The Death of Nursing Home Staffing Mandates: What It Means for Seniors, Families, and the Future of Care

In a move hailed as a "milestone victory" by the nursing home industry, the U.S. Department of Health and Human Services (HHS) has fully repealed the Biden administration's controversial minimum staffing rule for skilled nursing facilities, eliminating requirements that could have reshaped care quality for millions of residents. As reported by Kimberly Marselas, writing for  McKnight's Long-Term Care News, the repeal, effective 60 days after publication in the Federal Register, nullifies the 2024 rule's core mandates for 3.48 hours of nursing care per resident per day (including 0.55 hours from a registered nurse and 2.45 hours from a nurse aide) and a 24/7 onsite RN. For providers, it's a relief from what they called an "unrealistic" burden amid labor shortages; for seniors and families, it's a sobering reminder that we're back to square one in a chronically understaffed system where 24% of facilities fail federal standards. 

As readers of the Aging-in-Place Planning and Elderlaw Blog know, this development doesn't just highlight institutional care's vulnerabilities; it strengthens the case for aging in place, where family coordination and proactive planning can prevent the 2.5 times higher risk of institutionalization due to caregiver overburden and avoid the need for and risks of institutional care. This article explains the rule's resolution, why it was so divisive, the real-world implications for consumers in an understaffed landscape, and, beyond the obvious push for home, practical paths forward to demand better care wherever you choose.

The Staffing Mandate's Demise: A Timeline of Controversy and Relief
The 2024 staffing rule, finalized by CMS after years of debate, was born of undeniable crises related to understaffing.  It mandated 3.48 total nursing hours per resident daily,0.55 from RNs and 2.45 from aides, plus an RN on-site 24/7, with phased rollout starting in 2026 for larger chains.
Legal challenges from 11 states and industry groups led federal courts to vacate the RN and hourly minimums in August 2024. Then, the One Big Beautiful Bill Act (signed July 4, 2025) imposed a nine-year moratorium on staffing mandates, paving the way for HHS's full repeal on December 2, 2025.
AHCA/NCAL President Clif Porter called it "a victory for our nation’s seniors and their families," warning the rule "threatened to close nursing homes and displace vulnerable residents." CMS Administrator Mehmet Oz added, "Every American deserves access to compassionate, high-quality care...This repeal is a step toward smarter, more practical solutions that truly work for the American people." LeadingAge's Katie Smith-Sloan described it as "an important milestone," recognizing "the very real barriers that our nursing home members navigate in recruiting and retaining staff."A Troublesome Proposal: Ambitious Aims, Unrealistic Execution
Proponents saw the 3.48-hour threshold as evidence-based; the "minimum safe level" from a 2023 CMS study linking higher staffing to 15% fewer deficiencies. It addressed the RN shortage projected through 2030 (AHCA 2025) and aimed to curb unchecked falls and other indicators of negative health outcomes.
But troubles abounded:

• Rural and Small-Facility Strain: 40% of homes in underserved areas couldn't meet RN requirements without closures, potentially displacing 100,000+ residents (AHCA 2025).

• One-Size-Fits-All Flaw: Ignored acuity variations; dementia units need more aides than rehab wings, creating a 20% mismatch (AARP 2025).

• Enforcement Gaps: Phased rollout (2026-2030) lacked immediate teeth, with CMS recouping just $4 million of $1.1 billion in overpayments (GAO 2025).

Providers called it "unrealistic," while advocates decried the repeal as favoring profits over people. The compromise retains 8-hour RN shifts (waivable) and facility assessments for transparency, but no hard minimums.Back to Square One: The Harsh Reality for Consumers
For seniors and families considering or relying on nursing homes, the repeal feels like a gut punch.  We are reverting to a status quo in which "adequate" staffing means one CNA for 20 residents, contributing to 28% of falls going unchecked (CNA 2025) and 18% spikes in infections (OIG 2024). Facilities remain chronically understaffed (94% CNA turnover, Argentum 2025), with private equity chains (20% market) cutting hours 13% for profits (AARP Florida 2025). Consumers face:

• Higher Risks: 1 in 10 abuse odds (NCEA 2025), triple depression from isolation (2025 JAGS).
• Cost Burdens: No mandates mean uneven quality, forcing 75% of families to supplement with private pay ($2,000/month aides).
• Choice Illusion: Star ratings persist, but without floors, "high-rated" homes can still fail; 20% higher neglect in chains (GAO 2023).

