CMS Fines Are Getting Bigger: Average Penalties Up 73% Since 2023

CMS is issuing fewer penalties against nursing facilities. That might sound like good news - until you look at the dollar amounts. According to SilverOcean's analysis of 16,915 penalties assessed between 2023 and 2025, the average fine has increased 73%, from $25,058 to $43,297. The enforcement approach has fundamentally changed: fewer citations, but significantly larger financial consequences when they hit.

The Penalty Trend: Fewer But Costlier

Year	Penalties Issued	Total Fines	Average Fine	Avg Change vs 2023
2023	6,007	$150.5M	$25,058	Baseline
2024	5,230	$186.7M	$35,693	+42%
2025	3,033	$131.3M	$43,297	+73%

The pattern is clear. In 2023, CMS issued 6,007 penalties totaling $150.5 million. By 2025, the number of penalties dropped to 3,033 - roughly half - but the average fine nearly doubled. Total fines in 2024 actually exceeded 2023 despite fewer penalties, reaching $186.7 million.

This is not CMS going easy on the industry. This is CMS concentrating enforcement on the most serious violations and making those penalties count.

State-Level Exposure: Illinois and Texas Lead

SilverOcean's analysis of CMS data reveals significant geographic variation in penalty exposure. The states with the highest total fines are not always the ones you would expect:

State	Total Fines	Average Star Rating
Illinois	$64M	2.52
Texas	$63M	2.77
Florida	$21.5M	3.21

Illinois and Texas together account for over $127 million in total fines - more than a quarter of all penalty dollars assessed nationally. Both states also have below-average facility ratings (2.52 and 2.77 respectively, against the national average of 2.98), suggesting that concentrated enforcement pressure has not yet driven sufficient quality improvement.

Florida, while third in total fines at $21.5 million, actually has an above-average rating of 3.21 - suggesting that the penalty dollars there may be concentrated among a smaller number of poor performers rather than reflecting systemic issues.

What Triggers the Biggest Penalties

Not all deficiency citations lead to penalties, and not all penalties are equal. Based on SilverOcean's analysis of 418,972 health citations, the deficiency categories most commonly associated with enforcement action include:

Infection prevention and control (F0880) leads all categories with 23,429 citations. Post-pandemic, CMS has made infection control a top enforcement priority, and violations in this area carry elevated penalty risk.

Accident hazards (F0689) is the second most cited deficiency at 21,402 citations. Fall-related injuries are among the most common triggers for immediate jeopardy findings, which carry the highest per-incident fines.

Treatment and care per orders (F0684) accounts for 16,348 citations. Failures to follow physician orders represent direct care delivery breakdowns that CMS treats as high-severity.

Abuse reporting (F0609) rounds out the high-penalty categories with 8,931 citations. Failure to report suspected abuse triggers mandatory investigation and often results in both civil monetary penalties and enhanced oversight.

The Financial Impact Is Compounding

A single $43,000 fine may be manageable for a well-run facility. But penalties rarely occur in isolation. Facilities with one serious deficiency often have multiple. A facility that receives three penalties in a year at the 2025 average is looking at nearly $130,000 in direct fine costs - before accounting for the legal expenses, remediation costs, increased survey scrutiny, and potential census impact that follow.

For facilities operating on margins of 2-4%, even a single significant penalty can wipe out months of operating surplus. For the lowest-rated facilities already struggling with staffing costs and low census, cumulative penalties are contributing directly to closures - as evidenced by the 315 facilities that have shut down since 2023.

How to Reduce Penalty Exposure

The data suggests several practical strategies for reducing financial risk from CMS enforcement:

Prioritize infection control systems. With 23,429 citations in this category alone, robust infection prevention protocols and consistent documentation are the single highest-return compliance investment.

Address fall prevention proactively. Accident hazards generate the second-most citations nationally. Implementing evidence-based fall risk assessments and environmental modifications reduces both resident harm and regulatory exposure.

Automate compliance documentation. Many penalties stem not from care failures but from documentation gaps. Facilities that use technology to ensure real-time, accurate documentation are better positioned during surveys.

Monitor your deficiency trends. Facilities with recurring citations in the same categories face escalating penalties. Tracking your own citation history and addressing root causes before the next survey is essential.

CMS has made its enforcement philosophy clear: fewer penalties, but each one designed to drive real change. The operators who understand this shift and invest accordingly will avoid the financial pain. Those who do not may find themselves among the next round of closures.