CMS Nursing Home Regulations & Guidance for 2025

CMS regulations set the foundation for how nursing homes operate — everything from staffing and inspections to reimbursement rules. Staying compliant isn't optional — it directly affects your facility’s ability to receive Medicare and Medicaid payments and maintain accreditation.

If you’re managing a nursing home in 2025, there are specific updates and enforcement trends you need to be aware of.

In this article, we’ll cover:

• Key CMS nursing home regulations for 2025

• Compliance requirements for certified nursing facilities

• Best practices for adapting to new CMS guidelines and avoiding penalties

What are CMS nursing home regulations?

Every nursing home that participates in Medicare or Medicaid has to meet specific federal requirements set by CMS — short for the Centers for Medicare & Medicaid Services.

CMS is the federal agency responsible for enforcing quality and safety standards in long-term care facilities. These regulations cover everything from how residents are cared for to how facilities are inspected, how staffing is managed, and how serious issues like abuse or neglect are handled.

CMS doesn’t work in isolation: state agencies conduct the surveys (inspections), but those surveys follow strict federal standards and are reviewed at the federal level.

Compliance is non-negotiable. A facility must be in substantial compliance — which means any issues found pose no more than minimal harm — to stay certified.

Fall short, and you’re risking everything from fines to denied payments to full termination from Medicare and Medicaid. In short, these regulations are the gatekeepers to both accreditation and funding.

And CMS isn’t waiting around for facilities to self-correct. If issues are identified, especially anything that puts resident health or safety in jeopardy, remedies can be imposed immediately. Facilities are expected to monitor themselves, fix problems fast, and prove those fixes are lasting.

Key CMS nursing home regulations for 2025

What’s new or particularly important in 2025? While CMS regulations are rooted in long-standing federal laws like the Social Security Act and the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), each year brings updated guidance, and facilities are expected to keep up.

CMS has officially delayed the implementation of its updated survey guidance. It was initially expected in early 2025, but the changes will now take effect starting April 28, 2025. This gives facilities additional time to align policies, update staff training, and review documentation practices in line with the new enforcement focus.

Here are some of the key areas every nursing home should be focused on:

1. Resident rights and protections

Resident-centered care is a cornerstone of CMS oversight. Facilities are expected to support residents in reaching their highest practicable level of functioning, whether that’s physical, mental, or psychosocial. 

That means protecting rights to dignity, privacy, freedom from abuse and neglect, and involvement in care planning.

A new CMS requirement mandates that facilities must obtain clear, explicit consent from residents before starting or increasing the dose of psychotropic medications. This rule reinforces residents' rights to participate actively in their care decisions.

Failing to uphold these standards doesn’t just result in a citation; it can lead to serious enforcement actions if the deficiency contributes to substandard quality of care or immediate jeopardy.

2. Infection control and emergency preparedness

Post-pandemic, infection control remains under the microscope. Facilities must follow federal guidelines for infection prevention, isolation procedures, and outbreak response.

In addition, every nursing home must maintain a CMS-approved emergency preparedness plan that includes communication strategies, evacuation procedures, and continuity-of-care protocols.

This is not optional. CMS surveys pay close attention to emergency preparedness across all facilities — not just those in disaster-prone regions — as part of its mandatory Emergency Preparedness Rule.

3. Staffing requirements

CMS requires licensed nursing services 24/7 and mandates that at least one registered nurse (RN) be on duty for a minimum of 8 consecutive hours each day, 7 days a week — unless the facility qualifies for a waiver.

A full-time Director of Nursing is also required. However, waivers can be granted in certain cases, like rural facilities facing staffing shortages — but only under strict criteria.

CMS will now rely heavily on Payroll Based Journal (PBJ) data as the primary source for assessing staffing compliance. Facilities must ensure accurate and timely PBJ submissions, as discrepancies between reported staffing levels and actual staffing can trigger citations.

Training is also a focus. Surveyors can cite facilities that don’t provide proper in-service training, especially in areas like abuse prevention, infection control, and resident care protocols.

4. Quality care and safety standards

CMS expects facilities to meet not just clinical standards, but quality-of-life benchmarks as well. Surveyors look closely at care plans, resident assessments, and outcomes like pressure ulcers, weight loss, or hospital readmissions.

CMS has intensified its focus on the accuracy of Minimum Data Set (MDS) submissions. Surveyors are now instructed to closely monitor for patterns of coding inaccuracies. If there’s any suspicion of deliberate falsification, these cases will be escalated to the Office of Inspector General (OIG) for investigation.

Facilities should prioritize thorough staff training and internal audits to avoid serious enforcement actions.

CMS has reclassified "unnecessary use of psychotropic medications" (previously tag F758) under a new tag: F605 – Chemical Restraints. This adjustment sharpens enforcement by explicitly recognizing these medications as a form of restraint when used inappropriately.