According to advocates such as the Center for Medicare Advocacy, the repeal ignores current adverse health outcomes stemming from inadequate staffing, perpetuating a system in which quality varies widely. For those in facilities, it's a roll of the dice; for families, it's anxiety over "good enough" care.Where Do We Go from Here?  Aging in Place to Smarter System Demands
Aging in place remains the gold standard, saving 42% compared to facilities (Wakely 2025) and reducing the risk of institutionalization by 2.5 times (2025 JAGS). But for those in or considering facilities, here's how to forge ahead:

1. Demand Transparency Now: Use Care Compare's 2025 ownership data to filter chains; avoid those with less than 3 stars or OIG flags.
2. Push for Local Reforms: Advocate for Ohio's HB 521 (2026 hospital nursing requirements) and for extension to skilled nursing facilities.  Contact reps at house.ohio.gov.
3. Legal Shields: SDM agreements nominate family for oversight—our "SDM-Driven Supplemental Advanced Directive" template.
4. Fund Home Alternatives: Trusts pay private aides; MAPTs qualify for waivers without spend-down.

Conclusion: From Mandate to Momentum—Your Home Is Still the Answer
The repeal of the staffing mandate may be a setback, but it sharpens the focus: Facilities are understaffed, risky, and in need of reform. Aging in place, with planning, is the way forward. 
While this article provides a thorough analysis of the repeal and its strategies, it is by no means comprehensive. The landscape evolves rapidly. Readers must remain vigilant. By combining awareness with proactive planning, seniors and families can safeguard independence and thrive while aging in place. Your security depends on proactive engagement.

Nursing Homes' 'Bonus for Bad Care' Scandal: A Utah Spotlight on a National Crisis, and Why It Matters for Seniors and Families

A new investigation has peeled back the curtain on a troubling contradiction in American nursing home care: facilities receiving millions in taxpayer-funded bonuses for "high-quality" performance are often mired in allegations of neglect, understaffing, and abuse that endanger residents' lives. The report, published by Fox13 in Salt Lake City,  centers on Utah's Upper Payment Limit (UPL) program, which has allocated over $1 billion in federal funds to nursing homes since 2017 to improve care for Medicaid-eligible elderly and disabled adults. Yet, an analysis of federal data by a law firm revealed that UPL facilities underperform compared to non-UPL ones in staffing, health inspections, and overall ratings, despite the subsidies. For readers of the Aging in Place Planning and Elder Law Blog, this isn't a distant Utah tale; it's a microcosm of a national epidemic where profit motives and regulatory expediency clash with patient safety.  These revelations underscore the urgent case for proactive planning to prioritize home-based care over institutional risks. As we've delved into in "Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place," tools like advance directives, supported decision-making (SDM) agreements, technologies, aids, and trusts can help families sidestep these pitfalls, preserving dignity and assets amid a system where "bonuses for bad care" seem to be the norm.The Utah Scandal: Millions in Bonuses Amid a Culture of NeglectUtah's UPL program, designed to boost Medicaid reimbursement rates for nursing homes serving low-income residents, has distributed over $100 million annually since 2013, ostensibly to enhance staffing, training, and quality. The Fox13 analysis of CMS data from 2017-2025, however, paints a grim picture: UPL facilities scored lower in staffing (average 2.8 hours/resident/day vs. 3.2 for non-UPL), health inspections, and overall ratings (3.5 stars vs. 3.8), while accruing more deficiencies tied to abuse and neglect. One chain, Beaver Valley Hospital (licensing more than 40 facilities), pocketed $26 million since 2016. Yet, St. George Rehabilitation facility (under Ensign Group) faces lawsuits alleging untreated bedsores, falls, and "beyond disgusting" care, including a resident left in feces for days. Another, Gunnison Valley Hospital, received $20.9 million amid "below-average" staffing and high turnover.
Families like Doni Hunt Webb's in St. George, featured in the Fox13 report, recount  "real people suffering," with CNAs averaging one per 20 residents amid "high turnover." The report ties this to a 2017 audit that revealed Beaver Valley kept 51% of the funds for administrative "seed money," with little oversight.  In other words, funds intended for improving care were instead used to subsidize profits. Utah DHHS defends the program as preventing closures, but critics, such as attorney Barry Toone, counter: "When you look at every metric, they're not doing better." Amid reports that nearly one in four facilities fail to meet staffing standards, this "bonus for bad care" raises red flags: taxpayer dollars (over $1 billion in Utah alone) are subsidizing subpar care, where neglect escalates to tragedy.Is This a Utah Problem or a National Epidemic?
While the report highlights Utah's UPL program, it's far from unique.  It's a microcosm of a nationwide crisis where bonuses reward reported metrics, rather than actual positive outcomes. Federal data repeatedly reveal that "the overwhelming majority of US nursing homes are operating with insufficient staffing to meet the basic needs of their residents."  According to Long Term Care Community Coalition (LTCC) federal data reveals that a shocking 9 in 10 nursing homes fall below their expected staffing levels. In the fourth quarter of 2024, 36% of facilities reported having zero (0) presence of a medical director, despite federal requirements that a medical director oversee the quality of clinical care provided in every facility.  Facilities aren't even making it easier for residents to cope; the average facility provided less than ½ minute (30 seconds) per resident day of a mental health service worker’s time. The CMS's Incentive Payment Program (IPP) and Quality Reporting Program (QRP) have awarded more than $10 billion in bonuses since 2018. For-profit chains (accounting for most of the market) continue to provide the worst outcomes.  This explains why many residents view nursing home life as a "Fate Worse than Death," and why we warned that  "More is not Always Better" - CMS Adds Staffing Information to Care Compare.   Consider, also,  the following:   

