HHS OIG Data Brief  September 2017  OEI-01-16-00330 
 
A Few States Fell Short in Timely Investigation of the Most Serious 
Nursing Home Complaints: 20112015  
This Data Brief 
Key Takeaways: 
In this data brief, the Office of Inspector 
  Overall, States received one-third more  General (OIG) highlights the extent to 
nursing home complaints in 2015 than 
which State survey agencies (hereinafter, 
in 2011  
States) met onsite investigation timeframes 
 
for the most serious nursing home 
  States prioritized more than half of 
complaints from 2011 through 2015.  It 
nursing home complaints into the most 
updates our 2006 report and offers the 
serious categoriesimmediate 
Centers for Medicare & Medicaid Services 
jeopardy and high prioritywhich 
(CMS) some insights into the States that 
require onsite investigations within 2 or 
10 working days, respectively   have room to improve in prioritizing and 
  responding to nursing home complaints.  
  States conducted nearly all of the   
required onsite investigations for the  Introduction 
most serious nursing home complaints  The nursing home complaint process is a 
 
critical safeguard to protect vulnerable 
  Although almost all States conducted 
residents of nursing homes.  CMS relies on 
most of their onsite investigations 
the States respective survey agencies to 
within required timeframes, a few 
serve as the front-line responders to 
States fell short 
address health and safety concerns raised 
 
by residents, their families, and nursing 
  Two States accounted for most of the 
home staff.1  Examples of concerns that 
late investigations of immediate 
might result in a complaint are residents 
jeopardy complaints 
  being left sitting in their urine and feces for 
  Four States accounted for almost half  hours, residents being admitted to the 
of the late investigations of high priority  hospital because of preventable infections, 
complaints   and inappropriate social media posts by 
  nursing home employees.   
  Almost one-quarter of States did not   
meet CMSs performance threshold for  States must conduct onsite investigations 
timely onsite investigations of high 
within certain timeframes for the two most 
priority complaints in all 5 years 
serious levels of complaintsthose that 
 
allege serious injury or harm to a nursing 
  States substantiated almost one-third 
home resident and require a rapid 
of the most serious nursing home 
response to address the complaint and 
complaints each year  
ensure residents safety.  However, 
  previous reports by the OIG and the Government Accountability Office (GAO) found that 
States did not conduct onsite investigations within the required timeframes for some of 
these complaints.2,3  
 
 
CMS provides States with procedural guidelines for investigating complaints for 
Medicare/Medicaid-certified nursing homes.4  CMS provides a detailed protocol for 
States on the process that includes complaint intake, prioritization, and investigation.   
CMS requires that each complaint be prioritized by a qualified professional who has 
knowledge of current clinical standards and Federal requirements.  The priority level 
that the State assigns to a complaint is critical because it determines the States 
required action and timeframe for investigating.  The two highest priority levels are 
immediate jeopardy and non-immediate jeopardyhigh (high priority), which States 
must investigate onsite within 2 and 10 working days, respectively.  See Exhibit 1 for 
complaint priority levels and definitions. 
Exhibit 1:  Nursing Home Complaint Priority Levels  
 
Source: CMS State Operations Manual, ch. 5, Complaint Procedures, (Revised 120, 09-19-14). 
 
In addition to assigning a priority level to complaints, States categorize each allegation 
within a complaint by type.  (A complaint can consist of more than one allegation.)  
Some examples of allegation categories are quality of care, resident neglect, and 
violation of resident rights.   
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  2 
    During its investigation, the State determines whether to substantiate the complaint and 
may cite the nursing home for deficiencies related or unrelated to the complaint.  The 
State cites the nursing home for a deficiency when the facility is not compliant with 
specific Federal requirements.  CMS instructs surveyors to substantiate an allegation 
when the State verifies it with evidence, even if the noncompliance has been corrected. 
 
Every year, CMS evaluates each States performance in carrying out all its survey and 
certification responsibilities including, but not limited to, responding to complaints at 
nursing homes.  CMS uses its State Performance Standards System to ensure that the 
States meet Federal requirements and to identify areas for improvement.  As part of this 
evaluation, CMS reviews the timeliness of States complaint investigations for nursing 
homes and other facilities.   
 
For additional background, see Appendix A.   
 
Our primary source of data for this data brief was complaints regarding 
Medicare/Medicaid-certified nursing homes and associated investigation information 
entered into CMSs Automated Survey Processing Environment Complaints/Incidents 
Tracking System (ACTS) from 2011 through 2015.  For a detailed methodology, see 
Appendix B.   
 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
To complement this data brief, OIG has published an interactive map illustrating 
State-by-State trends in nursing home complaints.  The interactive map is available at 
https://oig.hhs.gov/oei/maps/nursing-home/. 
RESULTS  
Overall, States received one-third more nursing home 
complaints in 2015 than in 2011 
 
While the number of nursing home residents decreased slightly between 2011 and 
2015, the number of nursing home complaints States received increased 33 percent, 
from 47,279 to 62,790.  Over this 5-year period, the number of complaints that States 
received per 1,000 nursing home residents increased from 32.7 to 44.9 complaints per 
year (see Exhibit 2).  
 
   
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  3 
     
Exhibit 2: Rate of Complaints per 1,000 Nursing Home Residents, 20112015  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of ACTS data and CMS Minimum Data Set (MDS) 3.0 Frequency Report, 2017. 
State trends in nursing home complaints varied between 2011 and 2015.  Thirty-five 
States had increases in the number of complaints during this time, with increases of 
50 percent or more in 11 of those States.  In contrast, 16 States had decreases in the 
number of complaints, with decreases of 50 percent or more in 5 of those States.   
 
