March 17, 2026
In the 1980s, lawmakers and advocates in the United States recognized that nursing homes were failing to adequately protect the safety and well-being of their residents. A 1986 report from the Institute of Medicine Committee on Nursing Home Regulations documented widespread problems with quality of care and called into question the effectiveness of regulatory oversight. The findings spurred the passage of the Nursing Home Reform Act of 1987, which established a code of residents’ rights (including the right to voice grievances and make choices about their options for daily life); set federal standards for quality of care; and expanded oversight. Regular inspections were scheduled, and the law set the stage for sanctions against facilities that failed to meet standards of care.
Several decades later, however, many nursing homes across the country still fail to meet basic expectations for resident care. Every year, regulators identify thousands of health and safety violations across facilities, including failures to properly administer medications, to respect residents’ rights, and to provide nutritious meals. And a recent poll from Gallup found that Americans give nursing homes a D+ grade for quality of care. Additionally, research suggests that there is an unequal distribution of regulatory noncompliance, with studies finding that facilities serving higher proportions of racial and ethnic minorities tend to have more violations.
So, why hasn’t the promise of the Nursing Home Reform Act of ‘87 been fully realized? Part of the reason may be the sheer complexity of care required to manage an aging population. This includes everything from ensuring medications are fully and properly administered and kept up to date with residents’ needs, to providing compassionate and sufficiently frequent assistance with activities of daily living, such as eating, toileting, and bathing. Many facilities have also struggled to attract and retain staff, with shortages of key personnel only worsening since the COVID-19 pandemic.
Another fundamental issue may be the efficacy of regulatory enforcement. The federal Centers for Medicare and Medicaid Services (CMS) has a number of enforcement actions, or remedies, at its disposal to sanction nursing homes for poor performance. But how well do they work? This policy brief explores the role and effectiveness of the most common type of federal enforcement action: the civil money penalty (CMP). CMS can impose such CMPs on individual nursing homes, ranging from a few thousand to several hundred thousand dollars, depending on the severity of infractions. Records show that in 2023 alone, the agency imposed a total of $204 million in CMPs. Yet little is understood about whether these penalties effectively deter regulatory noncompliance, and there is ongoing debate about their appropriate size. This analysis aims to provide an overview of what CMPs are, what is known about their impact, and what can be done to improve our understanding of them.
