U.S. Department of Health and Human Services 

Office of Inspector General 

Onsite Surveys of Nursing 

Homes During the COVID-19 

Pandemic: 

March 23–May 30, 2020 

Christi A. Grimm 

Principal Deputy Inspector General 

December 2020, OEI-01-20-00430 
 

 

 

 

 

U.S. Department of Health and Human Services 

Office of Inspector General 

Report in Brief 

December 2020, OEI-01-20-00430 

Why OIG Did This Review 

We did this review to determine 

the number and results of onsite 

surveys of nursing homes during 

the COVID-19 pandemic. Nursing

home residents are particularly 

vulnerable to infectious diseases 

such as COVID-19, and infection 

control has been a persistent

problem for most nursing homes. 

As of November 8, 2020, more than 

67,000 nursing home residents

have died of COVID-19, which 

represented almost 30 percent of 

all COVID-19 deaths in the United 

States at that time. Onsite State 

surveys, conducted on behalf of the 

Centers for Medicare & Medicaid 

Services (CMS), assess the quality 

of services in nursing homes, a 

critical function for protecting 

residents. CMS changed survey 

practices in response to the

pandemic. These changes—

together with nursing home

residents’ high-risk status and the 

importance of the State surveys—

warrant close examination to assess 

the sufficiency of this oversight. 

How OIG Did This Review 

We analyzed CMS administrative 

data to determine the number of 

focused infection control and 

complaint surveys conducted from 

March 23 through May 30, 2020. 

We also identified the number and 

types of deficiencies cited as a 

result of these surveys. We 

interviewed officials in CMS and 10 

States to learn more about their 

approaches to oversight, 

challenges to conducting onsite 

surveys, and experiences during the

COVID-19 pandemic. 

Onsite Surveys of Nursing Homes During the 

COVID-19 Pandemic: March 23–May 30, 2020 

CMS and States share responsibility for oversight of the Nation’s nearly 

16,000 nursing homes. Following 

Key Takeaway CMS protocols, States conduct 

onsite surveys to assess compliance States conducted onsite surveys at with Federal requirements and to 31 percent of nursing homes from investigate complaints. In response March 23 through May 30, 2020, to the COVID-19 pandemic, CMS fewer than during the same time suspended annual “standard” period in 2019 when States and surveys in March 2020 and CMS were under normal operations introduced a new focused infection 

and conducting standard and other control survey. On June 1, 2020, 

surveys. These surveys resulted in CMS directed States to conduct 

few deficiencies but allowed States these focused surveys for all nursing to provide nursing homes with homes and to continue surveys for guidance and other support. States the most serious complaints. had challenges in securing personal

protective equipment and sufficient What OIG Found 

staff to conduct onsite surveys. Overall, States conducted onsite 

surveys at 31 percent of nursing 

homes from March 23 through May 30, 2020; however, States varied 

significantly. During the same time period in 2019—when States and CMS 

were under normal operations—53 percent of nursing homes received an 

onsite survey. The infection control surveys conducted during this timeframe 

in 2020 resulted in few deficiencies, in part because of their limited scope and

less surveyor time onsite. State officials reported ongoing challenges to 

securing personal protective equipment (PPE) and surveyors. States provided 

guidance and other support—such as training—to nursing homes outside of 

the survey process. State officials reported concerns about mounting 

backlogs of standard and complaint surveys, as the pandemic continues. 

What OIG Recommends 

We recommend that CMS assess the results of the infection control survey 

and revise the survey as appropriate. We also recommend that CMS work 

with States to overcome challenges with PPE and staffing, and that it clarify 

expectations for States to complete backlogs. CMS did not explicitly concur 

with our recommendations to assess and revise the infection control survey 

or to clarify expectations for States to complete backlogs but stated that it 

has taken steps to implement those recommendations. CMS did not concur 

with our recommendation to work with States to overcome challenges with 

PPE and staffing, citing its lack of authority to address issues of allocating PPE 

and staff. OIG continues to recommend that CMS identify opportunities 

within its authority to support States facing challenges with PPE and staffing. 
TABLE OF CONTENTS 

BACKGROUND 1 

Abbreviated Methodology 5 

FINDINGS 7 

Overall, States conducted onsite surveys at 31 percent of nursing homes from March 23 7 

through May 30, 2020; however, States varied significantly 

From March 23 through May 30, 2020, limited-scope surveys resulted in few cited 13 

deficiencies but provided opportunities for surveyors to support nursing homes 

States reported ongoing challenges to conducting safe onsite surveys of nursing homes 15 

during the COVID-19 pandemic 

As COVID-19 hindered onsite surveys, States made efforts to support nursing homes outside 20 

of the survey process 

CONCLUSION and RECOMMENDATIONS 22 

Assess the results of infection control surveys and revise the survey as appropriate 23 

Work with States to help overcome challenges with PPE and staffing 23 

Clarify expectations for States to complete backlogs of standard surveys and high-priority 24 

complaint surveys 

AGENCY COMMENTS AND OIG RESPONSE 25 

DETAILED METHODOLOGY 26 

APPENDICES 29 

A. CMS guidance to States pertaining to nursing homes from February through August 2020 29 

B. Percentage of nursing homes with onsite survey, by State 31 

C. Percentage of nursing homes surveyed in each State, March 23–May 30, 2020 33 

D. Summaries of instances of noncompliance identified for 68 infection control deficiencies 34 

E. Agency Comments 39 

ACKNOWLEDGMENTS AND CONTACT 44 

ABOUT THE OFFICE OF INSPECTOR GENERAL 45 

ENDNOTES 46 
 

BACKGROUND 

Objectives 

1. To determine the number and results of surveys of nursing homes 

conducted by the Centers for Medicare & Medicaid Services (CMS) and 

State survey agencies (States) from March 23 through May 30, 2020. 

2. To describe challenges that CMS and States experienced in conducting 

nursing home oversight during the COVID-19 pandemic and their insights 

into their experiences. 

Background 

Nursing home residents are particularly vulnerable to infectious diseases such as 

COVID-19 because of their age and underlying medical conditions.1

 The early 

COVID-19 outbreak at the Life Care Center in Kirkland, Washington, killed at least

37 people and demonstrated just how quickly infections can spread through a nursing

home.2

 As of November 8, 2020, more than 67,000 nursing home residents have died 

of COVID-19, which represents almost 30 percent of all U.S. COVID-19 deaths.3, 4 

Infection control has been a persistent problem for nursing homes.5

 From 2013 

through 2017, CMS and State surveyors cited 82 percent of nursing homes with 

infection control deficiencies, and half of those homes were cited across multiple 

years.6

 During the COVID-19 pandemic, these longstanding problems may be 

exacerbated by numerous challenges, including ensuring adequate staffing, 

equipment, and supplies, especially testing supplies and personal protective 

equipment (PPE).7,8 

CMS plays a pivotal role in the oversight of nursing homes to ensure quality care and 

safety for residents. During the COVID-19 pandemic, CMS suspended some of its 

usual oversight activities and introduced a new oversight tool focused on infection 

control. In addition, CMS is providing COVID-19-related guidance and other supports 

to help meet the emerging and evolving needs of residents and the staff in nursing 

homes during the pandemic. 

Nursing Home Oversight Prior to the COVID-19 Pandemic 

Onsite nursing home surveys are a fundamental safeguard to ensure that nursing 

home residents are safe and receive quality care. CMS, in conjunction with States, 

oversees nearly 16,000 Medicare and Medicaid nursing homes to ensure that they 

meet Federal requirements.9, 10, 11 States conduct standard certification surveys 

(standard surveys) on behalf of CMS for nursing homes on average every 12 months 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Background | 1 
 

 

but at least every 15 months.12, 13 These surveys evaluate the safety and quality of 

care that nursing homes provide.14, 15 In addition, between standard surveys, States 

conduct complaint surveys as needed in response to allegations of noncompliance 

with Federal requirements from residents, their families, and nursing home staff, 

among others.16 

Surveyors from CMS regional offices may also conduct surveys. CMS surveyors 

conduct Validation Surveys and Federal Oversight Support Surveys to observe and 

assess State surveyor performance. CMS surveyors also conducted infection control 

and complaint surveys during the COVID-19 pandemic. In this report, we include 

surveys conducted by CMS when we reference State surveys. Together, standard and 

complaint surveys ensure that nursing homes meet minimum Federal requirements, 

provide quality of care to all their residents, identify problems, and correct those 

problems. 

Standard Surveys. To monitor nursing home compliance with requirements for 

participation in Medicare and Medicaid, CMS enters into agreements with each State 

survey agency. State survey agencies conduct standard surveys of the State’s nursing 

homes and investigate nursing home complaints on behalf of CMS.17, 18 Standard 

surveys assess nursing home compliance with the CMS requirements for participation

and evaluate the safety and quality of nursing home care.19, 

Multidisciplinary teams of surveyors, including at least one registered nurse, complete 

a set of both offsite and onsite tasks to assess the nursing home.20 Offsite tasks 

include, but are not limited to, a review of the nursing home quality measures, 

statements of deficiencies, and complaints.21 While onsite, surveyors follow a 

protocol that includes a tour of the facility for observation, reviews of medical records, 

and interviews with residents, family, and staff, among other activities.22 

Surveyors cite deficiencies when they observe a nursing home in violation of Federal 

requirement. Surveyors also determine the scope and severity of each deficiency. 

The scope of a deficiency refers to the number of residents affected. The severity of a 

deficiency refers to its impact and is categorized using four levels of harm, with the 

two highest levels of harm defined as actual harm that is not immediate jeopardy and 

immediate jeopardy to resident health or safety.23, 24 

Complaint Surveys. In addition to conducting standard surveys, State survey 

agencies conduct onsite surveys to investigate complaints from residents, their 

families, nursing home staff, and others.25 CMS provides States with procedural 

guidelines for how to intake, prioritize, and investigate complaints for 

Medicare/Medicaid-certified nursing homes.26 To determine whether a complaint 

warrants an onsite survey, CMS requires that a qualified professional with knowledge 

of clinical standards and Federal requirements triage each complaint by assigning it a 

priority level.27 

A complaint’s priority level determines the State’s required timeframe for 

investigation. The two most serious priority levels are immediate jeopardy (IJ) and 

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OEI-01-20-00430 Background | 2 
 

 

non-immediate jeopardy–high (high priority). These complaints allege serious injury 

or that there may be harm and require a rapid response to address the complaint and 

ensure residents’ safety.28 States must initiate investigations of IJ complaints within 

2 business days of receipt and high-priority complaints within 10 business days of 

prioritization. From 2011 through 2018, the largest source of complaints overall—and 

of IJ complaints specifically—has consistently been family members of nursing home 

residents (about 40 percent).29, 30 

States also conduct onsite surveys in response to nursing home incidents.31 Incidents 

are self-reported by the nursing home, and nursing homes must report incidents that 

involve allegations of abuse, neglect, exploitation, or mistreatment.32 As with 

complaints, States must conduct onsite surveys for IJ incidents.33 

Oversight of State Survey Agency Performance. CMS oversees State survey agencies

and evaluates their performance in conducting surveys.34 The State Performance 

Standards System is an annual assessment that establishes performance measures 

and thresholds for acceptable performance. Acceptable performance is determined 

by three survey “dimensions”: frequency, quality, and enforcement and remedy.35 The 

performance measures include expectations that States begin complaint surveys 

within required timeframes for 95 percent of complaint allegations and that all 

nursing homes are surveyed at least once every 15.9 months.36 

The Emergence of COVID-19 

COVID-19 is a disease caused by a highly contagious coronavirus with symptoms that 

can include fever, fatigue, dry cough, and shortness of breath. It can be fatal in some 

cases.37, 38 The first reported case of COVID-19 in the United States was on January 

20, 2020.39 On February 26, the nursing home Life Care Center of Kirkland, 

Washington, notified State officials of an outbreak of respiratory illness that was later 

determined to be COVID-19.40 

On March 11, 2020, the World Health Organization characterized COVID-19 as a 

pandemic, which refers to an epidemic that has spread over several countries or 

continents, usually affecting a large number of people.41, 42, 43 On March 13, 2020, 

President Trump declared the COVID-19 outbreak to be a national emergency.44 The 

national emergency declaration triggered the Department of Health and Human 

Services (HHS) Secretary’s authority, under section 1135 of the Social Security Act, to 

temporarily waive certain requirements, including requirements for oversight surveys 

of nursing homes.45 Under this waiver authority, beginning in March 2020, CMS 

prioritized certain Federal and State surveys and suspended others to focus State and 

nursing home resources on limiting the spread of COVID-19.46, 47 

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OEI-01-20-00430 Background | 3 
 

 

CMS Guidance to States on Oversight of Nursing Homes During 

the COVID-19 Pandemic 

Starting in February, CMS issued a series of guidance documents adjusting its 

approach to nursing home oversight to focus on addressing and preventing the 

spread of COVID-19. See Exhibit 1 below for a timeline of key CMS guidance to 

States early in the COVID-19 pandemic. See Appendix A for the complete list of CMS 

memos to States from February 2020 through June 2020. 

