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Institutional Services > Nursing home trends

Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 2001 Through 2007

Prepared by Charlene Harrington, Helen Carrillo, and Brandee Woleslagle Blank

University of California, San Francisco

Released September, 2008

A new report has been completed by the University of California, San Francisco, showing trends in U.S. nursing homes by state for the 2001 through 2007. The data are from the federal On-Line Survey and Certification System (OSCAR) reports that are completed at the time of the annual nursing home surveys by state Licensing and Certification programs for the U.S. Centers for Medicare and Medicaid Services.

The highlights of the new report for all US nursing homes show that:

Facility Characteristics

• In calendar year 2007, 15,281 nursing homes with 1.6 million beds were surveyed by state agencies.

• Nursing home occupancy rates declined from 86 percent in 2001 to 84.8 percent in 2007 showing excess capacity, at a time when the population is aging.

• Of the 1.37 million residents in nursing homes, 64 percent had their care paid by Medicaid, 22 percent had care paid directly out of pocket or by private payers, and 14 percent of residents received Medicare in 2007.

• The number of for-profit nursing homes increased from 65 percent of all homes in 2001 to 66.8 percent while the number of non-profit nursing homes and public homes declined. Nursing home chains declined from 56 percent of the total homes in 2001 to 53.1 percent in 2007.

• The number of nursing homes operated by hospitals declined by 30 percent (from 11.5 to 8.0 percent) of total homes between 2001 and 2007. These hospital-based nursing homes had the highest staffing and the most Medicare residents.

Staffing

• The average number of registered nurse (RNs) hours per resident day declined by 25 percent between 1998 and 2000 and by 14 between (from 0.7 to 0.6 hours) in 2001 and 2007. The number of nursing assistants (NAs) increased to make up for the reduction in registered nurse hours. This shows a dramatic decline in the skills and training of staff since the implementation of the Medicare prospective payment system in 1998. Studies have shown facilities with more RN staffing have higher quality of care on average.

Resident Characteristics

• The percent of residents with dementia increased by 7 percent (from 42.7 to 45.6 percent) and the percent with other psychiatric diagnoses increased by 33 percent (from 16.1 to 21.4 percent of residents). The number of residents needing psychological and behavioral management is increasing.

• The percent of residents with limitations in activities of daily living remained fairly stable over the time period. Although most nursing home residents have a number of care needs, the need for physical assistance is not increasing.

• The percent of resident in nursing homes receiving rehabilitation services increased from 17.7 percent in 2001 to 23 percent in 2007.

• The percent of residents who were chair bound increased by 9.5 percent (from 51.1 to 56 percent between 2001 and 2007), in bed most of the time declined by 22 percent (from 5 to 3.9 percent), and those in physical restraints declined by 43 percent (from 9.7 to 5.5 percent between 2001 and 2007).

• Although the present of residents reported with pressure sores declined from 7.3 percent in 2001 to 6.9 percent in 2007, over 94,000 residents have pressure sores.

Quality of Care

• Across the country, about 114,600 deficiencies were issued to nursing homes for violations of federal regulations. The average number of deficiencies increased by 19 percent (from 6.3 in 2001 to 7.5 per facility in 2007). This suggests that there are many quality problems

• At the same time, the percent of facilities receiving serious deficiencies for causing harm or jeopardy declined by almost 16.5 percent (from 21.1 percent in 2001 to 17.6 percent in 2007). This suggests that quality violations are not as harmful or states are less likely to rate deficiencies as causing harm.

• Wide variations in the average number of deficiencies occur across states, ranging from 17.4 in the District of Columbia to only 2.7 in Rhode Island in 2007. Deficiencies vary widely across states and/or state enforcement varies widely; the latter is the most likely explanation.

• In 2007, violations of federal requirements to ensure a safe environment were cited in 37 percent of the nation’s nursing homes. Violations of food sanitation regulations were found in 35.3 percent of all US nursing homes and 28.9 percent of facilities received deficiencies for failure to meet quality standards.

• Of the total nursing homes, 27.6 received deficiencies for failure to meet professional standards, 22.4 percent for failure to provide comprehensive care plans, 19.5 percent for poor housekeeping, 19.2 percent for inadequate incontinence care, 19.1 percent for pressure sores, 19 percent for giving unnecessary drugs, and 18.1 percent for poor infection control in 2007.

These trends in nursing homes should be of concern to policy makers, nursing home providers, and consumer advocates because they do not show major improvements over the past seven years. Moreover, they show continued wide variations in staffing, residents, quality of care and enforcement across states.

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