U.S. Department of Health and Human Services 
 Office of Inspector General 
 
 
Data Brief 
 
 January 2023, OEI-02-20-00491 
More Than a Thousand Nursing Homes Reached Infection Rates of 
75 Percent or More in the First Year of the COVID-19 Pandemic; 
Better Protections Are Needed for Future Emergencies 
Why OIG Did This Review 
Key Takeaways 
Almost every American has been affected in some way by the 
Nursing homes had a surge of 
COVID-19 pandemic.  By the end of 2020, COVID-19 had spread 
COVID-19 cases during the 
throughout the United States.  The COVID-19 pandemic has been 
spring of 2020 and a greater 
particularly devastating for Medicare beneficiaries in nursing homes, 
surge during the fall, well after 
which is why OIG embarked on a three-part series of evaluations 
they were known to be 
focusing exclusively on the nursing home experience during 2020.  The 
vulnerable.  
first report in this series focused on beneficiaries and found that 2 in 5 
More than 1,300 nursing homes 
Medicare beneficiaries in nursing homes either had or likely had 
had extremely high infection 
COVID-19 in 2020.1  Some Medicare beneficiaries in nursing homes 
rates75 percent or more
seemed to be at greater risk than others.  Specifically, Black 
during these surges.  For-profit 
beneficiaries, Hispanic beneficiaries, and Asian beneficiaries were more 
nursing homes made up a 
disproportionate percentage of  likely than White beneficiaries to have or likely have COVID-19.  In 
these homes.   addition, overall mortality for Medicare beneficiaries in nursing homes 
increased by almost one-third in 2020 from the 2019 level.  
Nursing homes with extremely 
high infection rates experienced 
This is the second report in the series and builds on the first OIG report 
an average overall mortality rate 
by focusing on nursing homes themselves.  It looks at the extent to 
approaching 20 percent
which they had residents who were diagnosed with COVID-19 or likely 
roughly double that of other 
COVID-19, and the characteristics of nursing homes with extremely 
nursing homes.   
high infection rates.  The third report will feature specific challenges 
High COVID-19 transmission in a 
nursing homes faced and the strategies they used to deal with them. 
county did not always lead to 
nursing homes in that county  For the health and safety of residents, nursing homes must be 
reaching extremely high infection 
prepared to face current and future health emergencies.  
rates.  
Understanding how the COVID-19 pandemic has affected nursing 
Significant changes are needed  homes can help the Centers for Medicare & Medicaid Services (CMS), 
to protect residents and better  Congress, and other stakeholders learn from what has happened and 
prepare for future health  inform their decisions as they strive to improve care and better protect 
emergencies. 
residents.   
How OIG Did This Review 
We used Medicare claims data to determine the extent to which nursing homes had Medicare 
beneficiaries who were diagnosed with COVID-19 or likely COVID-19.  We looked at 15,086 nursing 
homes nationwide and identified nursing homes with extremely high infection rates during the surges 
of cases during the spring and fall of 2020.  These homes had three-quarters or more of their Medicare 
beneficiaries diagnosed with COVID-19 or likely COVID-19 during a surge period.  We examined the  characteristics of these nursing homes.  We also examined whether these nursing homes had been cited 
with any infection control deficiencies and whether their reported nursing hours met minimum 
Medicare requirements for these hours.   
What OIG Found 
Nursing homes had a surge of COVID-19 cases during the spring of 2020 and a greater surge during 
the fall, well after they were known to be vulnerable.  More than 1,300 nursing homes had extremely 
high infection rates75 percent or more of their Medicare beneficiariesduring these surges.  These 
nursing homes were more common and geographically widespread during the second surge.  Nursing 
homes with extremely high infection rates experienced dramatic increases in overall mortality (not 
limited to deaths of beneficiaries who had or likely had COVID-19).  Specifically, these nursing homes 
experienced an average overall mortality rate approaching 20 percent during these surgesroughly 
double the mortality rate of other nursing homes during the same time periods.  For comparison, in 
2019 the average mortality rate in these same nursing homes was 6 percent.   
For-profit nursing homes made up a disproportionate percentage of the nursing homes with extremely 
high infection rates during both surges.  Other characteristics varied by surge.  For example, urban 
nursing homes were more likely to have extremely high infection rates during the first surge, but rural 
nursing homes were more likely to have extremely high rates during the second surge. 
High COVID-19 transmission in a county did not always lead to nursing homes in that county reaching 
extremely high infection rates.  In addition, the survey process did not identify any deficiencies in 
infection control for the majority of the nursing homes with extremely high infection rates, raising 
questions about how effective the survey process is in preventing and mitigating the spread of 
infectious disease in nursing homes.  Also, the vast majority of nursing homes with extremely high 
infection rates reported nursing hours that met or exceeded Medicares specific minimum requirements 
for these hours, which may indicate that these requirements are not adequate to keep residents safe 
from infectious disease.  
What OIG Recommends  
These findings make clear that nursing homes in this country were not prepared for the sweeping 
health emergency that COVID-19 created, nor were they able to stem the devastation once it was 
evident that nursing homes were especially vulnerable.  Virtually all nursing homes experienced 
infections, and more than 1,300 nursing homes had extreme infection rates of 75 percent or higher 
during a surge period and an average overall mortality rate close to 20 percent.  Significant changes are 
needed to protect the health and safety of residents and better prepare nursing homes for current and 
future health emergencies.   
The administration recently announced a major initiative to improve safety and quality of care in 
nursing homes.  The findings in this report lend urgency to the administrations initiative.  We 
recommend that CMS, as it supports the administrations initiative, take the following actions: 
(1)re-examine current nursing staff requirements and revise them as necessary; (2) improve how
surveys identify infection control risks to nursing home residents and strengthen guidance on assessing
the scope and severity of those risks; and (3) target nursing homes in most need of infection control
intervention, and provide enhanced oversight and technical assistance to these facilities as appropriate.
CMS concurred with the intent of the first and third recommendations and neither concurred nor
nonconcurred with the second recommendation.  
RESULTS 
 
This data brief looks at nursing homes to better understand what happened to 
residents during the first year of the COVID-19 pandemic.  The goal is to provide 
objective data about nursing homes, particularly those with extremely high infection 
rates, to learn from their experiences in order to better prepare for current and future 
public health emergencies.  This information can help CMS build on the actions they 
have already taken to address the pandemic.2  It also can help other decisionmakers 
such as Congress, State governments, the long-term care industry, practitioners, and 
other stakeholders prepare and plan for the future to better protect the health and 
safety of residents.  
Nursing homes had a surge of COVID-19 cases during the spring 
of 2020 and a greater surge during the fall, well after they were 
known to be vulnerable 
Virtually all nursing homes had a resident diagnosed with 
COVID-19 or likely COVID-19 during 2020   
Almost all nursing homes99.8 percenthad at least one COVID-19 or likely 
COVID-19 case during 2020.  In total, all but 24 of the 15,086 nursing homes 
nationwide had a Medicare beneficiary who was diagnosed during 2020.3  The 
majority of nursing homes had more than 45 percent of their Medicare beneficiaries 
diagnosed with COVID-19 or likely COVID-19 during 2020.  
This analysis includes all beneficiaries who were enrolled in Medicare and resided in a 
nursing facility or skilled nursing facilitycollectively referred to here as nursing 
homesduring 2020.  It determines the number of beneficiaries who were diagnosed 
with COVID-19 or likely COVID-19 in a nursing home as well as those diagnosed in a 
hospital or other care setting after being transferred from a nursing home.  See 
Methodology for more detailed information. 
The first surge of cases during the spring made clear that nursing 
homes residents were vulnerable, but there was an even greater 
surge in nursing homes during the fall 
Nursing homes saw a surge of cases of COVID-19 and likely COVID-19 during spring 
2020, particularly during April and May.  On the whole, nursing homes went from 
dealing with hundreds of new cases per day to thousands per day in a matter of 
weeks.  The number of Medicare beneficiaries in nursing homes who had or likely had 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 3  COVID-19 increased almost tenfold in April, rising from 492 per day in March to more 
than 4,700 per day in April.  May saw an average of more than 4,400 new cases per 
day.4   
These first months made clear that nursing home residents were particularly 
vulnerable during this pandemic.  By the summer of 2020, this vulnerability was 
common knowledge, as it was recognized by CMS and others, and widely discussed in 
the media.5   
Nursing homes saw an even greater surge of cases 6 months after the first surge.  See 
Exhibit 1.  During the fall, on average more than 5,800 Medicare beneficiaries in 
nursing homes were being diagnosed each day in November.  In December, the 
average number topped 6,600 per day.6  This larger second surge occurred despite 
the country having a better understanding of COVID-19 transmission and prevention.7
Exhibit 1: Nursing homes experienced a surge of new COVID-19 and likely 
COVID-19 cases per day during the spring and a greater surge during the 
fall of 2020. 
Source: OIG analysis of CMS data, 2022. 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 4  More than 1,300 nursing homes had extremely high infection 
rates75 percent or moreduring these surges   
More than 1,300 nursing homes 
stand out for their particularly high 
infection rates.  In each of these 
1,358 nursing homes, three-quarters 
or more of the Medicare beneficiaries 
were diagnosed with COVID-19 or 
likely COVID-19 during the first or 
second surge.  In other words, for 
each nursing home, at least three out 
of every four Medicare beneficiaries 
had or likely had COVID-19 over a 
2-month surge period.  We refer to 
these nursing homes as nursing 
homes with extremely high infection 
rates.  
During the first surge, 542 nursing homes had 
extremely high infection rates.  From April 
through May, three-quarters or more of the 
nursing homes Medicare beneficiaries had 
COVID-19 or likely COVID-19.  As noted earlier, 
these first months made clear that nursing 
home residents were particularly vulnerable.   
Yet 6 months after the first surge, even more 
nursing homes817reached extremely high 
infection rates from November through 
December.8, 9   
Nursing homes with extremely high infection rates were more 
common and geographically widespread during 
the second surge  
Nursing homes with extremely high infection rates in the first surge were 
concentrated mainly in the Northeast.  In contrast, nursing homes with extremely high 
infection rates during the second surge were spread out across more States, 
particularly in the Midwest, and were not as concentrated geographically as during 
the first surge.  See Exhibit 2. 
 
 
 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 5   
Exhibit 2: Nursing homes with extremely high infection rates were concentrated in the 
Northeast during the first surge; they were more widespread during the second. 
 
