A Long Term Care Community Coalition report finds nursing home fines fell 56.5% between 2022 and 2024 even as cited deficiencies rose, with 49 states imposing fewer fines in 2024. Rehinged's data shows 1,986 scored facilities rated two stars or below on health inspections have no fines on record, while another 330 carry high penalty risk, 133 of them in Illinois. Separately, a roughly $2 million national study will examine how nursing homes use agency staff, and 2,060 scored facilities sit in the top fifth for contract labor spending.
Why it matters for vendors: Enforcement is the variable operators can no longer assume. The 1,986 poorly inspected facilities with clean fine records are where a tougher regulator would land hardest, led by California, Ohio and Indiana, so compliance and survey-readiness vendors have a timely opening. Workforce and scheduling vendors should start with the 955 facilities that pair heavy contract labor with turnover of 50% or more, concentrated in Pennsylvania, North Carolina, Ohio and Texas.
RegulatoryQuality & Ratings
Fines Fall 56.5% Across 49 States Even as Cited Deficiencies Climb, LTCCC Finds
What happened
The Long Term Care Community Coalition, a New York-based nonprofit, reports that nursing home fines fell 56.5% between 2022 and 2024 while the number of cited deficiencies rose, and that 49 states imposed fewer fines in 2024 than in 2022. The average fine per resident dropped from $186 to $153, ranging from $465 in Illinois to $35 in Arizona. Some 94% of deficiencies nationwide were classified below actual harm. In 2024, 30 states, D.C. and Puerto Rico cited no harm from understaffing, and Tennessee classified 11.3% of its infection control deficiencies as harm or immediate jeopardy while Alabama, Alaska, Maryland, Nevada and D.C. cited none. The group calls this a "persistent accountability gap."
Why it matters
Lighter enforcement lowers near-term penalty exposure, which can soften the urgency behind compliance purchases. But a report that frames the trend as an accountability gap invites pressure on regulators and state agencies, and the facilities that have escaped fines while performing poorly on inspections are the ones with the most to lose if the pendulum swings back.
Rehinged Intelligence analysis of 14,690 scored facilities shows the gap in the facility data. 8,180 facilities, 55.7% of the field, have no fines on record. Among them, 1,986 facilities, or 13.5% of all scored facilities, are rated two stars or below on health inspections. They average 1.92 overall stars and 113 beds, and together hold more than 225,000 beds. California leads with 195, followed by Ohio with 175 and Indiana with 146.
1,986
poorly inspected, no fines on record
8,180
facilities with no fines on record
330
high penalty-risk facilities
Poorly inspected facilities with no fines on record, by state
The other end of the distribution is concentrated. 330 facilities, 2.2% of the field, score 70 or higher on Rehinged's penalty-risk measure and average just 1.26 stars. Illinois holds 133 of them, 40% of the total, which fits the state's $465 average fine per resident in the LTCCC report. California follows with 37 and Texas with 22. Vendors selling compliance, survey-readiness or quality-reporting tools should treat Illinois as a live enforcement market and California, Ohio and Indiana as the largest pools of poorly inspected operators with no penalty history to date.
Watch for: Any state or CMS response to the accountability-gap findings, and whether penalty-risk facilities in Illinois, California and Texas begin to see fines reach their records.
StaffingQuality & Ratings
$2 Million Federal Study Will Examine How Nursing Homes Actually Use Agency Staff
What happened
Researchers at Emory University and Miami University, working under a roughly $2 million National Institute on Aging grant, will study how nursing homes use agency staff and what it means for quality of care. They will analyze national payroll, resident assessment and Medicare data and interview nursing home staff and state Medicaid officials. Instead of the usual yes-or-no or percent-of-hours measures, they plan to look at patterns such as whether a facility repeatedly books the same agency nurse or a different worker every day, and whether use spikes on weekends, holidays or particular shifts. Agency use rose sharply during the pandemic and fell afterward but remains above pre-pandemic levels, and many operators still use some agency support nearly every day. Preliminary findings are expected within the next few months.
Why it matters
Operators say they would prefer to avoid agency labor because of its cost, yet rates remain above pre-pandemic levels and part-time agency work keeps pulling would-be full-time staff. The researchers hope to identify strategies that make agency use work better, which is a roadmap for any vendor selling scheduling, float-pool, credentialing or retention tools.
Of the 10,296 facilities in the Rehinged pipeline that report contract labor cost in their latest cost report, 2,060 facilities, 14.0% of all scored facilities, spend $51.73 or more per day, the top fifth of reporters. The median is $25.29. Those heavy users average 2.89 overall stars and 112 beds. Pennsylvania has the most with 187, followed by New York with 149, and California and Massachusetts with 117 each.
2,060
top-fifth contract labor spenders
955
also at 50%+ nursing turnover
2.48
average stars of those 955
Heavy contract labor and 50%+ turnover, by state
The compound group is the sharpest target. 955 facilities, 6.5% of the field, combine top-fifth contract labor spending with total nursing turnover of 50% or more, and they average 2.48 stars, below the 2.89 of all heavy users. Pennsylvania holds 95 of them, with North Carolina at 71, Ohio at 67 and Texas at 55. These operators are paying for agency coverage and still losing staff. Vendors selling workforce management, scheduling or retention software should prioritize Pennsylvania, North Carolina, Ohio and Texas, and should be ready to speak to the repeat-versus-rotating agency distinction the study is built around.
Watch for: Preliminary findings in the coming months and any state moves on agency rate controls, which would change the economics for the 2,060 heaviest users.