Exhibit 1: Timeline of key CMS guidance to States early in the COVID-19 pandemic. 

 Source: OIG analysis of CMS guidance, 2020. 

COVID-19-Focused Survey for Nursing Homes 

As part of its March 23 guidance, CMS provided the COVID-19-focused survey tool 

for nursing homes to assess compliance with infection control.48 The survey tool 

includes a focused framework of several infection control categories that are 

associated with the transmission of COVID-19 and other communicable diseases and 

infections, including hand hygiene, PPE, and infection surveillance, among other areas. 

CMS also provided a brief training and protocol to help surveyors prioritize survey 

activities while onsite and identify activities that they could complete offsite to 

decrease the transmission of COVID-19.49, 50 The protocol also instructs States to 

ensure surveyors are trained in the proper use of PPE and to refrain from conducting 

onsite surveys if surveyors are unable to meet the PPE expectations outlined by 

Centers for Disease Control and Prevention (CDC).51 

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OEI-01-20-00430 Background | 4 
 

 

 

Related OIG Work 

This study is part of a larger body of forthcoming work from the Office of the 

Inspector General (OIG) examining the impact of COVID-19 on nursing homes. For 

instance, OIG has work underway that will describe the characteristics of the nursing 

homes that were hit hardest by COVID-19 (i.e., homes with high numbers of residents 

who had COVID-19 or had died). This work will also describe the strategies nursing 

homes have used to mitigate the effects of COVID-19 on their residents and staff in 

the face of these unique circumstances.52 Other forthcoming OIG work will determine 

whether selected nursing homes have programs for infection prevention and control 

and emergency preparedness in accordance with Federal requirements.53 OIG also 

has work underway that will assess nursing homes’ reporting of CMS-required 

information related to the COVID-19 pandemic.54 

In addition, OIG has several evaluations and audits of nursing home oversight and 

quality of care that began prior to the COVID-19 pandemic. Two are particularly 

relevant to this evaluation. One is a report examining complaint trends in nursing 

homes. This report updates OIG’s 2017 data brief and finds that States continued to 

fall short in meeting required timeframes for investigating nursing home complaints.55 

To complement this report, OIG has published an updated interactive map that 

illustrates State-by-State trends in nursing home complaints for 2016 through 2018. 

The interactive map is available at https://oig.hhs.gov/oei/maps/2019-nursinghome/index.asp. The other is a forthcoming OIG report that examines CMS oversight 

of State survey agency performance specific to nursing homes and may identify 

additional opportunities or recommendations for CMS to improve performance.56 A 

complete listing of OIG’s ongoing evaluations and audits is available in our online 

Work Plan at https://www.oig.hhs.gov/. 

Abbreviated Methodology 

Data Sources and Analysis 

CMS Complaint and Incident Data. We analyzed Automated Survey Processing 

Environment (ASPEN) Complaints/Incidents Tracking System (ACTS) data on nursing 

home complaints and incidents that State survey agencies received during the same 

2019 and 2020 time periods. We analyzed these data to determine the number of 

overall complaints and incidents States received, the number of complaints and 

incidents that States prioritized as IJ, and the sources of complaints (e.g., residents’

family members) from March 23 through May 30, 2019, and from March 23 through 

May 30, 2020. We used a longer time span of data in the calculation to identify the 

backlog of high-priority complaints (March 23 through June 28, 2020). This longer 

timespan was only available for this measure. 

CMS Survey and Deficiency Data. We used CMS’s publicly available data on Nursing 

Home Compare to examine onsite surveys (infection control surveys and IJ complaint 

surveys) and resulting deficiencies from March 23 through May 30, 2020. We used 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Background | 5 
 

ASPEN and Certification and Survey Provider Enhanced Reports (CASPER) data from 

CMS to analyze trends in nursing home surveys and deficiencies in the same 2019 

time period to provide historical context. Specifically, we assessed trends in standard 

surveys, surveys related to complaints/incidents, and resulting deficiencies from 

March 23 through May 30, 2019. 

Review of CMS-2567 Forms. We conducted a limited review of CMS-2567 

(statements of deficiencies) forms from onsite surveys during the pandemic. Using 

the CMS-2567 forms that CMS made available on Nursing Home Compare on June 

24, 2020, we identified and reviewed all 68 CMS-2567 forms that included the F-880 

infection prevention and control deficiency from March 23 through May 30, 2020. 

The CMS-2567 forms included the specific instances of noncompliance that resulted 

in the deficiency citation. Deficiencies may be based on more than one instance of 

noncompliance. 

We reviewed the narrative of each CMS-2567 form and categorized the instances of 

noncompliance into one or more category to determine the most common reasons 

for noncompliance with infection control practices (e.g., hand hygiene). 

Interviews with CMS and State Survey Agencies. Finally, we interviewed leadership 

in CMS’s Survey and Operations Group and the Quality, Safety, and Oversight Group 

regarding their approach to oversight during the pandemic. We also interviewed a 

purposive sample of 10 States regarding their experiences and challenges conducting 

surveys during the pandemic. We selected the sample of 10 States to ensure that we 

included States with a range of impact from COVID-19 and to represent each of the 

10 CMS locations. We conducted these interviews from June 9 through June 18, 2020. 

See the Detailed Methodology section on page 26 for additional information about 

our data collection and analysis. 

Limitations 

We did not assess the extent to which the data in ACTS, ASPEN/CASPER, and Nursing 

Home Compare are complete. We also did not assess the appropriateness and 

quality of State responses to complaints and incidents or survey results. In addition, 

the complaint survey data from ASPEN/CASPER includes the four most recent 

complaint surveys in each nursing home, rather than all complaint surveys conducted 

in 2019. Our analysis includes self-reported data from States that we did not 

independently verify. 

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. 

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OEI-01-20-00430 Background | 6 
FINDINGS 

Overall, States conducted onsite surveys at 31 percent of 

nursing homes from March 23 through May 30, 2020; however, 

States varied significantly 

Prior to the COVID-19 pandemic, States regularly conducted standard surveys to 

assess whether nursing homes met minimum Federal requirements, including 

evaluating nursing homes’ safety and quality of care. In addition, States conducted 

complaint surveys as needed in response to allegations from residents, their families, 

and nursing home staff. The COVID-19 pandemic prompted CMS to issue policy that 

changed the State survey process. On March 23, 2020, CMS directed States to 

suspend standard surveys and conduct COVID-19-focused infection control survey for 

nursing homes (infection control surveys) and surveys for the most serious (IJ) 

complaints/incidents. CMS stated that the change in survey activities was to focus 

State and nursing home resources on limiting the spread of COVID-19. In June, CMS 

updated its direction to States to require that they conduct infection control surveys 

for all nursing homes by July 31, 2020. 

During this time period, States conducted onsite infection control 

and complaint surveys. 

States conducted infection control surveys and/or IJ 

complaint/incident surveys for 31 percent of nursing 

homes from March 23 through May 30, 2020. For 

reference, 53 percent of nursing homes received an 

31% onsite survey during the same time period in of nursing homes had 

2019, when States and CMS were conducting standard an onsite survey from 

surveys and surveys for all complaints that required one. March 23 through 

Overall, during this time in 2020, States conducted May 30, 2020 

7,193 onsite surveys in 4,805 nursing homes.57 States 

surveyed 1,169 nursing homes more than once during 

this time period. 

States reached most of these nursing homes for an onsite survey in the first month of 

this time period. From March 23 through April 23, States surveyed 19 percent of 

nursing homes onsite. By May 30, States and CMS had surveyed an additional 

12 percent of nursing homes onsite. Although outside the scope of our analysis, CMS 

reported that more than 99 percent of nursing homes had some type of onsite survey 

from March 1 through August 21, 2020.58 

States we spoke with used their own criteria to prioritize nursing homes for infection 

control surveys. Most States used nursing homes’ prior deficiency citations or chose 

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homes with high numbers of COVID-19 infections and deaths to target these surveys.

For example, one State gave top priority to nursing homes with a history of multiple 

infection control deficiencies. Some States used other criteria, such as complaints 

received against a nursing home or the number of COVID-19 cases in the local 

community. 

Over two-thirds of States surveyed fewer than 10 percent of their 

nursing homes in the first month following CMS’s directive to 

conduct only infection control surveys and immediate jeopardy 

complaint surveys. 

In the first month after CMS suspended 

certain surveys (from March 23 through 

April 23, 2020), 36 States surveyed fewer 

than 10 percent of their nursing homes 

onsite, and 8 States did not survey any 

nursing homes onsite: Arizona, Idaho, 

Maryland, Montana, Nebraska, 

New Mexico, Virginia, and West Virginia 

(see Exhibit 2 on the next page). Overall, 

States surveyed 13 percent of their 

nursing homes on average in this first 

month. For reference, in 2019, States 

surveyed 23 percent of their nursing 

homes per month on average. CMS’s 

suspension of certain surveys—as well as 

States’ challenges with getting 

equipment and staff needed to survey 

nursing homes onsite—contributed to 

the difference in onsite survey activity 

between 2019 and this first month after 

CMS’s directive. See Appendix B for

details on the percentage of nursing 

homes that received a survey from 

March 23 through April 23 and the 

average per month during 2019, by State. 

The 10 States we interviewed in 

mid-June expected to meet CMS’s 

July 31 deadline to survey all nursing 

homes, but some with substantial 

difficulty. 

Some State officials were surprised by CMS’s 

July 31 deadline requiring States to survey all 

nursing homes. One State pointed out that

the timeframe was tight for the States that 

had a slow start on their surveys. Officials 

from another State reported that given the 

high threat of COVID-19 for nursing home 

residents, they had always planned to survey 

all nursing homes. 

Although outside the scope of OIG’s analysis 

of surveys, CMS reported to the Nursing 

Home Compare website that these 10 States 

had surveyed at least 98 percent of their 

nursing homes as of August 21, 2020. These 

results are based on data beginning March 1 

and include some surveys conducted prior to 

the directive to suspend certain survey 

activities. 

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Exhibit 2: Most States surveyed fewer than 10 percent of their nursing homes 

in the month following CMS’s directive to conduct only infection control 

surveys and surveys in response to immediate jeopardy complaints. 

Source: OIG analysis of Nursing Home Compare data, 2020. 

A couple of States reached far more nursing homes for onsite surveys than others in 

the first month following CMS’s directive. California and Washington conducted 

onsite surveys for about 85 percent of nursing homes in their States during this 

month-long period. In addition, both States surveyed some of their nursing homes 

more than once. California required nursing homes to submit their daily numbers of 

staff and COVID-19-positive cases (prior to this being required by CMS), and the State

developed a dashboard to identify high-risk facilities for onsite surveys. As California 

further developed the dashboard and metrics, officials formed a “strike team” to 

survey nursing homes with urgent problems and used predictive analytics to create a 

list of high-risk facilities, calculating risk by using deficiencies cited, proximity to hot 

spots, and other factors. Washington obtained PPE for surveyors early and was 

therefore able to get its surveyors onsite early to conduct surveys. Washington also 

surveyed some nursing homes multiple times in response to outbreaks. 

