The Special Focus Facility (SFF) program is CMS’s program is intended to address quality problems at the nation’s poorest-performing nursing homes with track records of serious noncompliance. Assessing the effectiveness of the SFF program is critical to ensure that CMS provides support and accountability for poorly performing nursing homes.
Special Focus Facility (SFF) Program
Nursing homes with the worst health inspection survey scores in a State are eligible for the SFF program. Since CMS began implementing the SFF program in 1998, the number of nursing homes that CMS includes in the SFF program has varied depending on the amount of funding received. Since 2014, the SFF program has had 88 slots for nursing homes across 49 States. Each State has between one and six slots for nursing homes in the SFF program.
As nursing homes leave the SFF program, others enter. To fill vacancies when nursing homes leave the program, CMS
identifies 440 nursing homes as SFF candidates (5 candidates per program slot). State agencies, with the approval of CMS, select a nursing home from the candidate list for the SFF program to fill the vacancy.
The Office of Inspector General,(OIG) issued a report in October 2025 entitled “CMS’s Special Focus Facility
Program for Nursing Homes Has Not Yielded Lasting Improvements” in which it reported:
The SFF program is not working because most nursing homes that graduate from the program do not keep the improvements they made over the long term. Between 2013 and 2022, nearly two-thirds of the nursing homes that were in the SFF program improved enough to graduate but soon afterward showed the type of quality problems that put them in the SFF program in the first place. For nursing homes in the SFF program that violate Federal requirements, the SFF program relies too heavily on financial penalties that do not require changes in nursing home operations. Our findings point to ways in which CMS could make the SFF program more effective:
Staffing: CMS minimally includes staffing in the SFF program, but nursing homes that graduate from the SFF program and sustain improvements maintain higher staffing levels than those that do not sustain improvements.
Ownership: CMS does not consider ownership at all in the SFF program. However, a handful of owners stand out as owning many low-quality nursing homes, which points to poor management practices. Also, State agencies told us that owners play an important role in whether nursing homes improve quality.
States’ quality improvement efforts: Some States build on the SFF program requirements with their own initiatives to support improvements in nursing homes. CMS can learn from these efforts to increase the effectiveness of the SFF program.
The OIG concluded:
The failure of the SFF program to facilitate sustained improvements in two-thirds of nursing homes that graduated from the program puts residents at risk. CMS revised the program in 2022, but the program remains centered on surveys and enforcement. These mechanisms are blunt tools to address systemic problems of poor-quality care in nursing homes.
Still, even with only these existing authorities and tools, CMS could do more. Our assessment shows that the SFF program relies too heavily on financial penalties and not enough on efforts to spur operational changes that could lead to sustained improvements. Additionally, the SFF program could take action to include two core elements of nursing home operations in its monitoring and oversight efforts: staffing and ownership. Beyond the Social Security Act’s requirements to select struggling facilities and survey them every 6 months, CMS could shape the SFF program by using its discretion in enforcement remedies to encourage sustained quality improvements.
The OIG recommended:
- CMS should impose more nonfinancial enforcement remedies that encourage sustained compliance.
- CMS should assess the extent to which it took enhanced enforcement actions for SFF graduates and the effectiveness of those actions, particularly for graduates that received a deficiency for staffing.
- CMS should incorporate nursing home ownership information into the SFF program, such as in selecting SFFs and identifying patterns of poor performance.
If you or a loved one may have been injured (or worse) in a nursing home in the United States due to nursing home staff shortage, nursing home understaffing, nursing home pressure ulcer (nursing home bedsore), a nursing home infection, nursing home fall, nursing home aspiration, nursing home neglect, nursing home negligence, nursing home abuse, or the nursing home failing to properly care for a vulnerable adult, you should promptly find a nursing home malpractice lawyer in your state who may investigate your nursing home negligence claim for you and represent you or your loved one in a nursing home malpractice case, if appropriate.
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