HHS Drops Appeal on Nursing Home Staffing Rule: A Setback for Care Quality and a Boost for Aging in Place Planning

In a quiet but seismic shift for long-term care, the U.S. Department of Health and Human Services (HHS) has dismissed its appeals in two key federal cases challenging the Biden-era nursing home staffing minimums rule. Filed in the Fifth and Eighth Circuit Courts of Appeals, these dismissals, announced in late September 2025, effectively concede the rule's fate, leaving the sector without enforceable national standards. For Ohio and Missouri families committed to aging in place, this development underscores the urgency of proactive planning: while nursing homes grapple with understaffing risks, aging-in-place strategies can help safeguard independence and assets from institutional pitfalls.

Recapping the Rule and Its Rocky RoadAs we discussed in our April 2025 blog post, "Federal Judge Blocks Biden-Era Nursing Home Staffing Rule: Implications for Care Quality and Families," the rule, finalized by CMS in April 2024, aimed to mandate 24/7 registered nurse (RN) coverage and at least 3.48 hours per resident day (HPRD) of total nurse staffing in Medicare/Medicaid-funded facilities. Rooted in the Federal Nursing Home Reform Act (FNHRA), it sought to combat chronic shortages exposed by COVID-19, where understaffed homes saw hospitalization rates spike 20–30% higher and physical and chemical restraint use climb due to overburdened aides.
The rule faced immediate backlash from trade groups like the American Health Care Association (AHCA) and states like Texas, which sued in May 2024, claiming HHS overstepped its authority under the Social Security Act. U.S. District Judge Matthew Kacsmaryk's April 7, 2025, ruling in Texas vacated core provisions, calling them a "one-size-fits-all" overreach that ignored the realities of rural areas and the variations in acuity of residents. Similar blocks followed in the Eighth Circuit. HHS appealed both, but with mounting opposition, including from 20 additional states and projected facility closures of 10–15% in underserved areas, the agency has now withdrawn, signaling a pragmatic pivot amid political and fiscal headwinds.The Bigger Picture: Understaffing's Toll on ResidentsWithout federal minimums, the U.S.'s 15,000+ nursing homes, serving 1.2 million residents, 60% Medicaid-funded, revert to patchwork state oversight. Studies we cited earlier, like the 2021 Health Affairs analysis, link adequate RN staffing (0.75 HPRD) to 15–20% fewer hospitalizations and infections. A 2022 CMS report tied understaffing to elevated COVID mortality, while a 2019 Gerontologist study showed it doubled chemical restraint use—violations of FNHRA rights affirmed in the Supreme Court's Talevski decision (2023).
For families, this means heightened risks of neglect, pressure ulcers, falls, and emotional distress, amplifying the emotional and financial strain of facility care. In Ohio, where Medicaid's $527 million nursing home shortfall (2024–2025) already strains resources, the absence of national standards could exacerbate closures in rural counties, displacing residents and pressuring families toward costlier private-pay options ($100,000+/year).Elder Law Ramifications: A Crack in ProtectionsThis retreat leaves elder law attorneys navigating regulatory quicksand. Without binding federal floors, litigation for substandard care relies more heavily on state surveys (e.g., Ohio's biennial inspections) and facility-specific plans, tools that often fall short due to underreporting (57% of falls go undocumented, according to AHRQ). Families may lean on ombudsman programs, but these are overwhelmed, handling just 20% of complaints effectively.
Critically, the ruling disrupts Medicaid planning, where irrevocable trusts shield assets during the five-year lookback period (42 U.S.C. § 1396p(c)), thereby preserving eligibility without a spend-down. Understaffing could trigger more penalties or denials, forcing asset liquidation and undoing trusts, echoing cases like Bartley Healthcare v. Ott (N.J. Super. App. Div. 2025), where facilities targeted family POA holders for "breaches" in Medicaid pursuit. In Ohio, filial responsibility (R.C. § 2919.21) remains criminal and narrow, but nursing homes may exploit contracts to claw back costs, threatening protected assets.A Silver Lining: Reinforcing Aging in Place StrategiesAs we noted in April, this saga highlights why aging in place, with structured home and community care, is a resilient alternative to institutional care in facilities. With nursing homes facing 15–20% staff turnover and quality dips, families can pivot to rigorous home-based healthcare and, when necessary, utilize Ohio's PASSPORT waiver (available to applicants with income under $2,901/month in 2025) for in-home aides, thereby avoiding FNHRA gaps altogether. Pair this with Medicare Advantage plans' supplemental benefits (e.g., $100–$300/month flex cards for home mods) to fund grab bars or telehealth, delaying institutional needs, and a family has a toolbag of options necessary to avoid institutional care.
Elder law tip: Review trusts now to include home care contingencies, and document POA limits to shield against facility pressures. The Talevski precedent still empowers suits for FNHRA violations, such as undue restraints; use it proactively.Looking Ahead: Advocacy in Uncertain TimesHHS's dismissal highlights the tension between care ideals and workforce realities, potentially stalling reforms until 2026 or beyond. Practitioners must monitor the Federal Register for state waivers or CMS updates, while counseling clients on their rights under the remaining federal baselines (e.g., 8-hour RN coverage).
For Ohioans and Missourians, this is a call to fortify plans. Subscribe to our blog for updates on staffing litigation or virtual workshops (e.g., our recorded "Aging in Place Essentials" at bit.ly/Aging-in-Place-Workshop). Contact OSHIIP (1-800-686-1578) for Medicare guidance, and consult an elder law attorney to align trusts with home-focused care. Aging in place isn't just viable—it's essential when facilities falter. Let's build resilience together.