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As the COVID-19 pandemic progressed, some States notably increased their surveys,

while others did not. By May 30, three additional States had surveyed over 80 percent 

of their nursing homes onsite since March 23: Connecticut, Oregon, and Wyoming. In 

addition, 13 States surveyed 50 percent or more of their nursing homes by May 30, 

compared to the 2 States that had done so in the first month. Several of these States 

greatly increased their onsite survey activity in May. For example, Oregon surveyed 5 

percent of its nursing homes onsite in the first month, but this increased to 92 percent

by May 30. (See Exhibit 3 on the following page for the 13 States that surveyed 50 

percent or more of their nursing homes.) However, 16 States still surveyed less than 

10 percent of their nursing homes through May. (See Appendix C for the percentage 

of nursing homes surveyed in each State during the period of March 23 through 

May 30.) 

Between March 23 and May 30, States experienced different degrees of COVID-19 

outbreaks, likely affecting the extent to which States could survey nursing homes and 

when they could conduct those surveys. For example, New York and New Jersey 

experienced severe COVID-19 outbreaks in March and April and they surveyed 

3 percent and 8 percent, respectively, of their nursing homes in the first month 

following CMS’s directive. By May 30, these two States had surveyed about 

20 percent of their nursing homes. Other States, such as Florida and Texas, did not 

experience severe COVID-19 outbreaks during this time and surveyed 50 percent of 

their nursing homes onsite by the end of May. As outbreaks continue to affect 

different States at different times, States’ ability to survey nursing homes onsite will 

likely change. For example, States may need to redirect surveyors or prioritize PPE if 

they experience an outbreak. 

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Exhibit 3: Thirteen States surveyed 50 percent or more of their nursing 

homes by May 30, 2020. 

Source: OIG analysis of Nursing Home Compare data, 2020. 

States prioritized more nursing home complaints as immediate 

jeopardy from March 23 through May 30, 2020, than during the 

same months in 2019 but received half as many complaints 

overall. 

In addition to conducting infection control surveys, States conducted surveys for 

IJ complaints and incidents. During the COVID-19 pandemic, States have prioritized a 

much higher proportion of complaints as IJ. From March 23 through May 30, States 

prioritized 31 percent of complaints as IJ, compared to about 7 percent in the same 

time period in 2019. (See Exhibit 4 on the next page.) States and CMS reported that 

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Exhibit 4: States prioritized a higher percentage of complaints as immediate 

jeopardy during the COVID-19 pandemic, but they received half as many 

complaints as in 2019. 

because COVID-19 increases the likelihood of serious harm or death for residents, 

some States prioritized more complaints related to infection control as IJ. Not 

surprisingly, States also received proportionally more complaints regarding infection 

control during the pandemic. From March 23 through May 30, the data showed that 

23 percent of complaint allegations were related to infection control. During this 

same time period in 2019, 1 percent of complaint allegations were related to infection

control. 

Source: OIG analysis of ACTS data, 2020. 

Although States prioritized a high proportion of complaints as IJ, they received far 

fewer complaints overall. From March 23 through May 30, States received about half 

the number of nursing home complaints as compared to the same time period in 

2019: from 14,592 in 2019 to 6,911 in 2020. (See Exhibit 4.) Starting on March 13, 

CMS issued guidance to nursing homes to restrict all visitors and non-essential health 

care personnel to limit the spread of COVID-19 and to protect residents. This change 

resulted in fewer people in nursing homes to observe conditions and likely 

contributed to fewer complaints in the following months. 

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Historically, the most common source of complaints has been nursing home 

residents’ family members, who in 2019 submitted about 6,000 complaints from 

March 23 through May 30. That number fell to about 2,000 for the same time period 

in 2020. Trends in total incidents self-reported by nursing homes and those incidents 

that States prioritized as IJ were similar to trends in complaints.59 

From March 23 through May 30, limited-scope surveys resulted 

in few cited deficiencies but provided opportunities for 

surveyors to support nursing homes 

While onsite, surveyors observe conditions for compliance with the Federal 

requirements. Infection control and complaint surveys focus on a narrower set of 

compliance concerns than standard surveys, which assess the overall quality of 

services provided in nursing homes.60 However, surveyors may observe and cite 

noncompliance with other Federal requirements during these limited-scope surveys. 

Surveyors can cite over 200 deficiencies, which cover topics including administration, 

resident rights, training, infection control, and quality of care, among others. 

Furthermore, while onsite, surveyors also have opportunities to share information with 

and provide support to nursing home staff. 

States cited a deficiency in 3 percent of nursing home surveys, 

with infection control deficiencies cited most often 

States and CMS conducted 7,193 onsite surveys from March 23 through May 30, and 

3 percent (193 surveys) resulted in a cited deficiency. This represents a decrease from 

the 40 percent of onsite surveys resulting in a cited deficiency during the same time 

period in 2019 when States and CMS were conducting standard surveys and surveys 

for all complaints that required one. Changes in State survey activities, the limited 

scope of the infection control surveys, and nursing facility use of CMS’s selfassessment tool may all have contributed to the decrease in deficiencies cited. During 

this timeframe in both 2019 and 2020, infection control problems were the most 

commonly cited deficiencies on nursing home surveys. Surveyors cited an infection 

control deficiency in 1 percent of onsite surveys from March 23 through May 30, 2020 

(68 surveys), and 10 percent of surveys during the same time period in 2019. 

Officials from CMS and some States reported that the limited scope of the infection 

control surveys and an increased focus on infection control at nursing homes 

contributed to the low number of deficiencies cited. Given the risk of COVID-19 to 

residents and staff, CMS designed the focused surveys to review aspects of care that 

could undermine infection control—a much narrower and more specific scope than 

standard surveys. According to State officials we interviewed, a more limited scope 

led to less time onsite by fewer surveyors. State officials told us that infection control 

surveys typically included one to two surveyors who were onsite for less than 2 days, 

and one State official explained that surveyors were onsite for about 2 hours. In 

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OEI-01-20-00430 Findings | 13 
contrast, State and CMS officials told us that a standard survey includes two to

five surveyors who are onsite for 3 to 5 days. State officials told us that this limited 

time onsite may have provided fewer opportunities for surveyors to observe 

noncompliance leading to fewer deficiencies being cited. CMS also provided the 

focused infection control survey tool to nursing homes and encouraged them to 

conduct self-assessments to learn about the latest practices for preventing the spread 

of COVID-19.61 Some officials also reported that they believed nursing homes had 

increased their vigilance around infection control protocols because of the risk of 

COVID-19, which may have also contributed to fewer citations of infection control 

deficiencies. 

The most common types of noncompliance cited in infection 

control deficiencies were improper use of PPE, contaminants on 

surfaces, and lapses in hand hygiene 

Infection control deficiencies included noncompliance with both preventive measures 

to avoid the spread of disease, and noncompliance with resident care. Among the 

68 infection control deficiencies cited by surveyors for all States between March 23 

and May 30, the most common instances of noncompliance were improper use of PPE 

(43 of 68 deficiencies), contaminants on environmental surfaces (32 of 68) and lapses

in hand hygiene (31 of 68). Other instances included failing to isolate infected 

residents and failing to provide staff education about COVID-19. For example, during 

an onsite survey conducted in April 2020, staff from one nursing home told surveyors 

that they were “unaware of a policy or procedure” specific to COVID-19. 

Most of the infection control deficiencies included more than one instance of 

noncompliance, including practices throughout the facility such as food service, 

laundry, and visitor entry. Analysis of the deficiencies revealed blatantly poor 

practices in some instances, such as one nursing home being cited for allowing staff 

to continue working despite showing signs of COVID-19. Surveyors found that 

another nursing home failed to enforce staff PPE use and handwashing despite having 

54 confirmed cases among its residents. See Appendix D for summaries of the 

instances of noncompliance identified for the 68 infection control deficiencies. 

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OEI-01-20-00430 Findings | 14 
 

States reported benefits of their onsite surveys beyond assessing

compliance 

Even though they spent limited time onsite, States reported value in their surveys. 

One State official suggested that the surveys “balanced” oversight with support to 

nursing homes during this time. Another State 

official said that the State was able to support “There is no replacement and train the nursing homes to “set them up for for being physically present. success” against COVID-19. Another State Even if we’re not citing, official said that these surveys provided an we’re ensuring that they opportunity for nursing homes to openly discuss have all the tools they need. concerns with surveyors. Some States reported The presence that sends the that CMS’s self-assessment tool was a good message: you're not alone, resource and encouraged its use among nursing you're not isolated, we're in homes to reinforce infection control practices, to this with you.” target issues of concern, and to potentially limit –State official surveyor time onsite. In addition, State officials 

reported benefit from the shorter time required

onsite during the abbreviated surveys. One State said that the abbreviated survey 

allowed surveyors to access more nursing homes more often than when the State 

conducted standard surveys. Another State mentioned the increased time in offsite 

activities associated with these surveys gave surveyors opportunities to review and 

follow up with nursing homes in greater depth. 

States reported ongoing challenges to conducting safe onsite 

surveys of nursing homes during the COVID-19 pandemic 

The health care community continues to grapple with COVID-19. The pandemic 

disrupted daily routines, and for many, the ability to continue working. No single 

roadmap existed to guide CMS’s and States’ oversight in this environment. State 

officials reported challenges to overseeing nursing homes under these conditions, 

and they voiced concern about mounting survey backlogs in this time of uncertainty. 

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OEI-01-20-00430 Findings | 15 
States reported difficulties in conducting onsite surveys because 

of challenges in acquiring and fitting PPE 

All of the States we interviewed reported difficulty obtaining PPE for surveyors to 

enter nursing homes. State officials reported that they were aware of the great need 

Personal Protective Equipment (PPE) for PPE among providers and wanted

to prioritize the limited amount of 

PPE is protective clothing, helmets, goggles, or PPE for nursing and other medical 

other garments or equipment designed to staff. In some States—including one 

protect the wearer from injury or infection. considered an early hot spot for its 

PPE also includes a variety of types of large number of COVID-19 cases—

respirators and face masks. A common mask the lack of PPE delayed onsite 

type used for treatment of individuals with surveys for weeks. States had known or suspected cases of COVID-19 is the particular difficulty in obtaining N95 respirator mask, a respiratory protective N95 face masks. CMS guidance device designed to achieve a close facial fit and 

efficient filtration of airborne particles. Certain stated from the outset of the 

respirator masks require fit testing, during pandemic that surveyors should not 

which the seal between the respirator and the go onsite without protective 

face is tested for proper fit; fit testing can take equipment, and States reported their 

15 to 20 minutes to complete and results in a concerns about compromising the 

properly fitting mask of a certain make, model, safety of their staff as well as that of 

and size. nursing home residents. 

States also reported difficulty in training surveyors in proper use of PPE, including 

putting on and taking off (donning and doffing) protective gear, and in conducting fit 

testing for N95 masks.62 These difficulties were caused in part because State survey 

agencies did not routinely acquire or use PPE prior to the COVID-19 pandemic; rather, 

they received PPE from the facilities as needed when they went onsite. As another 

example, one State reported that some staff require medical clearance for fit testing 

N95 masks and that staff sometimes do not pass fit testing. 

