CMS Requirements for Long Term Care Facilities — Nursing Home Standards

The federal nursing home reform law — enacted in the Omnibus Budget Reconciliation Act of 1987 and codified at 42 U.S.C. §§ 1395i-3 (Medicare) and 1396r (Medicaid) — is the most comprehensive federal protection for nursing home residents in American history. CMS implements these statutory protections through 42 CFR Part 483, Subpart B, which governs skilled nursing facilities (SNFs) participating in Medicare and nursing facilities (NFs) participating in Medicaid. Approximately 15,000+ nursing facilities across the United States are subject to these standards, providing care to over 1.2 million residents on any given day. The regulations establish resident rights (including the right to be free from abuse, neglect, and exploitation), staffing requirements, care planning processes, quality of care and quality of life standards, infection control, and quality assurance programs. Facilities that fail to meet these standards face a tiered enforcement response ranging from directed plans of correction to civil money penalties, denial of payment for new admissions, and ultimately termination from Medicare and Medicaid.

Current Rule (2026)

What This Rule Does

42 CFR Part 483, Subpart B is the federal operating standard for nursing homes that receive Medicare or Medicaid payments. Any facility providing nursing care to Medicare or Medicaid beneficiaries — the vast majority of U.S. nursing homes — must meet these conditions. CMS surveys facilities through State Survey Agencies using the State Operations Manual (SOM) and Interpretive Guidelines; survey findings are publicly reported on CMS's Care Compare website. Deficiencies are classified by scope and severity; the most serious (immediate jeopardy — actual harm or risk of death) trigger mandatory enforcement action.

The 2017 comprehensive update (82 FR 32259) added major provisions on behavioral health, person-centered care planning, staffing, dementia care, and pharmacy practices. The 2024 staffing rule (89 FR 40999) would have established the first-ever federal minimum nurse staffing requirements, but it was vacated in April 2025, blocked by a 10-year statutory moratorium in the OBBBA (July 4, 2025), and formally withdrawn by CMS effective February 2, 2026.

Key Provisions (Subpart B)

Resident Rights (§ 483.10):

• Every resident has the right to a dignified existence, self-determination, and communication with persons inside and outside the facility
• The right to participate in care planning, refuse treatment, receive information about their medical condition and care
• The right to privacy, to manage their personal finances (or have a facility-managed trust account with monthly statements), and to receive mail without interference
• The right to voice grievances without retaliation; the facility must have a grievance process and respond in writing
• The right to organize and participate in resident councils; the facility must make space available and respond to council recommendations

Freedom from Abuse, Neglect, and Exploitation (§ 483.12):

• The resident has the right to be free from all forms of abuse (verbal, sexual, physical, mental), neglect, misappropriation of property, and exploitation
• The facility must have a written policy prohibiting mistreatment, neglect, and abuse of residents and misappropriation of their property
• All alleged violations must be reported to the State within 24 hours if the situation involves serious bodily injury; otherwise within 5 working days
• The facility must investigate and take corrective action; must not employ individuals with substantiated findings of neglect or abuse on the abuse registry
• Mandatory reporting to law enforcement for incidents constituting a potential crime

Admission, Transfer, and Discharge Rights (§ 483.15):

• The facility may not require a Medicare or Medicaid beneficiary to pay a deposit or guarantee private-pay rates as a condition of admission
• The facility must establish and implement an equal-access admissions policy — residents cannot be discriminated against based on source of payment
• Transfer or discharge of a resident from the facility is permitted only for specified reasons: medical necessity, safety, the resident's welfare, the resident's failure to pay after reasonable notice, or the facility's closure
• The facility must provide a minimum 30-day advance notice of transfer or discharge in most circumstances (shorter in emergencies)
• Residents have the right to appeal a transfer or discharge to the State; the facility cannot effect the transfer while an appeal is pending (unless immediate medical necessity)
• The facility must provide a written discharge summary and assist in arranging a safe and appropriate placement

Resident Assessment (§ 483.20):

• The facility must conduct a comprehensive, standardized, reproducible assessment of each resident's functional capacity using the Minimum Data Set (MDS) — the federally mandated assessment instrument
• Comprehensive assessment must be completed within 14 days of admission, within 14 days of a significant change in physical or mental condition, and at least annually thereafter
• MDS data is submitted electronically to CMS; it drives Medicare payment under PDPM (Patient-Driven Payment Model) and is used for quality measure reporting

Comprehensive Person-Centered Care Planning (§ 483.21):

