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The Long-Term Care Standards ProjectPressure injuries, falls, staffing, and the record — sourced to primary authority.

Every figure in The Long-Term Care Standards Project, traced to its source

41 primary sources. Each URL was checked before publication and is rechecked whenever a page in The Long-Term Care Standards Project is revised.

The numbered markers throughout the Center overview and the standards link to the matching entry below. Where a source has been superseded or withdrawn, the entry is corrected on the page rather than quietly removed — the editorial policy explains how.

  1. 1.42 U.S.C. § 1395i-3 — Requirements for, and assuring quality of care in, skilled nursing facilities (Nursing Home Reform Act); “highest practicable” duty at (b)(2) and quality assessment and assurance committee record protection at (b)(1)(B). https://www.law.cornell.edu/uscode/text/42/1395i-3Legal Information Institute, Cornell Law School
  2. 2.42 U.S.C. § 1396r — Requirements for nursing facilities under Medicaid (Nursing Home Reform Act, Medicaid counterpart). https://www.law.cornell.edu/uscode/text/42/1396rLegal Information Institute, Cornell Law School
  3. 3.42 C.F.R. § 483.24 — Quality of life; decline in activities of daily living “unless … unavoidable”. https://www.law.cornell.edu/cfr/text/42/483.24Legal Information Institute, Cornell Law School
  4. 4.42 C.F.R. § 483.25 — Quality of care; skin integrity and pressure ulcers (b)(1), mobility and range of motion (c), accidents and supervision (d), assisted nutrition and hydration (g). https://www.law.cornell.edu/cfr/text/42/483.25Legal Information Institute, Cornell Law School
  5. 5.42 C.F.R. § 483.21 — Comprehensive person-centered care planning, including the baseline care plan and comprehensive care plan requirements. https://www.law.cornell.edu/cfr/text/42/483.21Legal Information Institute, Cornell Law School
  6. 6.42 C.F.R. § 483.10 — Resident rights, including notification of changes, access to records, and communication with officials and the Ombudsman. https://www.law.cornell.edu/cfr/text/42/483.10Legal Information Institute, Cornell Law School
  7. 7.State Operations Manual, Appendix PP — Guidance to Surveyors for Long Term Care Facilities; F686 avoidable/unavoidable pressure ulcer definitions, F689 wandering and elopement guidance, F759/F760 medication error definitions. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdfCenters for Medicare & Medicaid Services
  8. 8.Pressure Injury — StatPearls: NPIAP staging definitions for Stage 1 through Stage 4, unstageable, and deep tissue pressure injury. https://www.ncbi.nlm.nih.gov/books/NBK553107/NCBI Bookshelf, National Library of Medicine
  9. 9.42 C.F.R. § 483.35 — Nursing services, as restored effective February 2, 2026: sufficient staff, licensed nurses on a 24-hour basis, charge nurse each tour, registered nurse for at least 8 consecutive hours a day 7 days a week, full-time director of nursing. https://www.law.cornell.edu/cfr/text/42/483.35Legal Information Institute, Cornell Law School
  10. 10.42 C.F.R. § 483.71 — Facility assessment; documented facility-wide determination of the resources necessary to care for the resident population, reviewed at least annually (unaffected by the 2025 staffing repeal). https://www.law.cornell.edu/cfr/text/42/483.71Legal Information Institute, Cornell Law School
  11. 11.Medicare and Medicaid Programs; Repeal of Minimum Staffing Standards for Long-Term Care Facilities, 90 Fed. Reg. 55687 (Dec. 3, 2025) [CMS-3442-IFC, RIN 0938-AV25], effective February 2, 2026; recites the vacaturs in American Health Care Association v. Kennedy, 777 F. Supp. 3d 691 (N.D. Tex. 2025) and Kansas v. Kennedy (N.D. Iowa June 18, 2025). https://www.govinfo.gov/content/pkg/FR-2025-12-03/pdf/2025-21792.pdfOffice of the Federal Register (via GovInfo)
  12. 12.Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting, 89 Fed. Reg. 40876 (May 10, 2024) — the source of the 0.55 RN, 2.45 NA, and 3.48 total HPRD figures and the 24/7 RN requirement. https://www.govinfo.gov/content/pkg/FR-2024-05-10/pdf/2024-08273.pdfOffice of the Federal Register (via GovInfo)
  13. 13.Public Law 119-21 (enacted July 4, 2025), § 71111 — moratorium barring implementation, administration, or enforcement of the §§ 483.5 and 483.35 minimum staffing standards until September 30, 2034. https://www.govinfo.gov/content/pkg/PLAW-119publ21/pdf/PLAW-119publ21.pdfU.S. Government Publishing Office (GovInfo)
  14. 14.42 C.F.R. § 483.12 — Freedom from abuse, neglect, and exploitation; restraint restrictions and prohibition on employing individuals with abuse findings. https://www.law.cornell.edu/cfr/text/42/483.12Legal Information Institute, Cornell Law School