In addition, the number of nursing home complaints received varied from one State to 
another.  For example, in 2015 the number of complaints that States received ranged 
from 2.1 per 1,000 nursing home residents to 109 per 1,000 residents (see Exhibit 3).  
Across all 5 years, Hawaii generally had few complaintsan average of 3.3 per 
1,000 residentswhile Washington consistently had the highest number of complaints, 
with an average of 108.7 complaints per 1,000 residents.  Exhibit C-1 in Appendix C 
provides details on the number of nursing home complaints that each State received.    
 
 
 
 
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  4 
     
Exhibit 3: Rate of Complaints per 1,000 Nursing Home Residents by State in 2015 
 
 
Source: OIG analysis of ACTS data, 2017. 
*In this report, we refer to the District of Columbia as a State. 
Note: See https://oig.hhs.gov/oei/maps/nursing-home/ for rates of complaints for years 20112015 by State. 
  
Each year, half of all nursing home complaints required 
prompt onsite investigation  
 
The priority level that the State assigns to each nursing home complaint determines the 
States required action and timeframe for addressing the complaint. The two most 
serious priority levels of complaintsimmediate jeopardy and high priorityrequire the 
State to conduct an onsite investigation within 2 working days or 10 working days, 
respectively, to address the complaint and ensure the residents safety.   
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  5 
    In 2015, States prioritized 59 percent of complaints as either 
immediate jeopardy or high priority, compared to 55 percent in 2011 
 
Each year, States prioritized about 7 percent of complaints as immediate jeopardy, 
a level that requires a State to conduct an onsite investigation within 2 working days.  
Although the proportion of total complaints remained about 7 percent, the number of 
immediate jeopardy complaints almost doubled during this time, from 2,844 to 5,341.  
In addition, States prioritized about 50 percent of complaints each year as high priority, 
a level that requires a State to investigate onsite within 10 working days (see Exhibit 4).   
  
Exhibit 4: Percentage of Nursing Home Complaints That States Prioritized for 
Prompt Onsite Investigation: 20112015 
 
Source: OIG analysis of ACTS data, 2017. 
 
The percentage of complaints that States prioritized as immediate jeopardy and 
high priority varied from one State to another.  For example, in 2015, eight States did 
not prioritize any complaints as immediate jeopardy while three States (Georgia, 
Kentucky, and Tennessee) prioritized over 40 percent of their complaints as immediate 
jeopardy.  Of the eight States that prioritized no complaints as immediate jeopardy in 
2015, three StatesNew Hampshire, Oregon, and Rhode Islandprioritized 
no complaints as immediate jeopardy during the entire 5-year period we analyzed. 
 
We also found variation from one State to another in the percentages of complaints that 
they prioritized as high priority.  For example, in 2015, Hawaii and North Dakota 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  6 
    prioritized no complaints as high priority while 18 States prioritized more than 
50 percent of complaints as high priority.  Furthermore, North Dakota prioritized 
no complaints as high priority in 4 of the 5 years we analyzed.  Exhibit C-1 in 
Appendix C provides details on the percentages of nursing home complaints that each 
State prioritized as immediate jeopardy and high priority. 
 
Among the most serious complaints, the most common allegations 
related to quality of care or treatment 
 
Between 2011 and 2015, for complaints prioritized as immediate jeopardy or 
high priority, States categorized an average of 42 percent of the allegations as relating 
to quality of care or treatment.  In 2015, allegations regarding quality of care or 
treatment were the most common (41 percent), followed by allegations regarding 
resident neglect (12 percent) and resident rights (8 percent).  See Exhibit 5 for 
examples of allegations in each category and the percentages of total allegations for 
these categories in 2015.   
Exhibit 5: Percentages of the Types of Allegations Associated With the Most 
Serious Nursing Home Complaints in 2015, with Examples 
Source: OIG analysis of ACTS data and examples provided by CMS, 2017. 
   
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  7 
    States conducted nearly all required onsite investigations for 
the most serious nursing home complaints each year 
 
Over this 5-year period, States did not investigate 9 immediate jeopardy and 
166 high priority nursing home complaints onsite, representing less than 1 percent of 
these complaints collectively.  States received about half of these complaints in 2015 
(see Exhibit 6).  For immediate jeopardy complaints, no State missed more than 
two required onsite investigations in any year.  For high priority complaints, however, 
4 StatesArizona, California, Delaware, and New Jerseymissed onsite investigations 
for more than 10 high priority complaints in at least 1 of the 5 years.  Being onsite allows 
surveyors to directly observe the conditions and care practices at a nursing home. 
 
Exhibit 6: Number of Immediate Jeopardy and High Priority Complaints Without 
Onsite Investigations, 20112015  
Number of nursing home complaints without onsite investigations
Year Immediate Jeopardy Complaints High Priority Complaints
2011 0 of   2,844 total complaints 9 of   23,221 total complaints
2012 0 of   3,329 21 of   25,715
2013 3 of   3,905 16 of   26,681
2014 2 of   5,009 37 of   28,810
2015 4 of   5,341 83 of   31,748
Total 9 of 20,428 166 of 136,175 
 
 Source: OIG analysis of ACTS data, 2017. 
 
