DEPARTMENTOFHEALTH &. HUMANSERVICES Officeof InspectorGeneral
Washington, D.C. 20201
SEP 18 2008
TO: Kerry Weems
Acting Administrator
Centers for Medicare & Medicaid Services
~ ~ ~
FROM: Daniel R. Levinson
Inspector General
SUBJECT: Memorandum Report: "Trends inNursing Home Deficiencies and
Complaints," OEI-02-08-00140
This memorandum report describesthe nature and extentofnursing home deficiencies
and complaints in 2007 and identifies trends from 2005 to 2007. This study is part ofthe
Office ofInspectorGeneral's (GIG) continuing commitment to addressing the qualityof
care in nursing homes. Itbuilds on OIG's prior workby analyzing the most recent data
available on nursing home deficiencies and complaints.
Ineachofthe past 3 years, over 91 percentofnursing homes surveyed were cited for
deficiencies and a greater percentage offor-profit nursing homes were cited for
deficiencies than not-for-profitand government nursing homes. During those same
years, the most common deficiency categories cited were quality ofcare, resident
assessment, and quality oflife. Additionally, 17 percent ofnursing homes surveyed in
2007 were cited for actual harm or immediatejeopardydeficiencies, and 3.6 percentwere
cited for substandard quality-of-care deficiencies-a slight increase since 2005. Lastly,
the numberofsubstantiated complaints decreased nearly 3 percent since 2005.
BACKGROUND
Survey and Certification Process
All nursing homes that participate in Medicare and/or Medicaid must be certified as
meeting certain Federal requirements.! The Centers for Medicare & Medicaid Services
(CMS) contracts with States to performnursing home surveys before nursing homes may
be certified. States mustconductthese standard surveys at least every 15 months, and the
Statewide average interval between surveys must be 12 months or less.2 Surveys are
TitleXVIII(Parts Aand B)andXIXofthe SocialSecurityAct.
I
142CFR488.308(a)and(b).
OEI-02-08-00140 Trends inNursing Home Deficiencies and Complaints Page 2  Kerry Weems 
unannounced and may be conducted at any hour on any day.3 Surveys assess medical,  
nursing, and rehabilitative care; dietary and nutrition services; activities and social 
participation; and sanitation, infection control, and the physical environment.4    
 
Surveyors collect data from different sources.  They conduct a medical record review 
based on a case-mix stratified sample of nursing facility residents.5  They also review 
plans of care to determine their adequacy, audit residents assessments, and review 
compliance with legal requirements concerning residents rights.6  In addition, surveyors 
observe facility operations and interview residents, family members, and staff to 
determine whether facilities are providing appropriate care.7  
 
CMS provides guidance on long term care facility survey procedures and protocols 
through its State Operations Manual. The Manual describes the intent of the 
regulations pertaining to nursing homes as well as the process for determining whether 
deficiencies have occurred and how to categorize them.  Updates to the Manual are 
issued periodically. 
 
Deficiencies.  When a nursing home fails to meet one or more of the Federal 
requirements, surveyors cite a deficiency.  There are 190 possible deficiencies, which fall 
into the categories listed in the box below. 
 
 Deficiency Categories 
 
Resident rights        Physician services 
Admission, transfer, and discharge rights  Rehabilitative services 
Resident behavior and facility practices     Dental services 
Quality  of life        Pharmacy  services 
Resident assessment      Infection control 
Quality  of care        Physical environment 
Nursing services  Administration 
Dietary  services        Laboratory  and radiology services 
 
     
 
          Sources:  42 CFR  483, subpart B; CMS State Operations Manual, Appendix PP.  
 
Surveyors also decide the scope and severity of the deficiency based on a matrix that uses 
the letters A through L. See Figure 1 on the next page.  The scope of the deficiency 
measures the number of residents potentially or actually affected by the deficiency.  The 
scope rating has three different levels:  isolated, pattern, and widespread.  Isolated 
deficiencies occur when one or a very limited number of residents or staff are affected or 
the situation exists only occasionally.  Pattern deficiencies occur when more than a very 
limited number of residents or staff are affected or the situation occurs repeatedly.  
Finally, widespread deficiencies occur when the situation is pervasive throughout the 
facility or potentially affects a large portion of the nursing homes residents.8  
                                                 
3  42  CFR  488.307(a); CMS, State Operations  Manual, Pub. No. 100-07, ch. 7,  7207B2, p. 34. 

