Guide to Quality and Safety in Long-Term Care

Quality and safety really define the daily experiences of residents living in long-term care facilities. These systems protect residents from preventable harm, support evidence-based care, and shape how facilities respond to risks, deficiencies, and operational challenges. This guide outlines the federal quality and safety framework, the key areas of high-quality care, and some federal resources available for deeper learning.

Why Quality and Safety Are Important

Effective quality and safety programs ensure residents receive consistent, respectful, and clinically appropriate care. Data shows that facilities with strong processes experience fewer adverse events, greater staff stability, higher quality outcomes, and stronger trust among residents and families. These elements also influence CMS oversight, enforcement patterns, and public reporting.

The Federal Framework for Quality and Safety

Federal Requirements for Long-Term Care Facilities

To participate in Medicare and Medicaid, facilities must comply with extensive federal regulations governing resident rights, clinical services, staffing, infection control, and every major operational system. These requirements establish the national foundation for protecting residents and ensuring high-quality care.

Survey and Enforcement

State survey agencies conduct inspections and complaint investigations for CMS. Findings may result in deficiencies, severity and scope ratings, and enforcement actions. Penalties can include civil monetary fines, directed plans of correction, denial of payment, or termination from federal programs for severe or uncorrected noncompliance.

Quality Measures

CMS tracks and publicly reports standardized quality measures, including hospitalization rates, pressure injuries, antipsychotic medication use, falls, mobility changes, and vaccination rates. These measures provide a data-based view of how well facilities are meeting clinical and functional care expectations.

Staffing and Turnover

Facilities submit daily staffing data to the Payroll-Based Journal system. Public reporting reflects RN, LPN, and CNA hours, weekend staffing levels, agency use, and annual turnover. Staffing stability strongly influences quality, safety, and resident outcomes.

Infection Prevention and Control

Every CMS-certified facility must operate a comprehensive infection control program, led by a trained Infection Preventionist. Core functions include surveillance, outbreak management, isolation precautions, PPE practices, environmental cleaning, and antibiotic stewardship.

Emergency Preparedness

CMS requires an all-hazards emergency preparedness program that includes risk assessment, communications planning, training, and annual drills. This protects residents during natural disasters, power outages, infectious disease events, and other emergencies.

Quality Assurance and Performance Improvement (QAPI)

QAPI programs use data-driven methods to evaluate performance, identify systemic risks, and implement targeted improvements. Every facility must maintain an ongoing, interdisciplinary QAPI structure that supports long-term quality and safety.

Core Domains of Quality and Safety

Resident Rights and Autonomy

Residents have legally protected rights related to dignity, privacy, communication, visitation, and participation in care decisions. Upholding these rights is a fundamental element of quality.

Clinical Quality of Care

High-quality clinical care includes individualized care plans, accurate assessments, prevention-focused practices, medication safety, chronic disease management, and safe care transitions.

Infection Prevention and Control

Infection control systems protect residents from communicable diseases and outbreaks. Strong programs ensure the use of evidence-based precautions, hand hygiene, PPE, environmental cleaning, and continuous surveillance for risks.

Staffing Competency and Stability

Adequate and competent staffing is essential for resident safety. Facilities must maintain enough licensed nursing and CNA staff, provide competency-based training, and minimize turnover.

Physical Environment and Life Safety

The building environment must comply with federal Life Safety Code standards, including fire protection, emergency exits, hazard mitigation, and routine maintenance.

Medication and Behavioral Health Safety

Facilities must prevent medication errors, limit unnecessary antipsychotic use, monitor side effects, and support residents with dementia or mental health conditions using person-centered, non-pharmacologic approaches.

Public Tools to Monitor Quality

CMS Care Compare provides transparent ratings, survey findings, staffing data, and quality measures for every Medicare/Medicaid-certified nursing home.

CMS also publishes downloadable datasets covering staffing, deficiencies, ownership, quality measures, and enforcement actions.

CDC provides guidance, training tools, and infection prevention resources tailored to long-term care settings.

To see how quality and safety patterns appear in your state, visit the Reports page for current statewide and facility-level analysis.