Although almost all States conducted most of their onsite 
investigations within required timeframes, a few States fell 
short  
The potential for further harm to nursing home residents makes it essential that States 
conduct prompt onsite investigations of immediate jeopardy and high priority 
complaints.   
Two States accounted for most of the late investigations of immediate 
jeopardy complaints  
Each year, Tennessee and Georgia accounted for over half of the immediate jeopardy 
complaints that were not investigated within 2 working days.  Across the 5-year period, 
Tennessee accounted for most of the immediate jeopardy complaints that were 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  8 
    investigated within 2 working days, whereas until 2015 Georgia had accounted for only 
a few of the late investigations. 
In 2015, Tennessee and Georgia received a total of 912 immediate jeopardy complaints 
(17 percent of all immediate jeopardy complaints).  Of these 912 complaints, they 
investigated 654 complaints late.  These 654 complaints constituted 86 percent of the 
764 immediate jeopardy complaints nationwide that were investigated late (see 
Exhibit 7). 
Nationwide, the percentage of immediate jeopardy complaints that States did not 
investigate within 2 working days was 14 percent in 2015, compared to 7 percent in 
2011.  For the 49 States other than Tennessee and Georgia, the overall percentage of 
immediate jeopardy complaints not investigated within 2 working days was about 
2 percent each year.  
Exhibit 7: Number of Immediate Jeopardy Complaints Not Investigated Onsite 
Within 2 Working Days: 20112015 
Source: OIG analysis of ACTS data, 2017. 
CMS states that it is working with Tennessee to address a backlog of complaints, which 
the State attributed to insufficient staff and loss of institutional knowledge as a result of 
staff turnover.  CMS stated that vacancies contributed in a similar fashion to Georgias 
late complaint investigations, and that the State is working to hire additional surveyors.  
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  9 
    CMS noted that both States have hired contractors to help conduct surveys.  Exhibit C-2 
in Appendix C provides details on each States number of immediate jeopardy nursing 
home complaints not investigated within required timeframes.  
Furthermore, these two States investigated many immediate jeopardy complaints weeks 
late.  For example, in 2015, Tennessee and Georgia accounted for almost all of the 
immediate jeopardy complaints (467 of 473) that States investigated onsite 15 or more 
days after complaint receipt (see Exhibit 8). 
Exhibit 8: Number of Immediate Jeopardy Complaints Investigated by Number of 
Workdays From Complaint Receipt, 2015   
 
                                                               
 
Source: OIG analysis of ACTS data, 2017.  
 
Note:  See Appendix D for national data on the number of             
immediate jeopardy complaints investigated by the number of 
  workdays from complaint receipt for 2011 through 2015. 
Four States accounted for almost half of the late investigations of 
high priority complaints  
As was the case with immediate jeopardy complaints, some States accounted for 
a higher number of late onsite investigations of high priority complaints than did others.  
Across all 5 years, Arizona, Maryland, New York, and Tennessee accounted for almost 
half of the high priority complaints not investigated onsite within 10 working days.  For 
example, in 2015, these four States did not investigate 2,680 of 4,743 high priority 
complaints (57 percent) within the required timeframes (see Exhibit 9).  In 2015, these 
four States accounted for 13 percent of all high priority complaints.  The national 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  10 
    percentage of high priority complaints not investigated within 10 working days was 
15 percent in 2015, compared to 18 percent in 2011.  For the 47 States other than these 
4, the overall percentage of high priority complaints not investigated within 10 working 
days was 7 percent in 2015, compared to 11 percent in 2011.  
 
Exhibit 9: Number of High Priority Complaints Not Investigated Onsite Within 
10 Working Days: 20112015 
 
Source: OIG analysis of ACTS data, 2017. 
Furthermore, these four States investigated many high priority complaints weeks late.  
For example, in 2015, these States accounted for two-thirds (2,067 of 3,043) of high 
priority complaints that States investigated onsite 26 days or more after complaint 
receipt (see Exhibit 10). 
According to CMS, these States generally faced challenges related to staff shortages 
and are working to improve response times for complaint investigations.  Exhibit C-2 in 
Appendix C provides details on the each States number of high priority nursing home 
complaints not investigated within required timeframes.  
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  11 
    Exhibit 10: Number of High Priority Complaints Investigated by Number of 
Workdays From Complaint Receipt, 2015 
 
 
 
Source: OIG analysis of ACTS data, 2017. 
 
Note: See Appendix D for national data on the number of high 
priority complaints investigated by the number of workdays from 
  complaint receipt for years 2011 through 2015. 
 
Almost one-quarter of States did not meet CMSs performance 
threshold for timely onsite investigations of high priority complaints 
in all 5 years 
Although CMS requires that States investigate all high priority 
nursing home complaints onsite within 10 working days, it will 
impose a sanction or remedy when a State does not investigate 
95 percent of these complaints within that timeframe.5  Eleven 
States (22 percent) did not meet CMSs performance threshold 
for timely onsite investigations of high priority nursing home 
complaints every year between 2011 and 2015 (see Exhibit 11).  
In addition, Colorado, Connecticut, Iowa, and Maine did not 
meet CMSs threshold for 4 of these 5 years.   
Furthermore, Mississippi, and Tennessee did not conduct onsite 
investigations for 95 percent of the immediate jeopardy nursing 
home complaints they received each year.  We cannot 
determine whether these States met CMSs annual performance 
threshold for timely investigation of immediate jeopardy 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  12 
    complaints because CMS includes other facilities with nursing homes in its calculations 
for this performance threshold.  However, these 2 States are included among the 
11 States that did not meet CMSs performance threshold for timely investigations of 
high priority complaints each year.   
Exhibit 11: States That Did Not Meet CMSs Performance Threshold for Timely 
Investigations of High Priority Nursing Home Complaints Every Year Between 
2011 and 2015   
 
Source: OIG analysis of ACTS data, 2017. 
*In this report, we refer to the District of Columbia as a State. 
 
States substantiated almost one-third of the most serious 
nursing home complaints  
Between 2011 and 2015, States substantiated 31 percent, on average, of the immediate 
jeopardy and high priority nursing home complaints that they investigated (see 
Exhibit 12).6  When we analyzed the two priority levels of complaints separately, we 
found little difference between the average percentages substantiated for each priority 
levelon average, States substantiated 34 percent of immediate jeopardy complaints 
and 30 percent of high priority complaints.  
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  13 
    Exhibit 12: Average Percentage of the Most Serious Nursing Home Complaints 
That States Substantiated, 20112015 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of ACTS data, 2017. 
 