 
First Surge 
 
 
 
 
 
 
 
 
 
Nursing homes with extremely 
high infection rates 
 
Other nursing homes 
Second Surge 
 
 
 
 
 
 
 
Source: OIG analysis of CMS data, 2022. 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 6  For-profit nursing homes made up a disproportionate percentage 
of nursing homes with extremely high infection rates during both 
surges; other characteristics were also notable   
Overall, for-profit nursing homes made up 71 percent of all nursing homes, yet they 
made up 77 percent of the nursing homes with extremely high infection rates during 
both the first and second surges.  See Exhibit 3.   
In contrast, nonprofit nursing  Exhibit 3: For-profit nursing homes made up 
homes made up 23 percent of all  a disproportionate percentage of homes 
nursing homes and accounted for 
with extremely high infection rates during 
19 percent and 18 percent of the 
both surges; other characteristics varied. 
nursing homes with extremely 
 
high infection rates during the first 
 
and second surges, respectively.  Six 
percent of nursing homes were 
owned by government entities; they 
accounted for 4 percent and 5 
percent of nursing homes with 
extremely high infection rates 
during the first and second surges, 
respectively.   
Other characteristics of nursing 
 
homes with extremely high rates 
* Small nursing homes had 50 or fewer certified beds, medium 
were notably different during the  had 51 to 150, and large had more than 150. 
second surge compared to the first.                
During the first surge, nursing homes in urban areas were almost twice as likely as 
those in rural areas to have extremely high infection rates.  However, during the 
second surge nursing homes in rural areas were more than twice as likely as those in 
urban areas to have extremely high infection rates.  Large nursing homes were more 
likely to have extremely high infection rates during the first surge.  However, during 
the second surge, small nursing homes were more likely to have extremely high rates.   
See Appendix A for additional details.   
Nursing homes with extremely high infection rates experienced 
dramatic increases in overall mortalityroughly double those of 
other nursing homes 
The pandemic had far-reaching implications for nursing homes with extremely high 
infection rates.  The dramatic increases in overall mortality lay bare the human cost.  
For the first surge, Medicare beneficiaries in these nursing homes were three times 
more likely to die in April and May 2020 than in April and May of the previous year.   
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 7  The average mortality rate for homes with extremely high infection rates during the 
first surge reached 19 percent in April and May 2020.  That is, on average almost 1 in 
5 Medicare beneficiaries in these homes died during the 2-month span of the first 
surge.  This included beneficiaries who were diagnosed as having or likely having 
COVID-19 and those who were not.  Moreover, this rate is more than twice the 
9 percent average overall mortality rate for other nursing homes during the first 
surge.  See Exhibit 4 and Appendix B. 
Exhibit 4: The average overall mortality rate for nursing homes with 
extremely high infection rates outpaced that of other nursing homes.  
These rates increased dramatically from 2019 to 2020. 
Source: OIG analysis of CMS data, 2022.  
Nursing homes again experienced significant increases in mortality during the second 
surge.  Medicare beneficiaries in nursing homes with extremely high infection rates 
during this surge were three times more likely to die in November and December 
2020 than during those same months the previous year.  The average mortality rate 
for homes with extremely high infection rates during the second surge was 18 percent 
in November and December 2020.  Again, this mortality rate was markedly higher 
than the average overall mortality rate of 10 percent for other nursing homes during 
the second surge.   
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 8  High COVID-19 transmission in a county did not always lead to 
nursing homes in that county reaching extremely high 
infection rates 
During both surges, the majority of the counties with high COVID-19 transmission did 
not have any nursing homes with extremely high infection rates.10  Sixty-three percent 
of the counties with high transmission during the first surge did not have any nursing 
homes with extremely high infection rates, and 78 percent of the counties with high 
transmission during the second surge did not have any nursing homes with extremely 
high infection rates.11  In other words, being located in a high-transmission county did 
not make it inevitable that a nursing home would have an extremely high infection 
rate. 
Moreover, during the first surge more than half of the nursing homes with extremely 
high infection rates were in counties that did not have high COVID-19 transmission in 
the community.  Specifically, 304 of the 542 nursing homes with extremely high 
infection rates during the first surgethat is, 56 percent of these homeswere in 
counties that did not have high transmission.12  During this surge, 8 percent of all 
counties had high transmission.  During the second surge, almost all counties 
nationwide98 percent of the countieshad high transmission.  As such, almost all 
of the nursing homes with extremely high rates were found in counties with high 
transmission.   
The survey process did not identify any deficiencies in infection 
control for the majority of the nursing homes with extremely 
high infection rates 
As part of its oversight of nursing homes, CMS contracts with State agencies to 
conduct standard and other 
Nursing Home Survey Process  surveys that evaluate 
compliance.17  These surveys 
  CMS contracts with State agencies to conduct standard surveys of 
address a host of Federal 
nursing homes on average every 12 months but at least once every 
requirements, including those 
15 months.13  These are periodic, onsite inspections of nursing 
related to infection 
homes to determine compliance with Federal requirements.  
prevention and control.  For 
Surveyors also conduct surveys in response to complaints.14  
instance, a nursing home 
  Surveyors cite a nursing home with a deficiency when they observe 
must have an infection 
a violation of Federal requirements.  Surveyors classify deficiencies 
preventionist who is 
by scope and severity.15 
responsible for the facilitys 
  During the pandemic, CMS temporarily suspended many survey  infection prevention and 
activities and prioritized focused infection control surveys to  control program.18  In 2020, 
address the spread of COVID-19.16  Focused infection control 
State agencies also began 
surveys address hand hygiene, personal protective equipment, and 
conducting COVID-19 
infection surveillance, among other practices. 
focused infection control 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 9  surveys specifically designed to target infection control deficiencies during the 
pandemic.19  See box, Nursing Home Survey Process.   
More than half54 percentof the 
nursing homes with extremely high 
infection rates were not cited with an 
infection control deficiency during any 
survey in 2020.20  That is, surveyors did 
not note any deficiencies in infection 
control for more than half of the homes 
with infection rates so high that three out 
of four of their Medicare beneficiaries 
were diagnosed as having or likely 
having COVID-19 over the course of just 
2 months.   
Almost all97 percentof the nursing homes with extremely high infection rates had 
multiple surveys in 2020, and still more than half of these facilities were not cited with 
an infection control deficiency.  The vast majority of these surveys were focused 
infection control surveys and complaint surveys.     
Furthermore, fewer than 1 in 5 nursing homes with extremely high infection rates
that is, 17 percent of these homeswere cited with a serious infection control 
deficiency.  A serious deficiency is one that constitutes actual harm or widespread 
noncompliance with Federal requirements.21  Therefore, 83 percent of the nursing 
homes with the highest rates of infection in the country were not found to have any 
serious infection control deficiencies.  
This is consistent with prior OIG work on the early months of the COVID-19 pandemic, 
which also found that few infection control deficiencies were cited during onsite 
surveys.22  Taken broadly, these findings point to a disconnect between the survey 
process results and the fact that many nursing homes reached extremely high 
infection rates and were not identified as having deficiencies.  This raises questions as 
to how effective the survey process is in preventing and mitigating the spread of 
infectious disease in nursing homes.  
 
 
 
 
 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 10  The vast majority of nursing homes with extremely high 
infection rates reported nursing hours that met or exceeded 
Medicares minimum requirements for these hours 
Nursing homes with extremely high infection rates reported nursing hours at or above 
both of Medicares specific requirements for the numbers of these hours.  Medicare 
requires nursing homes to provide at least 8 consecutive hours of registered nursing 
services per day and 24 hours of licensed nursing services per day.24  Medicare also 
requires nursing homes to have 
Medicares Minimum Nursing Hour  sufficient nursing staff.25  Each 
Requirements  nursing home is expected to 
determine the nursing staff sufficient 
Medicare has established some specific nursing hour 
for that home based on an 
requirements that apply to all nursing homes.  They must: 
  provide 8 consecutive hours of registered nursing  assessment that the nursing home 
services per day, 7 days per week; and  itself conducts.  
  provide 24 hours of licensed nursing services per 
Medicares specific nursing hour 
day, 7 days per week.23 
requirementsat least 8 consecutive 
 
hours of registered nursing and 24 
hours of licensed nursing each daywere adopted under the 1987 Nursing Home 
Reform Act.26  These specific requirements are the same for all nursing homes 
regardless of their size or the acuity of residents.  As such, a nursing home could meet 
these two minimal thresholds while still not having enough nurses to safely meet 
residents needs.  
The vast majority95 percentof nursing homes with extremely high infection rates 
during the first surge reported nursing hours at or above these two Medicare 
requirements almost all of the time.27  During the second surge, 92 percent of nursing 
homes with extremely high infection rates reported the same.  These findings raise 
questions as to whether the current number of nursing hours that Medicare specifies 
is sufficient to keep residents safe from infectious disease.  See Exhibit 5.  For context, 
96 percent of the other nursing homes in each surge reported nursing hours at or 
above these requirements.  This is consistent with earlier OIG work on nursing home 
staffing prior to the pandemic.28  
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 11  Exhibit 5: The vast majority of nursing homes with extremely high 
infection rates during both surges reported nursing hours at or above 
Medicares specific minimum requirements. 
 