  15. 15.42 U.S.C. § 1320b-25 — Reporting to law enforcement of crimes occurring in federally funded long-term care facilities (Elder Justice Act § 1150B); 2-hour and 24-hour reporting deadlines and civil money penalties up to $200,000 / $300,000. https://www.law.cornell.edu/uscode/text/42/1320b-25Legal Information Institute, Cornell Law School
  16. 16.42 C.F.R. § 483.45 — Pharmacy services; drug regimen review, medication error rates not 5 percent or greater, and freedom from significant medication errors. https://www.law.cornell.edu/cfr/text/42/483.45Legal Information Institute, Cornell Law School
  17. 17.42 C.F.R. § 483.70 — Administration; binding arbitration agreement requirements at paragraph (m), including the prohibition on requiring signature as a condition of admission and the 30-calendar-day rescission right. https://www.law.cornell.edu/cfr/text/42/483.70Legal Information Institute, Cornell Law School
  18. 18.Medicare and Medicaid Programs; Revision of Requirements for Long-Term Care Facilities: Arbitration Agreements, 84 Fed. Reg. 34718 (July 18, 2019) [CMS-3342-F], effective September 16, 2019 — repeal of the 2016 prohibition and the transparency conditions adopted in its place. https://www.govinfo.gov/content/pkg/FR-2019-07-18/pdf/2019-14945.pdfOffice of the Federal Register (via GovInfo)
  19. 19.Marmet Health Care Center, Inc. v. Brown, 565 U.S. 530 (2012) (per curiam, decided February 21, 2012) — West Virginia's categorical bar on pre-dispute arbitration of nursing home personal-injury and wrongful-death claims is preempted by the Federal Arbitration Act. https://www.law.cornell.edu/supremecourt/text/11-391Legal Information Institute, Cornell Law School
  20. 20.Kindred Nursing Centers L.P. v. Clark, 581 U.S. 246 (2017) (decided May 15, 2017) — Kentucky's clear-statement rule for powers of attorney violates the FAA by singling out arbitration agreements for disfavored treatment. https://www.law.cornell.edu/supremecourt/text/16-32Legal Information Institute, Cornell Law School
  21. 21.Health and Hospital Corporation of Marion County v. Talevski, 599 U.S. 166 (2023) (decided June 8, 2023, 7-2) — FNHRA's unnecessary-restraint and predischarge-notice provisions confer individual federal rights enforceable under 42 U.S.C. § 1983; the defendant facility was county-owned. https://www.law.cornell.edu/supremecourt/text/21-806Legal Information Institute, Cornell Law School
  22. 22.Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide (July 2026) — health inspection ratings set on relative within-state performance: top 10 percent five stars, middle 70 percent in approximately 23.33 percent bands, bottom 20 percent one star. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdfCenters for Medicare & Medicaid Services
  23. 23.QSO-19-09-ALL — Revisions to Appendix Q, Guidance on Immediate Jeopardy; definition of immediate jeopardy and the three-part key elements framework for surveyors. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-09-ALL.pdfCenters for Medicare & Medicaid Services, Quality, Safety & Oversight Group
  24. 24.Nursing Homes Including Rehab Services — Health Deficiencies dataset (survey deficiency records by facility, F-tag, scope and severity, and survey date). https://data.cms.gov/provider-data/dataset/r5ix-sfxwCenters for Medicare & Medicaid Services, Provider Data Catalog
  25. 25.Nursing Homes Including Rehab Services — Provider Information dataset (ownership type, certified beds, average residents per day, star ratings, staffing hours, turnover). https://data.cms.gov/provider-data/dataset/4pq5-n9pyCenters for Medicare & Medicaid Services, Provider Data Catalog
  26. 26.Payroll-Based Journal Daily Nurse Staffing — auditable, payroll-verified daily staffing hours by facility and job category, submitted quarterly and published by CMS. https://data.cms.gov/quality-of-care/payroll-based-journal-daily-nurse-staffingCenters for Medicare & Medicaid Services (data.cms.gov)
  27. 27.National Partnership to Improve Dementia Care in Nursing Homes: Antipsychotic Medication Use Data Report — 23.9 percent in 2011Q4 falling 40.6 percent to 14.2 percent in 2025Q2; CMS statement that it does not expect prevalence to reach zero. https://www.cms.gov/files/document/data-report-national-partnership-improve-dementia-care-nursing-homes-antipsychotic-medication-use.pdfCenters for Medicare & Medicaid Services
  28. 28.Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled Residents, OEI-05-24-00180 (issued September 11, 2025; study period July 2022–June 2023). https://oig.hhs.gov/reports/all/2025/nursing-homes-failed-to-report-43-percent-of-falls-with-major-injury-and-hospitalization-among-their-medicare-enrolled-residents/Office of Inspector General, U.S. Department of Health and Human Services