 
States varied in the percentage of complaints they substantiated.  
CMS instructs 
According to CMS, how States apply CMSs definition of 
surveyors to 
substantiation may not be consistent from one State to another.  For 
substantiate an 
example, following an investigation, a State confirmed that a resident 
allegation when the 
fell and dislocated a shoulder as alleged in the residents complaint, 
State verifies it with 
but the State had insufficient evidence to support a Federal deficiency.  
evidence, even if the 
In this example, some States would consider the complaint 
substantiated because the resident did fall and did dislocate a  noncompliance has 
shoulder; however, other States would consider the complaint  been corrected. 
unsubstantiated because the State did not cite a Federal deficiency.  
 
For States that in 2015 investigated most than 20 of the most serious complaints 
(i.e., immediate jeopardy and high priority complaints), the percentages of the 
complaints that they substantiated ranged from 4 percent to 82 percent.  Six States 
substantiated more than 50 percent of their most serious complaints, whereas only 
Rhode Island substantiated less than 10 percent of its most serious complaints.  
Exhibit C-3 in Appendix C provides details on the percentages of immediate jeopardy 
and high priority nursing home complaints that each State substantiated.  
   
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  14 
    CONCLUSION
 
Overall, nursing home complaints rose by one-third across States from 2011 to 2015, 
while the number of nursing home residents decreased about 3 percent.  However, we 
do not know whether an increase in complaints represents a decrease in quality of care.  
Other factors may contribute to an increase in complaints, such as more accessible and 
user-friendly options to file complaints, better tracking of complaints, or possibly an 
increased willingness among consumers to report on their nursing home experiences.  
 
This data brief raises questions about how some States respond to complaints, as these 
responses could have serious consequences for nursing home residents in those 
States.  Residents and their families rely on a functioning complaint system to take their 
complaints seriously and to investigate them appropriately. A functioning complaint 
system also complements other oversight efforts, such as routine surveys.  However, a 
handful of States accounted for about half of the late investigations of the most serious 
nursing home complaints, with most such investigations being weeks late.  Further, 
some States never prioritized any complaints as immediate jeopardy. 
 
This data brief offers CMS some insights into the States that have room to improve in 
prioritizing and responding to nursing home complaints.  Nursing home residents are 
a vulnerable population, and States serve as the front-line responders in addressing 
concerns raised by residents, their families, and nursing home staff.  To ensure the 
health and safety of nursing home residents, CMS must remain vigilant and assist the 
States that are falling short in meeting timeframes for investigations of complaints.  OIG 
will continue to monitor the oversight of nursing homes and will initiate additional 
 
reviews as necessary.
 
 
   
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  15 
    APPENDIX A: DETAILED BACKGROUND
 
 
Nursing Home Oversight  
 
CMS, in conjunction with States, oversees nursing homes to ensure that they meet 
Federal standards.  States conduct certification surveys on behalf of CMS on average 
every 12 months but no less frequently than every 15 months.7  These surveys evaluate 
the safety and quality of care that nursing homes provide.8  In addition, States conduct 
complaint investigations as needed between certification surveys. 
Complaint Investigations 
 
Complaint Intake   
CMS instructs States to collect comprehensive information from complainants. This 
information includes, but is not limited to, information about the complainant; the nursing 
home; the individuals involved; a narrative of the allegation; how and why the 
complainant believes the problem leading to the allegation occurred; and the 
complainants expectation of the resolution.  CMS requires States to enter all data 
regarding complaints and incidents into ACTS. 
Complaint Priority Levels  
Complaints that States prioritize as immediate jeopardy allege a situation in which the 
providers noncompliance with Federal requirements has caused, or is likely to cause, 
serious injury, harm, impairment, or death to a resident.  States must prioritize and 
investigate these complaints onsite within 2 working days of receiving the complaint.  
To help States identify immediate jeopardy complaints, CMS provides examples of 
circumstances that may indicate immediate jeopardy situations.  For example, serious 
injuries such as head trauma or fractures may indicate that the nursing home has failed 
to protect the resident from abuse.   
Complaints that States prioritize as high priority allege a situation in which the providers 
noncompliance with Federal requirements may have caused harm that negatively 
affects the residents mental, physical, and/or psychosocial status.  A high priority 
situation is one that requires a rapid response because of its potential consequences to 
a residents well-being.  States must investigate high priority complaints onsite within 10 
working days of prioritization.   
For a complaint considered less serious than immediate jeopardy or high priority, 
a State may be required to schedule an onsite survey or to investigate the complaint 
during its next onsite survey at the nursing home.  In some cases, a State may perform 
a desk review of the complaint or refer the complaint to a more appropriate agency.  
Complaint Investigation and Substantiation 
The State will determine during its investigation whether to substantiate the complaint 
and may cite the nursing home for Federal deficiencies related or unrelated to the 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  16 
    complaint.  CMS also requires that the State follow up with the nursing home after its 
investigation and provide information to the complainant.  
When a State investigation cites a Federal deficiency at the level of immediate jeopardy, 
CMS requires the State to revisit the facility and confirm removal of the immediate 
jeopardy.  The facility must remove the immediate jeopardy no later than 23 days from 
the last day of the States investigation.9  The State should also impose other remedies 
such as monetary fines or State monitoring and require a corrective action plan to 
address any underlying deficiencies.  When a State investigation cites a deficiency but 
immediate jeopardy does not exist, the State may (1) require a corrective action plan to 
address deficiencies, (2) impose monetary penalties or other remedies, and/or (3) revisit 
the nursing home.  The facility must resolve any noncompliance no later than 6 months 
from the last day of the States investigation.  
State Performance Standards System 
 
