{
  "study": {
    "slug": "nursing-home-penalty-concentration-2026",
    "title": "Where nursing-home penalties concentrate: a repeat-citation story, 2026",
    "standfirst": "Between May 2023 and April 2026, CMS imposed $459.3M in civil money penalties and 2,513 payment denials on 6,884 nursing facilities. Enforcement concentrates: the 53.7% of penalized facilities cited more than once carry 80.1% of the fine dollars and 90.6% of the payment denials — the half cited once drew a fifth of the money.",
    "desk": "financial-distress",
    "article_type": "Original Research",
    "published": "2026-06-16",
    "issue": 76,
    "doi": "10.5072/fonteum/nursing-home-penalty-concentration-2026",
    "url": "https://fonteum.com/research/nursing-home-penalty-concentration-2026",
    "methodology_version": "cms-cmp/v1"
  },
  "data_as_of": "2026-06-16",
  "datasets": [
    {
      "slug": "cms-nursing-home-compare",
      "name": "CMS Nursing Home Compare",
      "publisher": "CMS — Nursing home quality (Care Compare)",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "80.1%",
      "finding": "of all fine dollars fall on the 3,699 nursing facilities (53.7% of those penalized) that CMS cited more than once in three years; those same facilities carry 2,277 of the 2,513 payment denials (90.6%). The 46.3% cited just once drew only a fifth of the money",
      "dataset": "cms-nursing-home-compare"
    },
    {
      "number": "$459.3M",
      "finding": "in civil money penalties across 13,764 fine actions, plus 2,513 payment-denial actions, fell on 6,884 Medicare/Medicaid-certified facilities between May 2023 and April 2026. The median fine was $14,576; the largest single fine was $713,795",
      "dataset": "cms-nursing-home-compare"
    },
    {
      "number": "716",
      "finding": "facilities — 10.4% of those penalized — drew five or more enforcement actions in the three-year window. They are the most-cited tier and carry 28.4% of the fine dollars and 35.0% of the payment denials",
      "dataset": "cms-nursing-home-compare"
    },
    {
      "number": "$66.1M",
      "finding": "in fines fell on Illinois facilities, 14.4% of the national total and more than any other state, across 467 facilities and 496 payment denials — roughly one in five payment denials nationwide — at an average fine of $50,190, the highest among the largest enforcement states",
      "dataset": "cms-nursing-home-compare"
    },
    {
      "number": "16,277",
      "finding": "enforcement actions across 53 states and territories make up the published file, CMS release dated 2026-05-01, keyed to 6,884 distinct facility CCNs. Every figure is a count or sum over published records — no individual facility is named, ranked, or scored",
      "dataset": "cms-nursing-home-compare"
    }
  ],
  "faqs": [
    {
      "q": "What is a CMS civil money penalty against a nursing home?",
      "a": "A civil money penalty (CMP) is a fine CMS imposes on a Medicare/Medicaid-certified nursing facility found out of compliance with federal Conditions of Participation. CMS can levy a per-day amount for an ongoing deficiency or a per-instance amount for a specific event. The penalty is a CMS enforcement determination; this study counts the published actions and does not assess any facility's compliance."
    },
    {
      "q": "How concentrated is nursing-home enforcement?",
      "a": "Heavily. Of the 6,884 facilities penalized between May 2023 and April 2026, the 3,699 cited more than once — 53.7% — account for 80.1% of all fine dollars and 90.6% of the payment denials. The 46.3% of facilities cited just once drew about a fifth of the dollars. A smaller tier of 716 facilities cited five or more times carries 28.4% of the money and 35.0% of the denials."
    },
    {
      "q": "What is the difference between a fine and a payment denial?",
      "a": "They are the two enforcement actions in the file. A fine is a monetary penalty: 13,764 fine actions total $459,337,807. A payment denial — a denial of payment for new admissions — suspends Medicare/Medicaid reimbursement until deficiencies are corrected and is the more severe remedy; there are 2,513 of them, lasting 27 days on average. CMS does not attach a separate dollar amount to a payment-denial action, so the dollar totals here cover fine actions only."