  29. 29.Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, OEI-06-11-00370 (February 2014) — 33 percent of residents experienced an adverse event or temporary harm within a stay of 35 days or fewer; physician reviewers judged 59 percent preventable. Sample drawn from August 2011 discharges. https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdfOffice of Inspector General, U.S. Department of Health and Human Services
  30. 30.FastStats — Nursing Home Care: 14,700 nursing homes, 1.6 million licensed beds, 72.4 percent for-profit ownership, and 1.2 million residents (2022). https://www.cdc.gov/nchs/fastats/nursing-home-care.htmNational Center for Health Statistics, CDC
  31. 31.Biennial Overview of Post-acute and Long-term Care in the United States — National Post-acute and Long-term Care Study (NPALS) web tables, the source for the FastStats nursing home figures. https://www.cdc.gov/nchs/npals/webtables/overview.htmNational Center for Health Statistics, CDC
  32. 32.Aging Services Professional Liability Claim Report, 12th Edition — claims closed January 1, 2021 through December 31, 2023; falls and pressure injuries 63.2 percent of closed claims; average total incurred $259,443 overall, $375,338 for skilled nursing resident abuse, $303,883 elopement, $306,373 medication error. https://www.cna.com/sites/default/files/assets/CNA-Aging-Services-Claim-Report-12th-Edition.pdfCNA Insurance
  33. 33.Gandhi A, Yu H, Grabowski DC. High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information. Health Aff (Millwood). 2021;40(3):384–391 — 492 million nurse shifts across 15,645 facilities; mean 128 percent and median 94 percent annual turnover. https://pubmed.ncbi.nlm.nih.gov/33646872/Health Affairs / PubMed
  34. 34.Shao L, Shi Y, Xie XY, Wang Z, Wang ZA, Zhang JE. Incidence and Risk Factors of Falls Among Older People in Nursing Homes: Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2023;24(11):1708–1717 — pooled fall incidence 43 percent (95% CI 38–49) across 18 prospective studies; meta-regression shows incidence generally decreased from 1998 to 2021. https://pubmed.ncbi.nlm.nih.gov/37433427/Journal of the American Medical Directors Association / PubMed
  35. 35.Yon Y, Ramiro-Gonzalez M, Mikton CR, Huber M, Sethi D. The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. Eur J Public Health. 2019;29(1):58–67. https://pubmed.ncbi.nlm.nih.gov/29878101/European Journal of Public Health / PubMed
  36. 36.Paulis SJC, Everink IHJ, Halfens RJG, Lohrmann C, Schols JMGA. Prevalence and Risk Factors of Dehydration Among Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc. 2018;19(8):646–657 — prevalence 0.8 to 38.5 percent across 19 studies depending on measurement method. https://pubmed.ncbi.nlm.nih.gov/30056949/Journal of the American Medical Directors Association / PubMed
  37. 37.Cereda E, et al. Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA. Clin Nutr. 2016;35(6):1282–1290 — malnutrition prevalence in nursing homes 17.5 percent (95% CI 14.3–20.6). https://pubmed.ncbi.nlm.nih.gov/27086194/Clinical Nutrition / PubMed
  38. 38.Ginde AA, Moss M, Shapiro NI, Schwartz RS. Impact of older age and nursing home residence on clinical outcomes of US emergency department visits for severe sepsis. J Crit Care. 2013;28(5):606–611 — severe sepsis in 14 percent of infection-related visits by nursing home residents versus 1.9 percent for non-residents; in-hospital mortality 37 percent versus 15 percent. https://pmc.ncbi.nlm.nih.gov/articles/PMC3770757/Journal of Critical Care / PubMed Central
  39. 39.Gupta A, Howell ST, Yannelis C, Gupta A. Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes. NBER Working Paper 28474 (later published, Review of Financial Studies, 2024) — private equity ownership associated with an approximately 10 percent increase in short-term mortality of Medicare patients, 2005–2017. https://www.nber.org/papers/w28474National Bureau of Economic Research
  40. 40.42 C.F.R. § 483.80 — Infection control; infection prevention and control program, antibiotic stewardship, and the infection preventionist requirement. https://www.law.cornell.edu/cfr/text/42/483.80Legal Information Institute, Cornell Law School
  41. 41.Federal Rule of Evidence 702, as amended effective December 1, 2023 — preponderance showing to the court and the Rule 702(d) reliable-application requirement. https://www.law.cornell.edu/rules/fre/rule_702Legal Information Institute, Cornell Law School

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