental oversight and further examination of the quality, financing, staffing and regulation of nursing-home, skilled-nursing and post-acute rehabilitation care in the United States. It is not intended to accuse any unnamed facility, employee, healthcare professional, owner or organization of negligence, abuse, criminal conduct or other wrongdoing. Government enforcement matters and lawsuits referenced herein are characterized according to the cited official records; allegations are not findings of liability unless expressly stated otherwise. Individual patient outcomes can result from underlying illness, age and numerous other medical factors and cannot, by themselves, establish neglect or causation. Readers should review the cited primary sources, conduct their own research and seek appropriate medical or legal advice regarding individual circumstances.