Choosing a Nursing Home or Skilled Nursing Facility: Navigating the Long-Term Care Crisis

Choosing a nursing home or skilled nursing facility (SNF) is a critical decision for seniors and families. A recent report from Nonprofit Quarterly, “The Triple Threat Facing Nursing Homes—And How to Overcome It, explains why many residents view nursing home life as being a "Fate Worse than Death." It highlights a crisis driven by private equity ownership, profit-driven care, and COVID-19’s lasting impact. Understanding these risks is essential to selecting a safe facility or planning to age in place with confidence.

This article will break down what the “triple threat” means for you, explain the risk, i.e., the balance of nonprofit versus for-profit facilities, show you how to choose safer nursing homes and how to identify private equity ownership, and why planning to stay out of an institution is more important than ever.

The Triple Threat: What It Means for You

The Nonprofit Quarterly report identifies three interconnected forces threatening nursing home care quality, which directly impact seniors and families considering institutional care:

• Commodification of Elder Care (“Gray Gold”): Nursing homes have shifted from care-focused to profit-driven models. The article references Timothy Diamond’s book Making Gray Gold, which describes how elder care became a marketable commodity, prioritizing financial gain over resident well-being. For you, this means some facilities may cut corners on staffing, resident meals, supplies, or services to boost profits, potentially leading to neglect, medication errors, or infections.

• Private Equity’s Aggressive Expansion: Private equity firms are increasingly acquiring nursing homes, using complex financial strategies like inflated service fees or property leasing to extract wealth. These practices often reduce resources for care, resulting in understaffing and substandard conditions. For seniors, this translates to a higher risk of harm in facilities owned by such firms, as seen in cases like the 2018 bankruptcy of HCR ManorCare, where care quality plummeted under private equity ownership.

• COVID-19’s Lasting Impact: The pandemic exposed and worsened existing flaws, with over 200,000 nursing home deaths highlighting staffing shortages and infection control failures. For families, this underscores the ongoing risk of infectious outbreaks in facilities with inadequate staff or protocols, making safety a top concern.

• What This Means for Quality of Care: These threats increase the risk of harm in nursing homes, particularly in for-profit facilities. A 2014 Department of Health and Human Services Office of Inspector General (OIG) report found that 33% of Medicare beneficiaries in SNFs experienced adverse events (e.g., hospital readmissions, permanent harm, or death), with 59% deemed preventable due to substandard care or errors. The triple threat amplifies these risks, making it essential to carefully evaluate facilities and prioritize alternatives like aging in place. There is significant incentive for executives too; in the case of HCR ManorCare, the final bankruptcy approved a payout to the former CEO of $116 million.

Nonprofit vs. For-Profit Nursing Homes: The Ratio and Why It Matters

Nationwide, there are approximately 15,000 nursing homes, serving over 1.3 million residents. The ownership breakdown is:

• For-Profit: 70-72% (roughly 10,500-10,800 facilities), increasingly dominated by private equity, REITs, and midsize chains.

• Nonprofit: 24% (about 3,600 facilities), often run by faith-based or community organizations.

• Government-Owned: 5-6% (750-900 facilities), typically public or VA facilities.

The vast majority of nursing homes are For-Profit; you may have to work to find a non-profit in your area.                                                                                                       

Why Nonprofits Are Safer: Studies consistently show nonprofits provide better care. A 2011 LeadingAge New York study found nonprofits had fewer hospitalizations, lower antipsychotic use, and higher staffing levels. A 2020 meta-analysis estimated that nonprofit facilities have 7,000 fewer pressure sores and provide 500,000 more nursing hours daily nationwide. For-profits, especially private equity-owned, have more deficiencies and lower quality ratings, as seen in the 2018 HCR ManorCare bankruptcy, where violations soared under Carlyle’s ownership.

What This Means for You: Prioritize nonprofit facilities when possible, as they’re less likely to prioritize profits over care. However, nonprofits are harder to find, with their share dropping from 30% in the 1990s to 24% today due to financial pressures and acquisitions. Use Nursing Home Compare to filter for nonprofit status and verify during tours.

Spotting Private Equity Ownership

Private equity-owned nursing homes are riskier due to profit-driven cost-cutting. A 2023 Good Jobs First report noted that midsize private equity chains often have fines averaging over $100,000 per facility for violations. Determining ownership cab seem a daunting task, particularly when ownership is not transparently offered to individuals considering that home. Here’s how to identify such ownership:

Check Ownership Details: Use CMS’s Nursing Home Ownership Data (go to data.cms.gov for other data sets) or state licensing records to find the facility’s parent company. Private equity firms often use complex structures with multiple subsidiaries (e.g., separate entities for operations and real estate). Look for names like Portopiccolo Group or HCP, Inc., (now known as Healthpeak Properties, Inc. after a 2019 rebranding, known for private equity or real estate investment trust (REIT) ties.