    },
    {
      "q": "Which states have the most nursing-home penalties?",
      "a": "By fine dollars, Illinois leads with $66.1M (14.4% of the national total) across 467 facilities, followed by Texas ($59.3M) and California ($30.8M). Illinois also records 496 payment denials — roughly one in five of all denials nationwide — and the highest average fine among the largest states, $50,190 against a national median of $14,576."
    },
    {
      "q": "Does a penalty mean a nursing home is unsafe today?",
      "a": "Not on its own. A penalty is a record that CMS cited a facility for a deficiency on a past survey and set an amount. Many facilities correct deficiencies promptly; the file does not show current condition, and a single enforcement record is one regulatory signal among many. This study draws no conclusion about the care at any facility and names none."
    },
    {
      "q": "Is Fonteum issuing or assessing these penalties?",
      "a": "No. Every penalty in this study is a CMS enforcement action published by CMS. Fonteum does not impose fines, assess facility compliance, or make enforcement determinations. The study aggregates the published records — by penalty type, repeat-citation count, fine size, and state — and reports the counts and sums."
    },
    {
      "q": "Can I reproduce these figures?",
      "a": "Yes. Every number is a direct count or sum over the public cms_civil_money_penalties table — CMS's Civil Money Penalties file, source release 2026-05-01 — with no modeling. The exact SQL for the penalty-type split, the per-facility concentration, the fine-size distribution, and the state breakdown is published in the reproducibility block below."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 16). Where nursing-home penalties concentrate: a repeat-citation story, 2026. Fonteum Research, Issue 76. https://doi.org/10.5072/fonteum/nursing-home-penalty-concentration-2026",
    "url": "https://fonteum.com/research/nursing-home-penalty-concentration-2026"
  },
  "reproducible_sql": "-- WHERE Medicare's nursing-home civil money penalties concentrate — and why it\n-- is a repeat-citation story. Fully reproducible query.\n--\n-- Question: of the civil money penalties (CMPs) and payment denials CMS has\n-- imposed on Medicare/Medicaid-certified nursing facilities, how are the dollars\n-- and the severe actions distributed across facilities, fine sizes, and states?\n-- The lead figure: of the 6,884 facilities penalized between May 2023 and April\n-- 2026, the 3,699 cited more than once (53.7%) carry 80.1% of all fine dollars\n-- and 90.6% of the payment denials. A penalty is a CMS enforcement action, NOT\n-- a Fonteum judgment, fraud signal, or assessment of current facility quality.\n--\n-- Source:\n--   public.cms_civil_money_penalties — CMS \"Civil Money Penalties\" public-use\n--     file, published quarterly via the CMS data catalog (data.cms.gov, dataset\n--     g6vv-u9sr). 16,277 enforcement actions; source release 2026-05-01.\n--     Public, read-only. License: US-Government-Works (17 U.S.C. Sec. 105).\n--     methodology_version = 'cms-cmp/v1'.\n--\n-- Universe: this study reads the published file AS A WHOLE — every row is one\n--   enforcement action CMS records against a certified facility, keyed to the\n--   facility CMS Certification Number (CCN). The file carries NO provider NPI;\n--   penalties join to facilities, never to a named clinician. It is the current\n--   enforcement record CMS releases each quarter, not a cumulative history.\n--\n-- Counting note: two penalty types appear. A \"Fine\" carries a fine_amount; a\n--   \"Payment Denial\" suspends Medicare/Medicaid payment for new admissions and\n--   carries a payment_denial_days length but NO dollar amount. All dollar totals\n--   below sum fine actions only. No individual facility is named in the study.\n\n-- ============================================================================\n-- (1) Universe reconciliation — the published file at a glance.