Understaffed Nursing Homes Take Hit in CMS Ratings

cms ratings

The U.S. Centers for Medicare and Medicaid Services (CMS) are acknowledging the vital role that proper staffing plays in the health and wellbeing of nursing home residents.  The newest ratings from CMS severely penalized understaffed nursing homes by giving them their lowest rating, a one-star rating.

Importance of CMS Ratings

CMS is in a unique position to gather information about the care and daily lives of nursing home residents.  The agency studies claims for treatment and care submitted through the federal programs Medicare and Medicaid.  When the time comes to consider a nursing home for your loved one, many families turn to the ratings issued by the CMS to vet potential facilities for their family members. 

CMS ratings report on nearly every aspect of nursing home life from sanitation and presence of health hazards to reports of abuse or neglect.  Most recently, CMS has set their sights on improving the widespread problem of understaffed nursing homes in America.

CMS Cracks Down on Understaffed Nursing Homes

The newest low ratings for understaffed nursing homes penalize facilities that go days at a time without a registered nurse on the payroll.   This year, more than 1,600 nursing homes received the lowest possible rating for staffing concerns.  Facilities with a one-star rating  for staffing:

  • Reported no registered nurse on staff for stretches of four days or more at a time.
  • Failed to produce any payroll data at all.
  • Produced payroll data that could not be verified.

These one-star ratings represent a more stringent standard than CMS has ever applied before.  Previously nursing homes had to go seven days or more without a registered nurse on staff in order to receive a one-star rating.  It is clear that CMS is taking the problem of understaffed nursing homes very seriously and intends to continue penalizing facilities for the deficiency.

Nursing Homes Need Registered Nurses

The absence of a registered nurse for many days in a row endangers the health and safety of nursing home residents.  To meet the standard of care nursing home residents deserve, facilities must provide reasonable access to a registered nurse.   

CMS standards require a registered nurse to be present for at least eight hours a day, every day.  An absence of four days or more at a time is plainly unacceptable.   An absence of such duration is not likely to be caused by a family emergency or an illness, but rather is a systemic understaffing problem caused by negligent nursing home administration.

The presence or absence of a qualified registered nurse is the largest factor in the quality of care nursing homes deliver.   CMS has been quoted saying that,

“…as staffing levels increase, quality increases.”

An Industry Teeming with Understaffed Nursing Homes

The government only began requiring nursing home facilities to submit payroll records for the verification of staffing levels last year.  Before that, CMS and other reporting agencies had to rely on a two-week window of observation gathered by inspectors as they performed their routine inspections.   The in-depth information available through the payroll records revealed an alarming trend of understaffed nursing homes across the country. 

Worst among for-profit nursing homes, understaffing can result in one registered nurse caring for up to 43 patients.  Non-profit nursing homes have an average of one registered nurse per 28 residents.  Overall, for-profit facilities have 16 percent fewer staff members available than non-profit centers do.  Sadly, an overwhelming majority of nursing homes are for-profit. 

Weekend staffing is particularly meager.  A Kaiser Health News Report  analyzing the payroll data collected by CMS shows that nurses on staff decline by more than 10 percent on weekends.   Other staff members’ presence is also reduced by about eight percent.

Tragically, it is not an uncommon sight in understaffed nursing homes to find residents wandering around or yelling for help for long periods of time before overworked staff members can attend to their needs.

Understaffing can Indicate Other Violations

Understaffed nursing homes that receive low ratings in the staffing category often receive low ratings in other categories for health codes or other safety violations.   Nurses and other workers cannot possibly provide a high standard of care with such a high ratio of patients to staff members. 

 Residents in understaffed nursing homes can suffer:

  • Long waits for medical assistance or medication
  • Long waits for assistance with restroom, hygiene, or grooming
  • Late or missed meals
  • Formation of bedsores when busy workers neglect to reposition immobile patients
  •  Avoidable injuries  and hospitalizations

Among the nursing homes who received a one-star rating for understaffing problems, CMS discovered the following:

  • More than 1,000 received a 1-or 2-star overall rating
  • 277 have a 3-star overall rating
  • 174 have a 4-star rating
  • 48 received the top rating of 5 stars

Above all, if you are considering a nursing home for your loved one, pay very close attention to all ranking metrics a facility receives from CMS.

Understaffing and Chemical Restraints

Nursing home groups protest the shifting standards for ratings. They argue that overtime limits and Medicare claim rules prevent them from recording payroll data that accurately reflects nurse staffing.  However, recent legislation and new CMS initiatives hint at the dark reality of understaffed nursing homes. 

The use of chemical restraints on vulnerable seniors is a deplorable yet widespread practice meant to drug dementia or Alzheimer’s patients into docility.  A facility full of zoned-out residents can conceivably be managed with one nurse to every 30 or 40 patients.  Residents who are deemed “difficult”, “needy”, or “agitated” may be administered medication that helps them relax, sleep, or be otherwise sedate. 

Who is to say whether understaffing is prompted chemical restraints or if it is the other way around? What we do know is about 179,000 nursing home residents per week suffer under chemical restraints in understaffed nursing homes. 

Nursing home advocacy groups would protest any measure that requires spending more money on staffing costs to keep their ratings up.  These groups are primarily concerned with the billion dollar profit margins in their industry, and not what is best for residents.

Does your Loved One Live in an Understaffed Nursing Home?

If you suspect that your loved one is living in an understaffed nursing home, take steps to protect his or her health.  Signs of an understaffed nursing home include:

  • When visiting, no staff members are present to greet or speak with you.
  • When visiting, your loved one indicates that they have not received their medication on schedule. 
  • You notice that your loved one is sedate or sleeping more than usual. 
  • You find out that sedatives or antipsychotic medications were administered without your knowledge or consent. 
  • Your loved one is malnourished or dehydrated
  • Your loved one is developing, or has developed bedsores.
  • You notice your loved one’s personal hygiene has changed. 
  • Your loved one has a noticeable decline in overall health.

Each of these situations may be indicative of nursing home abuse or nursing home neglect.  Certainly, you should take action the moment you suspect abuse or neglect, or inappropriate understaffing.  If you have questions or concerns about your loved one’s nursing home, contact Nursing Home Abuse Center.  Our nursing home abuse and neglect lawyers can help you understand your loved one’s legal rights, the standards of care, and what you can do to ensure he or she is safe.  To schedule a free consultation, call us at 1-800-516-4783 or complete our online form


meagan cline

Written By Meagan Cline

Meagan Cline is a professional legal researcher and writer. She lends her expertise to FNHA and our websites, including Birth Injury Guide and MedMalFirm.com.