Download the 2024 State Double G Data Report at NursingHome411 and explore the latest trends in compliance.
March 27, 2025 – Substandard care, abuse, and neglect are persistent and widespread problems in nursing homes, primarily due to inadequate enforcement of minimum safety standards. To help combat this, the federal Centers for Medicare & Medicaid Services (CMS) imposes automatic penalties on facilities receiving “Double G” citations. These citations occur when a facility is cited for violations at a G level or higher in two consecutive surveys. A classification of G-level or higher indicates that the violation has either caused harm to one or more residents or placed them in immediate jeopardy of serious harm.
Today, LTCCC is releasing the 2024 State Double G Data Report, which provides a detailed report of Double G citations by state and CMS region, along with trends in related penalties. Drawing on data from CMS Quality, Certification, and Oversight Reports, the report offers valuable insights into how effectively states identify serious issues in nursing homes. It also highlights an upward trend in both the issuance of Double G citations and the penalties imposed for violations of minimum care standards.
“The increasing number of Double G citations signals a deeply concerning trend of ongoing, serious noncompliance in nursing homes,” said Richard Mollot, LTCCC’s Executive Director. “This reflects the growing number of reports of substandard care and neglect that we are hearing from desperate families.”
Following are key national and regional findings. For information on specific facilities, visit our Provider Data page.
Key Findings:
- The number of facilities receiving Double G citations increased almost 18%, from 1,526 in 2023 to 1,801 in 2024.
- The per diem CMPs (civil money penalties) associated with these citations also increased by almost 18%, from $55.87 million in 2023 to $65.97 million in 2024.
- Per diem CMPs increased in both the total number and dollar amount, with a rise from 1,140 instances in 2023 to 1,365 in 2024.
- Per instance CMPs increased slightly from 432 in 2023 to 466 in 2024.
- The average dollar amount of per diem CMPs decreased slightly from $49,007.49 in 2023 to $48,326.57 in 2024, while the average per instance CMP increased about 12%, from $13,246.32 in 2023 to $14,807.02 in 2024.
| Category | 2023 Totals | 2024 |
|---|---|---|
| Number of Providers with Double G Citations | 1,176 | 1,340 |
| Number of Double G Citations | 1,526 | 1,801 |
| Total Number Per Diem Citations | 1,140 | 1,365 |
| Total Number of Per Instance CMPs | 432 | 466 |
| Total Dollar Amount Per Diem CMPs | $55,868,535.54 | $65,965,766.45 |
| Total Dollar Amount Per Instance CMPs | $5,722,411.67 | $6,900,071.66 |
| Average Dollar Amount Per Diem CMPs | $49,007.49 | $48,326.57 |
| Average Dollar Amount Per Instance CMPs | $13,246.32 | $14,807.02 |
| Average Days in Effect Per Diem CMPs | 30 | 28 |
| Total Number Discretionary DPNAs (Denial of Payment for New Admissions) | 304 | 338 |
| Average Days in Effect Discretionary DPNAs | 29 | 30 |
Regional Trends:
CMS’s 10 Regional Offices are responsible for assuring that health care providers meet applicable federal requirements. The effectiveness of oversight at the regional level is crucial, as variations in nursing home performance may reflect the strengths or weaknesses of these Regional Offices. [Note: There are many ways in which state and regional agency performance can be evaluated. For more information, see LTCCC’s study on nursing home oversight.]
- The Chicago region had the highest number of Double G citations in the country. Its citations increased by over 10%, from 660 citations in 2023 to 737 in 2024.
- The New York region had, by far, the lowest number of Double G citations at 16. This is roughly a quarter of the number of the next lowest region, Boston, and less than 10% of the Chicago region’s number.
- The Atlanta region saw a 32% increase, from 118 in 2023 to 156 in 2024.
- The San Francisco region had a 50% increase, with 117 citations in 2023 and 177 in 2024.
| CMS Region | 2023 # of Double G Citations | 2024 # of Double G Citations |
|---|---|---|
| Boston | 80 | 59 |
| New York | 13 | 16 |
| Philadelphia | 56 | 60 |
| Atlanta | 118 | 156 |
| Chicago | 660 | 737 |
| Dallas | 176 | 253 |
| Kansas City | 166 | 192 |
| Denver | 76 | 87 |
| San Francisco | 117 | 177 |
| Seattle | 64 | 64 |