In some cases when States were unable to secure 

“We did not want to be a PPE, CMS stepped in to conduct surveys, surveying 

transmission source since hundreds of facilities in the early months of the 

we knew that most cases pandemic.63 For example, officials from one State 

were brought into nursing reported that when they received IJ complaints 

homes from the outside.” before they could secure PPE, they requested that 

–State official CMS conduct those surveys given the need for 

timeliness. States also sought equipment and fit 

testing from other sources such as the National 

Guard, who also visited and provided equipment and training to nursing homes. In 

one State, the National Guard visited every nursing home in the early weeks of the 

pandemic, and also joined State surveyors onsite to monitor the surveyors’ donning 

and doffing practices. Some States also received assistance from State COVID-19 task 

forces—groups that included entities across State government to coordinate supplies 

and training. 

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OEI-01-20-00430 Findings | 16 
 

 

States we interviewed reported that challenges to acquiring PPE have continued 

beyond the first weeks of the pandemic. Although lack of PPE was the most 

significant limiting factor early on, States continue to prioritize PPE for frontline 

workers and sometimes struggle to provide it for surveyors. As one official reported 

in June 2020, “Every day is a conversation about PPE.” CMS officials explained that 

many of the challenges to acquiring PPE reflected scarcity of equipment, and not 

necessarily a lack of financial resources. To assist State surveyors in acquiring PPE, 

CMS sent a letter to governors in May 2020 encouraging them to allocate PPE 

resources to State surveyors.64 

CMS also experienced challenges with surveyor availability 

CMS also had difficulty in reaching some nursing homes to conduct surveys. In addition 

to having only 70 Federal surveyors nationwide (compared to about 8,400 State

surveyors), travel restrictions limited access to some locations. CMS officials explained 

that in the early days of the pandemic, travel restrictions were changing, and they 

feared sending surveyors to hot spots when they may not be able to get 

home. Therefore, CMS planned survey assignments based on where surveyors could 

drive. 

States explained that the COVID-19 pandemic exacerbated a 

longstanding challenge of maintaining sufficient staff levels 

Securing an adequate number of surveyors is a longstanding problem for many 

States,65 and State survey agencies reported that the COVID-19 pandemic led to 

additional shortages. Surveyors were unable to perform survey work during the 

pandemic for several reasons. Some surveyors had personal risk factors for 

contracting COVID-19, such as underlying medical conditions and older age. One 

State assigned these staff to tasks other than onsite surveys, including reviewing 

licensures and managing contact tracing.66 One State with nurse surveyors at higher 

risk lent the nurses to the State’s social services department to conduct clinical 

assistance video calls with providers. CMS officials reported that in some States, 

surveyors were also diverted to other urgent tasks, such as to staff testing centers and 

hotlines, or direct care. 

Further limiting available surveyors, one State reported that individual surveyors 

sometimes requested to go onsite with another surveyor, even when one surveyor 

might technically be sufficient. The State official explained that these surveyors were 

accustomed to having a full team onsite (typically two to five surveyors for a standard

survey) and felt uncomfortable conducting the work alone, particularly considering 

the added stress of having only recently learned PPE protocols, and fearing the risk of 

infection. 

Officials from one State voiced concern that as the pandemic continues, surveyor 

shortages may deepen. State officials worried that the growing number of nursing 

home infections and deaths could make it harder to recruit and retain surveyors. To 

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OEI-01-20-00430 Findings | 17 
 

compensate for shortages of State surveyors, States reported hiring contracted 

surveyors through vendors with Surveyor Minimum Qualification Test certifications.67 

States also assigned surveyors who were typically assigned to hospitals and other 

facility types to nursing homework. 

States expressed concern about the mounting backlogs of 

standard surveys and high-priority complaint surveys 

accumulating during the COVID-19 pandemic 

As of June 2020, States had delayed standard surveys and surveys in response to 

high-priority complaints at about one-fifth (21 percent) of nursing homes as a result 

of COVID-19. CMS’s suspension of surveys allowed providers time to implement the 

most recent infection control guidance from both CMS and CDC but also created 

backlogs for when States resume these required surveys.68, 69, 70 As of June 28, 2020, 

8 percent of nursing homes (1,281 of 15,416) had gone more than 15 months without 

a standard survey and 14 percent of nursing homes (2,127) had not received surveys

for high-priority complaints.71 The backlogs could continue to grow until States 

resume survey activities and they may compound pre-existing problems that some 

States had in completing surveys within required timeframes (see Exhibit 5). 

Exhibit 5: The number of nursing homes without a standard survey for more 

than 15 months could continue to grow. 

Source: OIG analysis of ASPEN/CASPER data, 2020. 

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OEI-01-20-00430 Findings | 18 
CMS authorized States to gradually expand survey activities.72, 73, 74 As of June 1, 2020, 

CMS authorized States to expand certain survey activities, including standard surveys 

and high-priority complaint surveys, at the State’s discretion.75 CMS revised this 

guidance on August 17, 2020, indicating that States should resume survey activities if 

States have the resources to conduct the surveys. 76 Still, some States expressed 

concerns about completing their respective backlogs as they resume normal survey 

activities. Addressing the backlogs could take substantial time and make it difficult to 

meet the timeliness requirements for new surveys that will be due in the coming 

months. 

Completing the backlogs of surveys as well as the upcoming surveys will add 

additional pressure to already tight resources and limited staff. One State estimated 

that it would take at least 2 years to eliminate its backlog of surveys and return to 

normal timeframes for completing surveys, and another reported that it would be 

unable to complete its backlog without external assistance. Two States also reported 

seeking additional funding to address their respective backlogs. (Two States made 

requests to CMS and one of these States also requested supplemental funding under 

the Coronavirus Aid, Relief, and Economic Security (CARES) Act).77 

These backlogs—and the possibility that it could take years for States to return to 

normal survey timeframes—raise concerns for nursing home residents’ safety and 

quality of care. Standard surveys are critically important for protecting nursing home 

residents.78 In 2019, standard surveys identified 98,242 deficiencies at nursing homes, 

some involving actual harm or IJ deficiencies.79, 80 Outside of the COVID-19 pandemic, 

Congress has determined that nursing homes should not exceed 15 months without a 

standard survey to certify compliance with Federal requirements, yet more and more 

nursing homes will, in fact, exceed 15 months.81, 82 The Federal requirements include 

those related to resident rights and quality of care, among many others. 

The backlogs in high-priority complaint surveys—which CMS also suspended—raise 

further concerns for resident safety and quality of care. High-priority complaints 

allege situations in which a nursing home’s noncompliance with Federal requirements

may have caused patient harm that negatively impacts residents’ mental, physical, 

and/or psychological status. In 2019, high-priority complaints resulted in surveyors 

citing 21,120 deficiencies. Those complaint allegations commonly related to quality 

of care/treatment, resident rights, and resident neglect. 

These backlogs may compound preexisting challenges that States faced in meeting 

required survey timeframes. According to CMS, 32 States failed to meet CMS 

performance standards for investigating high-priority complaints within 10 days 

during fiscal years 2016 through 2018 and 17 of these 32 failed to meet the 

performance standard in all 3 years.83 Furthermore, 23 States did not meet CMS 

performance standards for conducting standard surveys within the 15-month 

period.84 These past performance problems raise further concern that States may face 

significant difficulty in completing both their current survey activities and their 

backlogs. One State said that it spent 2 years overcoming performance problems 

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OEI-01-20-00430 Findings | 19 
regarding survey timeliness, only to relapse during the pandemic. Officials from this 

State identified this relapse as their “biggest concern.” 

Another issue that State officials raised was their ability to manage additional surges 

of COVID-19 in the coming months or years. State officials expressed a desire for 

CMS to further finalize protocols and guidance in the future, creating even more 

“definitive and concrete protocols” based on lessons learned from the initial months 

of the pandemic. They also expressed fear of cases continuing long into the future. 

As one official said, “We hope that prior to [a new surge,] any additional changes that 

are forthcoming could come at a time where there may be a lull, so we aren’t 

managing crises and following new protocols all at the same time.” 

As COVID-19 hindered onsite surveys, States made efforts to 

support nursing homes outside of the survey process 

CMS and State officials acknowledged the enormous toll of the presence or threat of 

COVID-19 in nursing homes, and that much work remained to improve practices and 

prevent infection. State officials reported generally that they supported CMS’s 

decision to suspend standard surveys to limit the spread of COVID-19. With the 

smaller number of surveys, States made efforts to increase support of nursing homes 

outside of the normal survey process. 

In addition to their role as regulators, CMS 

“I hope that as a Nation, we let this and States placed a new emphasis on assisting 

be an opportunity to see how we nursing homes. One State survey agency 

can look at quality and safety reported working with State and university 

infectious-disease specialists to help train oversight in a new light, that all nursing home staff. These specialists also States are looking at creative helped relay information about COVID-19 to new ways to go forward.” nursing home providers. Another State hired –State official social workers to communicate to resident 

families since nursing homes had difficulty 

responding to family members’ concerns, such as those about new COVID-19 

visitation policies. 

In addition, States have communicated more with nursing homes, including 

conducting webinars and discussion forums, and have coordinated closely with State 

nursing home associations. One official said, “We have spent a lot of time telling 

[facilities] that they still need to communicate with residents’ families. Families are 

champing at the bit, and if the administrator does not communicate with the families, 

the families call us.” Another official, from a State that appeared to have recovered 

from a significant outbreak, explained that collaboration with nursing homes and 

provider associations, including guidance and webinars, resulted in improved 

operations. 

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OEI-01-20-00430 Findings | 20 
State officials also reported assisting nursing homes with managing specific resident 

cases, such as by coordinating with the State Medicaid offices to transfer sick 

residents to facilities dedicated to COVID-19 patients. Assisting with other specific 

cases potentially reduced the survey workload; for example, some States worked with 

nursing homes and families to resolve less serious complaint issues. 

CMS supported States in these expanded efforts. CMS helped States acquire supplies 

and support from State leadership; consulted with States on issues of guidance and 

regulation; and posted a toolkit of State best practices that had been compiled by 

Quality Improvement Organizations. States we interviewed were positive about CMS 

support, particularly from CMS’s regional offices, citing examples of assistance and 

close collaboration in managing facility and resident needs. 

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OEI-01-20-00430 Findings | 21 
CONCLUSION AND RECOMMENDATIONS 

Conclusion 

CMS has an essential, ongoing responsibility to oversee nursing homes to ensure that 

their residents are safe and receiving high-quality care. In March 2020, CMS adjusted 

its oversight approach to suspend standard surveys, prioritize the most serious 

complaints, elevate attention on infection control, and develop a new survey tool to 

ensure that nursing homes are implementing actions to prevent the spread of 

COVID-19. 

Suspending standard surveys and surveys in response to high-priority complaints may 

have been the appropriate actions at that time to allow nursing homes and States to 

focus on responding to the COVID-19 pandemic and to reduce risks to nursing home 

residents, staff, and surveyors. However, the limited scope of the surveys, combined 

with other factors, such as a lack of PPE and limiting visitors, have resulted in less 

comprehensive oversight of nursing homes and residents. Onsite surveys have been 

fewer and shorter, and—with families often restricted from visiting—complaints have 

decreased. State survey agencies have shifted some of their time to providing more 

support to nursing homes—for example, helping homes communicate with residents’

family members. Meanwhile, nursing home residents remain among those at the 

highest risk of COVID-19 infection and death, as evidenced by the more than 67,000

nursing home residents who have died as of November 8, 2020. 

Although no system of oversight is foolproof, the spread of COVID-19 and resulting 

deaths in nursing homes raise questions about how well the oversight identified and 

addressed shortfalls in infection control.85 As CMS continues to work with States to 

ensure the safety of vulnerable nursing home residents, it has an opportunity to 

enhance its approach to oversight and adapt this oversight to take advantage of 

lessons learned. 

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OEI-01-20-00430 Recommendations | 22 
We recommend that CMS: 

Assess the results of infection control surveys and revise the 

survey as appropriate 

CMS deployed a limited-scope survey focused on infection control to ensure that 

nursing homes focused on preventing the spread of COVID-19 and other 

communicable diseases and infections. CMS should determine whether these 

infection control surveys are effective in determining whether nursing homes 

implement proper infection prevention and control practices. Because CMS 

mandated that States complete infection control surveys for 100 percent of nursing 

homes nationwide, CMS should have data from more than 15,000 nursing homes to 

assess the impact of this survey tool. 