• The facility must develop a baseline care plan within 72 hours of admission covering immediate care needs
• A comprehensive care plan must be completed within 7 days of completion of the comprehensive assessment — incorporating the resident's goals and preferences
• The care plan must be developed by an interdisciplinary team that includes the attending physician, a registered nurse, and other appropriate health professionals — and must include the resident and, if requested, the resident's family or legal representative
• Care plans must specify measurable objectives and timetables; must be revised when the resident's condition changes

Quality of Life (§ 483.24):

• Each resident must receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being — the foundational quality standard
• The facility must promote each resident's quality of life and dignity, including activities of interest and social engagement

Quality of Care (§ 483.25):

• Based on the comprehensive assessment, the facility must ensure each resident's abilities are maintained or improved unless a clinically unavoidable decline is documented
• Specific quality of care requirements: prevention and treatment of pressure ulcers (stage, document, treat); management of urinary incontinence (prompted voiding, appropriate catheterization protocols); adequate nutrition (must be provided in sufficient quantities to maintain or improve body weight and nutritional status); range of motion maintenance; psychosocial adjustment support; vision and hearing care

Pharmacy Services (§ 483.45):

• The facility must employ or obtain the services of a licensed pharmacist who consults on pharmacy services and advises on drug therapy
• A licensed pharmacist must review each resident's drug regimen at least monthly (quarterly for residents in a secure Alzheimer's/dementia unit)
• Antipsychotic medication: residents must not be given antipsychotic medications unless they are necessary to treat a specific condition diagnosed and documented; gradual dose reductions must be attempted unless clinically contraindicated — the "unnecessary drug" standard

Nursing Services and Staffing (§ 483.35):

• The facility must provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident
• 24-hour nursing coverage by licensed nurses is required; a registered nurse must be on duty for at least 8 consecutive hours per day, 7 days per week
• 2024 staffing rule rescinded (2025–2026): CMS finalized the first federal minimum staffing standard in May 2024 (89 FR 40999) requiring at least 0.55 RN HPRD, 2.45 nurse aide HPRD, and 24/7 RN coverage. On April 7, 2025, the U.S. District Court for the Northern District of Texas (Judge Kacsmaryk) vacated the HPRD and 24/7-RN provisions, and the OBBBA signed July 4, 2025 imposed a 10-year moratorium on enforcement (through Sept. 30, 2034). HHS dropped its appeal in October 2025, and CMS issued an interim final rule on December 3, 2025 formally withdrawing the staffing requirements (effective February 2, 2026). The federal staffing minimums are no longer in force.

Infection Control (§ 483.80):

• The facility must establish and maintain an infection prevention and control program (IPCP)
• An Infection Preventionist (IP) — with specialized training — must lead the IPCP; IP role was formalized in the 2017 reform rule following pandemic-era awareness of facility infection risks
• The IP must be a member of the facility's quality assurance committee; must assess risks, establish protocols, train staff, conduct surveillance, and manage outbreaks

Quality Assurance and Performance Improvement (§ 483.75):

• Each facility must have a QAPI program that encompasses all services the facility provides
• The QAPI program must address the quality of care, quality of life, and resident safety; must include systematic data collection, analysis, performance improvement projects, and corrective actions
• The governing body is responsible for and must ensure implementation of the QAPI program

How It Affects You

If you are choosing a nursing home for a family member: Federal law requires nursing homes to accept Medicaid patients — they cannot dump a Medicaid-certified resident simply because they've "spent down" from private pay to Medicaid (§ 483.15). The CMS Care Compare website (medicare.gov/care-compare) provides five-star quality ratings, staffing data, recent survey deficiencies, and inspection histories for every Medicare/Medicaid certified nursing home. Look specifically at the inspection rating and read recent survey reports — these are the unannounced CMS/state inspections that reveal what the facility is actually like. A facility with multiple G-, H-, I-level deficiencies (actual harm or immediate jeopardy) in recent surveys is a significant warning sign.

If your family member is being transferred or discharged: The facility must give at least 30 days written notice in non-emergency situations and must explain the reason, your right to appeal, and how to contact the State Long-Term Care Ombudsman (§ 483.15). You can appeal to the State and the transfer cannot be executed while the appeal is pending. If you believe the transfer is improper — for example, you suspect it's motivated by the resident's transition to Medicaid coverage — contact your State Long-Term Care Ombudsman immediately. Every state is required by federal law to operate a Long-Term Care Ombudsman program.

If you suspect abuse, neglect, or exploitation: The facility is required to report suspected abuse to the State and investigate. You can also file a complaint directly with your State Survey Agency (the state health department unit that licenses and inspects nursing homes), with the State Long-Term Care Ombudsman, or with local law enforcement. CMS's complaint intake process is at medicare.gov. Facilities found to have unreported or inadequately investigated abuse are subject to civil money penalties up to $23,000 per violation per day for serious deficiencies.