Look for Related-Party Transactions: Private equity firms may contract with affiliated companies for services (e.g., therapy, staffing), charging inflated fees that drain resources. Ask the facility for a list of contracted services and their providers. If multiple services come from related entities, it may signal profit extraction.

Research Recent Ownership Changes: Facilities that changed hands between 2016 and 2021 (over 20% of U.S. nursing homes) are more likely to be private equity-owned. Check news reports or Ziegler Investment Banking data for recent acquisitions. A 2024 KFF Health News article noted that 900 nonprofit nursing homes were sold to for-profit operators since 2015, often to private equity or REITs.

Ask Directly: During tours, ask administrators about ownership structure and whether the facility is part of a for-profit chain or investment group. Be wary of vague answers or reluctance to disclose.

Choosing Safer Nursing Homes: Key Steps

If institutional care is necessary and unavoidable, selecting a safer facility is critical. Here’s how to navigate the process:

Evaluate Staffing Levels: Staffing is the strongest predictor of care quality. Check the facility’s nurse-to-resident ratio on Nursing Home Compare. CMS’s 2024 minimum staffing rule requires 3.48 hours of direct care per resident day (including RNs and aides). Avoid facilities with frequent staff shortages, as these are linked to higher rates of infections and falls. Ask about staff turnover rates during tours—lower turnover suggests better working conditions and care consistency. Check to make sure that there is at least one RN on staff 24 hours each day.

Investigate Infection Control: Post-COVID, infection prevention is crucial. Ask about the facility’s infection control protocols, vaccination rates, and history of outbreaks. A 2024 OIG report found that 24% of for-profit SNFs failed to meet infection preventionist staffing requirements, increasing risks.

Tour and Observe: Visit potential facilities repeatedly, unannounced, at different times to observe cleanliness, staff responsiveness, and resident well-being. Red flags include unanswered call bells, unclean rooms, or residents appearing neglected (e.g., unassisted with meals or hygiene). Observe whether staff members know the names of residents and each other. Speak with residents and families about their experiences.

Assess Meal Quality: Nutrition is vital for your loved one’s health and well-being in a nursing home, yet some facilities may cut costs by offering bland, repetitive meals. When evaluating a facility, visit during mealtime, spend time in the dining room, and request a meal sample. Inquire about dietary options, such as vegetarian, kosher, heart-healthy, or diabetic diets, and ask residents whether they enjoy the food. A high-quality nursing home will confidently demonstrate its dining experience, prioritizing flavorful, nutritious meals tailored to residents’ needs. Poor-quality, unappealing food lacking variety can lead to malnutrition, mental decline, and serious health issues, diminishing your loved one’s quality of life. Choose a facility that invests in its dining program to ensure both health and happiness.

Review Inspection Reports: State inspection reports, available via Nursing Home Compare or state health departments, detail violations. Avoid facilities with repeated or severe deficiencies, such as failure to prevent pressure ulcers or medication errors.

Consider and Compare Costs, Expenses, and Fees: When considering a nursing home, meet with the admissions office to thoroughly review costs, fees, and expenses; lack of transparency can lead to unexpected financial burdens. Candor and transparency might reveal the home as less concerned with "getting a contract and starting billing" and more concerned with a transparent, cooperative, mutually rewarding relationship. Request a detailed, written breakdown of costs before deciding, clarifying what’s included in the base price and which services (e.g., therapy, specialized care) incur extra fees. Discuss Medicaid coverage with the facility’s social worker, even if it’s not immediately needed; some facilities guide families through the application process, potentially saving thousands in legal fees, while others offer little or no support. Inquire about policies for scenarios like hospitalization or hospice care, as these can trigger additional costs. 

Many families are unprepared for the complexity of long-term care financing, and facilities may not fully disclose fees upfront. Medicare and Medicaid often don’t cover all services, and some facilities may not accept both programs, leaving families to face out-of-pocket expenses, disputes, or even discharge. Proactive planning, including exploring Medicaid asset protection with an elder law attorney, can safeguard your finances and ensure your loved one’s care.

Use Multiple Rating Tools: First, use ProPublica's Nursing Home Inspect for abuse, deficiency, shortfall, and other relevant history. Second, check the name of a home or institution against the Blog for the National Association to Stop Guardianship Abuse.  The Blog has a convenient search tool and is one of the most comprehensive sources for news about nursing home cases of abuse and neglect.  

Now that you have information specific to the home that may not be reflected in ratings, Check out Medicare’s Nursing Home Compare to review a facility’s star rating (1-5 stars) based on health inspections, staffing, and quality measures, but recognize its limitations; you can read multiple articles about these limitations and weaknesses by selecting the label "Nursing Home Compare" at the lower right of this page (or simply click on the link to perform the search). Complement it with: 

• U.S.N&W.R.:  U.S. News & World Report’s Nursing Home Ratings evaluates nearly 15,000 nursing homes annually, rating them for short-term rehabilitation and long-term care based on CMS data but with a proprietary methodology that emphasizes outcomes like rehospitalization rates (ideally below 20%) and resident satisfaction.