Source: OIG analysis of CMS data, 2022. 
During both surges, residents received slightly less nursing time in nursing homes 
with extremely high infection rates than in other nursing homes.29  The time 
differences were small during the first surge and larger during the second.   
On average, nursing homes with extremely high infection rates during the first surge 
provided 3 hours and 58 minutes of nursing hours per resident per day, compared to 
4 hours and 3 minutes in other nursing homes.  Nursing homes with extremely high 
infection rates during the second surge averaged 3 hours and 48 minutes of nursing 
hours per resident per day, while other nursing homes on average provided 4 hours 
and 4 minutes.   
As noted earlier, Medicares current nursing requirements of 8 consecutive hours of 
registered nursing services per day and 24 hours of licensed nursing services per day 
are the same for all nursing homes, regardless of facility size or the acuity of 
residents.30  The administration has called for new research to determine the level and 
type of staffing needed to ensure safe and quality care.  It intends to propose new 
minimum staffing levels that nursing homes must meet or exceed.31   
In addition, industry groups, the media, and other stakeholders have chronicled a 
significant shortage of nursing home staff, noting that the pandemic has exacerbated 
preexisting challenges in recruitment and retention.32  Nursing homes report staffing 
shortages and cite difficulties in hiring new staff, particularly because of a lack of 
qualified or interested candidates.33  Experts in long-term care report that burnout, 
worry over COVID-19 exposure, and other factors have contributed to nursing home 
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 12  staff leaving the industry entirely.34  One expert described the situation as a crisis on 
steroids.35  These challenges have to be considered if minimum staffing levels are to 
increase.  The administration also is exploring ways to address nursing homes 
workforce challenges.36   
Data Brief: More Than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491   Results | 13   
RECOMMENDATIONS 
 
The tragic toll the COVID-19 pandemic took on nursing homes continued throughout 
2020, with virtually all nursing homes having a resident diagnosed with COVID-19 or 
likely COVID-19 during the year.  There was a surge of cases during the spring and a 
greater surge during the fall.  More than 1,300 nursing homes stood out as having 
extremely high infection rates.  These homes had at least three-quarters of their 
Medicare beneficiaries diagnosed with COVID-19 or likely COVID-19 during a 
2-month surge period.  Nursing homes with these extremely high infection rates were
more common and geographically widespread during the second surge, even though
this surge occurred several months after nursing homes were known to be vulnerable
and more was known about prevention and treatment.  For-profit nursing homes
made up a disproportionate percentage of nursing homes with extremely high
infection rates during both surges.
Nursing homes with extremely high infection rates experienced dramatic increases in 
overall mortalityroughly double the average mortality rate for all other nursing 
homes during these surges.  High COVID-19 transmission in a county did not always 
lead to nursing homes in that county reaching extremely high infection rates.  The 
survey process did not identify any deficiencies in infection control for the majority of 
nursing homes with extremely high infection rates, calling into question how effective 
the survey process is in preventing and mitigating the spread of infectious disease.  In 
addition, the vast majority of nursing homes with extremely high infection rates 
reported nursing hours that met or exceeded Medicares specific minimum 
requirements for these hours, which may indicate that these requirements are not 
adequate to keep residents safe from infectious disease. 
These findings make clear that nursing homes in the United States were not prepared 
for the sweeping health emergency that COVID-19 created.  Nor were they able to 
stem the devastation once it was evident that nursing homes were especially 
vulnerable.  The need for improvement is clear.  For the health and safety of residents, 
nursing homes must be prepared to face current and future health emergencies. 
The administration has announced a major initiative to improve safety and quality of 
care in nursing homes.  The findings in this report lend urgency to this initiative as 
well as the need to reform some areas of longstanding concern, including staffing and 
oversight.  We recommend that CMS, as it supports the administrations initiative, 
take the actions cited below.   
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Recommendations | 14  We recommend that CMS: 
Re-examine current nursing staff requirements and revise them 
as necessary 
We found that nursing homes with extremely high infection rates reported nursing 
hours that met or exceeded Medicares specific minimum requirements for these 
hours.  Meeting these requirements did not prevent these nursing homes from 
reaching the highest COVID-19 infection rates in the country.  Medicares specific 
nursing hour requirements were established in 1987.37  CMS should re-examine these 
requirements and revise them as necessary to ensure residents receive good care.   
Our findings provide further evidence of the need to determine the level and type of 
nursing staff necessary to ensure safe and high-quality care.  Our findings also 
provide evidence of the need to propose new minimum staffing levels that nursing 
homes must meet, which the administration has committed to undertaking.  In doing 
so, CMS should assess the level of nursing needed to adequately prevent and manage 
infection in addition to other quality-of-care considerations.  It should also examine 
the most effective use of infection preventionists in the nursing home setting.  This 
research could be included in the study that has been called for by the administration 
to help determine the level and type of staffing needed to ensure safe and quality 
care in nursing homes.38   
While considering its next steps, CMS should also re-evaluate the staffing data it 
collects from nursing homes and align these data with staffing requirements that will 
be used moving forward.  For example, amending staffing data to include a 
timestamp would better allow CMS to determine whether nursing homes have 
provided around-the-clock nursing services.  This would assist CMS in monitoring 
compliance with staffing requirements, as well as ensure quality data for future 
analyses.39 
Lastly, while developing new minimum requirements, CMS needs to recognize the 
staffing challenges faced by nursing homes in general and consider what role it could 
play in strengthening the nursing home workforce to ensure that nursing homes can 
viably staff at those required levels.   
Improve how surveys identify infection control risks to nursing 
home residents and strengthen guidance on assessing the scope 
and severity of those risks  
CMS should improve the survey process so that it more effectively identifies problems 
that put nursing home residents at risk for infectious disease.  The survey process is a 
critical oversight tool for CMS and, as such, must be meaningful.  Surveys must be 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Recommendations | 15  able to identify problems within a nursing home that put residents at risk for 
infectious disease.   
Previous OIG work looked at surveys conducted from March 23 through May 30, 
2020, and recommended that CMS assess the results of infection control surveys and 
revise the survey as appropriate.40  This current work expands on the previous work by 
looking at all surveys conducted in 2020.  Our findings demonstrate the need to 
re-examine more broadly the survey practices used to detect infection control 
problems that put residents at risk.  The surveys conducted in 2020 found few 
deficiencies at nursing homes that had extremely high infection rates.  Moreover, no 
deficiencies were found in more than half of these homes.  These homes passed 
Medicares infection control test, yet COVID-19 was able to engulf them in a matter of 
weeks.  This calls into question how effective the current surveys are in finding and 
preventing problems with infection control in nursing homes. 
CMS should seek input from a broad range of experts in infection control to develop 
more effective methods of identifying problems in nursing homes that put residents 
at risk.  CMS has successfully convened Technical Expert Panels for other purposes 
and may want to consider doing something similar as part of its effort to improve the 
survey process.  CMS could also consult with other knowledgeable sources on the 
best way to identify infection control problems within nursing homes.  These could 
include entities such as the Association for Professionals in Infection Control and 
Epidemiology, the Agency for Healthcare Research and Quality, and The Joint 
Commission.  
Identified problems must be cited at a scope and severity that adequately reflects the 
risk faced by residents of the nursing home.  Fewer than 1 in 5 nursing homes with 
extremely high infection rates were cited with a serious infection control deficiency.  
CMS should reevaluate and revise as appropriate its scope and severity guidance on 
citing deficiencies.41  Once problems are identified and appropriately cited, CMS must 
hold nursing homes accountable.  
Target nursing homes in most need of infection control 
intervention, and provide enhanced oversight and technical 
assistance to these facilities as appropriate 
Although it is an important oversight tool, the survey processeven when 
improvedcannot alone find all the nursing homes in most need of additional 
oversight or technical assistance.  CMS should supplement the survey process by 
conducting further data analysis to identify additional nursing homes in need of 
intervention.  These may be nursing homes with dramatic increases in mortality, a 
high percentage of residents with infectious diseases, or nursing homes with other 
characteristics that raise concern.  This analysis could help CMSs efforts to effectively 
target its resources toward nursing homes most in need of intervention.   
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Recommendations | 16  As our report demonstrates, analysis of existing data can be a powerful tool to 
identify nursing homes that may be unable to adequately protect their residents.  
These data include the Minimum Data Set (MDS); the Medicare Enrollment Database; 
Medicare Parts A, B, and C claims; the Payroll Based Journal; and the Certification and 
Survey Provider Enhanced Reporting system.  CMS should augment its existing efforts 
by analyzing these or other reliable, relevant data to determine which nursing homes 
warrant greater attention.  CMS should provide these nursing homes with technical 
assistance, increased scrutiny, or other innovative efforts that CMS deems 
appropriate. 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Recommendations | 17   
AGENCY COMMENTS AND OIG RESPONSE 
 
 
 
CMS concurred with the intent of two of our recommendations and neither concurred 
nor nonconcurred with another.  OIG is committed to protecting the health and safety 
of nursing home residents and will continue to work with CMS to promote its 
implementation of our recommendations aimed at that outcome.  Given the 
devastating impact the COVID-19 pandemic has had on nursing home residents, the 
findings call for doing all we can to improve protections for these residents. 
CMS concurred with the intent of the recommendation to re-examine current nursing 
staff requirements and revise them as necessary, as it aligns with the Presidents 
initiative to improve the safety and quality of care in the Nations nursing homes.  
CMS has begun to take steps, such as soliciting public comments on minimum 
staffing requirements and launching a staffing study.  OIG supports these steps and 
looks forward to learning the results of the study.  As CMS develops new minimum 
staffing requirements, it should also re-evaluate the staffing data it collects and align 
these data with any new requirements.     
CMS did not concur or nonconcur with the recommendation to improve how surveys 
identify infection control risks to nursing home residents and strengthen guidance on 
assessing the scope and severity of those risks.  Instead, CMS stated that it prioritized 
focused infection control and immediate jeopardy surveys at the start of the public 
health emergency.  It also shared the focused infection control tool with nursing 
homes so they could voluntarily review their own compliance.  We note that the 
surveys conducted in 2020, including the focused infection control surveys, found no 
deficiencies in more than half of the nursing homes with extremely high infection 
rates, despite these homes having undergone multiple surveys.  These findings call 
into question how effective the survey process is in preventing and mitigating the 
spread of infectious disease in nursing homes.  We continue to call for CMS to 
re-examine more broadly the survey practices used to detect infection control 
problems that put residents at risk.  One suggestion is to convene a Technical Expert 
Panel to seek input from a broad range of experts in infection control.  We ask that 
CMS clarify in its Final Management Decision the additional steps it will take to 
improve the survey process to better protect nursing home residents from infection 
control risks. 
CMS concurred with the intent of our third recommendation to target nursing homes 
in most need of infection control intervention, and provide enhanced oversight and 
technical assistance to these facilities as appropriate.  CMS stated that technical 
assistance to nursing homes is helpful and done in part by Quality Improvement 
Organizations (QIOs), which have provided educational activities and frontline training 
for nursing home staff.  OIG acknowledges the important activities of QIOs.  However, 
our findings make clear the need to do more.  For example, nursing homes with    
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies,  
OEI-02-20-00491  Agency Comments and OIG Response | 18  extremely high infection rates experienced dramatic increases in overall mortality
roughly double the average mortality rate for all other nursing homes during the 
surges of 2020.  Our recommendation is for CMS to supplement its efforts by 
conducting further data analysis to identify nursing homes in need of intervention, 
such as those with dramatic increases in mortality.  Analysis of CMSs existing data can 
be a powerful tool for identifying nursing homes that may be unable to adequately 
protect their residents.  Medicare claims data, the Minimum Data Set, the Payroll 
Based Journal, and the Certification and Survey Provider Enhanced Reporting system 
are all rich resources that can be used to identify nursing homes in need of more 
oversight or technical assistance.   
In addition to its responses to our recommendations, CMS offered feedback on our 
analysis, requesting different, more specific analytic breakouts that it would find 
helpful.  Our approach was to provide a comprehensive picture of the strain nursing 
homes were under.  The comprehensiveness of our data presents a picture of the full 
impact of the pandemic on nursing homes.  This must be understood so that needed 
improvements can be made.  Certainly, other analyses could also be useful to CMS, 
and where we were able to offer more detail, we did.  As previously stated, OIG is 
committed to protecting the health and safety of nursing home residents and will 
continue to work with CMS to help nursing homes be prepared to face current and 
future health emergencies.   
For the full text of CMSs comments, see Appendix C. 
 