If you are a nursing home administrator or operator: Survey compliance is existential — a termination from Medicare and Medicaid can close a facility. CMS's survey process has become more rigorous following multiple regulatory updates. Key areas that consistently generate deficiencies: antipsychotic medication documentation and quarterly reduction attempts (§ 483.45), pressure ulcer prevention and treatment protocols (§ 483.25), staff training on abuse prevention (§ 483.12), and infection control program documentation (§ 483.80). The 2024 federal minimum staffing rule (89 FR 40999) — which would have required additional RN and CNA hours — was vacated by a Texas federal court in April 2025, blocked by a 10-year statutory moratorium in the OBBBA (July 4, 2025), and formally withdrawn by CMS in December 2025; states' own staffing minimums (and the long-standing 8-hour-per-day RN requirement) still apply.

Implementing Regulations

42 CFR Part 442 — Standards for Payment to Nursing Facilities and Intermediate Care Facilities for Individuals with Intellectual Disabilities (CMS, 18 sections across 3 subparts — the Medicaid program's provider agreement and certification requirements for nursing facilities (NFs) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID); authority: 42 U.S.C. § 1302; distinct from the quality-of-care conditions in Part 483 — Part 442 governs the administrative pathway through which these facilities enter Medicaid as enrolled providers):

• Subpart B — Provider Agreements (§§ 442.10–442.17): a state Medicaid agency may enter a provider agreement with a nursing facility only after the facility receives certification under Part 483 Subpart B (the conditions of participation); § 442.10 — state plan must require compliance with Part 442; § 442.12 — provider agreements must be in writing, signed by an authorized facility official and the state Medicaid agency; § 442.14 — the agreement must specify the services covered, payment rate, and conditions of participation; § 442.15 — Agreements with facilities operated by federal agencies: special provisions for Indian Health Service (IHS) facilities and VA nursing homes — these federal facilities may participate in Medicaid without undergoing state survey if CMS certifies they meet the equivalent standards; § 442.17 — termination of agreements: the state must terminate a provider agreement when CMS or the state determines the facility no longer meets requirements; termination requires 30 days' notice to the facility, the state, and the public (with exception for immediate jeopardy situations requiring immediate action)

• Subpart C — Certification of ICFs/IID (§§ 442.100–442.118 — largest subpart): Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) — formerly called ICFs/MR (Mental Retardation), renamed by Rosa's Law (2010) — are facilities providing residential care and active treatment to individuals with intellectual disabilities; ICFs/IID are a distinct Medicaid service from nursing home care, governed by separate conditions at 42 CFR Part 483 Subpart D; Part 442 Subpart C defines the certification process:

  • § 442.101 — Obtaining certification: the state survey agency (typically the state health department) must conduct an on-site survey of the ICF/IID before CMS issues a certification; the survey evaluates compliance with Part 483 Subpart D active treatment standards — the distinctive ICF/IID requirement that facilities provide individualized programs to help residents develop and maintain maximum functional capacities rather than simply custodial care
  • § 442.109 — Certification period: a fully compliant ICF/IID receives a 12-month certification; § 442.110 — facilities with standard-level deficiencies (deficiencies not posing immediate jeopardy) may receive a conditional certification pending correction; corrective action must be verified within the conditional period (typically 6 months); § 442.117 — immediate jeopardy: a state survey agency must terminate a facility's certification if deficiencies create immediate jeopardy to resident health or safety; this is a non-negotiable termination — there is no grace period when residents are at immediate risk
  • § 442.118 — Denial of payment for new admissions: before terminating certification entirely, CMS or the state may deny Medicaid payment for new ICF/IID admissions while allowing existing residents to continue receiving services; this remedial option protects current residents while creating financial incentive for the facility to achieve compliance; ICFs/IID facing DPNA often undergo accelerated remediation to restore payment authority

ICFs/IID serve approximately 40,000 individuals nationally in residential settings — far fewer than in prior decades, as the deinstitutionalization movement and the expansion of Home and Community-Based Services (HCBS) Medicaid waivers (1915(c) waivers) have moved the vast majority of individuals with intellectual disabilities into community settings. Remaining ICFs/IID typically serve individuals with the most complex needs requiring around-the-clock medical oversight alongside active treatment. The Part 442 certification framework creates the administrative link between the quality-of-care standards (Part 483 Subpart D) and Medicaid payment — facilities must continually demonstrate standards compliance to retain Medicaid reimbursement authority.