\n-- ============================================================================\nSELECT\n  count(*)                                                          AS actions,\n  count(DISTINCT ccn)                                               AS distinct_ccn,\n  count(DISTINCT state)                                             AS states,\n  count(*) FILTER (WHERE penalty_type = 'Fine')                     AS fine_actions,\n  round(sum(fine_amount) FILTER (WHERE penalty_type = 'Fine'))      AS total_fine_usd,\n  count(*) FILTER (WHERE penalty_type = 'Payment Denial')           AS payment_denials,\n  min(penalty_date)                                                 AS earliest_action,\n  max(penalty_date)                                                 AS latest_action,\n  max(source_release_date)                                          AS source_release\nFROM public.cms_civil_money_penalties;\n--  actions 16,277 · distinct_ccn 6,884 · states 53 · fine_actions 13,764\n--  total_fine_usd 459,337,807 · payment_denials 2,513\n--  earliest 2023-05-17 · latest 2026-04-17 · source_release 2026-05-01\n\n-- ============================================================================\n-- (2) HEADLINE: enforcement is concentrated on repeat-cited facilities. Roll up\n--     to the facility (CCN), bucket by how many actions each facility drew, and\n--     read the share of dollars and payment denials per bucket. The 2-or-more\n--     buckets together = 53.7% of facilities, 80.1% of dollars, 90.6% of denials.\n-- ============================================================================\nWITH fac AS (\n  SELECT\n    ccn,\n    count(*)                                                        AS actions,\n    sum(coalesce(fine_amount, 0))                                   AS fines,\n    count(*) FILTER (WHERE penalty_type = 'Payment Denial')         AS denials\n  FROM public.cms_civil_money_penalties\n  GROUP BY ccn\n), bucketed AS (\n  SELECT\n    CASE WHEN actions = 1 THEN '1'\n         WHEN actions BETWEEN 2 AND 4 THEN '2-4'\n         WHEN actions BETWEEN 5 AND 9 THEN '5-9'\n         ELSE '10+' END                                             AS penalties_per_facility,\n    actions, fines, denials\n  FROM fac\n)\nSELECT\n  penalties_per_facility,\n  count(*)                                                          AS facilities,\n  round(100.0 * count(*) / sum(count(*)) OVER (), 1)                AS pct_facilities,\n  round(sum(fines))                                                 AS fine_dollars,\n  round(100.0 * sum(fines) / sum(sum(fines)) OVER (), 1)            AS pct_dollars,\n  sum(denials)                                                      AS payment_denials,\n  round(100.0 * sum(denials) / sum(sum(denials)) OVER (), 1)        AS pct_denials\nFROM bucketed\nGROUP BY penalties_per_facility\nORDER BY min(actions);\n--  1    3,185  46.3%  $ 91,417,534  19.9%  236   9.4%\n--  2-4  2,983  43.3%  $237,324,673  51.7% 1,397  55.6%\n--  5-9    597   8.7%  $108,506,786  23.6%  737  29.3%\n--  10+    119   1.7%  $ 22,088,814   4.8%  143   5.7%\n--  cited >1x  = 3,699 facilities (53.7%), 80.1% of dollars, 2,277 denials (90.6%)\n--  cited >=5x =   716 facilities (10.4%), 28.4% of dollars,   880 denials (35.0%)\n\n-- ============================================================================\n-- (3) The fine-amount distribution is itself skewed: a thick base of small fines\n--     and a thin tail of very large ones. The median fine is $14,576, but the\n--     1,138 fines of $100k+ (8.3% of fine actions) carry 40.7% of every dollar.\n-- ============================================================================\nSELECT\n  round(percentile_cont(0.5)  WITHIN GROUP (ORDER BY fine_amount)\n        FILTER (WHERE fine_amount > 0))                             AS median_fine,\n  round(percentile_cont(0.9)  WITHIN GROUP (ORDER BY fine_amount)\n        FILTER (WHERE fine_amount > 0))                             AS p90_fine,\n  round(percentile_cont(0.99) WITHIN GROUP (ORDER BY fine_amount)\n        FILTER (WHERE fine_amount > 0))                             AS p99_fine,\n  max(fine_amount)                                                  AS max_fine,\n  count(*) FILTER (WHERE