Every year, CMS evaluates each States performance in carrying out all its survey and 
certification responsibilities.  The State Performance Standards System consists of 
19 measures across 3 categories of performance standards: frequency; quality; and 
enforcement and remedy.  Under the quality standard, CMS reviews the timeliness of 
States investigations of complaints and facility-reported incidents for nursing homes 
and other facilities.10  
 
Although CMS requires States to investigate all immediate jeopardy and high priority 
nursing home complaints onsite within certain timeframes, the threshold by which it 
measures States performance is lower.  For purposes of the State Performance 
Standards System, States must conduct onsite investigations within 2 working days for 
95 percent of all immediate jeopardy complaints that they receive.  This performance 
threshold includes all immediate jeopardy complaints, whether for nursing homes or for 
other facilities, such as hospitals and ambulatory surgery centers.  Similarly, CMSs 
performance threshold regarding high priority complaints is for States to conduct onsite 
investigations within 10 working days for 95 percent of the high priority complaints they 
receive.  If a State does not meet one of these performance thresholds, CMS provides 
the State with a corrective action plan and follows up on the States implementation of 
the plan.11  
 
 
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  17 
    APPENDIX B: DETAILED METHODOLOGY
 
Our primary data source for this data brief was all nursing home complaints and 
associated investigation information entered in ACTS from 2011 through 2015.  We also 
interviewed CMS staff.  
ACTS Data 
CMS provided us with data on all Medicare/Medicaid-certified nursing home complaints 
and facility-reported incidents and associated investigation information entered into 
ACTS from 2011 through 2015.  We removed records in which the State entered a start 
date for the onsite investigation that was prior to the complaint receipt date (42,869 
records).  Our final dataset included 874,972 records from all 50 States and the District 
of Columbia.  Complaints and incidents can include multiple allegations; each record 
represents one allegation.   
We analyzed these data using SAS to determine national and State trends for nursing 
home complaints between 2011 and 2015.  We analyzed these data to determine: 
(1) the number of nursing home complaints that States received; (2) the percentage of 
complaints that States prioritized as immediate jeopardy and high priority; (3) the 
percentage of immediate jeopardy and high priority complaints that States investigated 
onsite within required timeframes; and (4) the percentage of immediate jeopardy and 
high priority complaints that States substantiated.  To compare across States, we 
obtained the number of nursing home residents for each State from the nursing home 
resident Minimum Data Set Public Reports on the CMS website.  To determine whether 
States investigated complaints within required timeframes, we excluded weekends and 
Federal holidays and calculated the number of days that elapsed between the complaint 
receipt date and onsite investigation date.  We did not exclude State-only holidays from 
our analysis.   
CMS Interviews 
We conducted interviews with CMS staff to learn about ACTS data and how States use 
ACTS.   
Nursing Home Incidents  
In addition to receiving complaints, States also receive reports of and respond to 
nursing home incidents.  Incidents are self-reported by the nursing home, whereas 
complaints come from all other sources, including residents, family members, and 
nursing home staff.  Nursing homes must self-report incidents that involve any 
suspected mistreatment, abuse, neglect, or misappropriation of resident property.  
States triage and prioritize incidents in the same manner as complaints.  In addition, 
CMS holds States to the same timeframe requirements for onsite investigation of 
incidents prioritized as immediate jeopardy or high priority.  We analyzed data on 
incidents in addition to complaints, but for the purposes of this data brief, we reported 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  18 
    results only on complaints.  We did this because CMS told us that complaints and 
incidents could be redundanti.e., a State might record a single situation in ACTS as 
an incident as well as a complaint.  In addition, our analysis of incidents revealed similar 
patterns as our analysis of complaints (See Appendix E).  
Limitations  
Our analysis had some limitations.  We did not assess the extent to which the data in 
ACTS are complete or the appropriateness of State responses to complaints or of 
investigation results.  We also did not independently verify the accuracy of the ACTS 
records.  Our analysis is based only on ACTS data and not on information collected 
directly from States.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  19 
    APPENDIX C:  Trends in Nursing Home Complaints By State, 
2011 and 2015 
 