Facilities should ensure robust justification and clear documentation for all psychotropic prescriptions.

In 2025, survey emphasis continues to be placed on:

• Accurate resident assessments

• Implementation of care plans

• Safe medication management

• Psychosocial well-being and activity programs

CMS is reorganizing its regulatory framework by deleting certain tags — including F622–F626 and F660–F661 — and introducing new ones: F627 and F628. These changes aim to streamline compliance assessments and improve clarity for surveyors and providers alike.

What are the biggest compliance challenges for nursing homes?

While CMS acknowledges ongoing staffing challenges, particularly in rural areas, facilities are still held accountable to core staffing requirements unless specific waivers are approved.

That’s one of the biggest hurdles for nursing homes, especially when new staff need to get up to speed on documentation, reporting, and care protocols fast.

Other pain points include:

• Documentation errors: Incomplete or inconsistent records are a top reason for citations.
  
  

• Delayed response to deficiencies: CMS can impose remedies before facilities get a chance to fix issues.
  
  

• Survey unpredictability: All surveys are unannounced and vary in timing –– weekends, early mornings, even holidays.

Compliance and documentation requirements for nursing homes

Regulatory compliance involves maintaining the kind of documentation that shows your facility is delivering safe, consistent, and high-quality care every day. Plus, CMS expects that documentation to be clear, complete, and accessible.

What CMS expects you to document

For nursing homes participating in Medicare or Medicaid, CMS requires detailed records in several key areas:

• Individualized care plans based on resident assessments

• Physician orders and clinical notes

• Staff training and credentialing documentation

• Incident reports and grievance logs

• Infection prevention and control records

• Emergency preparedness plans

• Quality assurance and performance improvement (QAPI) documentation

CMS has clarified that facilities cannot include clauses in admission agreements requiring third-party guarantees of payment. This protects residents and their families from being compelled into financial commitments they did not anticipate or agree to directly.

Surveyors will also look for proof of resident rights notifications, discharge summaries, and accurate medication administration records. If your records are missing, inconsistent, or fragmented across systems, that’s a red flag.

Where documentation breaks down

The most common compliance pitfalls aren’t always about what’s missing — they’re often about how information is organized:

• Notes stored in different systems that don’t talk to each other

• Manually transcribed data that’s inconsistent or incomplete

• Outdated care plans that don’t reflect current needs

• Missed documentation around high-risk meds or discharge planning

These gaps increase your risk of getting cited and may even delay or reduce Medicare or Medicaid reimbursement.

CMS is placing new emphasis on incorporating health equity considerations within your Quality Assurance & Performance Improvement (QAPI) program. Facilities should evaluate how disparities affect resident care outcomes and integrate strategies to address these gaps in their QAPI plans.

How ExaCare helps expedite record-keeping

This is where a tool like ExaCare can support compliance from day one of the admissions process. It’s designed to:

• Extract and summarize key clinical and financial data from referral packets, reducing the chance of missing critical details.
  
  

• Centralize referral management across major platforms so your intake team works from a single interface.
  
  

• Flag potential reimbursement concerns early, such as high-cost medications or incomplete payer data.
  
  

• Reduce data entry errors by surfacing essential information in a structured format your team can quickly review and act on.

How to prepare for CMS surveys and inspections

If you’ve been through a CMS survey, you already know: They’re unannounced, wide-ranging, and can escalate quickly. Surveyors are looking to see if your facility is actually following CMS requirements in practice, not just on paper.

What triggers citations?

Common reasons for deficiencies include:

• Outdated or missing care plans

• Poor infection control documentation

• Delays in reporting incidents or updating records

• Gaps between what’s documented and what’s observed on the floor

• Inconsistent or inaccurate physician orders

Serious issues (like anything that puts residents at risk) can lead to enforcement actions that take effect immediately, even before the survey wraps up.

Best practices for staying survey-ready

The facilities that handle surveys with confidence tend to have systems in place that make compliance a daily habit, not a once-a-year scramble.

That includes:

• Conducting internal audits and mock surveys regularly

• Keeping documentation current and centralized

• Training staff on how to respond to surveyor questions

• Having clear lines of communication around incident reporting and follow-up

ExaCare supports survey preparedness by improving the way your team handles admissions from the start:

• Referral packets are parsed and summarized, helping ensure that key clinical and financial information isn’t missed or lost.
  
  

• Documentation is stored in a single interface, so surveyors and staff can quickly access relevant data.
  
  

• Financial red flags (like high-cost meds or unclear payer info) are surfaced early so they can be addressed before they become survey risks.

While ExaCare doesn’t replace your full compliance strategy, it helps ensure that your admissions process isn’t the weak link when surveyors arrive.

Federal vs. state nursing home regulations

CMS sets the national baseline, but that’s not the whole story. Each state has its own set of nursing home rules layered on top of the federal regulations.