• NusingHome411: NursingHome411’s Problem Facilities Dataset, sponsored by the Long Term Care Community Coalition, this rating service and dataset flags Special Focus Facilities and one-star homes, often for-profits. Use this tool to avoid low performers.

• State-Specific Tools: Many states host their own alternatives to the federal CareCompare, some simply reporting CareCompare information, but many providing more granular data for specific homes in that state.  State-specific tools like Minnesota’s Nursing Home Report Card or Massachusetts’ Survey Performance Tool offer local insights. These alternatives provide a fuller picture of care quality, and align with the need to prioritize nonprofits, offering potentially better outcomes.

• Ohio Nursing Home Quality Navigator: Offers a searchable map, CMS star ratings, staffing stats, resident satisfaction, and violation counts for Ohio’s 960 nursing homes.

• Ohio Long-Term Care Consumer Guide: Offers inspection summaries, satisfaction surveys, and costs, ideal for nonprofit comparisons (24% of facilities, 7,000 fewer pressure sores).

• Missouri DHSS Facility Search: Delivers detailed inspection reports and deficiencies for 1,111 facilities, helping identify risky for-profits.

These tools help prioritize nonprofits and high-quality homes.

Leverage User Reviews:  Check Yelp, Facebook, or similar platforms for resident and family feedback or stories on staff responsiveness and care quality, but cross-reference with data-driven tools due to potential bias.

Monitor Consumer Feedback and News: Check X for resident/family posts using hashtags like #NursingHomeAbuse or #ElderCare. In Ohio, I was able to identify posts describing lawsuits against Majestic Care of Fairfield (March 2025) regarding alleged staffing-related deaths, and a Warrensville Heights death (January 2025), exposing monitoring failures. 

In Missouri, one-star Kansas City Homes (March 2025) faced abuse citations, and a 2024 report noted unnecessary confinement of mentally disabled residents. On the other hand, nonprofits like Friends Care Community in Ohio earn praise on X for resident satisfaction. These are, of course, anecdotal and, like all social media, subject to bias, misinformation, misunderstanding, and misattribution. In some cases, though, you may find information critical to your decision.

Beware of Guardianship Abuse: Even if unnecessary, you should ask the nursing homes how they handle guardians and conservators, and whether it has an affiliated entity that can serve as a guardian or conservator if needed.  You should ask what percentage of its residents have court-appointed guardians/conservators.  Some nursing homes have made guardianship a separate business. For-profit nursing homes may exploit guardianship petitions to collect debts or secure Medicaid payments, overriding valid Powers of Attorney (POAs) or family wishes. A 2024 report noted New York facilities coercing payment through guardianship, costing families up to $10,000 in legal fees.  Facilities may refer petitions to attorneys or nonprofit “guardianship mills,” not formal subsidiaries, to manage finances, but this practice—seen in 12% of Manhattan cases (2002-2012)—is profit-driven rather than resident-focused.  Be wary if the institution has a close relationship with a guardianship business or non-profit, particularly if it is directly affiliated with the nursing home.  A nursing home that prefers working with court-appointed guardians and conservators is possibly a threat to your independence and decision-making, and a possible threat to family-directed care and financial management.

   

Choosing Safer Nursing Homes: What to Avoid

Don't Overestimate the Value of Proximity- While proximity is often a top priority for seniors and families selecting a nursing home—wanting a facility close to the senior’s home or a family member’s residence—it shouldn’t overshadow care quality. Being nearby makes it easier to visit and monitor your loved one’s treatment, but a closer facility with frequent lapses in care —such as injuries, staff conflicts, or resident disputes —can lead to more unexpected trips and stress, reducing meaningful time with your loved one. A higher-quality nursing home, even if farther away, may require a longer drive but offer better care, fewer emergencies, and more rewarding visits. Balance proximity with quality to ensure your loved one’s safety and well-being.

Avoid Crisis Decision-making: When a parent or loved one’s Medicare hospital benefit nears its end, families often face intense pressure to find a nursing home quickly, tempting them to settle for the first available bed. This crisis-driven approach can lead to choosing a facility with substandard care, especially in for-profit homes influenced by private equity or REITs, where quality may suffer. Instead, plan ahead while your loved one is healthy, researching and shortlisting high-quality, preferably nonprofit facilities. Alternatively, explore options at the onset of a hospitalization or a diagnosis of a chronic condition. By proactively evaluating choices, you can avoid risky “last resort” facilities and ensure safer, more compassionate care.

Look Beyond the Surface!  Don't Be Fooled By Appearance: When selecting a nursing home, don’t be swayed by appearances alone. A sparkling new facility with elegant decor and cutting-edge technology may catch your eye, but true quality lies in the care provided. Older, less glamorous nursing homes with low patient-to-staff ratios, dedicated staff, and a genuine commitment to residents often offer safer, more compassionate care than luxurious but poorly managed homes. Fancy furnishings and white linen tablecloths mean little if a facility is overcrowded or understaffed. While modern infrastructure is a one-time investment (plus ongoing maintenance), quality staff, effective management, and continuous training are daily expenses that profit-driven facilities might skimp on. Focus on the bigger picture—prioritize the care your loved one will receive over superficial charm.