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies,  
OEI-02-20-00491  Agency Comments and OIG Response | 19   
METHODOLOGY 
 
 
We based this study primarily on an analysis of data from: (1) the MDS; (2) the 
Medicare Enrollment Database; (3) Medicare Parts A, B, and C claims; (4) the Payroll 
Based Journal; and (5) the Certification and Survey Provider Enhanced Reporting 
(CASPER) system.  
Identification of Medicare Beneficiaries Residing 
in Nursing Homes  
We used the MDS to identify individuals who resided in nursing homes.  The MDS 
includes assessments completed by the nursing home for each individual residing in 
these facilities.  Nursing homes must complete these assessments periodically for all 
residentsincluding beneficiaries receiving Medicare or Medicaid.  Using each 
residents unique identifier, we matched the data from the MDS to the Medicare 
Enrollment Database to identify residents who were enrolled in Medicare.  We then 
identified the Parts A, B, and C claims for these Medicare beneficiaries.   
This analysis includes all beneficiaries who were enrolled in Medicare and resided in a 
nursing home during 2020.  We considered a beneficiary to be a nursing home 
resident from the date of the first MDS assessment at the facility until the date that 
the beneficiary is discharged from the facility to go home or dies.  Therefore, a 
beneficiary who resided in a nursing home and entered a hospital for treatment is still 
considered a nursing home resident during the time spent in the hospital. 
Next, we identified which beneficiaries were diagnosed as having or likely having 
COVID-19.  We considered a beneficiary who had a diagnosis code of B97.29 or U07.1 
on a claim to have a diagnosis of COVID-19 and a beneficiary who had a diagnosis 
code of Z20.828 on a claim to likely have COVID-19.42  
For more information on how we identified Medicare beneficiaries with COVID-19 or 
likely COVID-19 residing in nursing homes, see our related report COVID-19 Had a 
Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020, 
OEI-02-20-00490. 
Identification of Nursing Homes With Extremely High 
Infection Rates  
We identified two distinct periods with dramatically high infection rates in nursing 
homes.  The first was April through May, and the second was November through 
December.43  We refer to these periods as surges.   
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Methodology | 20  Next, we determined the extent to which nursing homes had Medicare beneficiaries 
diagnosed with COVID-19 or likely COVID-19 during the respective surges.  To do 
this, we identified Medicare beneficiaries residing in each nursing home during the 
two surges.  We then calculated the percentage of beneficiaries who were diagnosed 
with COVID-19 or likely COVID-19.44  We based this study on 15,086 nursing facilities 
and skilled nursing facilitiescollectively referred to as nursing homesthat each 
served at least 30 Medicare beneficiaries in 2020. 
We analyzed the distribution and identified all nursing homes that had three-quarters 
or more of their Medicare beneficiaries diagnosed with COVID-19 or likely COVID-19 
during the first or second surge.  We considered these facilities to be nursing homes 
with extremely high infection rates. 
Analysis of Nursing Homes With Extremely High Infection Rates 
Characteristics of Nursing Homes.  We determined whether the nursing homes with 
extremely high infection rates were associated with certain characteristics.  We 
examined the extent to which these nursing homes were concentrated in particular 
geographic locations.  To do this, we mapped the locations of these nursing homes 
and all other nursing homes in the two surges based on the CASPER data.   
We also examined ownership status (for-profit, nonprofit, government-owned) and 
size (small, medium, large) based on CASPER data.45  Lastly, we determined whether 
the nursing homes with extremely high infection rates were located in a rural or urban 
county based on Core-Based Statistical Area (CBSA) data.46  We examined the extent 
to which all nursing homes and nursing homes with extremely high infection rates 
had these characteristics and how that differed between the first and second surges.   
Overall Mortality.  We determined the overall mortality rate among nursing homes 
with extremely high infection rates during the two surges.47  To do this, we calculated 
the percentage of beneficiaries who died during the respective surges for each 
nursing home.48  We used the date of death from the Social Security Administration, 
which is contained in the Medicare Enrollment Database, to identify those 
beneficiaries who died. 
We compared the average mortality rate among the nursing homes with extremely 
high infection rates to the average mortality rate among other nursing homes during 
each surge.  We also compared the average mortality rate among nursing homes with 
extremely high infection rates in the first surge (April through May 2020) to the 
average mortality rate among those same nursing homes during the corresponding 
2-month period in 2019.  We conducted a similar analysis for the second surge. 
Community Transmission.  We examined the extent to which nursing homes with 
extremely high infection rates were located in counties with high transmission of 
COVID-19.  We first determined the community transmission for each county.  To do 
this, we obtained daily county-level cumulative data on confirmed COVID-19 cases 
from USAFacts.org and county-level population data from the U.S. Census Bureau.49  
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Methodology | 21  We calculated the average number of new COVID-19 cases per 100,000 persons over 
any given 7 days during each surge, for each county.  We classified each county as 
having low, moderate, substantial, or high community transmission during each surge, 
using CDCs definition of community transmission.50  We then determined the 
percentage of counties that had high transmission for each surge.  Next, we 
determined the percentage of nursing homes with extremely high infection rates that 
were located in counties that had high transmission.  We also determined the 
percentage of counties with high transmission that had no nursing homes with 
extremely high infection rates.  
Infection Control Deficiencies.  We examined the extent to which nursing homes 
with extremely high infection rates were cited with infection control deficiencies.51  
Using CASPER data, we analyzed deficiencies cited on nursing home surveys 
conducted in 2020.  These surveys included standard surveys, focused infection 
control surveys, and surveys conducted in response to a complaint.52  Specifically, we 
analyzed whether the nursing home had any infection control deficiencies during any 
of its surveys in 2020.   
We also examined the extent to which nursing homes with extremely high infection 
rates were cited with infection control deficiencies that were serious.  To do this, we 
used the scope and severity information in the CASPER data.  We calculated the 
percentage of nursing homes with extremely high infection rates that had a serious 
deficiency.  We considered any infection control deficiency with a scope and severity 
at a level of F or above to be serious.53   
Staffing Levels.  We examined the extent to which nursing homes with extremely 
high infection rates reported staffing in 2020 that met Medicares specific 
requirements for nursing hours.54  We determined the extent to which these nursing 
homes reported nursing hours that met the Medicare requirements for these hours, 
specifically that nursing homes must have a registered nurse (RN) on staff for at least 
8 consecutive hours per day, 7 days per week and a licensed nurse (i.e., RN or licensed 
practical nurse/licensed vocational nurse (LPN/LVN)) on staff 24 hours per day, 7 days 
per week.55  Each quarter, nursing homes submit to the Payroll Based Journal daily 
staffing information that includes the hours and category of work an employee 
performs.56  We used these data to determine whether nursing homes reported at 
least 7.5 RN hours and 22.5 licensed nurse hours each day.57  We then calculated the 
percentage of nursing homes with extremely high infection rates that reported 
nursing hours at or above these levels.  We considered nursing homes that reported 
nursing hours at or above these levels at least 90 percent of the time to have staffing 
at or above the requirements.   
We also examined the extent to which nursing homes with extremely high infection 
rates provided nursing time each day to each resident.  Specifically, we assessed the 
average number of nursing hours per resident per day (HPRD) in 2020.  Each quarter, 
CMS calculates the average HPRD for all nursing staff.58  CMS then adjusts the HPRD 
values to account for the acuity, or case-mix, of the residents in the nursing home.59  
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Methodology | 22  We determined each nursing homes average nursing HPRD by averaging the 
adjusted nursing HPRD measure that CMS calculates.60  
Limitations 
This study determines the extent to which nursing homes had Medicare beneficiaries 
who were diagnosed as having COVID-19 or likely COVID-19 based on Medicare 
claims data; it does not include a review of medical records.  It also determines the 
number of Medicare beneficiaries who died; it does not include a review of death 
certificates nor determinations about whether COVID-19 was the cause of death for 
these beneficiaries.  Lastly, we note that CMS requires nursing homes to submit to the 
Payroll Based Journal only those hours that staff are paid to work, but that it is 
possible that a nurse may have worked additional hours that were unpaid and 
therefore not reported.61   
Standards 
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.  
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Methodology | 23   
APPENDIX A 
 
Characteristics of Nursing Homes With Extremely High 
Infection Rates 
Exhibit A-1: Percentage of All Nursing Homes and Nursing Homes With Extremely High Infection 
Rates by Profit Status 
Percentage of Nursing Homes  
With Extremely High Infection Rates  
Percentage of All 
Profit Status  Nursing Homes  First Surge  Second Surge 
For-profit  71%  77%  77% 
Nonprofit  23%  19%  18% 
Government  6%  4%  5% 
Source: OIG analysis of CMS data, 2022. 
 
Exhibit A-2: Percentage of All Nursing Homes and Nursing Homes With Extremely High Infection 
Rates by Area 
Percentage of Nursing Homes  
With Extremely High Infection Rates  
Percentage of All 
Area  Nursing Homes  First Surge  Second Surge 
Rural  27%  17%  47% 
Urban  73%  83%  53% 
Source: OIG analysis of CMS data, 2022. 
 