If you’re only looking at CMS guidelines, you may be missing state-level requirements that carry real consequences.

State regulations for nursing homes: Federal vs. state

There are several key points to remember about the differences between state and federal laws here:

• CMS (Federal): Oversees all Medicare- and Medicaid-certified facilities. Sets national standards around staffing, safety, resident rights, infection control, and more.
  
  

• State agencies: While state agencies conduct CMS surveys, licensing may be handled by a separate division within your state’s health department or licensing board, depending on your state’s structure.

Your facility has to meet both sets of requirements to stay in good standing, and they don’t always align perfectly.

Examples of state-specific differences: CMS regulations for nursing homes

While CMS sets the federal floor, states often raise the bar in ways that can directly impact your daily operations.

These state-level rules vary widely. Overlooking them can lead to licensing issues, citations, or delays in reimbursement.

Some examples of how states differ:

• Higher staffing ratios: Some states mandate a lower CNA-to-resident ratio than the federal minimum, particularly during night shifts or high-acuity care hours like a Baylor shift.
  
  

• Structured daily schedules: Certain states require specific timeframes for meals, activity programs, and rest periods to promote resident quality of life.
  
  

• Faster reporting windows: You may have just hours (not days) to report abuse allegations, elopements, or adverse events under your state’s rules.
  
  

• Expanded documentation standards: Some states demand additional paperwork for advance directives, behavioral health plans, or family involvement in care planning.

If you operate in more than one state, these variations can stack up quickly. Even if you're only in one state, failing to follow localized requirements can compromise your compliance standing.

How to stay compliant at both levels

Balancing federal and state regulations doesn’t mean doubling your workload — but it does mean staying organized, informed, and proactive. Here’s how to make dual compliance more manageable:

• Subscribe to updates from your state’s Department of Health, licensing board, or long-term care division. Rule changes and inspection priorities can shift without much warning.
  
  

• Schedule regular policy audits to make sure your facility's internal procedures match both CMS guidance and your state’s requirements.
  
  

• Use tech tools that support state-level flexibility. Intake and referral systems — like ExaCare — can help streamline documentation and standardize key workflows, reducing the risk of state-specific oversights.

Pro tip: State policies are usually published on your Department of Health’s website, often under a long-term care or provider section. Bookmark those pages and check them monthly, especially if you’re managing multiple locations.

Maintaining dual compliance is about protecting your licensure, keeping your reimbursement on track, and ensuring residents receive the standard of care your state demands. With the right processes in place, staying ahead of both sets of rules becomes far more manageable.

Frequently asked questions

How often does CMS update nursing home guidelines?

CMS updates nursing home regulations through QSO memos, Federal Register notices, and revisions to the State Operations Manual — sometimes multiple times a year, depending on new laws or urgent issues.

Facilities are expected to stay current by regularly reviewing CMS memos, updates to the State Operations Manual, and QSO (Quality, Safety & Oversight) communications.

What happens if a facility fails a CMS inspection?

If a facility is found out of compliance during a CMS survey, it may receive a citation and be required to submit a plan of correction.

Depending on the severity of the deficiency, CMS may also impose enforcement actions — ranging from civil money penalties and denial of payments for new admissions (DPNA) to, in the most serious cases, termination from the Medicare and Medicaid programs.

How do CMS regulations affect Medicare/Medicaid reimbursement?

CMS regulations directly impact a facility’s ability to bill and receive payment for Medicare and Medicaid services. Non-compliance with participation requirements (especially in areas like documentation, staffing, or resident care) can lead to denied claims, delayed payments, or full loss of reimbursement eligibility. 

Accurate, timely records are critical to maintaining compliance and getting paid.

Discover how ExaCare helps your nursing home

Keeping up with CMS nursing home laws and regulations requires more than knowing the rules; it requires systems that make compliance easier to maintain day to day.

That’s where operational tools like ExaCare come in. While the platform was built to speed up admissions, its impact on compliance is just as important. By structuring how clinical and financial data is reviewed and recorded from the start, ExaCare helps nursing homes avoid the kinds of errors that can lead to penalties or denied claims later on.

Here’s how ExaCare supports compliance behind the scenes:

• Built-in EHR integration keeps patient information consistent across platforms
  
  

• AI-powered document screening surfaces key data early, reducing the risk of missed or incorrect entries
  
  

• Flags potentially ineligible cases upfront to avoid reimbursement issues
  
  

• Reduces manual entry errors by standardizing intake data, especially important for CMS-required discharge and transfer documentation

Staying on top of CMS compliance can also help improve hospital referral partnerships and reduce the risk of low census due to delayed or denied admissions.

Want to see how ExaCare can help your team tighten up documentation and avoid costly compliance risks?

Schedule a demo.