In considering any revisions to the infection control survey, CMS should also consider 

whether to add elements beyond infection control. CMS designed the infection 

control survey to be limited in scope so that surveyors could focus on what CMS 

deemed most important during the COVID-19 pandemic. However, as the pandemic 

continues, this interim survey protocol may not provide sufficient oversight if used in 

the longer term. If States are unable to resume standard surveys as the COVID-19 

pandemic continues, CMS should determine whether to expand the limited scope of 

the infection control surveys. CMS could include assessments of additional quality of 

care requirements, creating a broader interim survey to be used as long as States 

continue to struggle obtaining PPE and staffing and may be months from 

reestablishing normal operations. 

Work with States to help overcome challenges with PPE and 

staffing 

CMS relies on States to ensure that nursing homes meet Federal requirements, 

including by conducting onsite surveys. The COVID-19 pandemic exacerbated 

existing staffing challenges in States as well as introduced new challenges in 

obtaining and appropriately using PPE. These challenges hampered some States in 

conducting surveys. Although CMS does not typically provide direct assistance, it 

responded by having Federal surveyors conduct some surveys and wrote a letter to 

encourage State Governors to prioritize testing in nursing homes. 

States indicated that staffing and PPE shortages remain, and may be an ongoing 

problem. As CMS oversees States during the remainder of the pandemic, it has an 

opportunity to consider longer-term policies and strategies for assisting States during 

this pandemic and in future crises. To that end, CMS could pursue a number of 

avenues to assist States with staffing and PPE challenges, including: 

(1) Developing plans for CMS and States to ensure sufficient capacity for conducting 

onsite surveys that are based on lessons learned during the early months of the 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Recommendations | 23 
 

COVID-19 pandemic. The plans could include technical assistance, such as best 

practices for States in acquiring PPE, and sources for training and N95 fitting. The 

plans could also make clear the circumstances under which CMS might send its 

limited number of Federal surveyors to supplement State surveys and other types of 

direct assistance. For example, it could describe the criteria that it might use to 

determine how, when, and where to send Federal surveyors to assist States. 

(2) Requiring States to establish their own clear action plan for reducing barriers to 

conducting onsite surveys, including practical information about sources for PPE and 

supplemental staffing, and other support as needed to assist State surveyors in 

conducting onsite surveys. 

(3) Assisting States in other ways, such as serving as a liaison and advocate for States

in interacting with Federal agencies for PPE acquisition (Federal Emergency 

Management Agency) or PPE training (CDC). 

Clarify expectations for States to complete backlogs of standard 

surveys and high-priority complaint surveys 

Onsite nursing home surveys, including those that respond to serious complaints, are 

critical safeguards to protect nursing home residents. CMS’s suspension of standard 

surveys and high-priority complaint surveys resulted in substantial backlogs of 

required surveys. On August 17, CMS authorized States to resume these surveys 

when the States have the resources to do so. Although this will reduce the growth of 

the backlogs, States expressed concerns that additional resources and time are 

needed to address the backlogs that already exist. In addition, past performance 

problems—prior to COVID-19—indicate that many States were already struggling to 

meet required survey timeframes. CMS should provide clear expectations for 

addressing the backlogs of standard and complaint surveys, including guidance on 

how States are to prioritize survey activities and required timeframes for eliminating 

backlogs, as well as information about how delayed surveys will be evaluated with 

respect to required timeframes. 

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OEI-01-20-00430 Recommendations | 24 
AGENCY COMMENTS AND OIG RESPONSE 

We received comments on the draft report from CMS. 

In its comments, CMS did not explicitly concur with our recommendation that it 

assess results of the infection control survey and revise as appropriate, but CMS 

described actions it has taken that address the recommendation. For example, in 

August 2020, CMS revised the infection control survey to incorporate new COVID-19

requirements regarding testing and designating a facility infection preventionist. 

CMS also stated that it will continue to assess and revise the survey as appropriate, 

and reiterated that it did not intend for the infection control survey to replace 

standard surveys. We encourage CMS to continue assessing and revising the 

infection control survey as needed, including expanding its scope if States are unable 

to resume standard surveys as the pandemic continues. We ask that CMS detail any 

additional and planned steps toward implementing this recommendation in its Final 

Management Decision. 

CMS also did not explicitly concur with our recommendation that it clarify 

expectations for States to complete survey backlogs, but CMS described actions it has 

taken that address the recommendation. For example, CMS issued guidance 

regarding how States are to resume onsite surveys when they have the resources to 

do so. CMS also stated that it will continue working with States regarding how to

address backlogs of standard and complaint surveys. As CMS continues to work with 

States on this, we encourage CMS to more specifically detail any required timeframes 

for eliminating backlogs, as well as provide information about how it will evaluate any 

delayed surveys with respect to required timeframes. This is especially important 

given the importance of surveys to resident safety and ongoing difficulties with States 

meeting survey timeframes. We ask that CMS detail any additional and planned steps 

toward implementing this recommendation in its Final Management Decision. 

CMS did not concur with our recommendation that it work with States to help 

overcome challenges with PPE and staffing, citing its lack of authority to address 

issues of allocating these resources to States. CMS noted that it has taken steps to 

support States in these areas where feasible. OIG is not recommending CMS exceed 

its authority; rather, we continue to recommend that CMS identify opportunities 

within its authority to support States facing challenges securing PPE and staffing. 

CMS could do this by providing additional guidance and leadership, as articulated in 

this recommendation. We ask that CMS detail any additional and planned steps 

toward implementing this recommendation in its Final Management Decision. 

For the full text of CMS’s comments, see Appendix E. 

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OEI-01-20-00430 Agency Comments and OIG Response | 25 
DETAILED METHODOLOGY 

Data Sources 

This study used the following data sources: (1) complaint, incident, and associated 

survey information entered into ACTS; (2) survey and deficiency data from CMS’s 

ASPEN and CASPER systems; (3) survey and deficiency data from Nursing Home 

Compare; (4) statements of deficiencies (CMS-2567 forms) from onsite surveys in 

2020; (5) an interview with CMS; and (6) brief interviews with 10 State survey agencies. 

Data Analysis 

CMS Complaint and Incident Data. OIG’s Division of Data Analytics (DDA) 

obtained ACTS data from CMS on nursing home complaints and incidents that States 

received in comparable 2019 and 2020 time periods. CMS extracted the data on 

June 29, 2020. We removed records in which the State entered a start date for the 

onsite survey that was prior to the complaint receipt date. Our final dataset included 

observations from all 50 States and the District of Columbia. We analyzed these data 

to determine the number of complaints and incidents that States prioritized as IJ in 

Medicare and Medicaid-certified nursing homes from March 23 through May 30, 

2019, and from March 23 through May 30, 2020. We also determined the sources of 

complaints during these time periods (e.g., nursing home residents, their family 

members, and nursing home staff). In addition, we analyzed the types of allegations 

for complaints received. Finally, we determined the number of nursing homes that 

received a high-priority complaint from March 23 through June 28, 2020. 

CMS Survey and Deficiency Data. We used CMS’s publicly available data on 

the Nursing Home Compare website to assess surveys and deficiencies during the 

COVID-19 pandemic in 2020. On June 24, 2020, CMS posted data on surveys 

completed between March 4 and May 30, 2020. We assessed trends in onsite surveys 

and the deficiencies cited in these surveys from March 23 through May 30, 2020, in all 

50 States and the District of Columbia. To determine the percentage of nursing 

homes that received an onsite survey nationally, we used the number of nursing 

homes by State for 2020, available on Nursing Home Compare. 

OIG’s DDA provided ASPEN data from CMS on nursing home surveys and deficiencies 

from January 1, 2018, through June 28, 2020. The data were extracted on June 29, 

2020. We used these data to assess trends in surveys and deficiencies during the 

same time period in 2019 in all 50 States and the District of Columbia. When 

determining the number of nursing homes that CMS and States surveyed onsite, we 

counted nursing homes that had at least one standard survey or complaint survey. 

We excluded those complaint surveys with zero onsite hours. We calculated the 

average percentage of nursing homes with an onsite survey by month in 2019. For 

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OEI-01-20-00430 Detailed Methodology | 26 
this calculation, we used the number of nursing homes by State in 2019 available on 

Nursing Home Compare. For our comparison to deficiencies cited in 2019, we 

included any deficiency cited from standard surveys and complaint surveys between 

March 23 through May 30, 2019. In addition, we determined the number of nursing 

homes that did not have a standard survey during the 16 months prior to March 23 

through June 28, 2020, to estimate the backlog of surveys for each State. To 

determine the number of deficiencies associated with a high-priority complaint in 

2019, OIG’s DDA matched complaint data from ACTS to complaint survey data in 

ASPEN with an algorithm provided by CMS. 

Finally, we determined the number of infection control deficiencies by counting 

instances of CMS’ F-880 infection prevention and control deficiency during both the 

comparable 2019 time period and the COVID-19 pandemic. 

Review of CMS-2567 Forms. We conducted a limited review of CMS-2567 

forms (statements of deficiencies) from onsite surveys during the pandemic. A 

completed CMS-2567 form includes detailed descriptions about deficiencies cited 

during a survey and the plan of correction for each deficiency. 

Using the CMS-2567 forms that CMS made available on Nursing Home Compare on

June 24, 2020, we identified and reviewed all 68 CMS-2567 forms that included the 

F-880 infection prevention and control deficiency from March 23 through May 30, 

2020. The CMS-2567 forms included the specific instances of noncompliance that 

resulted in the deficiency citation. Deficiencies may be based on more than one 

instance of noncompliance. 

We developed 11 categories to describe specific instances of noncompliance for the 

68 infection control deficiencies. We based the categories on critical elements 

associated with the transmission of COVID-19 as described in the CMS 

COVID-19-focused survey. We reviewed the narrative of each CMS-2567 form and 

categorized the instances of noncompliance into 1 or more of the 11 categories to 

determine the most common reasons for noncompliance with infection control 

practices (e.g., hand hygiene). 

Interview with CMS. We conducted an interview with leadership in the Survey 

and Operations Group and the Quality, Safety, and Oversight Group on June 18, 2020. 

We asked about CMS’s approach to nursing home oversight during COVID-19, 

including: (1) the process for selecting and prioritizing nursing homes for focused 

infection control surveys, (2) the number of focused infection control surveys that 

CMS conducted as well as future plans to conduct surveys, (3) plans for reopening 

and addressing backlogs resulting from the suspension of surveys, and (4) how CMS 

has collaborated with States and other groups across HHS. 

Interviews with State Survey Agencies. To provide additional insight 

about nursing home oversight during the COVID-19 pandemic, we selected a 

purposive sample of 10 States for brief telephone interviews: California, Illinois, 

Louisiana, Massachusetts, Nebraska, New Jersey, Tennessee, Utah, Washington, and 

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OEI-01-20-00430 Detailed Methodology | 27 
 

 

 

 

 

 

 

West Virginia. We conducted these interviews from June 9 through June 18, 2020. 

The interviews covered five topics: (1) experiences conducting complaint surveys, 

(2) experiences selecting and conducting focused infection control surveys, (3) any 

barriers to conducting surveys during the pandemic, (4) any strategies to overcome 

those barriers, and (5) experiences with other oversight activities conducted during 

the pandemic. 

We selected the sample of 10 States to ensure that we captured States with a range of 

impact from COVID-19 and represented each of the 10 CMS regional offices. We 

categorized States as having a high, medium, or low impact from COVID-19 based on 

cumulative cases, density of the disease within the population, and percentage of 

deaths within the State occurring in long-term care facilities. We selected about half 

of the sample from States with a high impact from COVID-19 and about half from 

States with a moderate or low impact. See Exhibit 6 for statistics associated with the 

selected States. 