Statutory Authority

This rule implements:

• 42 U.S.C. § 1395i-3 — Medicare skilled nursing facility requirements: resident rights, quality of care, staffing, inspection authority, enforcement remedies
• 42 U.S.C. § 1396r — Medicaid nursing facility requirements: mirrors the Medicare SNF requirements for Medicaid-certified facilities; creates the unified regulatory framework that applies to most nursing homes participating in both programs
• 42 U.S.C. § 1302 — Secretary's authority to prescribe regulations for Medicare and Medicaid program administration

Recent Rulemakings

• Minimum staffing standards (89 FR 40999, May 2024) — rescinded (2025–2026): CMS finalized the first federal minimum nursing home staffing requirements (0.55 RN HPRD, 2.45 nurse aide HPRD, 24/7 RN presence). The HPRD/24/7 provisions were vacated by the N.D. Texas in April 2025; the OBBBA enacted July 4, 2025 imposed a 10-year moratorium on enforcement; CMS published an interim final rule December 3, 2025 formally withdrawing the requirements (effective Feb. 2, 2026). The staffing mandate is no longer in effect.
• Comprehensive nursing home reform rule (82 FR 32259, September 2017): The most comprehensive overhaul of Part 483 Subpart B since the 1991 original implementation. Added requirements for person-centered care planning, expanded behavioral health services, new pharmacy practices provisions (antipsychotic reduction), dementia care standards, discharge planning, and formalized Infection Preventionist requirements.

Recent Developments

• Federal minimum staffing rule vacated and rescinded (April 2025 – February 2026): CMS finalized the first-ever federal minimum staffing standards for nursing homes in May 2024 (89 FR 40999): 0.55 registered nurse HPRD, 2.45 certified nurse aide HPRD, and 24/7 RN presence. On April 7, 2025, the U.S. District Court for the Northern District of Texas (Judge Kacsmaryk) vacated the HPRD and 24/7-RN provisions, holding CMS exceeded its statutory authority under the Nursing Home Reform Law. The One Big Beautiful Bill Act (Pub. L. 119-21, signed July 4, 2025) imposed a 10-year moratorium on implementation and enforcement of the rule, blocking enforcement until September 30, 2034. HHS voluntarily dismissed its Fifth Circuit appeal in October 2025, and CMS published an interim final rule on December 3, 2025 formally withdrawing the staffing requirements (effective February 2, 2026).
• Pre-rescission impact estimates: CMS had estimated that the now-defunct minimum staffing rule would have required roughly 75% of nursing homes to increase staffing, at an estimated annual cost of $6.8 billion industry-wide. Industry groups had argued the costs would force facility closures and exacerbate rural access problems — concerns that contributed to the political consensus behind the 2025 rescission.
• COVID-19 infection control legacy: CMS strengthened infection prevention and control requirements during the COVID-19 pandemic, including mandating vaccination of nursing home staff (a requirement upheld by the Supreme Court in 2022). Post-pandemic, infection control standards — including the Infection Preventionist credential requirement — remain elevated from pre-COVID baselines. CMS COVID-19 inspection data revealed widespread pre-existing deficiencies in infection control practices at many facilities.
• Nursing home ownership transparency rule: CMS finalized regulations in 2024 requiring nursing homes to disclose ownership structures and management arrangements more comprehensively, addressing concerns about private equity ownership through layered corporate structures that have complicated enforcement actions against poorly performing facilities. The transparency requirements extend to management company contracts, real estate investment trust (REIT) relationships, and related-party transactions.
• Five-Star Quality Rating System updates: CMS annually revises the nursing home Five-Star Quality Rating System on Nursing Home Care Compare. Benchmark updates in 2024–2025 recalibrated the staffing and quality measure domains, resulting in rating changes for many facilities. The Five-Star system is used by Medicare beneficiaries choosing facilities and by insurers and managed care organizations evaluating preferred provider networks.

Pending Action

The federal minimum staffing rule (89 FR 40999, May 2024) — 0.55 RN HPRD, 2.45 CNA HPRD, and 24/7 RN presence — has been vacated, blocked by a 10-year statutory moratorium in the OBBBA (Pub. L. 119-21, July 4, 2025), and formally withdrawn by CMS effective February 2, 2026. Pending action now centers on whether Congress will revisit a federal staffing baseline before the 2034 moratorium expires, and on continued state-level efforts (California, New York, and others) to set or update their own minimum staffing thresholds. CMS rulemaking on nursing home ownership transparency, infection control, and related quality measures continues independently of the staffing rescission.