Exhibit A-3: Percentage of All Nursing Homes and Nursing Homes With Extremely High Infection 
Rates by Size 
Percentage of Nursing Homes  
With Extremely High Infection Rates  
Percentage of All 
Size*  Nursing Homes**  First Surge**  Second Surge 
Large  16%  19%  6% 
Medium  72%  74%  77% 
Small  13%  6%  17% 
* Small nursing homes had 50 or fewer certified beds, medium homes had 51 to 150, and large had more than 150. 
** Percentages in this column may not equal 100 percent because of rounding. 
Source: OIG analysis of CMS data, 2022. 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix A | 24   
APPENDIX B 
 
Overall Mortality Rates Among Nursing Homes With Extremely 
High Infection Rates 
Exhibit B-1: Average Overall Mortality Rates in April and May 2019 and in April and May 2020 for 
Nursing Homes With Extremely High Rates During the First Surge and Other Nursing Homes 
  Nursing Homes With 
Extremely High  
Infection Rates During  
the First Surge  Other Nursing Homes 
 
2019  2020  2019  2020 
Average overall mortality 
6%  19%  6%  9% 
rate in April and May 
Source: OIG analysis of CMS data, 2022. 
 
Exhibit B-2: Average Overall Mortality Rates in November and December 2019 and in November 
and December 2020 for Nursing Homes With Extremely High Infection Rates During the Second 
Surge and Other Nursing Homes 
  Nursing Homes With 
Extremely High  
Infection Rates During  
the Second Surge  Other Nursing Homes 
 
2019  2020  2019  2020 
Average overall mortality 
rate in November and  6%  18%  6%  10% 
December 
Source: OIG analysis of CMS data, 2022
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix B | 25   
 APPENDIX C 
 