4 42 CFR   488.305(a)(2). 
 
5 42 CFR   488.305(a)(1). 
 
6 42 CFR   488.305(a)(3) and (4). 

7 42 CFR   488.110(f). 

8 CMS, State Operations Manual, Pub. No. 100-07, App. P, pp. 9394. 

OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 3  Kerry Weems 
The severity rating measures the extent of the health and safety risk to residents.  The 
most serious level, immediate jeopardy, occurs in a situation in which the providers 
noncompliance with one or more of the requirements of participation has caused, or is 
likely to cause, serious injury, harm, impairment or death to a resident.9  Immediate 
jeopardy requires the nursing home to take immediate corrective action.  The three levels 
of deficiencies that are not immediate jeopardy are:  (1) actual harm that is not immediate 
jeopardy; (2) no actual harm with a potential for more than minimal harm, but not 
immediate jeopardy; and (3) no actual harm with a potential for minimal harm.10    
 
Figure 1:  Scope and Severity Matrix for Nursing Home Deficiencies 
 
Scope of the Deficiency  
   Isolated   Pattern  Widespread  
Immediate jeopardy to  
cy  resident health or safety   J  K  L 
n
e
ci
efi
D Actual harm that is not 
e  immediate jeopardy   G  H  I 
h
of t
y  No actual harm with a 
rit potential for more than  
e D  E  F 
v minimal harm, but not 
e
S immediate jeopardy  
No actual harm with 
A  B  C 
potential  for minimal harm 
 
 
Note: Shading indicates substandard quality of care for the categories of quality of care,  

quality  of life, and resident behavior and facility practices. 

 
The scope and severity of the deficiency are primary factors in determining the 
appropriate corrective action to be taken.11  Corrective actions include termination of 
participation in Medicare and Medicaid, civil money penalties, State monitoring, transfer 
of residents, and closure of the facility, among other remedies.12  
 
Substandard Quality of Care.  Substandard quality of care exists when a facility has one 
or more deficiencies at the more serious scope and severity levels within certain 
categories.  The scope and severity levels of  substandard quality of care are shown in the 
shaded area of Figure 1 above. The categories related to substandard quality of care are 
quality of care, quality of life, and resident behavior and facility practices.  A brief 
description of these categories is provided in the box on the next page.   
                                                 
9 42 CFR   488.301. 
10 42 CFR   488.404(b)(1). 
11 42 CFR   488.404(b). 
12 42 CFR   488.406(a). 
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 4  Kerry Weems 
 
If a nursing home is found to have 
 
The Three Deficiency Categories Related   provided substandard quality of care,
to Substandard Quality of Care   surveyors must conduct an extended 
 
survey within 14 days. An extended
Quality of Care:   Includes, among other issues, 
appropriate treatment to prevent and treat pressure sores  survey includes a review of the policies 
and urinary tract infections and resident freedom from 
and procedures related to such substandard 
unnecessary drugs and significant medication errors. 
   quality of care as well as an examination 
Quality of Life:   Includes, among other issues, care that 
of staffing, training, and a larger sample of 
maintains or enhances dignity; the provision of social 
services to attain the highest practicable well-being of each  residents assessments.13  Substandard
resident; and a safe, clean, comfortable, and homelike 
quality of care requires specific corrective 
environment. 
  actions such as a directed plan of
Resident Behavior and Facility  Practices:   Includes, 
correction, temporary management 
among other issues, freedom from physical or chemical 
restraints for purposes of discipline and convenience and  change, or termination of the provider 
freedom from abuse, corporal punishment, and involuntary  
seclusion.   agreement.   
 