 
Exhibit C-1:  Number and Prioritization of Nursing Home Complaints By State, 
2011 and 2015 
  2011  2015 
Percentage  Percentage 
of  Percentage  of  Percentage 
Complaints  of  Complaints  of 
Total  Rate of  Prioritized  Complaints  Total  Rate of  Prioritized  Complaints 
Number of  Complaints  as  Prioritized  Number of  Complaints  as  Prioritized 
Complaints  per 1,000  Immediate  as High  Complaints  per 1,000  Immediate  as High 
  Received  Residents  Jeopardy   Priority   Received  Residents  Jeopardy   Priority 
Alabama  218  9.3  39%  29%  143  6.2  22%  29% 
Alaska  19  31.3  0%  16%  9  14.6  0%  33% 
Arizona  612  47.5  1%  64%  1,108  89.5  0%  73% 
Arkansas  736  39.7  7%  64%  653  36.5  12%  65% 
California  227  2.1  3%  62%  6,521  60.5  6%  73% 
Colorado  282  17.0  5%  61%  356  21.1  3%  58% 
Connecticut  336  12.9  1%  5%  457  18.9  1%  6% 
Delaware  238  55.8  0%  19%  79  18.2  0%  87% 
District of 
Columbia  26  9.9  4%  12%  63  24.1  0%  3% 
Florida  2,135  27.6  4%  44%  2,433  32.0  2%  26% 
Georgia  908  26.0  6%  80%  1,081  31.8  44%  35% 
Hawaii  16  4.1  6%  13%  8  2.1  0%  0% 
Idaho  106  24.8  4%  24%  144  35.4  3%  11% 
Illinois  2,687  35.1  1%  41%  4,792  65.6  6%  64% 
Indiana  1,442  36.1  4%  42%  1,851  46.2  1%  35% 
Iowa  652  25.7  3%  65%  765  31.3  3%  56% 
Kansas  797  42.0  3%  11%  972  53.3  8%  14% 
Kentucky  667  28.5  24%  66%  685  28.7  46%  51% 
Louisiana  447  17.3  24%  64%  553  21.1  27%  37% 
Maine  316  49.2  2%  69%  318  51.0  1%  22% 
Maryland  1,083  41.8  1%  87%  1,164  45.5  <1%  75% 
Massachusetts  525  11.9  0%  91%  442  10.6  1%  65% 
Michigan  1,331  31.5  7%  89%  2,977  73.7  4%  75% 
Minnesota  362  12.7  19%  58%  877  33.9  7%  24% 
Mississippi  269  16.6  6%  68%  213  13.2  22%  74% 
Missouri  2,733  69.9  8%  49%  4,070  105.0  9%  52% 
Montana  69  14.3  3%  13%  83  18.8  1%  10% 
Nebraska  392  30.9  2%  16%  658  54.9  3%  15% 
Nevada  221  38.2  1%  19%  211  40.2  <1%  11% 
New 
Hampshire  45  6.3  0%  9%  209  30.7  0%  <1% 
New Jersey  1,971  41.1  1%  2%  975  21.3  19%  19% 
New Mexico  146  23.0  2%  18%  77  12.9  8%  20% 
New York  4,569  40.0  2%  33%  4,338  40.0  2%  43% 
North Carolina  1,986  51.5  9%  29%  2,391  63.1  8%  34% 
North Dakota  29  5.1  0%  3%  37  6.6  3%  0% 
Ohio  3,111  38.7  7%  52%  2,817  36.5  16%  73% 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  20 
      2011  2015 
Percentage  Percentage 
of  Percentage  of  Percentage 
Complaints  of  Complaints  of 
Total  Rate of  Prioritized  Complaints  Total  Rate of  Prioritized  Complaints 
Number of  Complaints  as  Prioritized  Number of  Complaints  as  Prioritized 
Complaints  per 1,000  Immediate  as High  Complaints  per 1,000  Immediate  as High 
  Received  Residents  Jeopardy   Priority   Received  Residents  Jeopardy   Priority 
Oklahoma  1,050  53.3  13%  37%  1,036  54.4  7%  29% 
Oregon  262  32.2  0%  89%  310  38.7  0%  89% 
Pennsylvania  1,955  24.0  <1%  95%  2,287  28.7  <1%  62% 
Rhode Island  324  38.4  0%  3%  436  54.1  0%  11% 
South Carolina  114  6.5  8%  87%  207  12.2  4%  93% 
South Dakota  10  1.6  0%  30%  101  16.0  1%  13% 
Tennessee  698  21.8  25%  64%  892  31.1  49%  49% 
Texas  6,975  67.9  10%  56%  8,939  90.0  14%  49% 
Utah  128  21.1  5%  15%  152  25.9  5%  18% 
Vermont  139  48.5  6%  21%  170  63.9  3%  19% 
Virginia  544  18.3  <1%  15%  530  18.4  <1%  16% 
Washington  2,127  118.5  4%  69%  1,915  109.0  2%  55% 
West Virginia  294  30.2  1%  45%  113  11.7  2%  29% 
Wisconsin  874  28.9  5%  19%  1,052  39.8  3%  25% 
Wyoming  76  30.9  5%  13%  120  50.3  7%  19% 
National Total  47,279  32.7  6%  49.1%  62,790  44.9  8.5%  50.6% 
 
Source: OIG analysis of ACTS data, 2017. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  21 
    Exhibit C-2: Number of Immediate Jeopardy and High Prority Complaints Not 
Investigated Onsite Within Required Timeframes By State, 2011 and 2015 
 
  2011  2015 
Number of  Number of 
Immediate  Number of  Immediate  Number of 
Jeopardy  High Priority  Jeopardy  High Priority 
Complaints  Complaints  Complaints  Complaints 
Not  Not  Not  Not 
Investigated  Investigated  Investigated  Investigated 
Within  Within  Within  Within 
2 Working  10 Working  2 Working  10 Working 
  Days  Days  Days  Days 
Alabama  2  1  0  2 
Alaska  N/A  0  N/A  0 
Arizona  0  344  N/A  682 
Arkansas  0  7  1  3 
California  0  5  6  104 
Colorado  3  27  1  25 
Connecticut  0  3  1  4 
Delaware  N/A  34  N/A  44 
District of Columbia  0  0  N/A  0 
Florida  0  12  0  10 
Georgia  6  31  258  185 
Hawaii  0  1  N/A  N/A 
Idaho  0  0  0  9 
Illinois  3  390  1  33 
Indiana  0  14  0  6 
Iowa  0  13  0  49 
Kansas  1  5  1  5 
Kentucky  4  296  5  10 
Louisiana  6  11  4  6 
Maine  0  102  0  0 
Maryland  0  742  0  648 
Massachusetts  N/A  183  0  232 
Michigan  3  320  2  70 
Minnesota  6  18  4  10 
Mississippi  2  62  5  22 
Missouri  0  64  0  76 
Montana  0  1  0  1 
Nebraska  0  2  0  3 
Nevada  0  13  0  5 
New Hampshire  N/A  0  N/A  0 
New Jersey  0  0  50  138 
New Mexico  0  1  0  0 
New York  0  448  2  976 
North Carolina  7  17  6  108 
North Dakota  N/A  0  0  N/A 
Ohio  1  16  1  2 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  22 
     