Exhibit 6: Statistics for 10 sample States as of May 14, 2020. 

Percentage of State COVID-19 Cases COVID-19 COVID-19 Deaths in State Per 1,000,000 Cumulative Cases Long-Term Care Population Facilities 

California 73,218 2,160 39 

Illinois 84,874 7,925 48 

Louisiana 32,662 7,597 39 

Massachusetts 80,497 12,908 63 

Nebraska 9,075 5,609 71 

New Jersey 141,560 16,975 52 

Tennessee 16,261 2,696 32 

Utah 6,624 2,405 40 

Washington 18,604 2,470 53 

West Virginia 1,404 862 55 

Source: Kaiser Family Foundation.86 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Detailed Methodology | 28 
APPENDIX A 

CMS guidance to States pertaining to nursing homes from February 

through August 2020 

Date Title & Number Key Provisions 

February 6, 2020 Information for Healthcare Facilities Strongly urges the review of CDC guidance and 

Concerning 2019 Novel Coronavirus encourages facilities to review their own infection 

Illness (2012-nCoV), QSO-20-09-ALL87 prevention and control policies and practices to

prevent the spread of infection 

March 4, 2020 Suspension of Survey Activities, QSO- Limits survey activity to the following (in Priority

20-12-All88 Order): 

 surveys in response to all immediate 

jeopardy complaints and allegations of 

abuse and neglect; 

 surveys in response to complaints alleging

concerns about infection control, 

including facilities with potential COVID19 or other respiratory illnesses; 

 statutorily required recertification surveys; 

 any re-visits necessary to resolve current 

enforcement actions; 

 initial certifications surveys; 

 surveys of facilities that have a history of 

infection control deficiencies at the 

immediate jeopardy level in the past 3 

years; and 

 surveys of facilities centers that have a 

history of infection control deficiencies at 

lower levels than immediate jeopardy. 

March 13, 2020 Guidance for Infection Control and Updates the March 4, 2020, memo with guidance 

Prevention of Coronavirus Disease to restrict all visitors and non-essential health care 

2019 (COVID-19) in Nursing Homes personnel with exceptions for health care workers 

(Revised), QSO-20-14-NH89 and surveyors 

March 23, 2020 Prioritization of Survey Activities, Limits surveys to: 

Admin Info: QSO-20-20-All90  surveys prompted by complaint/facilityreported incident surveys, 

 targeted Infection Control surveys, and 

 self-assessments. 

Instructs State or Federal surveyors to refrain from 

performing an onsite survey if they are unable to 

meet the PPE expectations outlined by CDC 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix A | 29 
Date Title & Number Key Provisions 

April 19, 2020 Upcoming Requirements for Requires that facilities notify residents and their 

Notification of Confirmed COVID-19 representatives to keep them informed of the 

(or COVID-19 Persons Under conditions inside the facility. 

Investigation) Among Residents and 

Staff in Nursing Homes, QSO-20-26-

All91 

April 24, 2020 Nursing Home Five Star Quality Rating Waives the timeframe requirement for submitting

System Updates, Nursing Home Staff resident assessment data and staff data. 

Counts and Frequently Asked Announced that the results of health inspections

Questions, QSO-20-28-NH92 conducted on or after March 4, 2020, will be 

posted publicly but not used to calculate 

inspection star ratings. 

May 6, 2020 Interim Final Rule Updating Requires nursing homes to report COVID-19 

Requirements of Confirmed and facility data to the CDC and to residents, their 

Suspected COVID-19 Cases Among representatives, and families of residents in

Residents and Staff in Nursing Homes, facilities. 

QSO-20-29-NH93 

May 18, 2020 Nursing Home Reopening Provides recommendations to determine the level 

Recommendations for State and Local of mitigation needed for their communities to 

Officials, QSO-20-30-NH94 allow for relaxing restrictions in nursing homes. 

June 1, 2020 COVID-19 Survey Activities, CARES Act Requires States to complete 100 percent of 

Funding, Enhanced Enforcement for infection control surveys for all nursing homes. 

Infection Control deficiencies and Authorized States to expand certain survey 

Quality Improvement Activities in activities, including standard surveys and highNursing Homes, QSO-20-31-NH95 priority complaint surveys. 

June 4, 2020 Posting of Nursing Home Inspections, Announces posting of health inspection (i.e., 

QSO-20-33-NH96 surveys) results that were conducted on or after

March 4, 2020, which is the first date that CMS 

altered the way inspections are scheduled and 

conducted. 

June 4, 2020 Release of COVID-19 Nursing Home Announces posting of COVID-19 data submitted 

Data, QSO-20-32-NH97 by facilities via the CDC National Healthcare Safety 

Network. 

June 25, 2020 Changes to Staffing Information and Ends the waiver requirement for nursing homes to 

Quality Measures Posted on the submit staffing data through the Payroll-Based 

Nursing Home Compare Website and Journal System. 

Five Star Quality Rating System due to 

the COVID-19 Public Health 

Emergency, QSO-20-34-NH98 

August 17, 2020 Enforcement Cases Held During the Authorizes the expansion of survey activities and 

Prioritization Period and Revised provides guidance to States about resolving 

Survey Prioritization, QSO-20-35-ALL suspended enforcement cases. 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix A | 30 
APPENDIX B 

Percentage of Nursing Homes With Onsite Survey, by State 

State March 23–April 23, 2020 Average per Month in 2019 

ALABAMA 

ALASKA 

ARIZONA 

ARKANSAS 

CALIFORNIA 

COLORADO 

CONNECTICUT 

DELAWARE 

DISTRICT OF COLUMBIA 

FLORIDA 

GEORGIA 

HAWAII 

IDAHO 

ILLINOIS 

INDIANA 

IOWA 

KANSAS 

KENTUCKY 

LOUISIANA 

MAINE 

MARYLAND 

MASSACHUSETTS 

MICHIGAN 

MINNESOTA 

MISSISSIPPI 

MISSOURI 

MONTANA 

NEBRASKA 

NEVADA 

NEW HAMPSHIRE 

NEW JERSEY 

NEW MEXICO 

NEW YORK 

NORTH CAROLINA 

NORTH DAKOTA 

2% 

5% 

0% 

23% 

88% 

8% 

48% 

7% 

6% 

35% 

3% 

7% 

0% 

1% 

11% 

1% 

10% 

38% 

6% 

2% 

0% 

9% 

26% 

38% 

1% 

3% 

0% 

0% 

47% 

4% 

8% 

0% 

3% 

4% 

3% 

10% 

11% 

10% 

31% 

56% 

21% 

13% 

19% 

21% 

33% 

18% 

10% 

9% 

43% 

33% 

16% 

27% 

24% 

21% 

30% 

21% 

21% 

35% 

21% 

21% 

49% 

13% 

16% 

27% 

12% 

18% 

18% 

22% 

23% 

9% 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix B | 31 
State March 23–April 23, 2020 Average per Month in 2019 

OHIO 0% 33% 

OKLAHOMA 8% 19% 

OREGON 5% 19% 

PENNSYLVANIA 1% 28% 

RHODE ISLAND 13% 23% 

SOUTH CAROLINA 5% 10% 

SOUTH DAKOTA 2% 11% 

TENNESSEE 14% 37% 

TEXAS 44% 42% 

UTAH 1% 15% 

VERMONT 3% 30% 

VIRGINIA 0% 10% 

WASHINGTON 84% 77% 

WEST VIRGINIA 0% 11% 

WISCONSIN 4% 24% 

WYOMING 41% 24% 

AVERAGE ACROSS STATES 13% 24% 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix B | 32 
APPENDIX C 

Percentage of Nursing Homes Surveyed in Each State, 

March 23–May 30, 2020 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix C | 33 
Code Category Examples 

A Improper PPE Usage Staff not wearing or changing PPE, staff unaware of PPE practices 

B Environmental 

Contamination 

Staff contaminating and/or not properly disinfecting facility equipment 

and resident surroundings 

C Improper Hand Hygiene Staff not washing hands or washing inadequately 

D 

E 

F 

G 

Transmission Concerns 

Resident Care Concerns 

Screening, Monitoring, 

and Education of Staff 

IPCP Standards 

Lack of PPE, handwashing, and/or signage within or outside of 

transmission-based precaution rooms 

Lack of resident isolation or social distancing, not communicating with 

hospitals about transfers 

Not screening and monitoring staff for infectious disease; lack of staff 

education; lack of appropriate return-to-work policies 

Facility’s Infection Prevention and Control Program (IPCP) not meeting 

standards 

H Infection Surveillance Facility not tracking, monitoring, and/or testing for reported infectious 

disease 

I Visitor Entry Facility not screening, monitoring, or properly restricting visitors 

J Laundry Staff not handling contaminated laundry appropriately 

K Other 

Additional problems not listed above, such as staff not storing 

equipment and supplies or handling food correctly, and the facility’s 

water not reaching correct temperatures 

APPENDIX D 

Summaries of Instances of Noncompliance Identified for 

68 Infection Control Deficiencies 

Exhibit D-1: Categories of Noncompliance with Infection Control. 

Source: OIG Analysis of nursing home infection control surveys nationally, March 23–May 30, 2020. 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix D | 34 
Exhibit D-2: Instances of Noncompliance by Category for 68 Infection Control Deficiencies, 

(March 23–May 30, 2020). 

Instance of Noncompliance Number Percentage (n = 68) 

Improper PPE Usage 43 63% 

Environmental Contamination 32 47% 

Improper Hand Hygiene 31 46% 

Transmission-based Precautions 18 26% 

Resident Care 13 19% 

Screening, Monitoring, and Education of Staff 13 19% 

IPCP Standards 7 10% 

Infection Surveillance 7 10% 

Visitor Entry 6 9% 

Laundry 4 6% 

Other 6 9% 

Source: OIG Analysis of nursing home infection control surveys nationally, March 23–May 30, 2020. 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix D | 35 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Exhibit D-3: Summary of 68 Infection Control Deficiencies with Categories of 

Noncompliance (March 23–May 30, 2020). 

Summary of Deficiency Categories of Noncompliance 

A B C D E F G H I J K 

Staff did not place resident on transmission precautions. Facility did not 

isolate resident; did not report infectious disease. 

 X X X 

Staff had no documentation of tuberculosis screening. X 

Staff did not disinfect scissors between uses. X 

Facility did not implement social distancing. X 

Staff entered isolation room without PPE; did not wash hands; did not 

know which residents had infectious disease. Facility did not isolate 

residents; did not educate staff; did not require visitors to wear PPE. 

X X X X X X X 

Staff did not change soiled gloves. X 

Staff left a catheter bag on the floor. X 

Staff did not wear PPE when treating resident on isolation; did not 

sanitize thermometer; entered resident’s room without washing hands. 

X X X X 

Staff fed resident with bare hands; placed supplies on surface with no 

barrier; did not wash hands. Facility did not educate staff; had no

protocols regarding handling PICC [peripherally inserted central catheter 

lines]. 

X X X X X X 

Staff wore masks improperly; did not wash hands; entered room marked 

for droplet isolation without protective eyewear. 

X X X 

Staff did not disinfect a blood pressure cuff. X 

Facility held event without social distancing; did not prohibit visitors. X X 

Facility did not monitor staff temperatures. X 

Staff did not wash hands between glove changes; did not sanitize 

shower chair between uses; cross-contaminated linens. 

X X X X 

Staff touched a soiled mop pad with bare hands, then touched cleaning 

supply cart; did not wash hands after taking out trash. 

X X X 

Staff changed gloves without washing hands. X X 

Staff placed personal items on isolation cart; did not wash hands. Facility 

did not ask visitors to wash hands; dishwasher did not reach 120°F.