Why Plan to Age in Place

The triple threat underscores why avoiding institutional care through aging in place is a smarter strategy. Here’s why and how to plan:

Lower Risk of Harm: Nursing homes carry inherent risks, with 20-23.5% of Medicare patients rehospitalized within 30 days, often due to preventable issues like infections or medication errors. Home-based care reduces exposure to institutional risks, as shown by Medicare’s Independence at Home program, which cut hospitalizations and saved $2,700 per beneficiary annually.

Better Quality of Life: Aging in place allows seniors to stay in familiar surroundings, maintaining independence and emotional well-being. The Nonprofit Quarterly article emphasizes amplifying resident voices, which is easier at home with family or caregiver support.

Cost Savings: Nursing home care is expensive, averaging $8,700/month for a semi-private room (2024 NPR report). Medicaid covers costs for eligible seniors but requires the depletion of assets, threatening family legacies like farms or homes. Home care, while not cheap, can be more affordable with Medicare home health benefits or long-term care insurance.

How to Plan To Age in Place

Legal Planning: Work with an elder law attorney to create an Aging in Place Planning Trust and/or Medicaid Asset Protection Trust or update your estate plan from a simple will or simple probate avoidance revocable trust to state your wishes, and protect your assets and decision-making. Powers of attorney and advance directives for health and dementia help ensure your care preferences are honored.

Home Modifications: Install grab bars, ramps, or stairlifts to make your home safer. A certified aging-in-place specialist can assess needs.

Care Coordination: Explore home health aides or telehealth services (e.g., virtual care hubs like Good Samaritan’s 2022 initiative) to manage medical needs. Medicare covers skilled home health for qualifying conditions.

Financial Planning: Purchase long-term care insurance early (ideally in your 50s-60s) to cover home care costs. Budget for private-pay caregivers if needed.

Community Support: Engage family, friends, or local senior services (e.g., Area Agencies on Aging) to build a support network, reducing reliance on institutional care.

Additional Considerations

Advocacy and Oversight: The Nonprofit Quarterly article suggests advocating for stronger regulations and ombudsman programs. Families should connect with Long-Term Care Ombudsmen (available in every state) to report concerns or monitor facility quality. Joining resident or family councils empowers you to demand better care.

Medicaid Funding Gaps: Low Medicaid reimbursement rates strain facilities, especially for-profits, leading to closures or quality cuts. Support policies increasing Medicaid funding to improve care options.

For-Profit Risks: Beyond private equity, for-profit chains like Skyline Healthcare (bankrupt in 2018) have left residents stranded. A 2024 CBS News investigation found neglect patterns in for-profit facilities, with cases like a 92-year-old left alone and injured. Scrutinize for-profit facilities, especially midsize chains with opaque ownership.

Conclusion: Plan Smart, Stay Safe

The triple threat—commodification, private equity, and COVID-19’s fallout—has made nursing homes riskier, particularly for-profit facilities, which dominate 70-72% of the market. For seniors and families, this means, in the worst case, prioritizing nonprofit facilities, thoroughly vetting ownership, and checking staffing and quality metrics before choosing a nursing home. The safest and most fulfilling option is to plan for aging in place, leveraging legal, financial, and home modifications to stay independent. By working with elder law professionals and exploring home-based care, you can avoid the risks of institutional care and protect your health, assets, and legacy.

For personalized guidance, contact our office to discuss aging in place planning, Medicaid planning, long-term care options, or home safety assessments. Visit Medicare.gov for facility comparisons, and reach out to your state’s Long-Term Care Ombudsman for support. Your future deserves careful planning—start today.

Executive Order Expanding Apprenticeships Could Ease Staffing Shortages in Nursing Homes, Assisted Living Facilities

An executive order to consolidate federal workforce programs could address workforce shortages among senior living and other aging services providers by expanding apprenticeships, according to an article penned by Kimberly Bonvissuto, writing for McKnight's Senior Living. This comes at a critical time given that Biden era staffing mandates have been stuck down by a federal court.

Trump signed an executive order, “Preparing Americans for High-Paying, Skilled Trade Jobs of the Future,” on April 23 with the goal of expanding and improving job training for skilled trades. The order directs the Labor, Education and Commerce departments to streamline and consolidate federal workforce programs, with a focus on expanding registered apprenticeships to more than 1 million annually.

Although the initiative is most directly aimed at the  administration’s goal to revive US manufacturing, LeadingAge Director of Workforce Policy Amanda Mead said in a written announcement that it could help alleviate critical workforce shortages in the aging services sector: 

“While the president’s executive order is widely seen as part of the administration’s push to revitalize US manufacturing, the initiative to expand apprenticeships could also benefit direct care workers — such as nursing assistants and home health aides — by offering enhanced training and alternative educational pathways beyond traditional four-year degrees.” 

Argentum is a national trade association representing senior living communities across the United States. It advocates for policies that benefit the senior living industry and its residents, serving companies that own, operate, and support professionally managed senior living communities. Argentum’s mission includes promoting quality care, operational excellence, and workforce development within the sector.