Agency Comments 
Following this page are the official comments from CMS. 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 26  DATE:   November 14, 2022 
TO:   Gregory E. Demske 
Acting Principal Deputy Inspector General 
FROM:  Chiquita Brooks-LaSure 
Administrator 
SUBJECT:  Office of Inspector General Draft Brief: More Than a Thousand Nursing Homes 
Reached Infection Rates of 75 Percent or More in the First Year of the COVID-19 
Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-
00491 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
CMS thanks the OIG for their review in this area and is similarly committed to transparency, 
which we have used to highlight the disproportionate impact of COVID-19 on patient 
populations, including individuals residing in nursing homes.1 In the first year of the COVID-19 
pandemic, nursing homes were severely impacted by COVID-19, with outbreaks causing high 
rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home 
population combined with the inherent risks of living in a congregate health care setting have 
required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 
within nursing homes. Given the continued high incidence of COVID-19 and the likelihood that 
new variants and other infectious agents may cause future outbreaks, CMS sought to understand 
the relationship between nursing homes and the COVID-19 public health emergency and 
published data and several analyses. This includes an in-depth look at the impact of COVID-19 
on Medicare beneficiaries residing in nursing homes during 20202 and a CMS-funded study to 
analyze the relationship between quality ratings and COVID-19 infections, published in May 
2021.3 
Even before the COVID-19 pandemic began, CMS had acted to strengthen infection prevention 
and control practices in nursing homes. CMS took pivotal actions in the 2016 final rule, 
Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and 
Suppliers, which outlined the need for nursing homes to prepare for infectious disease threats.4 
1 CMS, CMS COVID-19 Data Products, Updated on November 05, 2021 
2 CMS, The Impact of COVID-19 on Medicare Beneficiaries, 2021 
3 Williams, C., Zheng, Q., White, A., Bengtsson, A., Shulman, E., Herzer, K., Lee F., The Association of Nursing 
Home Quality Ratings and Spread of COVID-19, Vol. 6, Is. 8, Journal of the American Geriatrics Society, May 31, 
2021 
4 Medicare and Medicaid Programs; Emergency Preparedness Requirements, 81 Fed. Reg. 63860, 63862 (Sept. 16, 
2016). 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 27  CMS also outlined specific reform requirements for long-term care facilities in the 2016 final 
rule, Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities, 
which was the impetus for the requirement that nursing homes develop an infection prevention 
and control program that includes an antibiotic stewardship program.5 
Since the COVID-19 public health emergency declaration in early 2020, CMS has taken a 
number of actions to further strengthen infection prevention and control within nursing homes. 
CMS began by issuing guidance to nursing homes, encouraging them to take appropriate action 
to address potential and confirmed COVID-19 cases and mitigate transmission. CMS reiterated 
the importance of longstanding infection control guidelines and guidelines on screening 
processes and the use of personal protective equipment (PPE). CMS has held regular calls with 
stakeholders, nursing home associations, and State Survey Agencies (SSAs) to keep them up to 
date on the latest information to respond to COVID-19 and listened to the challenges faced by 
nursing homes, such as access to PPE, continuing staffing issues, and a lack of availability of 
testing and vaccinations during the first year of the public health emergency. 
In an effort to focus on controlling the spread of COVID-19, CMS provided SSAs, who conduct 
onsite surveys to assess compliance with federal requirements and investigate facility 
complaints, with a streamlined review tool to conduct focused infection control surveys of 
providers identified through collaboration with the Centers for Disease Control and Prevention 
(CDC) and the Administration for Strategic Preparedness & Response (ASPR). This tool was
shared with providers who were encouraged by CMS to use it to self-assess their own ability to
prevent the spread of COVID-19. By July 2020, over 99 percent of Medicare and Medicaid
certified nursing homes had a focused infection control survey conducted onsite. As the public
health emergency continued, the focused infection control survey was revised to incorporate new
infection control requirements to address the spread of COVID-19 as appropriate. CMS also
published a toolkit comprised of recommendations and best practices from a variety of frontline
health care providers, state governors COVID-19 task forces, associations, and other experts
that is intended to serve as a catalog of resources dedicated to addressing the specific challenges
facing nursing homes as they combat COVID-19.6 CMS continues to review and revise guidance
as needed.
At the beginning of the public health emergency in 2020, CMS required nursing homes to report 
COVID-19 cases in their facility to the CDCs National Healthcare Safety Network on a weekly 
basis. This data was used to strengthen surveillance locally and nationally, monitor trends in 
infection rates, and help local, state and federal health authorities get help to nursing homes 
faster. This data was also posted online for the public. For example, CMS used this data, in part, 
to identify which nursing homes may need targeted help through the Quality Improvement 
Organizations (QIOs) to strengthen infection control practices to reduce and prevent 
transmission of COVID-19. Throughout the course of the public health emergency, QIOs have 
helped facilities address many COVID-19 challenges related to staffing, PPE, infection 
prevention and control activities, COVID-19 testing, and vaccine uptake. The QIOs connect 
5 Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities, 81 Fed. Reg. 68688 
(Nov. 28, 2016). 
6 QSO-21-08-NLTC: COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care Providers 
and Suppliers (Revised). 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 28  nursing homes with local resources, provide educational activities, and train nursing home staff 
and management. At the current phase of the public health emergency, QIOs focus on 
vaccination and infection prevention and control practices to reduce the spread of infection and 
manage outbreaks effectively, as well as providing individualized training resources based on the 
nursing homes specific needs through toolkits, resource materials, guides, webinars, and 
clinician office hours to provide expert consultation on the particular challenges nursing homes 
face. CMS collects best practices and lessons learned from each of the QIOs and coordinates the 
sharing of that information across QIOs nationally for rapid deployment. Additionally, CMS 
partners with federal agencies such as the CDC and ASPR, which are the agencies tasked with 
national leadership of disease prevention and control and public health emergency response, to 
ensure coordination of services and alignment of guidance for nursing homes. 
Given the severity of COVID-19s impacts on nursing home residents, they were among the first 
in the country to be offered a vaccine once the Food and Drug Administration granted 
emergency use authorization to the first COVID-19 vaccine in December 2020. CMS also issued 
an interim final rule with comment period (86 FR 26306) to ensure nursing homes educate on 
and offer the COVID-19 vaccine to residents, clients, and staff.7 Continuing CMSs commitment 
to transparency, in September of 2021, CMS began posting nursing home staff and resident 
COVID-19 vaccination data in a user-friendly format on its Nursing Home Care Compare 
website. Subsequently, in February 2022, CMS began posting staff and resident booster shot data 
to the website.8 
As we continue to emerge from the COVID-19 pandemic, ensuring that residents in nursing 
homes receive safe, high-quality care is a high priority for the agency. CMS is continuing the 
work it started before the COVID-19 pandemic to strengthen its health and safety requirements 
that protect residents rights and improve the quality of care they receive. Based on lessons 
learned from the pandemic, CMS released guidance related to the requirement for all nursing 
homes to have an Infection Preventionist (IP) who has specialized training to effectively oversee 
the facilitys infection prevention and control program. With emerging infectious diseases such 
as COVID-19, CMS believes the role of the IP is critical in nursing homes efforts to mitigate the 
onset and spread of infections. CMS recently revised guidance to clarify its expectations for 
infection control and prevention.9  
CMS appreciates OIGs review of likely COVID-19 infection rates at nursing homes in the first 
year of the pandemic; however, CMS is concerned that OIGs methodology may have led to an 
overestimation of cases and infection rates. For example, OIG used three medical diagnosis 
codes to calculate the number of infections, only one of which includes confirmed COVID-19 
cases. After testing became available, beginning on April 1, 2020, the CDC directed providers to 
document a confirmed diagnosis of COVID-19, as confirmed by a positive test result, or a 
7 Medicare and Medicaid Programs; COVID-19 Vaccine Requirements for Long-Term Care (LTC) Facilities and 
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs-IID) Residents, Clients, and Staff, 
May 21, 2021 
8 CMS Makes Nursing Home COVID-19 Booster Vaccination Online Increasing Transparency, CMS News Alert, 
Feb. 09, 2022. 
9 QSO-22-19-NH Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phase 2 & 3, 
Arbitration Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial 
Outcome Severity Guide. 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 29  presumptive test result, with the code U07.1.10 CMSs COVID-19 analyses of claims and 
encounter data about the impact of COVID-19 on Medicare beneficiaries before April 1, 2020 
included the code B97.29 (other coronaviruses as the cause of diseases, which does not 
distinguish between more than 30 types of coronaviruses, including some that cause the common 
cold).11 Starting on April 1, 2020, based on guidance from the CDC, CMS updated the analyses 
to include the code U07.1 (confirmed COVID-19 test result).12  
However, CMSs understanding of OIGs analysis is that the OIG included an additional code 
for contact with or suspected exposure (Z20.828), including after testing was widely available, 
without distinguishing the number of cases in each category. OIG included instances using this 
code as Likely COVID-19 for the entire study period even though Z20.828 represents persons 
who (a) had contact and suspected exposure with someone else confirmed or presumed to have 
COVID-19, but also (b) a negative or unknown COVID-19 test result. 
CMS encourages OIG to report the results of the three codes separately within the report to 
differentiate nursing homes with high volumes of COVID-19 cases from those with high 
proportions of reported suspected exposures. While CMS shares OIGs commitment to 
identifying COVID-19 infections, including individuals with contact or suspected exposure but 
with an unconfirmed COVID-19 infection, combining these categories, especially after testing 
was widely available, provides an incomplete and potentially inaccurate picture of circumstances 
in these nursing homes and limits CMSs ability to act on the findings because the root cause is 
not identified.  
Another area of concern is that OIG did not distinguish residents who contracted a COVID-19 
infection before entering a nursing home from those who contracted an infection during their 
nursing home stay. Based on CMSs understanding of the OIGs methodology, the methodology 
may overestimate the number of infections and potentially misrepresents the extent of COVID-
19 infection spread within nursing homes. For example, if a nursing home resident received a 
COVID-19 diagnosis before entering a nursing home and then had another claim or encounter 
record with a COVID-19 diagnosis upon entry to the nursing home during a surge, then OIG 
counted that resident in its figures as having COVID-19 in the nursing home, which does not tell 
CMS the critical information about the number of residents that contracted the infection while 
residing in the nursing home versus whether the resident contracted COVID-19 while residing 
elsewhere prior to entering the nursing home. CMS encourages OIG to determine the number of 
nursing home residents that contracted the virus prior to entering the nursing home and report on 
those separately so CMS can get a better understanding of the scope of OIGs findings. Different 
infection control and prevention interventions may be needed for nursing homes admitting 
residents with a pre-existing COVID-19 infection rather than nursing homes with residents who 
may have contracted COVID-19 during their nursing home stays, which CMS cannot determine 
without a full understanding of the scope, severity, and root cause of infections. 
10 The Centers for Disease Control and Prevention, ICD-10-CM Official Coding and Reporting Guidelines, April 1, 
2020 through September 30, 2020 
1111 The Centers for Disease Control and Prevention, ICD-10-CM Official Coding Guidelines - Supplement Coding 
encounters related to COVID-19 Coronavirus Outbreak, February 20, 2020 
12CMS, The Impact of COVID-19 on Medicare Beneficiaries in Nursing Homes, 2021 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 30  OIGs recommendations and CMSs responses are below. 
OIG Recommendation 
Reexamine current nursing staff requirements and revise them as necessary. 
CMS Response 
CMS concurs with the intent of this recommendation but notes it is duplicative of our ongoing 
efforts announced in February 2022 as outlined in the Presidents initiative to improve the safety 
and quality of care in the nations nursing homes.13 Since that announcement, CMS published a 
Request for Information in April 2022 soliciting public comments on minimum staffing 
requirements to inform a staffing study design. CMS received over 3,000 comments from a variety 
of interested parties, including advocacy groups; long-term care ombudsmen; industry associations 
(providers); labor unions and organizations; nursing home staff and administrators; industry experts 
and other researchers; family members; and caretakers of nursing home residents. In August 2022, 
CMS launched a staffing study to support the establishment of minimum staffing levels.14 CMS is 
assessing the level of nursing that is required to provide safe and high-quality care in nursing 
homes, which includes that facilitys ability to prepare for and respond to infectious diseases. CMS 
notes that both nurse and non-nurse staffing roles are included during the study to make appropriate 
policy proposals in future rulemaking. CMS plans to issue its proposal for minimum staffing 
requirements in Spring 2023, and that proposal will go through the notice-and-comment rulemaking 
processproviding further opportunities for all interested parties to weigh in. 
OIG noted that, when developing new minimum requirements, CMS needs to recognize the staffing 
challenges faced by nursing homes and consider what role it could play in strengthening the nursing 
home workforce. In addition to considering the industrys concerns received in response to the 
April Request for Information, CMS has already taken steps within its authority to support nursing 
homes in the retention and strengthening of their workforce. For example, in May 2020,15 CMS first 
issued a toolkit for nursing homes outlining best practices ranging from infection control to 
workforce and staffing. This document is updated on a regular basis.16 CMS has also issued Civil 
Money Penalty Reinvestment Program toolkits as resources to help nursing homes improve 
employee satisfaction and performance.17 In addition, the White House Fact Sheet for improving 
nursing homes details other efforts CMS and other HHS agencies plan to take relating to the 
nursing home workforce.  
CMS notes that OIGs analysis focused only on two statutory requirements relating to minimum 
nurse staffing hours and did not include a comprehensive review of CMSs staffing requirements 
for nursing homes. Federal staffing requirements are intended to work together to ensure 
appropriate staffing to care for the facilitys resident population; for example, CMS has 
requirements for a facility assessment to determine what resources are necessary to care for its 
13 The White House, FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nation's 
Nursing Homes, February 23, 2022 
14 Centers for Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing 
Homes, August 22, 2022 
15 CMS Issues Nursing Homes Best Practices Toolkit to Combat COVID-19, May 13, 2020  
16 Toolkit on State Actions to Mitigate COVID-10 Prevalence in Nursing Homes, March 2022 (version 26) 
17 CMS Guide to Improving Nursing Home Employee Satisfaction 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 31  residents both for day-to-day operations and emergencies that accounts for the size and acuity of the 
resident population (42 C.F.R. CFR 483.70(e)). As part of the staffing study, quantitative 
analyses will be conducted to identify staffing levels associated with improved quality of care and 
resident safety in nursing homes. In addition to analyses of the relationship between staffing and 
safety and quality care, CMS will also conduct descriptive analyses of staffing levels, examining 
trends in nursing home staffing from 2018  2021 and identifying specific factors that are related to 
staffing levels.18  
As described above, CMS began implementation before the conclusion of this study and therefore 
requests that the OIG remove this recommendation.  
OIG Recommendation 
Improve how surveys identify infection control risks to nursing home residents and strengthen 
guidance on assessing the scope and severity of those risks.  
CMS Response 
CMS relies on CDC expertise and guidance to identify infection prevention and control best 
practices. CMS works closely with the CDC, and when infection control guidance is updated, 
CMS updates the guidance for the focused infection control survey process as necessary. At the 
start of the public health emergency, CMS prioritized focused infection control and immediate 
jeopardy surveys, allowing State Survey Agencies (SSA) to turn their focus on the most serious 
health and safety threats like infectious diseases and abuse. This shift in approach allowed SSAs 
to focus on addressing the spread of COVID-19. Survey inspections are only a point-in-time 
assessment of nursing homes compliance, and so CMS shared the focused infection control 
survey tool with facilities to use as a voluntary self-assessment tool to review their own 
compliance with federal infection control requirements. The focused infection control survey 
continued to be revised to incorporate new infection control requirements to address the spread 
of COVID-19. CMS also revised the focused infection control survey to integrate it into the 
entire survey process. For surveys beginning after November 30, 2020, the probes of the focused 
infection control survey tool were combined with the Infection Control Facility Task Pathway 
and incorporated into the Long-Term Care Survey Process survey software.19 This revised 
pathway is now used for all long-term care recertification surveys.  
In June 2022, CMS released revised infection control guidance for surveyors related to the 
requirement for all nursing homes to have an Infection Preventionist (IP) who has specialized 
training to effectively oversee the facilitys infection prevention and control program. CMS 
updated the State Operations Manual, including Appendix PP to provide additional guidance for 
infection prevention and control-related deficiencies, with the appropriate scope and severity 
18 Centers for Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing 
Homes, August 22, 2022 
19 CMS, QSO-20-38-NH, : Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions 
in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing 
Requirements, August, 26, 2020 and revised September 23, 2022 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 32  examples.20 In addition, CMS urged providers to consider making changes to their physical 
environment and explore ways to reduce room occupancy. 
Based upon the action CMS has already taken to review and update the infection control survey, 
which applies to the entire survey process, we request that the OIG remove this recommendation. 
OIG Recommendation 
Target nursing homes in most need of infection control intervention, and provide enhanced 
oversight and technical assistance to these facilities as appropriate.  
CMS Response 
CMS concurs with the intent of this recommendation but notes it is duplicative of our ongoing 
efforts. CMS agrees that, in addition to its role holding nursing homes accountable for compliance 
with the requirements, technical assistance to nursing homes that are in need of assistance is 
helpful, particularly during a public health emergency.  
This is done in part through the ongoing work of the Quality Improvement Organizations. There has 
been a targeted focus on infection control by providing educational activities and assistance, 
including frontline training of nursing home staff and management on infection prevention practices 
to reduce the spread of infection and manage outbreaks effectively. These organizations also 
provide individualized training resources based on a nursing homes specific needs through toolkits, 
resource material, guides, webinars, and clinician office hours to provide expert consultation on the 
particular challenges nursing homes face.  
Based upon the action CMS has taken to target nursing homes most in need of assistance, we 
request that the OIG remove this recommendation. 
20 QSO-22-19-NH Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phase 2 & 3, 
Arbitration Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial 
Outcome Severity Guide. June 29, 2022 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Appendix C | 33   
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Jenell Clarke-Whyte served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include Sarah Guyer.  Office of 
Evaluation and Inspections staff who provided support include Joe Chiarenzelli and 
Robert Gibbons.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff including Elina Breton and Christine Moritz.   
This report was prepared under the direction of Jodi Nudelman, Regional Inspector 
General for Evaluation and Inspections in the New York regional office, and Nancy 
Harrison and Meridith Seife, Deputy Regional Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies,  
OEI-02-20-00491  Acknowledgments and Contact | 34   
EEEEEEEENNNNNNNNDDDDDDDDNNNNNNNNOOOOOOOOTTTTTTTTEEEEEEEESSSSSSSS        
 
 
 
