Where are the inspectors? How a lack of nursing home oversight is endangering residents.

A new congressional investigation released Thursday found that most states have nursing home inspection backlogs largely because federal oversight funding has stalled, leaving them with fewer inspectors.

State inspectors are on the front line of protecting the quality of care for and the rights of more than 1 million Americans who live in nursing homes, either because of aging, illness or disability, or who have short-term stays for rehabilitation. 

The report from the U.S. Senate Committee on Aging found 31 states and the District of Columbia had inspection staff vacancy rates above 20% on average; nine were short-staffed by half or more. The highest rates were in Kentucky (83%), Alabama (80%) and Idaho (71%).

“States reported that severe staffing shortages and high turnover rates, driven largely by the inability to offer competitive salaries, hampers their ability to conduct annual surveys on time and promptly investigate complaints,” the report read. “Such delays negatively affect nursing home residents … (and) also diminish the timeliness and accuracy” of Care Compare, the federal rating system most consumers use to evaluate a nursing home’s quality. 

“The system responsible for ensuring that nursing homes meet health and safety standards is in crisis,” said Sen. Bob Casey, a veteran Democrat from Pennsylvania who chairs the senate committee. “My investigation reveals unacceptable rates of vacancies at state survey agencies, threatening the safety and health of nursing home residents as their complaints collect dust while inspectors struggle to meet the demand."

USA TODAY Report Card:See how your local nursing home fared under the pressure of COVID-19

The report cited USA TODAY's investigation, which revealed that most nursing home facilities with fewer nurses and aides than federal guidelines are not cited for it by inspectors. That is true even though decades of research have found it to be one of the best predictors of care quality and critical to reducing violence and neglect. 

Watch the congressional hearing about the report here. Here are five takeaways: 

1) The state agencies that enforce federal rules for nursing homes struggle with low wages, frequent turnover and high vacancy rates among inspectors.

This is not a new problem. The Government Accountability Office documented vacancy rates for nursing home inspectors two decades ago, then finding the highest to be 34%. 

But it has gotten worse: The new congressional report found 17 states now have vacancy rates higher than that. Officials in Alabama, with 41 of 51 inspector jobs vacant, wrote, “the staffing numbers have reached a critical level.” 

Turnover, too, has challenged states’ ability to complete inspections promptly and have enough experienced inspectors to lead the most difficult assessments. The pandemic contributed to an increase in retirements. 

Nevada said it has had 80% turnover among “life safety code inspectors” in the past five years. Idaho reported that 80% of its inspection staff has less than two years' experience. In Oklahoma, three-quarters of the state’s inspectors retired between 2019 and 2022.

It typically takes one to two years for a new surveyor to complete training and certification to work alone. Officials in Mississippi told Congress this is a stark contrast from a nurse hired by a hospital, who can begin working floor shifts the next day. 

2) Inspectors are leaving for higher pay, less stress and less travel.

Because inspectors are health professionals – including registered nurses, pharmacists, social workers and dietitians – states have to compete with the private sector on pay and perks. 

“We find that we often invest the time to train new staff then they leave for a higher paying role before they become productive contributors,” California officials wrote.

In Florida, the average salary of a registered nurse working as a state inspector is $45,000 – less than half the statewide average of $72,000, according to the report. Missouri said its starting salary of $60,000 is still “$32,000 less than salaries offered in hospital settings and $22,000 less than salaries in long-term care.”

The role also is emotionally demanding, especially when inspectors receive a cool reception from nursing home workers and when families routinely suggest they’ve not done enough. Investigations of abuse and neglect can be particularly taxing. 

Officials in West Virginia described the job as “nearly impossible” for people with families because “surveyors are in the field away from home 4 to 5 days per week.”

State leaders also cited pandemic stresses, staff deaths and employee burnout as other reasons inspectors have left.

3) Watchdogs provided vivid examples of poor care and violence that inspectors delayed investigating − if they did at all.

Long-term care ombudsmen, who advocate for nursing home residents and their federal rights, wrote letters to investigators. 

“One ombudsman recalled a nursing home resident who was punched in the face by a worker; however, the state did not investigate the complaint for months,” the report read. “Another ombudsman shared stories of nursing home residents who filed complaints regarding skin breakdown – a serious condition that can lead to infection and death – that was not investigated at all.”

A third made clear the significance of weak oversight: “Poor conditions in nursing homes are directly connected to insufficient enforcement capacity.”

4) Obama, Trump and Biden all asked for more oversight funding, but Congress has not provided it.

Congress contracts with states to enforce nationwide rules for nursing homes that accept Medicaid and Medicare dollars, as is the case for the vast majority of facilities. Although states chip in some funding, the majority of inspection team support comes from the federal budget. 

The congressional investigation described a “slow deterioration” of nursing home oversight, particularly over the last decade, and tied it to stagnant federal funding. Congress has increased that spending just 2.5% since 2015. To keep up with inflation alone, the budget would have needed to increase 30%. 

Former President Donald Trump’s 2021 budget request noted that reactionary inspections – instead of proactive ones – leaves problems at nursing homes unaddressed, including “life-threatening circumstances.”

President Joe Biden’s 2024 budget noted that the coronavirus pandemic fueled additional departures from inspection agencies even as the number of complaints grew, leading to lower quality of care and reduced safety at nursing homes. 

Temporary CARES Act funding did help states hire more inspectors to focus on infection control assessments during the pandemic, but that program ends this fall. 

5) Other nursing home reforms are unlikely to succeed if enforcement remains weak.

Biden and members of Congress have called for numerous reforms to nursing home regulation after more than 100,000 deaths from COVID-19 exposed the consequences of slow action in response to decades of research detailing crucial needs for change.

The congressional report’s authors said those proposals probably will hinge on adequate and timely inspections, the cornerstone of enforcement.

“While increased funding may not solve all of the issues,” the report read, “states have made clear that absent sustained federal investment, any effort to improve the monitoring of nursing home care quality and resident safety will fall short.”

Jayme Fraser is a data reporter on the USA TODAY investigations team. Contact Jayme at jfraser@gannett.com, @jaymekfraser on Twitter and Facebook, or on Signal and WhatsApp at (541) 362-1393.