Back in 2020, Argentum  touted the success of the Healthcare Apprenticeship Expansion Program, which served more than 7,600 incumbent workers through a $6 million Closing the Skills Gap grant from the Department of Labor. The association also petitioned the Centers for Medicare & Medicaid Services (CMS) to include assisted living in an incentive program geared toward attracting registered nurses to skilled nursing facilities.

Since the 2020 grant, staffing challenges in the senior living industry have persisted and intensified, particularly due to the COVID-19 pandemic. In response, several efforts emerged to bolster the workforce:

• Workforce Development Initiatives: Argentum has continued to prioritize workforce development, launching initiatives such as partnerships with educational institutions in 2022. These programs aim to create career pathways, offering training and opportunities for individuals entering the senior living field.

• Legislative Actions: At both state and federal levels, there have been efforts to address staffing shortages in healthcare, including senior living. These include funding for training programs, loan forgiveness for healthcare workers, and incentives for employers to hire and retain staff. For instance, discussions around immigration reform in 2023 have explored allowing more foreign workers to fill caregiving roles, while some states have introduced minimum staffing requirements for nursing homes, potentially influencing senior living practices.

• Improved Compensation and Benefits: To attract and retain staff, many senior living providers have increased wages and enhanced benefits, recognizing the competitive labor market and the need to make these roles more appealing.

• Technological Innovations: The industry has also turned to technology to supplement staffing needs. Solutions like telehealth services and remote monitoring have been adopted to enhance care delivery and reduce the workload on existing staff.

In late 2023, a survey I conducted for an article (I never published) suggested that  38 states and the District of Columbia had established their own minimum staffing standards for nursing homes, but that figure was gleaned from internet searches; I could find no readily available source cataloguing the states and their staffing regulations.  I was surprised that the information wasn't more readily available since federal staffing mandates were then a hot topic.  

An Argentum spokesman told McKnight’s Senior Living:

“There are far too few caregivers to meet the needs of our rapidly aging population, and it will take an across-the-board approach to recruit and retain more than 20 million workers who will be needed across long-term care by 2040.” Three million of that 20 million will be needed in senior living alone, according to Argentum."

The American Seniors Housing Association (ASHA) told McKnight’s Senior Living that  the aging population demands a steady pipeline of workers to serve older adults living in senior living communities and other long-term care settings. ASHA Vice President of Government Relations Jeanne McGlynn Delgado appears optimistic:  

“Identifying and implementing federal training programs that can attract and grow this workforce, whether it be in retooling existing grant programs or expanding apprenticeships specifically for senior living workers, shows much promise,” ASHA ."

The American Health Care Association/National Center for Assisted Living told McKnight’s Senior Living that it continues to support making apprenticeship programs more available and accessible, including supporting the recently introduced American Apprenticeship Act to provide tuition assistance to fund apprenticeship programs:

“We’ve seen the value they can bring through our own apprenticeship partnership with Equus Solutions, who has supported some of our long-term care providers with the process. Apprenticeships are one of the many solutions we need to help recruit and retain more long-term caregivers, and we appreciate this effort to help address the nation’s growing caregiver shortage.”

Despite these efforts, staffing remains a critical and ongoing challenge in senior living. The effectiveness of these measures is under evaluation as needs increase, and the industry and governments continue to seek innovative and sustainable solutions to ensure high-quality care for residents. 

You can help.  Develop a plan to age in place.  To the extent possible, relegate institutional choices to "when and if it is absolutely necessary, and there is no available alternative."  You and your loved ones will likely experience better outcomes, and you will relieve an already burdened system.  

Federal Judge Blocks Biden-Era Nursing Home Staffing Rule – Implications for Care Quality and Families

On April 8, 2025, a federal judge in Texas struck down a Biden administration rule aimed at establishing minimum staffing requirements for nursing homes that receive Medicare and Medicaid funding. This ruling, issued by U.S. District Judge Matthew Kacsmaryk, has significant implications for the quality of care in nursing homes, the families who depend on these facilities, and the broader debate over healthcare regulations in the U.S. I'll explores the details of the rule, the lawsuit challenging it, the court’s rationale for blocking it, and the potential effects on nursing home residents and their families.

The Blocked Rule: Minimum Staffing Standards for Nursing Homes

The rule, announced by the U.S. Department of Health and Human Services (HHS) in April 2024, sought to address chronic staffing shortages in nursing homes by imposing the first-ever federal minimum staffing standards for long-term care facilities. Issued by the Centers for Medicare & Medicaid Services (CMS), the regulation required nursing homes to:

• Employ a registered professional nurse (RN) 24 hours per day, seven days a week, a significant increase from the existing federal requirement of eight hours per day.

• Maintain total nurse staffing, including nurse aides, at a minimum of 3.5 hours per resident per day (HPRD), ensuring a baseline level of care for residents.

The Biden administration framed the rule as a critical step to improve care quality for the 1.2 million residents in Medicare- and Medicaid-certified facilities, citing systemic issues exposed during the COVID-19 pandemic, such as understaffing leading to neglect and poor health outcomes. CMS argued that higher staffing levels would enhance resident safety, reduce infections, and improve overall care, aligning with the Federal Nursing Home Reform Act’s (FNHRA) goal of protecting residents’ “health, safety, and dignity”.