Complaints.  Surveyors also investigate complaints.  Complaints may be made by 
nursing home residents, family members, and facility employees, among others, and may 
be either verbal or written.14  State survey agencies must review all allegations.  
Depending on the outcome of the review, the survey agency may conduct a standard or 
abbreviated standard survey to investigate the allegation.15  These allegations are either 
substantiated or unsubstantiated during the survey.  A substantiated allegation results in 
the citation of a deficiency.16  Surveyors may also cite additional deficiencies during this 
process. Complaints are grouped into the categories listed in the box below.17 
 
 Complaint Categories 
 
Resident abuse      Proficiency  testing 
Resident neglect      Falsification of records/reports 
Resident rights      Unqualified personnel 
Patient dumping      Quality  control 
Environment      Specimen handling 
Care or services      Diagnostic discrepancy/erroneous test results 
Dietary        Fraud/false billing 
Misuse of funds/property     Fatality/transfusion fatality  
Certification/unauthorized testing  Other 
   
   Source:  CMS Form 562. 
 
                                                 
13 42 CFR   488.310. 
 
14 CMS, State Operations Manual, Pub.  No. 100-07, ch. 5,   5010, pp. 78. 

15 42 CFR   488.308(e)(2). 
 
16 CMS Form 562. 

17 These categories are also  used  for hospitals.  Some categories, such as  patient dumping,  are not  relevant 
 
to nursing  homes. 

OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 5  Kerry Weems 
Related Work 
In 2003, OIG published a report entitled Nursing Home Deficiency Trends and Survey 
and Certification Process Consistency.  This report found that the percentage of nursing 
homes with deficiencies, the total number of deficiencies, and the average number of 
deficiencies per nursing home increased between 1998 and 2001.  In addition, there was 
wide variation among States in the percentage of nursing homes with deficiencies and the 
average number of deficiencies per home.  OIG found that this variability was due at least 
in part to differences in the survey process among States.  Factors contributing to these 
differences included inconsistent survey focus, unclear Federal guidelines on citing 
deficiencies, and the lack of a common review process for draft survey reports. 
 
METHODOLOGY 
 
The information provided in this memorandum report is based on an analysis of data 
from CMSs Online Survey and Certification Reporting System (OSCAR). OSCAR 
includes the results of all State nursing home surveys.  It contains the most current survey 
and the three previous surveys for every nursing home that is certified for Medicare 
and/or Medicaid. 
 
To carry out our analysis, we identified all surveys conducted in 2005, 2006, and 2007 
that were included in OSCAR.  If a nursing home had more than one survey in a 
particular year, we included only the most recent survey for that year.  We also used 
OSCAR to identify for-profit, not-for-profit, and government nursing homes as well as 
nursing homes that were part of an organization that owned two or more facilities 
(hereafter referred to as multifacility) and those that were not (hereafter referred to as 
single-facility). 
 
We analyzed OSCAR data to determine the nature and extent of nursing home  
deficiencies and to identify trends.  For each year, we determined the number of nursing  
homes surveyed, the percentage with at least one deficiency, and the average number of 
deficiencies per nursing home.  In addition, we examined the scope and severity of 
deficiencies and determined the percentage of nursing homes that were cited for 
deficiencies considered substandard quality of care.  We identified trends in these 
measures from 2005 to 2007.  We also described instances in which there were 
differences of at least 1 percentage point among for-profit, not-for-profit, and government 
nursing homes and between multifacility and single-facility nursing homes.  In all cases, 
the percentages cited were based on nursing homes that were surveyed. 
 
We also obtained complaint information for 2005, 2006, and 2007 from OSCAR.  We 
analyzed this information to determine the nature and extent of complaints and to identify 
trends. A complaint may contain several allegations.  For the purposes of this report, we 
refer to each allegation as a complaint.  We determined the number of substantiated 
complaints and the number of nursing homes associated with these complaints. 
 
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 6  Kerry Weems 
This memorandum report describes the nature and extent of nursing home deficiencies 
and complaints in 2007 and identifies trends from 2005 to 2007.  This review was not 
designed to provide explanations for changes in these measures. 
 
This review was  conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency and the Executive Council 
on Integrity and Efficiency. 
 
RESULTS 
 
In Each of the Past 3 Years, Over 91 Percent of Nursing Homes Surveyed Were 
Cited for Deficiencies  
In 2005, 2006, and 2007, more than 91 percent of nursing homes surveyed were cited for 
deficiencies. Although this percentage remained stable during this time, it has increased 
over the last decade. According to the 2003 OIG report, the percentage of nursing homes 
cited for deficiencies increased from  81 percent in 1998 to 89 percent in 2001.18  Table 1 
below shows the trends in deficiencies from 2005 to 2007. 
 
