LTCCC analysis finds steep decline in fines and widespread classification of violations as “no harm” in years following the COVID-19 Pandemic.

September 15, 2026 – The Long Term Care Community Coalition (LTCCC) has released The Accountability Gap: A National Examination of Nursing Home Oversight and Enforcement, 2022–2024, a comprehensive analysis of federal and state nursing home oversight using data from the Centers for Medicare & Medicaid Services (CMS).

Federal law provides strong protections for nursing home residents, including requirements for sufficient staffing, appropriate clinical care, freedom from unnecessary drugging, and respect for residents’ dignity and rights. The new study finds a substantial gap between those protections and their enforcement in practice.

Among the key findings:

  • Financial penalties fell dramatically. The number of reported fines declined from 11,501 in 2022 to 5,210 in 2024, a decrease of approximately 55%.
  • Surveyors classified approximately 94% of health deficiencies as below the level of actual harm in each year studied. Such classifications are particularly consequential because facilities cited below actual harm are highly unlikely to face any penalty for the violation.
  • Staffing shortfalls were widespread, but citations were rare. In 2024, about 90% of nursing homes with valid comparisons provided total nurse staffing below levels expected to meet their residents’ clinical needs, and nearly two-thirds were at least 20% below expected staffing. Yet surveyors issued only 1,012 sufficient-staffing citations nationwide, and only 33 were classified as resulting in harm or immediate jeopardy to residents.
  • Surveyors almost never identified harm for violations of federal psychotropic drug protections. Across 2022–2024, surveyors substantiated 5,594 violations, but classified only 26 — 0.46% — as actual harm or immediate jeopardy.
  • Resident-rights violations were also overwhelmingly classified as “no harm.” Approximately 97.6% of substantiated resident-rights violations over the three years were classified as causing no physical, clinical, or psychosocial harm to any resident.
  • Where a resident lives matters. States varied substantially in how frequently they identified violations, recognized resident harm, and imposed financial consequences. However, even higher performing states failed to provide sufficient oversight to ensure that federal minimum standards were consistently realized in the lives of residents.

“Nursing home residents have strong rights and protections under federal law, but those protections mean little if violations are not identified, resident harm is not recognized, and meaningful consequences do not follow,” said Richard Mollot, LTCCC’s Executive Director. “Our findings show an accountability system that too often treats violations of minimum care standards as harmless and allows substandard care to continue with little or no financial consequence. Residents and their families deserve better.”

Explore the Findings — and the Data Behind Them

LTCCC has created a public study resource center so that residents, families, journalists, policymakers, ombudsmen, advocates, researchers, and other stakeholders can examine the findings for themselves.

The study webpage includes the full national report, searchable state and national data files, and other resources designed to help the public understand state performance and use the findings to support better care and stronger accountability.

Access the report, data, and resources at https://nursinghome411.org/ltccc-enforcement-study-2026/.

This study was undertaken with the generous support of The New York Community Trust.