 X X X X X 

Staff did not disinfect a blood pressure cuff. X 

Staff changed gloves without washing hands. X X 

Staff stored clean laundry and open box of PPE alongside dirty laundry. X X X 

Staff did not use PPE when caring for resident on transmission

precautions; cleaned a thermometer with a contaminated sponge. 

X X X 

Staff did not wash hands before donning PPE or touching environment. 

Facility did not monitor staff compliance with COVID-19 protocols. 

X X X X 

Staff did not don PPE or wash hands before entering isolation room. X X X 

Staff did not sanitize an emergency eyewash station. X 

Staff brought dirty linen into clean linen area. X 

Staff did not doff contaminated PPE. Facility did not report COVID-19. X X X 

Staff did not remove gloves or wash hands before leaving resident’s 

room. Facility had vent filled with gray substance. 

X X X 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix D | 36 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of Deficiency Categories of Noncompliance 

A B C D E F G H I J K 

Facility did not monitor its staff for COVID-19; did not document or 

report instances of COVID-19; did not implement entry procedures for 

staff or visitors in accordance with CDC guidelines. 

 X X X 

Staff did not require residents to wear masks over mouths; did not 

disinfect a mechanical lift; did not wash hands after handling laundry; left

dirty laundry on the floor. Facility did not implement social distancing. 

X X X X X 

Staff did not provide a visitor with mask. Facility did not implement 

social distancing; did not screen visitors for COVID-19. 

X X X 

Staff wore masks improperly; exited rooms and handled food without 

washing hands. Facility did not require visitors to wash hands. 

X X X X X 

Staff did not disinfect a blood pressure cuff. X 

Staff did not doff contaminated PPE; picked up a dead roach and then

touched water faucet; did not wash hands before donning PPE. 

X X X 

Staff doffed PPE incorrectly. Facility did not post isolation signage; did 

not maintain a list of COVID-19 cases. 

X X X 

Staff did not wear a mask while moving resident. X 

Staff did not wash hands before entering room. X 

Staff changed gloves without washing hands; placed supplies on soiled 

surface with no barrier. 

X X X 

Staff wore masks improperly. Facility policy did not address hand

washing; did not ask visitors or staff to wash hands when entering. 

X X X X 

Staff donned gloves and prepared medicine without washing hands. X X 

Staff did not wear masks. Facility policy did not implement masks due to 

a mandate from its corporate office. 

X X 

Staff did not sanitize a pulse oximeter; did not wash hands. X X 

Staff placed PPE in pocket; did not sanitize handrails; did not wash 

hands; placed isolation room tray on cart. Facility did not implement 

social distancing. 

X X X X X 

Staff sanitized equipment with the same disinfectant wipe. X 

Staff did not disinfect a mechanical lift. X 

Staff did not wear PPE in kitchen. Facility had no policy requiring staff to 

wear PPE in kitchen despite guidelines. 

X X 

Staff entered room without removing soiled gloves; did not sanitize a 

blood glucose monitor; did not wash hands. 

X X X 

Facility did not complete fit testing for masks; did not isolate residents

with COVID-19; had no policies for addressing residents with COVID-19. 

Staff continued to work despite chills and fever. 

X X X X 

Staff did not wear masks. Facility did not train staff to ask residents to

cover their faces and mouths with masks. 

X X 

Staff did not wash hands prior to taking resident’s blood pressure. X 

Staff wore masks improperly; did not wash hands; did not isolate 

resident; did not cover their face while serving food. 

X X X X 

Staff changed gloves and did not wash hands; cleaned toilet and then 

touched countertop. Facility did not post isolation signage or implement 

social distancing. 

X X X X X 

Staff did not monitor resident’s temperature despite doctor’s orders. X 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix D | 37 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Summary of Deficiency Categories of Noncompliance 

A B C D E F G H I J K 

Staff entered transmission precautions room without PPE or washing 

hands. 

X X X 

Staff did not wear masks; transferred maskless resident through facility; 

did not isolate resident. 

X X X 

Staff entered a room without PPE or washing hands; touched controller 

with contaminated hands. 

X X X 

Staff did not disinfect a blood pressure monitor; did not wash hands. X X 

Staff did not disinfect equipment; did not ask residents to wear masks. 

Facility did not train staff to ask residents to cover faces and mouths with

masks. 

X X X 

Staff entered transmission precautions room without PPE or washing 

hands; touched wheelchair with contaminated hands. 

X X X X 

Staff wore mask improperly; touched wheelchair with contaminated

gloves. Facility did not post isolation signage; did not implement social 

distancing; did not train staff on proper PPE practices. 

X X X X X 

Staff wore masks improperly. X 

Facility did not have a screening station for staff and visitor entry. X 

Staff reused PPE. Facility did not require staff to discontinue this 

practice. 

X X 

Staff entered room without PPE or washing hands; touched wheelchair. X X X 

Staff cleaned surfaces with mislabeled chemicals without knowledge of 

dwell time. Facility did not document staff temperatures. 

 X X 

Staff did not allow surface cleaner to sit for the appropriate dwell time. X 

Staff did not use PPE; did not sanitize equipment; did not wash hands. 

Facility did not post isolation signage. 

X X X X 

Staff did not stock isolation room carts with PPE. X X 

Staff did not use PPE. Facility did not educate staff on COVID-19; did not

isolate resident; did not transfer resident to emergency room despite 

orders. 

X X X X 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix D | 38 
APPENDIX E 

Agency Comments 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix E | 39 
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix E | 40 
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix E | 41 
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix E | 42 
Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Appendix E | 43 
ACKNOWLEDGMENTS AND CONTACT 

Acknowledgments 

Ben Gaddis and Kimberly Ruppert served as the project leaders for this study, and 

Shanna Weitz served as the lead analyst. Others in the Office of Evaluation and 

Inspections who conducted the study include Sarah Lee, Shweta Palakkode, Karl 

Santos, and Troy Yamaguchi. Office of Evaluation and Inspections staff who provided 

support include Joseph Chiarenzelli, Kevin Farber, and Christine Moritz. 

This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector 

General for Evaluation and Inspections in the Dallas regional office, Joyce Greenleaf, 

Regional Inspector General for Evaluation and Inspections in the Boston regional 

office; and Amy Ashcraft and Danielle Fletcher, Deputy Regional Inspectors General in 

the Dallas and Boston regional offices, respectively. 

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 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Acknowledgments and Contact | 44 
ABOUT THE OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-

452, as amended, is to protect the integrity of the Department of Health and Human 

Services (HHS) programs, as well as the health and welfare of beneficiaries served by 

those programs. This statutory mission is carried out through a nationwide network 

of audits, investigations, and inspections conducted by the following operating 

components: 

The Office of Audit Services (OAS) provides auditing services for HHS, 

either by conducting audits with its own audit resources or by overseeing audit work 

done by others. Audits examine the performance of HHS programs and/or its 

grantees and contractors in carrying out their respective responsibilities and are 

intended to provide independent assessments of HHS programs and operations. 

These audits help reduce waste, abuse, and mismanagement and promote economy 

and efficiency throughout HHS. 

The Office of Evaluation and Inspections (OEI) conducts national 

evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 

information on significant issues. These evaluations focus on preventing fraud, waste, 

or abuse and promoting economy, efficiency, and effectiveness of departmental 

programs. To promote impact, OEI reports also present practical recommendations 

for improving program operations. 

The Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of fraud and misconduct related to HHS programs, operations, and 

beneficiaries. With investigators working in all 50 States and the District of Columbia, 

OI utilizes its resources by actively coordinating with the Department of Justice and 

other Federal, State, and local law enforcement authorities. The investigative efforts 

of OI often lead to criminal convictions, administrative sanctions, and/or civil 

monetary penalties. 

The Office of Counsel to the Inspector General (OCIG) provides 

general legal services to OIG, rendering advice and opinions on HHS programs and 

operations and providing all legal support for OIG’s internal operations. OCIG 

represents OIG in all civil and administrative fraud and abuse cases involving HHS 

programs, including False Claims Act, program exclusion, and civil monetary penalty 

cases. In connection with these cases, OCIG also negotiates and monitors corporate 

integrity agreements. OCIG renders advisory opinions, issues compliance program 

guidance, publishes fraud alerts, and provides other guidance to the health care 

industry concerning the anti-kickback statute and other OIG enforcement authorities. 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 About the OIG | 45 
 

 

ENDNOTES 

1 CDC, Coronavirus Disease 2019 (COVID-19): Older Adults, June 25, 2020. Accessed at https://www.cdc.gov/coronavirus/2019-

ncov/need-extra-precautions/older-adults.html on July 23, 2020. 

2 New York Times, Nursing Home Linked to 37 Coronavirus Deaths Faces Fine of $600,000, April 2, 2020. Accessed at 

https://www.nytimes.com/2020/04/02/us/virus-kirkland-life-care-nursing-home.html on July 13, 2020. 

3 CMS, COVID-19 Nursing Home Data, submitted data as of week ending November 8, 2020. Accessed at 

https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/ on November 24, 2020. 

4 Johns Hopkins University of Medicine, Coronavirus Resource Center, COVID-19 United States by County. Accessed at 

https://coronavirus.jhu.edu/us-map on November 24, 2020. 

5 Government Accountability Office, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to 

COVID-19 Pandemics, GAO-20-576R, May 20, 2020. 

6 Ibid. 

7 Washington Post, Mask shortage for most health-care workers extended into May, Post-Ipsos poll shows, May 20, 2020. 

Accessed at https://www.washingtonpost.com/health/mask-shortage-for-most-health-care-workers-extended-into-may-postipsos-poll-shows/2020/05/20/1ddbe588-9a21-11ea-ac72-3841fcc9b35f_story.html on June 24, 2020. 

8 OIG, Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23–27, 2020, 

OEI-06-20-00300, April 4, 2020. 

9 Social Security Act § 1864(a); 42 CFR § 488.330; CMS, State Operations Manual (SOM), Pub. No. 10-07 ch. 1, Program 

Background and Responsibilities, Section 1002. 

10 When we refer to nursing homes, we make no distinction between Medicare Skilled Nursing Facilities and Medicaid Nursing 

Facilities. We calculated the number of nursing homes nationally by counting the number of distinct skilled nursing facilities

and Medicaid Nursing Facilities that received a standard survey in the past 4 years (Source: OIG analysis, 2020). 

11 Social Security Act §§ 1819(g) and 1919(g). 

12 42 CFR § 488.308. 

13 Sections 1819(f)(1) and 1919(f)(1) of the Social Security Act. 

14 Ibid. 

15 CMS, Action Plan for Further Improvement of Nursing Home Quality. Accessed at https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/CertificationandComplianc/Downloads/2016-2017-Nursing-Home-Action-Plan.pdf on July 12, 

2020. 

16 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16). 

17 Social Security Act § 1864(a); 42 CFR § 488.330; SOM, ch. 1, Section 1002. 

18 Social Security Act §§ 1819(g) and 1919(g). 

Onsite Surveys of Nursing Homes During the COVID-19 Pandemic: March 23–May 30, 2020

OEI-01-20-00430 Endnotes | 46 
 

 

19 Sections 1819(g) and 1919(g) of the Social Security Act. 

20 Social Security Act §§ 1819(g)(2)(E) and 1919(g)(2)(E); CMS, SOM, Pub. No. 100-07, ch. 7, Survey and Enforcement Process for 

Skilled Nursing Facilities and Nursing Facilities (Revised 185, 11-16-18). 

21 CMS, SOM, Pub. No. 100-07 Appendix P: Survey Protocol for Long Term Care Facilities—Part I. Accessed at 

https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/GuidanceforLawsAndRegulations/Downloads/som107ap_p_ltcf.pdf on July 13, 2020. 

22 Ibid. 

23 CMS defines the other two levels of harm as follows: no actual harm with potential for minimal harm and no actual harm 

with the potential for more than minimal harm that is not immediate jeopardy. 