  2011  2015 
Number of  Number of 
Immediate  Number of  Immediate  Number of 
Jeopardy  High Priority  Jeopardy  High Priority 
Complaints  Complaints  Complaints  Complaints 
Not  Not  Not  Not 
Investigated  Investigated  Investigated  Investigated 
Within  Within  Within  Within 
2 Working  10 Working  2 Working  10 Working 
  Days  Days  Days  Days 
Oklahoma  1  274  1  2 
Oregon  N/A  105  N/A  233 
Pennsylvania  0  2  0  2 
Rhode Island  N/A  0  N/A  27 
South Carolina  0  59  0  147 
South Dakota  N/A  0  1  0 
Tennessee  136  362  396  374 
Texas  6  25  18  400 
Utah  0  3  0  1 
Vermont  0  6  0  0 
Virginia  1  16  0  19 
Washington  0  3  0  62 
West Virginia  1  30  0  1 
Wisconsin  1  7  0  7 
Wyoming  0  0  0  0 
National Total  190  4,075  764  4,743 
 
Source: OIG analysis of ACTS data, 2017. 
Not Applicable (N/A) - States had none of these complaints to investigate. 
 
 
 
 
 
 
 
 
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  23 
    Exhibit C-3: Number of Immediate Jeopardy and High Priority Complaints 
Investigated Onsite and Substantiatated by State, 2011 and 2015 
 
  2011  2015 
Number of  Number of 
Immediate  Number (and  Immediate  Number (and 
Jeopardy  Percentage) of  Jeopardy  Percentage) of 
and High  Immediate  and High  Immediate 
Priority  Jeopardy and  Priority  Jeopardy and 
Complaints  High Priority  Complaints  High Priority 
Investigated  Complaints  Investigated  Complaints 
  Onsite  Substantiated  Onsite  Substantiated 
Alabama  148  59  (40%)  72  21  (29%) 
Alaska  3  1  (33%)  3  1  (33%) 
Arizona  395  136  (34%)  786  132  (17%) 
Arkansas  525  230  (44%)  497  205  (41%) 
California  147  103  (70%)  5,148  1,900  (37%) 
Colorado  186  135  (73%)  217  116  (53%) 
Connecticut  20  13  (65%)  31  22  (71%) 
Delaware  44  28  (64%)  54  16  (30%) 
District of Columbia  4  1  (25%)  2  1  (50%) 
Florida  1,026  350  (34%)  694  241  (35%) 
Georgia  779  207  (27%)  853  140  (16%) 
Hawaii  2  1  (50%)  N/A  N/A  N/A 
Idaho  29  16  (55%)  21  15  (71%) 
Illinois  1,146  587  (51%)  3,370  1,532  (45%) 
Indiana  672  468  (70%)  671  552  (82%) 
Iowa  446  192  (43%)  451  188  (42%) 
Kansas  110  53  (48%)  211  87  (41%) 
Kentucky  601  254  (42%)  665  158  (24%) 
Louisiana  393  211  (54%)  356  119  (33%) 
Maine  224  34  (15%)  72  15  (21%) 
Maryland  951  354  (37%)  881  327  (37%) 
Massachusetts  478  117  (24%)  288  69  (24%) 
Michigan  1,271  646  (51%)  2,351  1,009  (43%) 
Minnesota  277  33  (12%)  273  49  (18%) 
Mississippi  198  89  (45%)  204  53  (26%) 
Missouri  1,565  273  (17%)  2,458  342  (14%) 
Montana  11  6  (55%)  9  5  (56%) 
Nebraska  67  33  (49%)  117  44  (38%) 
Nevada  45  21  (47%)  25  7  (28%) 
New Hampshire  4  1  (25%)  1  0  N/A 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  24 
      2011  2015 
Number of  Number of 
Immediate  Number (and  Immediate  Number (and 
Jeopardy  Percentage) of  Jeopardy  Percentage) of 
and High  Immediate  and High  Immediate 
Priority  Jeopardy and  Priority  Jeopardy and 
Complaints  High Priority  Complaints  High Priority 
Investigated  Complaints  Investigated  Complaints 
  Onsite  Substantiated  Onsite  Substantiated 
New Jersey  54  11  (20%)  354  109  (31%) 
New Mexico  29  11  (38%)  21  8  (38%) 
New York  1,608  172  (11%)  1,961  218  (11%) 
North Carolina  764  146  (19%)  981  207  (21%) 
North Dakota  1  1  (100%)  1  1  (100%) 
Ohio  1,844  667  (36%)  2,486  626  (25%) 
Oklahoma  515  194  (38%)  372  130  (35%) 
Oregon  232  80  (34%)  276  112  (41%) 
Pennsylvania  1,858  454  (24%)  1,417  506  (36%) 
Rhode Island  11  3  (27%)  47  2  (4%) 
South Carolina  108  38  (35%)  201  54  (27%) 
South Dakota  3  3  (100%)  14  10  (71%) 
Tennessee  616  174  (28%)  873  217  (25%) 
Texas  4,601  965  (21%)  5,609  947  (17%) 
Utah  25  10  (40%)  34  14  (41%) 
Vermont  37  13  (35%)  38  10  (26%) 
Virginia  81  52  (64%)  87  59  (68%) 
Washington  1,538  294  (19%)  1,089  224  (21%) 
West Virginia  136  61  (45%)  35  16  (46%) 
Wisconsin  214  119  (56%)  294  130  (44%) 
Wyoming  14  11  (79%)  31  20  (65%) 
National Total  26,056  8,131  (31%)  37,002  10,986  (30%) 
 
Source: OIG analysis of ACTS data, 2017. 
Not Applicable (N/A) - States had none of these complaints to investigate. 
 