The Lawsuit: Basis for Challenging the Rule

The lawsuit by the American Health Care Association (AHCA), a major nursing home industry group, and Texas Attorney General Ken Paxton, among others, in May 2024 argued that the rule was unlawful on several grounds:

Exceeding Statutory Authority: The plaintiffs contended that HHS and CMS lacked the authority to impose such stringent staffing mandates. Federal law, specifically the Social Security Act, explicitly requires nursing homes to have an RN on-site for eight consecutive hours per day and to provide “sufficient” staff to meet residents’ nursing needs. The plaintiffs argued that the new rule’s 24/7 RN requirement and 3.5 HPRD standard went beyond what Congress had authorized, effectively rewriting the law.

Financial and Operational Burdens: The nursing home industry highlighted the practical challenges of compliance, citing workforce shortages and financial strain. The AHCA claimed that the mandate would force many facilities to close, displacing vulnerable seniors, as the industry already struggles to hire and retain staff amid a national shortage of healthcare workers. At least one operator, LaVie Care Centers, blamed the staffing rule for its bankruptcy filing.

Arbitrary and Capricious Rulemaking: The plaintiffs argued that CMS failed to adequately justify the rule’s immediate implementation and did not tailor the staffing requirements to the diverse needs of nursing home populations, as required by federal law. They claimed the 3.5 HPRD formula was a “one-size-fits-all” approach that ignored facility-specific factors.

The Court’s Ruling: Legal Basis for Blocking the Rule

Judge Matthew Kacsmaryk, granted summary judgment to the plaintiffs on April 7, 2025, vacating key provisions of the CMS rule. His decision rested on the following legal bases:

Lack of Congressional Authority: Kacsmaryk ruled that HHS and CMS exceeded their statutory authority under the Social Security Act. He noted that Congress had explicitly set the RN staffing requirement at eight hours per day, and the 24/7 RN mandate went beyond this limit. Similarly, the 3.5 HPRD standard was deemed inconsistent with the law’s requirement for “sufficient” staffing tailored to residents’ needs, as it imposed a rigid national formula.

Failure to Tailor Requirements: The court found that CMS did not meet statutory requirements to customize staffing levels based on the specific needs of each facility’s resident population. Kacsmaryk criticized the 3.5 HPRD formula as an unlawful “one-size-fits-all” approach, arguing that it did not account for variations in resident acuity or facility resources.

Procedural Deficiencies: The judge held that CMS failed to adequately explain the need for immediate implementation of the rule, a requirement under the Administrative Procedure Act. This procedural lapse further supported the decision to block the mandate.

The ruling was celebrated by the AHCA and industry groups as a victory for nursing homes, with AHCA President Clif Porter stating that the “unrealistic staffing mandate threatened to close nursing homes and displace vulnerable seniors.” Critics, including elder abuse attorney Ed Dudensing, argued that the decision “undermines the very safeguards designed to protect our elders’ dignity and well-being.”

Impact on Quality of Care: RN Staffing and Health Outcomes

Vacating the staffing rule raises significant concerns about the quality of care in nursing homes, particularly given the establishment view of well-documented correlation between RN staffing levels and resident health outcomes.  In a later article I will address critically recent challenges to this establishment view.  Regardless,  studies have consistently shown that higher RN and LPN staffing is associated with generally better physical and psychological outcomes for residents, while understaffing contributes to neglect, infections, and increased mortality.

Physical Health Outcomes: 

• A 2021 study published in Health Affairs found that nursing homes with higher RN staffing levels (at least 0.75 hours per resident per day) had significantly lower rates of hospitalizations, pressure ulcers, and infections compared to facilities with lower RN staffing. The study estimated that increasing RN staffing to this level could prevent 136,000 hospitalizations annually.

• During the COVID-19 pandemic, a 2022 CMS report highlighted that nursing homes with RN staffing below 0.4 HPRD had a 30% higher mortality rate from the virus, as understaffed facilities struggled with infection control and timely care. See, CMS, “Nursing Home Staffing and COVID-19 Outcomes” (2022).

• The blocked rule’s requirement of 3.5 HPRD, including RN presence 24/7, aimed to address these issues by ensuring consistent oversight and care. Without this mandate, facilities may continue to operate with insufficient RN staffing, potentially leading to increased physical health risks for residents, such as falls, medication errors, and untreated infections.

Psychological Health Outcomes:

• A 2019 study in The Gerontologist found that higher RN staffing was associated with lower rates of depression and anxiety among nursing home residents. RNs, with their advanced training, are better equipped to recognize and address psychological distress, provide emotional support, and coordinate mental health interventions.

• Understaffed facilities often rely on chemical restraints (e.g., psychotropic medications) to manage resident behavior, a practice that led to litigation in the Talevski case, where the Supreme Court affirmed residents’ rights under the FNHRA to be free from unnecessary restraints. The blocked staffing rule could have reduced such practices by ensuring RNs were available to implement non-pharmacological interventions, improving residents’ psychological well-being.