In the past 3 years, the average number of deficiencies per nursing home increased 
slightly. In 2007, nursing homes were cited for an average of 7.0 deficiencies per home, 
compared to 6.4 deficiencies in 2005.  During this period, the total number of 
deficiencies rose by almost 10 percent, while the number of nursing homes surveyed 
decreased by 1 percent. 
 
Table 1:  Trends in Deficiencies, 20052007 
  Percentage Change 
2005  2006  2007 
20052007 
Percentage of nursing homes with deficiencies   91.1%  91.8%  91.9%  0.9 %* 
Average number of deficiencies per nursing home  6.4  6.9  7.0  10.7%* 
Total number of deficiencies  95,624  102,487  104,665  9.5% 
Total number of nursing homes surveyed   15,046  14,954  14,872  -1.2% 
 Source:  OIG analysis of  OSCAR data, 2008. 
*Percentage change may vary because of rounding. 
 
Deficiency rates varied widely among States.  In 2007, the percentage of nursing homes 
surveyed with deficiencies ranged from 76 percent in Rhode Island to 100 percent in 
Alaska, the District of Columbia, Idaho, and Wyoming.  The average number of 
deficiencies also varied among States, from 2.5 deficiencies per nursing home in  
Rhode Island to 14.4 in the District of Columbia.  These ranges were similar for each of 
the past 3 years. See Appendixes A and B for the trends in deficiencies by State.    
 
A Greater Percentage of For-Profit Nursing Homes Were Cited for Deficiencies  
Than Not-for-Profit and Government Nursing Homes in Each of the Past 3 Years  
In 2007, 94 percent of for-profit nursing homes surveyed were cited for deficiencies, 
compared to 88 percent of not-for-profit and 91 percent of government nursing homes.  
                                                 
18 OIG, Nursing  Home Deficiency Trends and Survey and Certification Process Consistency,  
OEI-02-01-00600, March 2003, p. 7.  
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 7  Kerry Weems 
See Figure 2 below. Since 2005, the percentages of for-profit nursing homes with 
deficiencies were between 3 and 6 points higher than the percentages of the other types of 
nursing homes with deficiencies. In each of the past 3 years, for-profit nursing homes 
made up 67 percent of the nursing homes surveyed, not-for-profit homes accounted for 
27 percent, and government-owned homes accounted for the remaining 6 percent. 
 
Figure 2:  Percentage of Nursing Homes Surveyed With Deficiencies by Type of Ownership,  
20052007 
96 
es  94  93.0  93.4  93.5 
m
o
H 92 
ng  89.9  90.2  90.5 
si 90 
r
u 88.4 
N 88.0 
e of  88  86.8 
g
nta 86 
e
c
er 84 
P
82 
2005  2006  2007 
For-Profit  Not-for-Profit  Government 
 
    
Source:  OIG analysis of OSCAR data, 2008. 
 
For-profit nursing homes also had a higher average number of deficiencies per home than 
the other types of nursing homes.  In 2007, for-profit nursing homes averaged  
7.6 deficiencies per home, while not-for-profit and government homes averaged 5.7 and 
6.3, respectively. As Table 2 below shows, the averages for all types of nursing homes 
increased since 2005. 
 
In addition, a greater percentage of multifacility nursing homes were cited for 
deficiencies, compared to single-facility nursing homes.  In 2007, 93 percent of 
multifacility nursing homes surveyed were cited for deficiencies, as opposed to 91 
percent of single-facility nursing homes.  These numbers have not changed significantly 
since 2005. The average number of deficiencies was also higher for multifacility homes 
than for single-facility homes in each of  the past 3 years.  See Table 2 below. 
 
Table 2:  Average Number of Deficiencies per Nursing Home Surveyed  
by Type of Home, 20052007 
 Type of Nursing Home  2005  2006  2007  Percentage Change* 
For-profit  7.0  7.4  7.6  9.8% 
Not-for-profit  5.1  5.6  5.7  13.1% 
Government  5.5  6.0  6.3  14.1% 
Multifacility   6.6  7.2  7.3  10.9% 
Single-facility   6.1  6.5  6.7  10.4% 
  Source:  OIG analysis of OSCAR data, 2008. 