fine_amount >= 100000)                     AS fines_100k_plus,\n  round(100.0 * sum(fine_amount) FILTER (WHERE fine_amount >= 100000)\n        / sum(fine_amount) FILTER (WHERE fine_amount > 0), 1)       AS pct_dollars_100k_plus,\n  count(*) FILTER (WHERE fine_amount > 0 AND fine_amount < 10000)   AS fines_under_10k\nFROM public.cms_civil_money_penalties;\n--  median_fine $14,576 · p90 $86,392 · p99 $229,243 · max $713,795\n--  fines_100k_plus 1,138 · pct_dollars_100k_plus 40.7% · fines_under_10k 4,753\n\n-- ============================================================================\n-- (4) WHERE the dollars are — top 8 states by total fine dollars, with each\n--     state's facility count, payment denials, and average fine. Illinois leads\n--     ($66.1M, 14.4% of all dollars) and records 496 payment denials — about one\n--     in five nationwide — at the highest average fine of the largest states.\n-- ============================================================================\nSELECT\n  state,\n  count(DISTINCT ccn)                                               AS facilities,\n  round(sum(coalesce(fine_amount, 0)))                              AS fine_dollars,\n  round(100.0 * sum(coalesce(fine_amount, 0))\n        / sum(sum(coalesce(fine_amount, 0))) OVER (), 1)            AS pct_dollars,\n  count(*) FILTER (WHERE penalty_type = 'Payment Denial')           AS payment_denials,\n  round(avg(fine_amount) FILTER (WHERE fine_amount > 0))            AS avg_fine\nFROM public.cms_civil_money_penalties\nWHERE state IS NOT NULL\nGROUP BY state\nORDER BY fine_dollars DESC\nLIMIT 8;\n--  IL 467 $66,149,870 14.4% 496 $50,190 · TX 826 $59,272,333 12.9% 162 $32,074\n--  CA 526 $30,757,146  6.7% 287 $25,760 · OH 318 $21,223,444  4.6% 169 $40,580\n--  FL 284 $19,252,995  4.2%  23 $28,650 · MO 233 $17,073,306  3.7% 151 $34,011\n--  PA 298 $17,000,120  3.7%  58 $31,717 · NC 249 $16,499,013  3.6%  82 $31,790\n\n-- ============================================================================\n-- (5) Payment denials are the severe tier — denial of payment for new admissions\n--     until deficiencies are corrected. They cluster with repeat-cited\n--     facilities (90.6% fall on facilities cited >1x, see query 2) and run 27\n--     days on average. CMS attaches no dollar amount to a denial action.\n-- ============================================================================\nSELECT\n  count(*) FILTER (WHERE payment_denial_days > 0)                   AS payment_denials,\n  round(avg(payment_denial_days) FILTER (WHERE payment_denial_days > 0)) AS avg_days,\n  percentile_cont(0.5) WITHIN GROUP (ORDER BY payment_denial_days)\n        FILTER (WHERE payment_denial_days > 0)                      AS median_days,\n  max(payment_denial_days)                                          AS max_days\nFROM public.cms_civil_money_penalties;\n--  payment_denials 2,513 · avg_days 27 · median_days 19 · max_days 458\n\n-- ============================================================================\n-- (6) The action window by year, for context only (NOT a trend model). The file\n--     spans a partial 2023 (from May 17) through a partial 2026 (to April 17),\n--     so the first and last years are incomplete. Counts are by penalty_date.\n-- ============================================================================\nSELECT\n  extract(year FROM penalty_date)::int                              AS action_year,\n  count(*)                                                          AS actions,\n  count(*) FILTER (WHERE penalty_type = 'Fine')                     AS fine_actions,\n  round(sum(coalesce(fine_amount, 0)))                              AS fine_dollars,\n  count(*) FILTER (WHERE penalty_type = 'Payment Denial')           AS payment_denials\nFROM public.cms_civil_money_penalties\nGROUP BY action_year\nORDER BY action_year;\n--  2023 5,539 4,876 $117,210,368 663 (partial, from 2023-05-17)\n--  2024 6,170 5,098 $183,989,128 1,072\n--  2025 4,162 3,423 $143,381,741 739\n--  2026   406   367 $ 14,756,570  39 (partial, to 2026-04-17)",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}