Impact on Families of Nursing Home Residents

Families who depend on nursing homes to keep their loved ones safe and well face significant challenges as a result of this ruling. To family members, the decision removes a federal safeguard that could have ensured consistent care, leaving families with heightened uncertainty and potential risks:

Increased Risk of Neglect and Abuse: 

• Understaffing is a leading cause of neglect and abuse in nursing homes, as overworked staff may lack the time to provide adequate care. The NHRA requires personalized care plans and regular reviews, but without sufficient RNs, these plans may not be implemented effectively. Families may worry about their loved ones experiencing preventable issues like pressure ulcers, dehydration, or untreated infections due to inadequate staffing.

• For example, in the Talevski case, a family discovered that their father was chemically restrained with psychotropic medications due to understaffing at a county-owned facility, leading to his deterioration. Families will likely worry that such incidents may become more common without mandated staffing improvements.

Emotional and Financial Strain:

• Families often choose nursing homes expecting professional care that they cannot provide themselves, particularly for loved ones with complex needs like dementia. The ruling may force families to spend more time monitoring their loved ones’ care or hiring private caregivers to fill gaps, increasing emotional and financial burdens.

• If facilities close due to financial pressures, as the AHCA warned, families may face the trauma of relocating their loved ones, potentially to facilities farther away or with even lower staffing levels.

Aging in Place Planning

One positive effect of the court's decision, and the controversy surrounding it, is that more potential residents and families of potential residents will take seriously the need to age in place, and implement comprehensive aging in place planning. If you would like to know more, subscribe to this blog.  You will be receive periodic notifications of online aging in place planning workshops. If you can't or don't want to wait, there is a recorded, somewhat dated, workshop available here: https://bit.ly/Aging-in-Place-Workshop.  You can watch this presentation in the comfort of your home, and share it with your successor trustees and health care agents. 

Aging in Place Planning is a comprehensive estate, financial, and health care plan orienting your decision-making and resources to make aging in place more attainable, likely, and enforceable by your trusted advisors and fiduciaries, all to the goal of avoiding non-hospital institutional care entirely.  It incorporates reducing the risks of guardianship, and protecting assets from a court-appointed guardian.  

Aging in Place Planning can be incorporated into any existing estate plan.  It can be can be used in conjunction with irrevocable trust planning to shield assets from nursing home spend down, or as an alternative to such planning if it is deemed unnecessary or unacceptable.  

Advocacy Challenges

The NHRA provides for ombudsmen to investigate and address nursing home issues, but without federal staffing mandates, families may need to rely more heavily on these advocates to ensure care quality. Ombudsmen, too, are often overstretched, and their ability to enforce improvements may be compromised by increased demand resulting from the consequences of inadequate staffing.  Of course, like any funded resource, the ombudsmen program is limited without robust federal backing.

Broader Implications and Critical Analysis

The ruling reflects a broader tension between regulatory oversight and industry autonomy in healthcare. While the AHCA and nursing homes argue that the mandate was unworkable amid workforce shortages, critics assert that it was a necessary step to protect vulnerable residents. The decision also highlights the political divide on healthcare policy: Congressional Republicans and the Trump administration, including CMS Administrator Mehmet Oz, have signaled opposition to the rule, while Democrats sought to preserve it.

The establishment narrative—both from CMS and the industry—has obvious gaps. CMS’s rule, while well-intentioned, did not adequately address the root causes of staffing shortages, such as low wages, poor working conditions, vaccine mandates, and a lack of training programs, which continue to drive nurses away from the industry. Mandatory staffing may, actually miss the point entirely, since it is the nature of the resident population that dictates needs; some populations require less from an RN, and more from either LPNs or aids. Finally, staffing is not likely a panacea for the inherent risks of institutional care, many of which lead to rehospitalizations, the real target of federal effort. 

On the other hand, the AHCA’s claim that the mandate would lead to widespread closures may be overstated, as some facilities might have adapted by leveraging technologies like telehealth, and future demand may slow as a result of greater reliance on hospital-at-home, the former as specifically suggested by Oz.

Regardless, from a resident and family perspective, the ruling is a setback. The public will likely perceive that without federal enforcement, care quality may remain inconsistent, particularly in underfunded facilities, leaving families to bear the burden of advocacy and oversight.

A focus on either providing more alternatives to institutional care or encouraging and financing aging in place where possible might provide greater and more satisfying solutions. Reconsideration and reorientation of long-term care in the U.S. is long overdue.

Conclusion

The federal judge’s decision to block the Biden-era nursing home staffing rule on April 7, 2025, removes a critical safeguard intended to improve care quality for nursing home residents. The rule aimed to address systemic understaffing by mandating 24/7 RN coverage and a minimum of 3.5 HPRD, but the court ruled that CMS exceeded its authority, citing inconsistencies with congressional legislation and procedural deficiencies. The ruling is likely to perpetuate understaffing, increasing risks of neglect, infections, and psychological distress for residents, as evidenced by studies showing the benefits of higher RN staffing.

For families, the decision heightens concerns about safety and well-being, potentially requiring greater involvement and resources to ensure adequate care. While the nursing home industry celebrates the ruling, the long-term impact on vulnerable residents underscores the need for alternative solutions, such as state-level mandates or incentives to address workforce shortages, to uphold the FNHRA’s promise of dignity and care for nursing home residents.