A new national study has determined that nursing homes will often ramp up staffing levels in anticipation of state inspections and then cut staffing once the inspectors have left the building.
The study, by the National Bureau of Economic Research, examines the overall impact of government inspections on the quality of care in U.S. nursing homes. Using payroll records and admissions data, the researchers found nursing homes “respond strategically” to government inspections by increasing the quantity and the quality of their staffing, and by reducing admissions and temporarily discharging patients, in a short-term effort to improve patient care and boost their inspection ratings.
The study is presented in the form of a published “working paper,” intended to elicit discussion and comment, and has not been peer-reviewed or subject to review by the national bureau’s board of directors.
“Nursing homes significantly increase the work hours of nurses and nurse assistants, the main nursing home staff, in response to health inspections,” the report states. “On the day of peak response, the work hours of nurses and nurse assistants rise by 10.2 and 6.6 hours on average, respectively.” Similar increases in work hours were noted for physical therapists, occupational therapists, social workers, activities professionals, administrators, physical therapy assistants, dietitians and other care providers.
The researchers also noted “a significant increase in temporary discharges — i.e., the number of patients who are discharged but return to a nursing home within two weeks — in response to health inspections. On the peak day, temporary discharges increase by 4%.”
Those two factors, combined with a decrease in new admissions during inspections, result in improved staff-to-patient ratios — which may improve patient care. However, all of the changes that improve the staff-to-patient ratios “drop immediately once the inspection is completed,” according to the report. “The work hours of all types of staff decline to the typical levels — i.e., those on days relatively distant from the inspection — or fall even slightly below the typical levels, on the day right after the inspection.”
The authors note that nursing home inspections generally last a few days, during which a team of inspectors employed by the state, often nurses, will travel to the facility to conduct an onsite evaluation of care quality. Although the inspections are conducted on an annual basis, the federal government does not require them to be conducted exactly every 365 days — as long as an inspection is within 15 months of the previous one and the state’s average interval between inspections at all nursing homes does not exceed 12 months.
In theory, the broad range of time in which an annual inspection can be conducted makes the visits less predictable and the inspection findings less likely to be skewed by artificial increases in staffing. Even so, a facility that’s waited 14 months since its last inspection can fully expect inspectors to arrive on the scene within four weeks, which would allow for a ramp-up in staffing.
“This research should prompt elected leaders in Congress and in state legislatures to ask some basic questions of those conducting nursing home inspections,” said John Hale, co-owner of The Hale Group, an Ankeny-based consulting firm focused on older and disabled Iowans. “Questions like, ‘What’s the goal of doing nursing home inspections? Is it to improve the quality of care? If that is the goal, is it being accomplished? Has care been improved and how do we know? If it’s not being improved, why not?’”
According to the National Institutes of Health, some states appear to routinely schedule visits during the same week each year, making their inspections predictable.
Last December, for example, the North Carolina Office of State Auditor reviewed that state’s scheduling of nursing home inspections and found the state wasn’t adhering to federal guidelines on how to make inspections less predictable.
About 43% of annual inspections occurred in the same month as the previous inspection, and 73% began on a Monday. In addition, a fifth of nursing homes were being inspected in a geographically predictable manner, with inspectors moving from one facility to the next in the same order as in previous years.
Dean Lerner, who headed Iowa’s Department of Inspections and Appeals under former Gov. Chet Culver, said he initiated efforts to make the inspections less predictable so the department would have a more accurate picture of the facility.
“I did off-schedule inspections — having folks do the annual inspections after six months, or after seven months,” he said. “In addition, we’d have the inspectors show up in the middle of the night, which would be unexpected, of course.”
A review of the inspections that occur now in Iowa shows that the comprehensive annual inspections — technically, they’re called “recertification surveys” — typically take place in a different month than the previous year’s inspection, and repeat violators may find themselves facing two such inspections in less than 10 months.
At Cedar Rapids’ Heritage Specialty Care, for example, inspectors conducted an annual inspection on Aug. 22, 2024. Amid a series of additional, focused inspections that were triggered by complaints, the state inspectors were back for another comprehensive annual inspection just nine months later, on May 22, 2025.