1 OIG, COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020, OEI-02-20-00490, June 
2021. 
2 CMS, Independent Nursing Home COVID-19 Commission Findings Validate Unprecedented Federal Response, September 16, 
2020.  Accessed at  https://www.cms.gov/newsroom/press-releases/independent-nursing-home-covid-19-commission-
findings-validate-unprecedented-federal-response on August 19, 2022. 
3 These 15,086 nursing homes included in our analysis each served at least 30 Medicare beneficiaries in 2020.  
4 OIG, COVID-19 Had a Devastating Impact on Medicare Beneficiaries in Nursing Homes During 2020, OEI-02-20-00490, June 
2021. 
5 CMS announced at the end of April 2020 the formation of a new commission to assess the nursing home response to the 
pandemic and make recommendations to ensure that residents are protected from COVID-19.  See CMS, CMS Announces 
Independent Commission to Address Safety and Quality in Nursing Homes, April 30, 2020.  Accessed at 
https://www.cms.gov/newsroom/press-releases/cms-announces-independent-commission-address-safety-and-quality-
nursing-homes on March 22, 2022.  In May 2020, CMS issued a toolkit that included actions that States have taken to protect 
residents of nursing homes during the pandemic.  See CMS, CMS Issues Nursing Homes Best Practices Toolkit to Combat 
COVID-19, May 13, 2020.  Accessed at https://www.cms.gov/newsroom/press-releases/cms-issues-nursing-homes-best-
practices-toolkit-combat-covid-19 on March 22, 2022.  See also K. Yourish, K.K. Lai, D. Ivory, and M. Smith, One-Third of All 
U.S. Coronavirus Deaths Are Nursing Home Residents or Workers, The New York Times, May 11, 2020.  Accessed 
https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html?searchResultPosition=55 on 
July 5, 2022.  M. Kwiatkowski, T. Nadolny, J. Priest, and M. Stucka, A national disgrace: 40,600 deaths tied to US nursing 
homes, USA Today, June 2, 2020.  Accessed at https://www.usatoday.com/story/news/investigations/2020/06/01/coronavirus-
nursing-home-deaths-top-40-600/5273075002/ on July 5, 2022.  
6 Ibid. 
7 M. Godoy, CDC Acknowledges Coronavirus Can Spread Via Airborne Transmission, NPR, October 5, 2020.  Accessed at 
https://www.npr.org/sections/health-shots/2020/10/05/920446534/cdc-acknowledges-coronavirus-can-spread-via-airborne-
transmission on July 5, 2022.  See also CDC, CDC Museum COVID-19 Timeline.  Accessed at 
https://www.cdc.gov/museum/timeline/covid19.html on July 5, 2022.  N. Greenfieldboyce, For Scientists Who Study Virus 
Transmission, 2020 Was A Watershed Year, NPR, December 26, 2020.  Accessed at https://www.npr.org/sections/health-
shots/2020/12/26/946901965/for-scientists-who-study-virus-transmission-2020-was-a-watershed-year on July 5, 2020.   
8 One nursing home reached the threshold of having three-quarters or more of its beneficiaries diagnosed with COVID-19 or 
likely COVID-19 during both surges.  Therefore, this nursing home is considered to have had extremely high infection rates 
during both surges.  
9 For more than half of the nursing homes with extremely high infection rates during the second surge, likely COVID-19 
diagnoses accounted for less than 6 percent of their overall cases.   
10 From September 2020 to February 2022, CDC classified county-level COVID-19 transmission as low, moderate, substantial, or 
high.  This classification was based on two indicators: 1) the total number of new cases per 100,000 persons during the past 7 
days, and 2) the percentage of Nucleic Acid Amplification Test results that are positive during the past 7 days.  See 
Methodology for more detailed information on community transmission.  See also CDC, Indicators for Monitoring COVID-19 
Community Levels and COVID-19 and Implementing COVID-19 Prevention Strategies, Overview and Scientific Rationale, p. 3.  
Accessed at https://www.cdc.gov/coronavirus/2019-ncov/downloads/science/Scientific-Rationale-summary-COVID-19-
Community-Levels.pdf on March 22, 2022. 
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Endnotes | 35   
11 This analysis includes only counties that contain one or more nursing homes.   
12 This analysis includes only counties that contain one or more nursing homes. 
13 Social Security Act  1864(a); 42 CFR  488.330; CMS, State Operations Manual, Ch. 1, 1002.  See also Social Security Act 
 1819(g)(2)(A)(iii); 42 CFR  488.308.  State agencies are also required to conduct surveys to investigate complaints related to 
Federal participation requirements.   
14 42 CFR  488.301; CMS, State Operations Manual, Ch. 5, 5300; 42 CFR  488.332. 
15 CMS, State Operations Manual, Ch. 7, 7400.3.1. 
16 CMS, Prioritization of Survey Activities, Admin Info: QSO-20-20-All, March 20, 2020. 
17 Social Security Act  1864(a); 42 CFR  488.330; CMS, State Operations Manual, Ch. 1, 1002.  In addition, CMS conducts 
onsite validation surveys of a representative sample of nursing homes in each State to assess the adequacy of surveys 
conducted by the State agencies.  See CMS, State Operations Manual, Ch. 4, 4157. 
18 42 CFR  483.80(b). 
19 CMS, Prioritization of Survey Activities, Admin Info: QSO-20-20-All, March 20, 2020. 
20 We determined whether nursing homes had been cited with one of four infection control deficiencies during any of their 
surveys in 2020, including COVID-19-focused infection control surveys.  These deficiencies included: (1) F880 (infection 
prevention and control); (2) F882 (infection preventionist qualifications and role); (3) F885 (reporting to residents, 
representatives, and families); and (4) F886 (COVID-19 testing for residents and staff).  See Methodology for more information 
about the analysis of deficiencies.  
21 We considered deficiencies with a scope and severity level of F or above to be serious.  A scope and severity level of G-L 
constitutes actual harm.  Specifically, these deficiencies constitute actual harm that is not immediate (G-I) or immediate 
jeopardy to resident health or safety (J-L).  In addition, a scope and severity level of F constitutes noncompliance with the 
participation requirements that is determined to be widespread.  See Methodology for more information about the analysis of 
deficiencies.  See also CMS, State Operations Manual, Ch. 7, 7400.3.1.   
22 OIG, Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23-May 30, 2020, OEI-01-20-00430, December 
2020.  
23 42 CFR  483.35(a)(1)(i) and  483.35(b).   
24 Ibid.   
25 See 42 CFR  483.35.  Nursing homes are required to have sufficient nursing staff with the appropriate competencies sets to 
provide nursing and related services to meet resident safety and maintain the well-being of each resident while considering the 
number, acuity, and diagnoses of a nursing homes resident population.  CMS does not set specific requirements on the 
quantity of nursing staff beyond the minimal thresholds required for registered nurses and licensed nurses, 8 consecutive 
hours per day and 24 hours per day, respectively.   
26 Omnibus Budget Reconciliation Act of 1987, H.R. 3545, 100th Congress, 1987.  Accessed at  
https://www.congress.gov/bill/100th-congress/house-bill/3545 on March 22, 2022. 
27 42 CFR  483.35(a)(1)(i) and  483.35(b).  CMS assesses compliance with Federal staffing requirements through the survey 
and certification process.  Payroll Based Journal (PBJ) data have certain limitations which mean that these data cannot be used 
to assess compliance with Federal requirements.  Therefore, we determined whether a nursing home reported staffing in the 
PBJ system that was consistent with the Federal staffing requirements, but we did not state whether the nursing home was or 
was not in compliance with Federal requirements.  Nursing homes that reported staffing levels at or above requirements at 
least 90 percent of days were considered to report these levels almost all of the time.  See Methodology for more detailed 
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Endnotes | 36   
information about the staffing analysis.  See also CMS, Payroll Based Journal Methodology.  Accessed at  
https://data.cms.gov/resources/payroll-based-journal-methodology on June 10, 2022.   
28 See OIG, Some Nursing Homes Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased, 
OEI-04-18-00450, August 2020.  See also OIG, CMS Use of Data on Nursing Home Staffing: Progress and Opportunities To Do 
More, OEI-04-18-00451, March 2021.  These studies prompted CMS to begin publishing information on weekend nurse staffing 
and nurse turnover on Care Compare and incorporate these measures into the Nursing Home Five Star Quality Rating System.  
See CMS, Nursing Home Staff Turnover and Weekend Staffing Levels, QSO-22-08-NH, January 7, 2022. 
29 For all nursing homes, we calculated the average total nursing hours per resident per day (HPRD) over three quarters in 2020 
(Q2 through Q4 2020).  This analysis does not assess the average HPRD during the specific surge periods.  For both surges, we 
compared the average total nursing HPRD during 2020 for nursing homes with extremely high infection rates to the average 
HPRD for other nursing homes.  See Methodology for more detailed information about the staffing analysis.  
30 42 CFR  483.35(a)(1)(i) and  483.35(b).   
31 The White House, FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nations Nursing Homes, 
February 28, 2022.  Accessed at https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-
protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/ on 
April 7, 2022. 
32 Office of the Assistant Secretary for Planning and Evaluation (ASPE), COVID-19 Intensifies Nursing Home Workforce 
Challenges, October 2020.  Accessed at https://aspe.hhs.gov/reports/covid-19-intensifies-nursing-home-workforce-challenges-
0?msclkid=f7a72701cfe111ec9a050b932b26e1c2 on May 6, 2022.  See also J. Abbasi, Abandoned Nursing Homes Continue 
to Face Critical Supply and Staff Shortages as COVID-19 Toll Has Mounted, JAMA, June 11, 2020.  Accessed at 
https://jamanetwork.com/journals/jama/fullarticle/2767282 on May 6, 2022.  The National Academies of Sciences, Engineering, 
and Medicine, The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and 
Staff, 2022.  Accessed at https://nap.nationalacademies.org/catalog/26526/the-national-imperative-to-improve-nursing-home-
quality-honoring-our on May 3, 2022.  R. Chatterjee, The pandemic pummeled long-term care  it may not recover quickly, 
experts warn, NPR, February 22, 2022.  Accessed at https://www.npr.org/sections/health-shots/2022/02/22/1081901906/the-
pandemic-pummeled-long-term-care-it-may-not-recover-quickly-experts-warn on May 6, 2022.  S. Quinton, Staffing Nursing 
Homes Was Hard Before the Pandemic. Now Its Even Tougher, Stateline, Pew Charitable Trusts, May 18, 2020.  Accessed at 
https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/05/18/staffing-nursing-homes-was-hard-before-
the-pandemic-now-its-even-tougher on May 9, 2022.  
33 Kaiser Family Foundation, Nursing Facility Staffing Shortages During the COVID-19 Pandemic, April 4, 2022.  Accessed at 
https://www.kff.org/coronavirus-covid-19/issue-brief/nursing-facility-staffing-shortages-during-the-covid-19-
pandemic/?msclkid=98f045f5cfe211ecbb9431a72045684a on May 2, 2022.  See also American Health Care Association and 
National Center for Assisted Living, State of the Long Term Care Industry: Survey of nursing home and assisted living providers 
show industry facing significant workforce crisis, September 2021.  Accessed at https://www.ahcancal.org/News-and-