 *Percentage  change may vary because of rounding. 

OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 8  Kerry Weems 
The Most Common Deficiency Categories Cited in Each of the Past 3 Years Were 
Quality of Care, Resident Assessment, and Quality of Life 
The most common deficiency categories cited in 2005, 2006, and 2007 were quality of 
care, resident assessment, and quality of life.  As shown in bold in Table 3 below, almost 
74 percent of nursing homes surveyed were cited for quality-of-care deficiencies in 2007.  
The most common quality-of-care deficiencies involved accident hazards; providing care 
for residents highest practicable physical, mental, and psychosocial well-being; and 
urinary incontinence. About 58 percent of nursing homes were cited for resident 
assessment deficiencies.  The most common resident assessment deficiencies involved 
services meeting professional quality standards, comprehensive care plans, and service 
provision by qualified persons. Over 43 percent of nursing homes were cited for quality-
of-life deficiencies. The most common quality-of-life deficiencies involved 
housekeeping and maintenance services, dignity, and accommodation of needs.  In 
addition, almost 43 percent of nursing homes were cited for deficiencies in the dietary 
services category. 
 
Table 3:  Percentage of Nursing Homes Surveyed That Received at Least One Deficiency  
by Category, 20052007 
Percentage-Point 
Deficiency Category   2005  2006  2007  Difference, 
20052007* 
Quality of care  70.6  71.5  73.6  3.1 
Resident assessment  54.4  58.0  58.2  3.8 
Quality of life  43.1  45.6  43.3  0.2 
Dietary services  43.1  44.4  42.9  -0.2 
Resident rights  33.4  34.5  34.3  0.9 
Administrative services  28.9  31.5  30.7  1.9 
Pharmacy services  23.8  25.3  28.8  5.0 
Infection control  26.3  28.7  28.4  2.1 
Resident behavior and facility practices  26.4  26.7  27.4  1.0 
Physical environment  22.9  23.7  23.8  0.9 
Laboratory  and radiology services  6.9  7.9  9.1  2.2 
Nursing services  4.2  5.3  6.9  2.7 
Physician services  4.6  5.4  5.7  1.1 
Admission, transfer, discharge rights  1.6  1.6  1.7  0.1 
Rehabilitative services  1.3  1.5  1.4  0.2 
Dental services  1.2  1.4  1.4  0.2 
       
          Source:  OIG analysis of  OSCAR data, 2008. 

         *Percentage-point difference may  vary because of rounding. 

 
The 2003 OIG report found that the most common deficiency categories cited in 2001 
were also quality of care, resident assessment, quality of life, and dietary services, in the 
same descending order.19  During that year, 68 percent of nursing homes were cited for 
                                                 
19 OIG, Nursing  Home Deficiency Trends and Survey and Certification Process Consistency,  
OEI-02-01-00600, March 2003, p. 9.  
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 9  Kerry Weems 
quality-of-care deficiencies, 50 percent were cited for resident assessment deficiencies, 
43 percent were cited for quality-of-life deficiencies, and 42 percent had dietary services 
deficiencies.  
 
Most categories of deficiencies had minor increases between 2005 and 2007.  The 
pharmacy services category measured the largest percentage-point increase.  Deficiencies 
cited in this category, which addresses the accurate dispensation and administration of 
drugs to residents, increased by 5 percentage points.  This increase coincided with the 
implementation in 2006 of Medicare Part D, which provided voluntary drug coverage to 
Medicare beneficiaries. In addition, CMS issued guidance in late 2006 that combined 
several drug-related deficiencies and revised its guidelines for citing these deficiencies.  
 
Three types of deficiencies have been the most common since 2005.  Approximately  
36 percent of nursing homes surveyed were cited for deficiencies associated with 
accident hazards each year; between 33 percent and 35 percent of nursing homes were 
cited for deficiencies for the improper storage, preparation, distribution, or serving of 
food; and almost 28 percent were cited for deficiencies for not providing the care 
necessary for residents highest practicable physical, mental, and psychosocial well-
being. These most common deficiencies fell within the quality-of-care category and the 
dietary services category. 
 
