One-third of Medicare beneficiaries experienced harm or adverse events during a nursing facility stay, and about 60% of those instances were preventable, according to reports from the Inspector General of the Department of Health and Human Resources.

A new 60-page report from the Centers for Medicare & Medicaid Services (CMS) delves into the steps nursing homes can take to avoid harm to their residents.

“There is no single, magic bullet to prevent all causes of harm to residents, and therefore, the [report] covers a wide range of strategies and actions to promote resident safety, including shoring up staffing, identifying gaps in care, and promoting multidisciplinary team work,” report authors stated.

Nursing homes participating in the development of the full 60-page CMS report provided six strategies that nursing homes can pursue to begin their effort in preventing harm to residents:

  1. Shore up staffing.
  • Ensure you have the right people in key positions.
  • Ensure you have adequate mix and number of staff on the units – use the facility assessment as a guide.
  • Define the specific competencies and skills needed by your organization in order to ensure staff competence (nursing, therapy, dietary, etc.).
  • Focus on staff development, training, and continuing education.
  • Be clear about standards of behavior for staff, have those in writing.
  • Decrease or eliminate use of pool staff that do not know your residents and organizational processes.
  • Take care of the staff and build resiliency – happy, stable staff leads to happy, safer residents, and contributes to improved safety.
  • Partner with local academic organizations and community to enhance nursing assistant training and nursing assistant referral process.
  • Consider your census and be bold enough to hold admissions in response to staffing issues.
  1. Know the residents and their needs and areas of risk; plan care with them.
  • Leaders and staff must have in-depth knowledge about each resident, anticipate problems and needs.
  • Work with each resident to set goals and plans of care (balancing resident freedoms with safety).
  • Ensure that residents receive appropriate care and that care plans are kept up to date.
  • Make sure all staff have the information they need to provide safe care for the resident.
  • Identify and address concerns before they become a problem “safety is everyone’s responsibility – if you see something, say something.”
  • Have a system for staff to share knowledge/best practice for individual resident care plans.
  1. Prevent, identify, and address gaps in care.
  • Establish a consistent admissions process to prevent errors and improve the resident/patient/family experience.
  • Back each other up – build in multiple, independent checks to ensure there are no gaps in evidenced-based care and treatments, processing and following-up on orders, tests and results, appointments, etc.
  • Look for gaps from survey results; quality measures; resident, family, and staff feedback and complaints; provider and community feedback; audits.
  • Address any known gaps in care immediately by improving processes and systems.
  • Recognize recurring problems as weaknesses or failures of the organization’s processes and systems – which leadership has responsibility to address.
  1. Promote excellent multidisciplinary team work.
  • Focus on efficient and effective communication within and across teams.
  • Provide care, monitor residents and staff, problem solve and make decisions together.
  • Push decision making to those with the most expertise and those impacted by the processes being discussed.
  • Model and set expectations that all team member voices are valued and trusted.
  1. Provide tangible leadership engagement with staff and residents.
  • Ongoing frequent rounding and presence on the units/floors and during meetings, interacting with and supporting residents, families, staff, providers, ensuring care safety risks are identified and addressed, ensuring adequate and safe physical environment, equipment, supplies.
  • Pay close attention to what is happening on the front lines that impacts direct care – looking for any actual or potential areas of failure in care or environment – no area too big or too small to address.
  • Articulate, model, and recognize high expectations around safety, quality, rights, choice, and respect – care for residents as family, safety is everyone’s role.
  • Use resident and family quality of life/satisfaction surveys as a tool for conversation in resident and family councils.
  1. Ensure excellent, competent, available, continuous care—onsite.
  • Medical: Providers with expertise in geriatrics, wound care, psychiatry, podiatry, dental, vision (all areas of specialty needed for your population).
  • Psychosocial: Staff with expertise in activities, spiritual, social, recreational aspects of well-being.
  • Offer individualized and group activities to promote psychosocial, physical, and spiritual health, and prevent loneliness, isolation, depression, and boredom which can lead to harm and injury.
  • Use staff with specialized training (social services, etc.) to help formulate strong behavioral plans/interventions.

The full 60-page CMS report is attached here –

Download (PDF, 1.11MB)

For additional information concerning nursing home law and litigation, visit:

Nursing Home Law and Litigation



Donald D. Vanarelli has been a practicing attorney since 1983 in New Jersey and New York. Don provides legal services in the areas of elder law, estate planning, trust administration, special education, special needs planning and trial advocacy, including probate litigation, will contests, contested guardianships and elder abuse trials.

Don is a Certified Elder Law Attorney, an Accredited Veterans Attorney and a Past Chair of the Elder and Disability Law Section of the New Jersey State Bar Association. Don is a recipient of the Lifetime Achievement Award, the highest honor given by the New Jersey State Bar Association – Elder and Disability Law Section. The Lifetime Achievement Award is bestowed on an attorney with an established history of distinguished service who has made significant contributions in the field of elder and disability law throughout his or her career. Recently, Don was selected by the New Jersey Law Journal as a Top Rated New Jersey Lawyer in 2019.

Don is actively involved in trial advocacy on behalf of elderly and disabled citizens. Don was lead counsel representing the plaintiff in a seminal estate planning / guardianship / Medicaid planning case entitled In re Keri, 181 N.J. 50 (2004), in which the New Jersey Supreme Court, for the first time, permitted guardians to engage in public benefits planning to obtain Medicaid eligibility for their wards. Don also represented the plaintiff in a pivotal case entitled Saccone v. Police and Firemen’s Retirement System, 219 N.J. 369 (2014) in which the New Jersey Supreme Court, for the first time, permitted a special needs trust to be designated as the beneficiary of a state pension. Don was also co-counsel representing the plaintiff in Galletta v. Velez, Civil No. 13-532 (D.N.J. June 3, 2014) in which a federal court ruled, for the first time, that a pension from the Department of Veterans Affairs may not be counted as income in determining Medicaid eligibility.

When he’s not working, Don spends his time with his wife, Marion, and his three children, Julianne, Evan and Alex.