Communications/Fact-Sheets/FactSheets/Workforce-Survey-September2021.pdf on May 6, 2022. 
34 The National Academies of Sciences, Engineering, and Medicine, The National Imperative to Improve Nursing Home Quality, 
Honoring Our Commitment to Residents, Families, and Staff, 2022.  Accessed at 
https://nap.nationalacademies.org/catalog/26526/the-national-imperative-to-improve-nursing-home-quality-honoring-our on 
May 3, 2022.  See also ASPE, COVID-19 Intensifies Nursing Home Workforce Challenges, October 18, 2020.  Accessed at 
https://aspe.hhs.gov/reports/covid-19-intensifies-nursing-home-workforce-challenges-
0?msclkid=f7a72701cfe111ec9a050b932b26e1c2 on May 6, 2022.  L. Romero, Pandemic, labor shortages have left long-term 
care facilities competing for staff, ABC News, August 19, 2021.  Accessed at https://abcnews.go.com/US/pandemic-labor-
shortages-left-long-term-care-facilities/story?id=79508224 on May 6, 2022.   
35 R. Tan, Low-wage workers prop up the nursing home industry. Theyre quitting in droves, The Washington Post, January 22, 
2022.  Accessed at https://www.washingtonpost.com/dc-md-va/2022/01/23/nursing-home-dc-staffing-omicron/ on May 9, 
2022.  
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Endnotes | 37   
36 The White House, FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nations Nursing Homes, 
February 28, 2022.  Accessed at https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-
protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/ on 
April 7, 2022. 
37 Omnibus Budget Reconciliation Act of 1987, H.R. 3545, 100th Congress, 1987.  Accessed at  
https://www.congress.gov/bill/100th-congress/house-bill/3545 on March 22, 2022. 
38 The White House, FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nations Nursing Homes, 
February 28, 2022.  Accessed at https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-
protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/ on 
April 7, 2022.  In August 2022, CMS launched the staffing study called for by the administration.  CMS stated that the study 
would include a literature review, site visits to nursing homes, quantitative analyses, and cost analyses.  See CMS, Centers for 
Medicare & Medicaid Services Staffing Study to Inform Minimum Staffing Requirements for Nursing Homes, August 22, 2022.  
Accessed at https://www.cms.gov/blog/centers-medicare-medicaid-services-staffing-study-inform-minimum-staffing-
requirements-nursing-homes on January 9, 2023. 
39 See CMS, Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration Agreement 
Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial Outcome Severity Guide: 
QSO-22-19-NH, June 29, 2022.  CMS recently added new guidance for surveyors to incorporate the use of PBJ staffing data to 
investigate potential noncompliance with CMSs nurse staffing requirements.  This guidance became effective October 2022. 
40 Previous OIG work that focused on the survey process early in the pandemic recommended that CMS evaluate the 
effectiveness of focused infection control surveys and revise as appropriate.  CMS has since integrated content from the 
focused infection control survey into its standard survey.  See OIG, Onsite Surveys of Nursing Homes During the COVID-19 
Pandemic: March 23-May 30, 2020, OEI-01-20-00430, December 2020.  Other OIG work has focused on CMSs oversight of 
State survey agencies performances in conducting nursing home surveys.  See OIG, CMS Should Take Further Action to Address 
States with Poor Performance in Conducting Nursing Home Surveys, OEI-06-19-00460, January 2022.   
41 CMS issued a memo outlining several updates CMS made to the State Operations Manual, Appendix PP, effective October 
24, 2022.  See CMS, Revised Long-Term Care Surveyor Guidance: Revisions to Surveyor Guidance for Phases 2 & 3, Arbitration 
Agreement Requirements, Investigating Complaints & Facility Reported Incidents, and the Psychosocial Outcome Severity Guide: 
QSO-22-19-NH, June 29, 2022.  Among these updates, CMS provided additional guidance for categorizing deficiencies related 
to infection prevention and control (IPC).  The new guidance includes examples of deficiencies at each of the four severity 
levels for a set of the IPC deficiencies.  See also CMS, State Operations Manual, Appendix PP.   
42 These beneficiaries include those diagnosed in a nursing home as well as those diagnosed in a hospital or other care setting 
after being transferred from a nursing home. 
43 We identified these periods based on our analysis for the OIG report COVID-19 Had a Devastating Impact on Medicare 
Beneficiaries in Nursing Homes During 2020, OEI-02-20-00490, June 2021. 
44 We count only the first diagnosis of COVID-19 or likely COVID-19 during a nursing home stay.  Furthermore, if a beneficiary 
was diagnosed during a given surge with likely COVID-19 and later during the surge was diagnosed with COVID-19, we 
considered that beneficiary to be diagnosed with COVID-19 as opposed to likely COVID-19.   
45 We categorized nursing homes as small if they had 50 or fewer certified beds, medium if they had 51 to 150 certified 
beds, and large if they had more than 150 certified beds. 
46 Counties designated by the Office of Management and Budget as included in metropolitan statistical areas are considered 
urban counties.  All other counties, including those located in micropolitan statistical areas, are considered rural counties.  See 
Census Bureau, Delineation Files, Core based statistical areas (CBSAs), metropolitan divisions, and combined statistical areas 
(CSAs).  Accessed at https://www.census.gov/geographies/reference-files/time-series/demo/metro-micro/delineation-files.html 
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Endnotes | 38   
on September 23, 2021.  See also Health Resources and Services Administration, Defining Rural Population.  Accessed at 
https://www.hrsa.gov/rural-health/about-us/definition/index.html on March 14, 2022. 
47 We determined the overall mortality of Medicare nursing home beneficiaries, not just those with COVID-19. 
48 These beneficiaries include those who died in a nursing home, as well as those who died in a hospital or other health care 
setting such as hospice, after being transferred from a nursing home. 
49 USAFacts, US COVID-19 cases and deaths by state.  Accessed at https://usafacts.org/visualizations/coronavirus-covid-19-
spread-map on September 21, 2021.  These data are collected from State and local public health agencies and CDC. 
50 We adapted CDCs definition of COVID-19 community transmission levels, which was in use from September 2020 to 
February 2022.  Using this definition, we classified counties as having low transmission if they had 0 to 9.99 new COVID-19 
cases per 100,000 persons over an average of 7 days during a surge period, moderate as 10 to 49.99, substantial as 50 to 
99.99, and high as greater than or equal to 100.  For more information, see CDC, Indicators for Monitoring COVID-19 
Community Levels and COVID-19 and Implementing COVID-19 Prevention Strategies, Overview and Scientific Rationale, p. 3.  
Accessed at https://www.cdc.gov/coronavirus/2019-ncov/downloads/science/Scientific-Rationale-summary-COVID-19-
Community-Levels.pdf on March 22, 2022.  
51 These deficiencies included: (1) F880 (infection prevention and control); (2) F882 (infection preventionist qualifications and 
role); (3) F885 (reporting to residents, representatives, and families); and (4) F886 (COVID-19 testing for residents and staff).  
We examined these four deficiencies because they are related to the prevention and treatment of COVID-19 and were in effect 
during the study period.   
52 Standard surveys are periodic, resident-centered inspections designed to gather information about the quality of service 
furnished in a facility to determine compliance with the requirements of participation.  See 42 CFR  488.301.  Focused 
infection control surveys were introduced during the COVID-19 pandemic and designed specifically to determine compliance 
with infection control.  See also CMS, Prioritization of Survey Activities, QSO-20-20-All, March 20, 2020.  In addition to these 
surveys, we also reviewed surveys that were conducted in response to a complaint, as well as Federal Monitoring Surveys and 
limited-scope surveys, such as those conducted to assess a nursing homes Quality Assurance and Performance Improvement 
program.   
53 CMSs scope and severity rating system is used by State agencies when conducting surveys of nursing homes.  For each 
deficiency, the surveyors determine the level of harm to the resident(s) involved (severity) and the number of residents 
potentially or actually affected within the nursing home (scope).  The surveyors then assign an alphabetic scope and severity 
value, A through L, to the deficiency.  A-rated deficiencies are the least serious and L-rated deficiencies are the most serious.  
See CMS, State Operations Manual, Ch. 7, 7400.3.1.   
54 CMS waived the requirements for nursing homes to submit staffing data through the PBJ system for the first quarter 2020.  
See CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, p. 16.  Accessed at 
https://www.cms.gov/files/document/covid-19-emergency-declaration-waivers.pdf on April 14, 2022.  We included nursing 
homes in this analysis if they had at least two quarters of data from Q2 through Q4 in the PBJ. 
55 42 CFR  483.35(a)(1)(i) and  483.35(b).  
56 42 CFR 483.70(q).  Nursing homes must electronically submit these data.  
57 See CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care Facility Policy Manual (pp. 2-5 and 2-6).  
Accessed at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf on June 10, 2022.  This 
guidance indicates that each 8-hour shift should include a 0.5-hour meal break that is not reported to the PBJ.  See also, CMS, 
Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users Guide.  Accessed at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf 
on June 10, 2022.  RN hours include hours from RNs, the RN director of nursing, and RNs with administrative duties.  Licensed 
nurse hours include hours from LPNs/LVNs, LPNs/LVNs with administrative duties, and any type of RN hours noted above. 
 
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Endnotes | 39   
58 To do this, CMS uses daily staffing data reported to the PBJ as well as information on the number of residents from the MDS.  
See CMS, Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users Guide.  Accessed at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf  
on June 10, 2022. 
59 CMS includes the HPRD values in the Provider Information files contained in the Provider Data Catalog.  The Provider 
Information file reflects the information presented on Care Compare.  See CMS, Nursing homes including rehab services data 
archive.  Accessed at https://data.cms.gov/provider-data/archived-data/nursing-homes on May 26, 2021. 
60 We averaged the quarterly adjusted total nursing HPRD measure published by CMS.  We included nursing homes in this 
analysis that had adjusted total nursing HPRD values in CMSs Provider Information files from at least two quarters during the 
period Q2 through Q4 2020. 
61 CMS, Payroll Based Journal Methodology.  Accessed at https://data.cms.gov/resources/payroll-based-journal-methodology 
on June 10, 2022.   
Data Brief: More than a Thousand Nursing Homes Reached Infection Rates of 75 Percent or More in the First Year of the 
COVID-19 Pandemic; Better Protections Are Needed for Future Emergencies, OEI-02-20-00491  Endnotes | 40