Almost 17 Percent of Nursing Homes Surveyed Were Cited for Actual Harm or  
Immediate Jeopardy Deficiencies in 2007 
In 2007, nearly 17 percent of nursing homes surveyed were cited for immediate jeopardy 
or actual harm deficiencies.  Specifically, almost 3 percent of nursing homes were cited 
for immediate jeopardy deficiencies, and 15 percent were cited for actual harm  
deficiencies in 2007.20  The majority of the nursing homes with actual harm deficiencies  
had isolated (G-level) rather than pattern or widespread deficiencies (H- and I-level).  
 
The most common scope and severity ratings in 2007 were at the D and E levels.   
Eighty-three percent of nursing homes surveyed were cited for D-level deficiencies, and 
63 percent were cited for E-level deficiencies.  Both ratings indicate a severity of no 
actual harm with potential for more than minimal harm.  Although most of the scope and 
severity levels did not change substantially since 2005, there was a small shift from   
B-level to C-, E-, and F-level deficiencies. This trend indicates that nursing homes were 
cited for more severe deficiencies as well as deficiencies that were wider in scope in 
2007, compared to those in the prior 2 years.  Table 4 on the next page shows the scope 
and severity levels for 2005 through 2007, with the largest percentage-point changes in 
bold. 
                                                 
20  One percent was cited for both deficiencies.  
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 10  Kerry Weems  
 
Table 4: Percentage of Nursing Homes Surveyed That Had 
at Least One Deficiency by  Scope and Severity Levels,  
20052007  
Scope and  Percentage-Point 
Severity   2005  2006  2007  Difference,  
Level  20052007* 
A  0.0%  0.0%  0.0%  0.0 
B  30.5%  28.7%  27.6%   -3.0 
C  20.8%  21.9%  22.2%   1.4 
D  82.4%  83.1%  83.2%  0.9 
E  58.4%  61.8%  62.8%   4.4 
F  19.2%  21.1%  21.2%   2.0 
G  14.1%  15.4%  14.9%  0.7 
H  1.0%  1.1%  1.0%  0.1 
I  0.1%  0.1%  0.1%  0.0 
J  1.2%  1.1%  1.3%  0.1 
K  1.0%  1.0%  1.2%  0.2 
L  0.4%  0.4%  0.4%  0.1 
    Source:  OIG analysis of OSCAR data, 2008. 

        
*Percentage-point difference may vary because of rounding.
 
 
According to the 2003 OIG report, the most common scope and severity ratings in 2001 
were also at the D and E levels.21  However, the percentage of nursing homes with these 
ratings was somewhat lower than the figures above, at 77 percent and 55 percent, 
respectively. In addition, OIG reported that between 1998 and 2001, there was a shift 
away from G-level to more D- and E-level deficiencies.  This shift demonstrated that 
nursing homes had deficiencies that were less severe but equal or wider in scope in 2001 
compared to 1998.   
 
In each of the past 3 years, a higher percentage of for-profit nursing homes surveyed were 
cited for immediate jeopardy or actual harm deficiencies, compared to the other types of 
nursing homes. In 2007, 17 percent of for-profit nursing homes surveyed were cited for 
these deficiencies, compared to 15 percent of not-for-profit and government homes.  In 
addition, a slightly greater percentage of multifacility nursing homes were cited for 
immediate jeopardy or actual harm deficiencies, compared to single-facility homes, at  
17 percent and 16 percent, respectively. 
 
Substandard Quality-of-Care Deficiencies Increased Slightly Since 2005 
The percentage of nursing homes with substandard quality-of-care deficiencies has risen 
slightly since 2005. In 2007, 3.6 percent of nursing homes surveyed were cited for these 
deficiencies, up from 3.0 percent in 2005.  The small increase in substandard quality of 
care differs from the slight downward trend in the 2003 OIG report.22  That report found 
                                                 
21 OIG, Nursing  Home Deficiency Trends and Survey and Certification Process Consistency,  

OEI-02-01-00600, March 2003, p. 11. 

22  Ibid., p. 10.  

OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 11  Kerry Weems  
that the percentage of nursing homes cited for quality-of-care deficiencies decreased from  
4.5 percent in 1998 to 4.2 percent in 2001. 
 
