U.S. Department of Health and Human Services 
O ffice of Inspector General 
Ad dendum to OEI-01-20-00430 
July  2021, OEI-01-20-00431 
States Backlogs of Standard Surveys of Nursing Homes Grew 
Substantially During the COVID-19 Pandemic 
Our report, Onsite Surveys of Nursing Homes During the COVID-19 
Key Takeaway  Pandemic: March 23  May 30, 2020, found that State Survey 
States backlogs of standard  agencies (States) faced backlogs of standard surveys of nursing 
nursing home surveys have grown  homes early in the COVID-19 pandemic, with 8 percent of nursing 
substantially, even after August  homes having gone at least 16 months without a standard survey as 
2020 when CMS lifted its  of June 2020.  This Addendum updates that analysis.  We found that 
suspension of those surveys  States backlogs grew substantially during the COVID-19 pandemic.  
(which it had suspended due to 
Nationally, 71 percent of nursing homes (10,913 of 15,295) had gone 
the COVID-19 pandemic).  
at least 16 months without a standard survey as of May 31, 2021.  By 
Nationally, 71 percent of nursing 
State, the backlogs for standard surveys ranged from 22 percent to 
homes had gone at least 16 
96 percent of nursing homes (see Table 1 on page 2 for the 
months without a standard survey 
backlogs for each State).   
as of May 31, 2021.  The rising 
backlogs add urgency to our 
States, on behalf of the Centers for Medicare & Medicaid Services 
existing recommendation that 
(CMS), are required to conduct standard surveys of 
CMS clarify expectations and 
Medicare/Medicaid-certified nursing homes at least every 
provide guidance to States on 
completing these important   15 months to ensure that they meet Federal requirements.1, 2  
surveys.  Standard surveys are comprehensive onsite inspections that evaluate 
the safety and quality of care provided by nursing homes.3, 4  
Surveyors cite deficiencies during these surveys when they observe a nursing home violating a Federal 
requirement.  These deficiencies can result in CMS imposing remedies, such as civil monetary penalties, 
on the nursing home.5  In addition, surveyors discuss observations with nursing home staff throughout 
these surveys and may alert them to concerns with resident care, providing the nursing home with the 
opportunity to address these concerns by presenting additional information to the surveyors.6
In March 2020, to protect public health and address other concerns associated with the Public Health 
Emergency, CMS suspended standard surveys in nursing homes to reduce surveyor time on site.  CMS 
shifted oversight to infection control surveys, which are more limited in scope than the standard 
surveys.7  States also continued to conduct surveys for the most serious nursing home complaints while 
CMS suspended standard surveys.8  In August 2020, CMS authorized States to resume standard surveys 
as soon as they have the resources (e.g., staff and/or Personal Protective Equipment) to do so.9   
Backlogs in Standard Surveys Need CMSs Attention  
Comprehensive nursing home inspectionsstandard surveysare CMSs main tool to ensure that 
nursing homes meet the minimum standards necessary for the safety and wellbeing of residents.  Yet, 
Addendum: States Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic 
OEI-01-20-00431   1  due to the COVID-19 pandemic, States have conducted substantially fewer of these standard surveys, 
which help to identify and address deficiencies.  
Our updated analysis underscores the importance and urgency of our previous recommendation to 
CMS to clarify expectations for States to complete backlogs of standard surveys, including by issuing 
guidance on prioritization of surveys and required timeframes to complete these backlogs.  In its 
response to this recommendation in our report, issued in December 2020, CMS said it will continue 
working with States on how to address these backlogs.  We encourage CMS to take the steps described 
above to implement this recommendation and help States provide needed oversight of nursing homes. 
 
Table 1: Number and Percent of Nursing Homes Without a Standard Survey for at Least 
16 Months (February 1, 2020, through May 31, 2021) by State 
 
Number of nursing  Percent of nursing 
homes without  Total nursing  homes without 
State  standard survey  homes  standard survey 
Connecticut  201  209  96% 
Georgia  335  359  93% 
Oregon  120  130  92% 
Vermont  32  35  91% 
Maryland  202  226  89% 
Delaware  41  46  89% 
Oklahoma  265  298  89% 
California  1,037  1,183  88% 
Idaho  71  81  88% 
Washington  176  201  88% 
Ohio  828  954  87% 
Massachusetts  315  371  85% 
Utah  82  97  85% 
Kentucky  240  284  85% 
Montana  59  70  84% 
Tennessee  263  313  84% 
Indiana  440  533  83% 
Mississippi  168  204  82% 
South Dakota  84  104  81% 
Virginia  228  286  80% 
Maine  74  93  80% 
New York  490  616  80% 
Minnesota  284  364  78% 
North Carolina  329  428  77% 
District of Columbia  13  17  76% 
Colorado  171  225  76% 
Addendum: States Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic 
OEI-01-20-00431   2 
 
  Number of nursing  Percent of nursing 
homes without  Total nursing  homes without 
State  standard survey  homes  standard survey 
Alabama  173  228  76% 
Missouri  390  516  76% 
Wisconsin  259  348  74% 
Arizona  107  146  73% 
Nevada  47  66  71% 
Alaska  14  20  70% 
Iowa  296  431  69% 
Texas  818  1,211  68% 
Hawaii  29  43  67% 
West Virginia  79  123  64% 
Wyoming  23  36  64% 
New Jersey  215  359  60% 
Louisiana  165  276  60% 
Michigan  259  435  60% 
North Dakota  47  79  59% 
Kansas  173  324  53% 
South Carolina  100  189  53% 
Pennsylvania  344  687  50% 
New Hampshire  35  73  48% 
Illinois  336  708  47% 
Rhode Island  35  78  45% 
Florida  284  704  40% 
Nebraska  71  195  36% 
Arkansas  51  224  23% 
New Mexico  15  69  22% 
National   10,913  15,295  71% 
 
Source: OIG analysis of CMS Care Compare data, 2021. 
 
 
1 Social Security Act  1864(a); 42 CFR  488.330; SOM, ch. 1, Section 1002. 
2 Social Security Act  1819(g) and 1919(g). 
3 Social Security Act  1819(g)(2) and 1919(g)(2); CMS, SOM, Pub. No. 100-07, ch. 7, Survey and Enforcement 
Process for Skilled Nursing Facilities and Nursing Facilities (Revised 185, 11-16-18). 
4 CMS, SOM, Pub. No. 100-07 Appendix P: Survey Protocol for Long Term Care FacilitiesPart I.  Accessed at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/som107ap_p_ltcf.pdf on June 16, 2021. 
5 Social Security Act  1819(h) and 1919(h); CMS, SOM, Pub. No. 100-07, ch. 7, Survey and Enforcement Process 
for Skilled Nursing Facilities and Nursing Facilities (Revised 185, 11-16-18). 
Addendum: States Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic 
OEI-01-20-00431   3 
 
   
6 CMS, Long-Term Care Survey Process (LTCSP) Procedure Guide (Effective February 6, 2021).  Accessed at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Downloads/LTCSP-Procedure-Guide.pdf on July 7, 2021.  
7 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 20, 2020.  Accessed at 
https://www.cms.gov/files/document/qso-20-20-allpdf.pdf-0 on June 15, 2021. 
8 Ibid. 
9 CMS, Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, Ref: QSO-20-35-
ALL, August 17, 2020.  Accessed at https://www.cms.gov/files/document/qso-20-35-all.pdf on June 15, 2021.  
Addendum: States Backlogs of Standard Surveys of Nursing Homes Grew Substantially During the COVID-19 Pandemic 
OEI-01-20-00431   4