24 CMS, Nursing Home Enforcement. Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationEnforcement/Nursing-Home-Enforcement on July 23, 2020. 

25 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16). 

26 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16). 

27 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 191, 07-19-19), Section 5070. 

28 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16). 

29 OIG analysis of ASPEN Complaint Tracking System (ACTS) data, April 2020. 

30 A complaint survey focuses on the specific issues of the complaint. However, if surveyors observe other compliance issues 

while investigating the complaint allegation then they will cite the nursing home for these deficiencies as well. 

31 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 155, 06-10-16). 

32 42 CFR § 483.12(c)(1). 

33 CMS, SOM, Pub. No. 100-07, ch. 5, Complaint Procedures (Revised 191, 07-19-19), Section 5075.9. 

34 CMS, SOM, Pub. No. 100-07, ch. 1, Program Background and Responsibilities, Section 1006. 

35 CMS, FY 2016 to FY 2017 Nursing Home Action Plan, May 2016, p. 11. Accessed at https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-26.pdf on August 20, 2019. 

36 CMS, FY 2020 State Performance Standards System Guidance, Admin Info: 20-02-ALL, October 17, 2019. 

37 CDC, Coronavirus Disease 2019 (COVID-19) Symptoms of Coronavirus. Accessed at https://www.cdc.gov/coronavirus/2019-

ncov/symptoms-testing/symptoms.html on March 29, 2020. 

38 National Public Radio, How COVID-19 Kills: The New Coronavirus Disease Can Take a Deadly Turn. Accessed at 

https://www.npr.org/sections/goatsandsoda/2020/02/14/805289669/how-covid-19-kills-the-new-coronavirus-disease-cantake-a-deadly-turn on July 15, 2020. 

39 NPR, 1st U.S. Case of Coronavirus Confirmed in Washington State, January 22, 2020. Accessed at 

https://www.npr.org/2020/01/22/798392221/1st-u-s-case-of-coronavirus-confirmed-in-washington-state on July 7, 2020. 

40 Seattle Times, Life Care Center of Kirkland, the epicenter of Seattle-area coronavirus outbreak, faces $611,000 fine, April 2, 

2020. Accessed at https://www.seattletimes.com/seattle-news/life-care-center-of-kirkland-the-epicenter-of-seattle-areacoronavirus-outbreak-faces-611000-fine-for-jeopardy-to-patients/ on July 27, 2020. 

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OEI-01-20-00430 Endnotes | 47 
41 World Health Organization, WHO Director-General’s opening remarks at the media briefing on COVID-19, 11, March 2020. 

Accessed at https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-oncovid-19---11-march-2020 on April 3, 2020. 

42 An epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that 

population in that area. CDC, Principles of Epidemiology in Public Health Practice. Accessed at 

https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html on March 27, 2020. 

43 World Health Organization, The classical definition of a pandemic is not elusive, July 2011, Accessed at 

https://www.who.int/bulletin/volumes/89/7/11-088815/en/ on August 20, 2020. 

44 CMS, CMS Takes Action Nationwide to Aggressively Respond to Coronavirus National Emergency, March 13, 2020. Accessed at 

https://www.cms.gov/newsroom/press-releases/cms-takes-action-nationwide-aggressively-respond-coronavirus-nationalemergency on July 10, 2020. 

45 CMS, Prioritization of Survey Activities, Admin Info: QSO-20-20-All, March 23, 2020. 

46 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020. 

47 CMS, Suspension of Survey Activities, Ref: QSO-20-12-All, March 4, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-12-all.pdf on July 7, 2020. 

48 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020. 

49 CMS, COVID-19 Surveyor Training. Accessed at 

https://qsep.cms.gov/pubs/VideoInformation.aspx?id=274&cid=0CMSCOVID19_LTC on July 14, 2020. 

50 CMS, COVID-19-Focused Survey Protocol. Accessed at https://qsep.cms.gov/data/274/COVID-19FocusedSurveyProtocol.pdf 

on July 14, 2020. 

51 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020. 

52 OIG Work Plan, Meeting the Challenges Presented by COVID-19: Nursing Homes, OEI-02-20-00490. 

53 OIG Work Plan, Audit of Nursing Homes’ Infection Prevention and Control Program Deficiencies, W-00-20-31545. 

54 OIG Work Plan, Audit of Nursing Homes’ Reporting of COVID-19 Information Under CMS’s New Requirements, W-00-20-

31546. 

55 OIG, States Continued to Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016–2018, 

OEI-01-19-00421, September 2020. 

56 OIG Work Plan, Nursing Homes: CMS Oversight of State Survey Agencies, OEI-06-19-00460. 

57 During the COVID-19 pandemic, CMS surveyors conducted about 700 surveys, from March 19 through July 9, to assist the 

States. 

58 These results are based on data beginning March 1, 2020, and include some surveys conducted prior to the directive to 

suspend certain survey activities. CMS, Nursing Home Compare—Nursing Home Infection Control Survey Reports, August 24, 

2020. Accessed at https://www.cms.gov/files/zip/nursing-home-infection-control-surveys.zip on August, 26, 2020. 

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OEI-01-20-00430 Endnotes | 48 
 

 

 

59 Incidents are self-reported by nursing homes and, as with complaints, do not depend on visitors observing conditions.

There is some duplication between incidents and complaints in nursing homes. We do not know why incidents also decreased 

during the COVID-19 pandemic as compared to 2019. 

60 42 CFR § 488.301. 

61 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020. 

62 Fit testing is an important component to a respiratory protection program to ensure users receive the expected level of 

protection. The Occupational Safety and Health Administration requires annual fit testing for any respirator, such as N95 

respirators used by surveyors, before being used in the workplace. CMS does not require N95 fit testing for health care 

providers in certified facilities. 

63 CMS surveyors also conducted infection control and complaint surveys during the COVID-19 pandemic. The data in this 

report include surveys conducted by both CMS and States. 

64 CMS, Letter to the Governors, May 31, 2020. Accessed at https://www.cms.gov/files/document/6120-letter-governors.pdf on 

July 13, 2020. 

65 OIG, Nursing Home Complaint Investigations, OEI-01-04-00340, July 2006. 

66 Contact tracing is the practice of identifying and monitoring individuals who may have had contact with an infectious person 

as a means of controlling the spread of a communicable disease. Source: https://www.cdc.gov/coronavirus/2019-

ncov/php/contact-tracing/contact-tracing-plan/overview.html. 

67 All nursing home surveyors are required to successfully complete the Surveyor Minimum Qualifications Test (SMQT). The 

SMQT addresses the knowledge, skills, and abilities needed to conduct surveys in nursing homes. Section 1819(g)(2) and 

19191(g)(2) of the Social Security Act requires surveyors to meet minimum qualifications. Source: 

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/SCLetter08-

14.pdf. 

68 CMS, Suspension of Survey Activities, Ref: QSO-20-12-All, March 4, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-12-all.pdf on July 7, 2020. 

69 CMS, Prioritization of Survey Activities, Ref: QSO-20-20-All, March 23, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-20-all.pdf on July 7, 2020. 

70 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality 

Improvement Activities in Nursing Homes, Ref: QSO-20-31-All, June 1, 2020. Accessed at 

https://theconsumervoice.org/uploads/files/issues/6.1.20-20COVID-CAREs-20Survey-20and-20Enforcement-20Memo-FINAL20.pdf on July 1, 2020. 

71 This analysis uses a 16-month interval between surveys rather than 15.9. 

72 CMS, Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH, May 18, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-30-nh.pdf-0 on August 11, 2020. 

73 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality 

Improvement Activities in Nursing Homes, QSO-20-31-ALL, June 1, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-31-all.pdf on August 20, 2020. 

74 CMS, Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, QSO-20-35-ALL, August 17, 

2020. Accessed at https://www.cms.gov/files/document/qso-20-35-all.pdf on August 20, 2020. 

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75 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality 

Improvement Activities in Nursing Homes, QSO-20-31-ALL, June 1, 2020. Accessed at 

https://www.cms.gov/files/document/qso-20-31-all.pdf on August 11, 2020. 

76 CMS, Enforcement Cases Held during the Prioritization Period and Revised Survey Prioritization, QSO-20-35-ALL, August 17, 

2020. Accessed at https://www.cms.gov/files/document/qso-20-35-all.pdf on August 20, 2020. 

77 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies, and Quality 

Improvement Activities in Nursing Homes, QSO-20-31-All, June 1, 2020. Accessed at https://www.cms.gov/files/document/qso20-31-all.pdf on July 7, 2020. 

78 CMS, SOM, Pub. No. 100-07, ch. 4, Program Administration and Fiscal Management (Revised 188, 04-26-19), Section 4157C. 

79 CMS defines Serious Injury, Harm, or Death (Actual OR Likely), as a component of Immediate Jeopardy, as follows: “Has 

caused or is likely to cause serious injury, harm, impairment, or death to a resident” CMS, SOM, Pub. No. 100-07, Appendix Q: 

Guidelines for Determining Immediate Jeopardy. Accessed at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf on July 25, 2020. 

80 CMS defines a deficiency cited as “actual harm but not immediate jeopardy” as follows: “Noncompliance with the 

requirements that result in actual harm to residents or employees that is not immediate jeopardy.” CMS, Public Release of 

Nursing Home Enforcement Information Announcement. Accessed at https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-27.pdf on August 7, 2020. 

81 42 CFR §§ 488.308. 

82 Social Security Act §§ 1819(g)(2)(A)(iii) and 1919(g)(2)(A)(iii). 

83 CMS, Release of Fiscal Year (FY) 2018 State Performance Standards Systems (SPSS) Results. Accessed at 

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/AdminInfo-20-

01-ALL.pdf on July 7, 2020. 

84 Ibid. 

85 OIG Work Plan, Meeting the Challenges Presented by COVID-19: Nursing Homes, OEI-02-20-00490. Accessed at 

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000474.asp on July 13, 2020. 

86 Kaiser Family Foundation, State Data and Policy Actions to Address Coronavirus, COVID-19: Confirmed Cases, Deaths, and 

Testing Data (as of May 14, 2020). Accessed at https://www.kff.org/health-costs/issue-brief/state-data-and-policy-actions-toaddress-coronavirus/ on May 15, 2020. 

87 CMS, Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2012-nCoV), QSO-20-09-ALL, February 

06, 2020. Source: https://www.cms.gov/files/document/qso-20-09-all.pdf. 

88 CMS, Suspension of Survey Activities, QSO-20-12-All, March 4, 2020. 

89 CMS, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised), 

QSO-20-14-NH, March 13, 2020. 

90 CMS, Prioritization of Survey Activities, Admin Info: QSO-20-20-All, March 23, 2020. 

91 CMS, Upcoming Requirements for Notification of Conformed COVID-19 (or COVID-19 Persons Under Investigation) Among 

Residents and Staff in Nursing Homes, QSO-20-26-All, April 19, 2020. 

92 CMS, Nursing Home Five Star Quality Rating System updates, Nursing Home Staff Counts and Frequently Asked Questions, 

QSO-20-28-NH, April 24, 2020. 

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93 CMS, Interim Final Rule Updating Requirements of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in 

Nursing Homes, QSO-20-29-NH, May 6, 2020. 

94 CMS, Nursing Home Reopening Recommendations for State and Local Officials, QSO-20-30-NH, May 18, 2020. 

95 CMS, COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement for Infection Control deficiencies and Quality 

Improvement Activities in Nursing Homes, QSO-20-31-NH, June 1, 2020. 

96 CMS, Posting of Nursing Home Inspections, QSO-20-33-NH, June 4, 2020. 

97 CMS, Release of COVID-19 Nursing Home Data, QSO-20-32-NH, June 4, 2020. 

98 CMS, Changes to Staffing Information and Quality Measures Posted on the Nursing Home Compare Website and Five Star 

Quality Rating System due to the COVID-19 Public Health Emergency, QSO-20-34-NH, June 25, 2020. 

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