The percentage of for-profit nursing homes with substandard quality-of-care deficiencies 
was higher compared to the other types of nursing homes.  In 2007, 4.2 percent of 
for-profit homes were cited for these deficiencies, in contrast to 2.3 percent of  
not-for-profit homes and 3.0 percent of government homes.  These percentages increased 
slightly for all three types of homes since 2005.  During the same time, the percentage of 
multifacility homes with substandard quality of care deficiencies increased from   
2.9 percent to 3.9 percent while the percentage of single-facility homes stayed at about  
3 percent. 
 
The Number of Substantiated Complaints Decreased Slightly Since 2005 
The number of substantiated complaints decreased nearly 3 percent since 2005.  As 
shown in Figure 3 below, a total of 14,394 complaints were substantiated in 2007, a 
decrease from 14,781 in 2005. The total number of complaints has similarly decreased 
since 2005. Almost 39 percent of complaints in each year were substantiated.   
 
The number of nursing homes associated with these complaints also decreased.  In 2007, 
2,759 nursing homes were associated with at least one substantiated complaint, compared 
to 2,856 in 2005. In each of the past 3 years, almost 40 percent of these complaints were 
related to care or services. About 20 percent of substantiated complaints involved 
resident abuse or neglect. 
 
Figure 3:  Numbers of Complaints and Substantiated  Complaints, 20052007 
45,000 
40,716 
40,000  38,147  37,153 
35,000 
30,000 
25,000 
20,000 
15,806 
14,781  14,394 
15,000 
10,000 
5,000 
0 
2005  2006  2007 
Complaints  Substantiated Complaints
 
    Source:  OIG analysis of OSCAR data, 2008. 
 
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 12  Kerry Weems  
CONCLUSION 
 
Deficiency rates have not changed significantly over the past 3 years.  More than 
91 percent of nursing homes surveyed were cited for deficiencies, and a greater 
percentage of for-profit nursing homes were cited for deficiencies than not-for-profit and 
government nursing homes.  The most common deficiency categories cited in each of the 
past 3 years were quality of care, resident assessment, and quality of life.  Additionally, 
17 percent of nursing homes surveyed in 2007 were cited for actual harm or immediate 
jeopardy deficiencies, and 3.6 percent were cited for substandard quality-of-care 
deficienciesa slight increase since 2005.  Lastly, the number of substantiated 
complaints decreased nearly 3 percent since 2005. 
 
We note that many factors in addition to quality of care may affect deficiency rates.  
These factors may include an increase in enforcement, additional guidance or training 
from States and CMS, legislative changes, and State surveyor practices.   
 
This report is being issued directly in final form because it contains no recommendations.  
If you have comments or questions about this report, please provide them within 60 days.  
Please refer to report number OEI-02-08-00140 in all correspondence. 
 
OEI-02-08-00140     Trends in Nursing Home Deficiencies and Complaints  Page 13  Kerry Weems  
       Appendix A 
 
