The link is to the full report by DHHS Office of Inspector General dated 2/27/2014 which noted that in this study an estimated 22 % of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 % of Medicare beneficiaries experienced temporary harm events during their SNF stays.

Physician reviewers determined that 59 % of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care