A USA TODAY investigation has documented, for the first time, how rarely the federal government enforces decades-old staffing guidelines and rules for nursing homes.

Citations and penalties remained sparse even as regulators developed three ways to measure staffing. In the spring, they will propose a fourth approach.

Having enough nurses and aides is the strongest predictor of whether nursing home residents will thrive, researchers have found. When facilities are short-staffed, essential medical tasks are ignored. Doctor’s appointments are missed, call buttons go unanswered, diapers are not changed, showers are not given and wounds are not cleaned. Dementia can set in faster. People get sicker, and die, alone.

The desperation of residents and their relatives can be heard in emergency 911 calls.

Read more in USA Today.