• NYT: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public;
• Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death;
• Nursing Home Compare Does Not Accurately Reflect Patient Safety In Nursing Homes;
• Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators.

What Does It Mean for Seniors and Their Families?For families, this means betrayal amid vulnerability. You select a "high-performing" home based on CMS stars, only to face neglect that drains savings, risks physical and psychological health, and emotional well-being, and strips seniors and their families of dignity.  For everyone, the financial toll is brutal: your taxes subsidize understaffing, leading to falls, infections, and worse, resulting in lawsuits and increased medical expenses, all of which are subsidized by taxpayer dollars.  Emotionally, it's devastating; trust is shattered, guilt amid suffering divides families and communities, and institutional alternatives only spread the misery, resulting in the "acuity mismatch" that we discussed in "Rising Malpractice Claims in Assisted Living."  Facilities profit from your trust, but care lags.Strategies to Avoid the Trap: Beyond Awareness to Autonomy

• Ruthlessly Investigate and Evaluate Facilities: In the worst cases, where institutional care is unavoidable and necessary, use every tool available, and don't default to the cleanest, closest, or most convenient facility. Check out our article, Choosing a Nursing Home or Skilled Nursing Facility: Navigating the Long-Term Care Crisis , for comprehensive guidance and links to valuable tools and information. Use ProPublica's Nursing Home Inspect for abuse history; demand social media policies in contracts.

• Legal Shields: To incentivize aging in place and prevent unnecessary and avoidable institutionalization, deploy legal tools ranging from advance directives to trusts. Check out our articles, Rethinking Elder Abuse Strategies: How Prophylactic Planning Can Safeguard Autonomy and Aging in Place.  Include in SDM and advance directives: "Choose homes with no abuse history; fund home care first." Trusts should withhold payments for poor care.

• Home as Priority: Use advance directives. Deploy technology. Leverage HCBS waivers (Missouri/Ohio) for aides.

• Caregiver Networks: Build SDM teams to monitor care; report red flags via ombudsmen (1-888-678-7277).

• Advocate for Reform: Support calls for bonus audits; contact your senator to tie payments to verified staffing.

Conclusion: Bonuses for Bad Care Are a Call to Action

The Tennessee scandal reveals a system rewarding neglect, but you can opt out. While this article has provided a thorough analysis of taxpayer-funded care failures, it is by no means comprehensive. The landscape evolves rapidly. Readers must remain vigilant, consulting ProPublica, AARP, and elder law attorneys while evaluating risks. By combining awareness with SDM and trusts, families can safeguard independence and thrive while aging in place. For support, consult a professional—your security depends on proactive engagement.