Percentage of Nursing Homes Surveyed  With 
Deficiencies by State, 20052007  
STATE  2005  2006  2007 
Alabama  97.6%  97.0%  96.8% 
Alaska  80.0%  100.0%  100.0% 
Arizona  92.9%  96.2%  97.4% 
Arkansas  95.4%  97.6%  97.9% 
California  98.6%  98.2%  99.1% 
Colorado  95.0%  95.9%  96.6% 
Connecticut  95.6%  97.4%  98.7% 
Delaware  97.6%  100.0%  97.6% 
District of Columbia  100.0%  100.0%  100.0% 
Florida  97.1%  96.8%  97.2% 
Georgia  95.2%  95.0%  88.1% 
Hawaii  100.0%  97.9%  97.4% 
Idaho  94.4%  100.0%  100.0% 
Illinois  87.1%  87.5%  90.4% 
Indiana  89.2%  88.9%  89.1% 
Iowa  85.3%  86.6%  88.4% 
Kansas  92.3%  95.2%  96.9% 
Kentucky   90.1%  91.2%  87.6% 
Louisiana  92.5%  91.8%  94.7% 
Maine  100.0%  98.2%  95.2% 
Maryland  93.4%  96.9%  94.4% 
Massachusetts  83.3%  81.4%  80.3% 
Michigan  95.4%  94.4%  96.0% 
Minnesota  96.6%  98.6%  97.5% 
Mississippi  86.6%  87.1%  86.7% 
Missouri  88.0%  89.7%  92.5% 
Montana  96.5%  92.8%  91.4% 
Nebraska  86.9%  91.6%  91.4% 
Nevada  82.6%  90.9%  83.3% 
New  Hampshire  85.7%  70.3%  83.5% 
New  Jersey   88.7%  88.0%  92.2% 
New  Mexico  92.7%  92.5%  97.1% 
New  York  90.4%  91.2%  92.0% 
North Carolina  88.8%  91.1%  89.6% 
North Dakota  98.7%  97.6%  93.5% 
Ohio  86.1%  85.9%  87.4% 
Oklahoma  93.7%  95.5%  93.8% 
Oregon  72.6%  74.1%  81.4% 
Pennsylvania  89.7%  93.4%  89.7% 
Rhode Island  85.7%  86.8%  76.3% 
South Carolina  93.1%  96.9%  92.7% 
South Dakota  89.8%  94.2%  88.6% 
Tennessee  95.5%  91.1%  92.0% 
Texas  92.1%  91.4%  89.6% 
Utah  86.3%  93.3%  97.5% 
Vermont  91.7%  100.0%  94.6% 
Virginia  84.4%  87.2%  93.1% 
Washington  90.9%  91.5%  90.9% 
West Virginia  97.5%  96.2%  95.8% 
Wisconsin  79.3%  83.8%  85.6% 
Wyoming  100.0%  100.0%  100.0% 
             Source:  OIG analysis of  OSCAR data, 2008. 
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints  Page 14  Kerry Weems  
       Appendix B 
 
Average Number of Deficiencies per Nursing Home 
Surveyed by  State, 20052007  
STATE  2005  2006  2007 
Alabama  7.2  6.8  6.4 
Alaska  5.3  9.5  6.5 
Arizona  8.7  9.2  7.7 
Arkansas  9.3  10.7  8.6 
California  10.2  11.3  11.8 
Colorado  8.5  9.3  9.7 
Connecticut  8.0  8.5  9.0 
Delaware  8.3  13.1  13.3 
District of Columbia  13.6  12.5  14.4 
Florida  7.5  8.3  8.0 
Georgia  6.6  6.8  6.5 
Hawaii  8.5  7.0  7.0 
Idaho  8.8  9.9  8.7 
Illinois  4.4  4.9  5.3 
Indiana  5.8  6.8  7.9 
Iowa  4.2  4.3  5.0 
Kansas  8.9  9.8  9.9 
Kentucky  4.5  5.5  4.5 
Louisiana  8.2  7.1  7.9 
Maine  8.5  8.3  8.3 
Maryland  7.8  9.5  9.8 
Massachusetts  5.3  5.2  5.5 
Michigan  7.4  7.6  8.8 
Minnesota  8.5  10.1  10.2 
Mississippi  3.7  4.0  4.3 
Missouri  6.2  7.1  8.2 
Montana  6.3  6.4  6.9 
Nebraska  4.1  5.3  6.9 
Nevada  9.4  10.2  6.9 
New Hampshire  5.5  4.5  4.4 
New Jersey   4.2  4.3  4.3 
New Mexico  7.7  7.1  7.1 
New York  4.1  4.6  5.3 
North Carolina  4.9  4.7  4.4 
North Dakota  4.8  4.8  4.3 
Ohio  4.5  4.8  5.5 
Oklahoma  8.0  8.9  9.1 
Oregon  4.7  4.8  4.7 
Pennsylvania  4.6  5.2  4.6 
Rhode Island  4.9  3.5  2.5 
South Carolina  8.2  7.9  7.6 
South Dakota  4.0  4.9  4.5 
Tennessee  6.6  5.9  5.7 
Texas  6.5  6.8  6.5 
Utah  4.2  4.7  5.7 
Vermont  6.4  7.2  8.0 
Virginia  5.2  6.4  7.3 
Washington  6.3  6.3  6.6 
West Virginia  7.9  7.8  8.6 
Wisconsin  3.3  4.2  4.7 
Wyoming  7.9  15.1  12.3 
           
             Source:  OIG analysis of  OSCAR data, 2008. 
OEI-02-08-00140      Trends in Nursing Home Deficiencies and Complaints