 
 
 
 
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  25 
    APPENDIX D:  Number of Immediate Jeopardy and High 
Priority Complaints Investigated by Number of Workdays 
From Complaint Receipt, 20112015
 
 
Exhibit D-1: Number of Immediate Jeopardy Complaints Investigated by Number 
of Workdays From Complaint Receipt, 20112015  
Number of Days from Receipt of 
Complaint to Onsite Investigation 2011 2012 2013 2014 2015
2 days or less       2,654         3,178         3,612         4,620         4,573 
3-4 days 47 53 46 81 118
5-9 days 28 15 36 35 111
10-14 days 13 12 19 25 62
15+ days 102 71 189 246 473
Not Investigated 0 0 3 2 4
   Total Investigated       2,844         3,329         3,902         5,007         5,337 
 
Source: OIG analysis of ACTS data, 2017. 
 
 
 
Exhibit D-2: Number of High Priority Complaints Investigated by Number of 
Workdays From Complaint Receipt, 20112015  
Number of Days from Receipt of 
Complaint to Onsite Investigation 2011 2012 2013 2014 2015
10 days or less        19,137         21,348         22,343         24,327         26,922 
11-15 days 918 872 933 887 868
16-20 days 497 458 523 428 459
21-25 days 335 394 379 361 373
26+ days          2,325           2,622           2,487           2,770           3,043 
Not Investigated 9 21 16 37 83
   Total Investigated        23,212         25,694         26,665         28,773         31,665 
 
Source: OIG analysis of ACTS data, 2017. 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  26 
    APPENDIX E: Trends in Nursing Home Incidents, 20112015 
Exhibit E-1:  Rate of Incidents per 1,000 Nursing Home Residents, 20112015 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of ACTS data, 2017. 
Exhibit E-2:  Percentage of Nursing Home Incidents That States Prioritized for 
Prompt Onsite Investigations, 20112015 
Source: OIG analysis of ACTS data, 2017. 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  27 
    Exhibit E-3:  Number of Immediate Jeopardy and High Priority Incidents Without 
Onsite Investigations, 20112015  
Number of nursing home incidents without onsite investigations  
Year Immediate Jeopardy Incidents High Priority Incidents
2011 2  of     678 total incidents  17  of 10,328 total incidents 
2012 1  of     827  1  of 12,296 
2013 0  of 1,032  1  of 12,423 
2014 0  of 1,178  4  of 12,330 
2015 1  of 1,507  19  of 14,323 
Total 4 of 5,222 42  of 61,700 
Source: OIG analysis of ACTS data, 2017. 
 
Exhibit E-4: Number of Immediate Jeopardy Incidents Investigated by Number of 
Workdays From Incident Receipt, 20112015  
Number of Days from Receipt of 
Incident to Onsite Investigation 2011 2012 2013 2014 2015
2 days or less        641         792            863         1,023         1,187 
3-4 days 13 14 23 14 24
5-9 days 9 4 16 15 35
10-14 days 2 3 17 11 26
15+ days           11            13            113            115            234 
Not Investigated 2 1 0 0 1
   Total Investigated        676         826         1,032         1,178         1,506 
 
Source: OIG analysis of ACTS data, 2017. 
 
 
Exhibit E-5: Number of High Priority Incidents Investigated by Number of 
Workdays From Incident Receipt, 20112015  
Number of Days from Receipt of 
Incident to Onsite Investigation 2011 2012 2013 2014 2015
10 days or less          8,163           9,732         10,281         10,732         12,337 
11-15 days 538 663 537 433 522
16-20 days 284 375 306 190 233
21-25 days 205 265 181 137 184
26+ days          1,121           1,260           1,117              834           1,028 
Not Investigated 17 1 1 4 19
   Total Investigated        10,311         12,295         12,422         12,326         14,304 
Source: OIG analysis of ACTS data, 2017. 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  28 
    Exhibit E-6:  Average Percentage of the Most Serious Nursing Home Incidents 
That States Substantiated, 20112015   
 
           Source: OIG analysis of ACTS data, 2017. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  29 
    ACKNOWLEDGMENTS 
 
Kimberly Ruppert served as the team leader for this study.  Other Office of Evaluation 
and Inspections staff from the Boston regional office who conducted the study include 
Jeremy Tourish.  Office of Evaluation and Inspections central office staff who provided 
support include Berivan Demir Neubert and Christine Moritz.   
 
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Jane Cys and Jessica Swanstrom. 
 
This report was prepared under the direction of Joyce Greenleaf, Regional Inspector 
General for Evaluation and Inspections in the Boston regional office, and 
Danielle Fletcher and Kenneth Price, Deputy Regional Inspectors General.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, contact the 
Office of Public Affairs at Public.Affairs@oig.hhs.gov.   
 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  30 
    ENDNOTES 
                                                           
1 Section 1819(g)(4)(A) of the Social Security Act 
2 OIG, Nursing Home Complaint Investigations, OEI-01-04-00340, July 2006. 
3 GAO, Nursing Homes: More Reliable Data and Consistent Guidance Would Improve CMS Oversight of 
State Complaint Investigations, GAO-11-280, April 2011. 
4 State Operations Manual, Pub. No. 100-07, ch. 5, Complaint Procedures. 
5 State Operations Manual, Pub. No. 100-07, ch. 8, Standards and Certification. 
6 States did not investigate some of the most serious nursing home complaints and therefore did not 
make a determination regarding substantiation in those complaints. 
7 Sections 1819(g)(1)(A) and 1819(g)(2)(A)(iii)  of the Social Security Act. 
8 Sections 1819(g)(1)-(2) of the Social Security Act. 
9 State Operations Manual, Pub. No. 100-07, ch. 7, Survey and Enforcement Process for Skilled Nursing 
Facilities and Nursing Facilities. 
10 CMSs Fiscal Year 2016 State Performance Standards System Guidance (CMS internal guidance sent 
to State survey agencies each year and provided to OIG for the purposes of this report). 
11 Ibid. 
DATA BRIEF:  Nursing Home Complaints (OEI-01-16-00330)  31