Nursing Home Staffing Regulations Meet the New Regime
Emily K. Abel
A critical goal of the second Trump administration is to rescind business regulations. The conflict around staff shortages in the nation’s 15,000 nursing homes illustrates the absolute necessity of regulating those facilities as well as the limitations of relying solely on rules to improve the quality of care.
Since the establishment of nursing homes in the 1930s, reports of the poor quality of their care have circulated widely. The US Senate Committee on Aging held a series of hearings between 1963 and 1974, leading to reform of both federal and state regulations. Nevertheless, the Institute of Medicine concluded in 1986 that a high proportion of nursing home residents still received “shockingly” deficient care. The 1987 Nursing Home Reform Act addressed some, but by no means all, of the problems. The growing dominance of for-profit enterprises, especially corporate chains and private-equity firms, heightened quality concerns. Staff shortages increased while safety precautions, including infection control, languished.
When staffing levels are low, call buttons go unanswered, and residents spend hours lying in soiled sheets, develop bedsores, contract infections, and fall when they try to go to the bathroom. Nursing aides face special challenges even when their numbers are adequate. Although often required to perform medical tasks, they receive very little training. The work is extremely hazardous, involving heavy lifting, needle punctures, and assaults. Nursing home aides report more injuries than workers in any other occupation, including construction and truck driving. Remuneration is paltry, especially for those who can find only part-time work. Unsurprisingly, approximately 50 percent of direct-care workers flee each year for better jobs in retail and restaurants. Many of those who remain hold more than one job to make ends meet.
The Covid pandemic that struck in March 2020 shone a bright light on nursing home deficiencies. On March 8, Tom Friedan, former director of the US Centers for Disease Control and Prevention, declared long-term care institutions “ground zero for Covid-19.” Two weeks later the nation learned that thirty of the forty-six deaths in Washington had occurred at the Life Care Center in Kirkland, Washington. One-fourth of the residents had died; dozens of others were in the hospital. It was soon clear that the Kirkland facility was not an aberration. By June 26, the virus had killed fifty-four thousand nursing home residents and workers, representing 43 percent of all US fatalities. More recent studies report that although far fewer than one percent of Americans live in nursing homes, 18 percent of all US deaths from Covid occurred in those facilities. Researchers in both California and Connecticut reported that nursing homes with low staffing levels had the highest number of Covid infections.
Nevertheless, some observers blamed nursing home staff for the high death toll, charging that they disregarded safety protocols, traveled on public transportation with people who were sick, brought the virus from their communities, and worked at multiple facilities, thus spreading disease from one to another. Other commentators, however, noted that many workers lacked adequate personal protective equipment, low wages forced them to seek employment at different institutions, few could afford to travel by car, the lack of paid sick days compelled them to work when ill, and they transferred disease not only to their workplaces but also to communities with overcrowded homes and high rates of morbidity and mortality. Shantonia Jackson, a nursing aide in a nursing home in Cicero, Illinois, told a Guardian reporter that she quarantined herself at home after returning from work, communicating with family members only by video calls. Workers also worried about their own health. A survey released in June 2020 by the Service Employees International Union (SEIU), the largest union of nursing home staff, reported that nearly 80 percent believed they placed their lives at risk when they went to work.
As a growing number of workers quit their jobs, a smaller staff was responsible for a sicker and more distraught population. Shantonia Jackson noted that she worked sixteen-hour days, seven days a week, caring for seventy residents at one time. The absence of residents’ family members undoubtedly contributed to her workload. On March 3, 2020, the Center for Medicare and Medicaid (CMS) restricted all visitation by residents’ relatives and friends except to deliver “compassionate care” for residents near death. Suddenly everyone seemed to discover the critical role families play in nursing homes.
A guest editorial in the Washington Post co-authored by a professor of medicine, a professor of health care policy, and a professor of law wrote, “Many family members are not company as much as essential caregivers and care monitors. Their involvement is vital, especially at facilities with shortages in staffing. Caring visitors make sure that their loved ones eat, can communicate with staff, and receive daily hygiene and dignified engagement. Family members are often the first to see changes in a resident’s condition.” When Sylvia Jones learned that her mother’s facility permitted only essential workers to enter, she exclaimed, “I am essential to my mom’s care. I am the one who makes sure that she has toothpaste, clothes that are clean, that there are no poopy Depends in her dresser drawer, that she has soap in her bathroom dispenser, that she is bathing, that she does not smell.” After the visitation restrictions were lifted, family members reported that residents had seriously declined both physically and cognitively.
Although the first Trump regime responded to the devastation in nursing homes by easing regulations, the Biden administration took the opposite approach. In his January 2022 State of the Union address, Biden announced his intention to implement a series of reforms for nursing homes. The factsheet he released the following month indicated that he would focus first on staffing levels because they are the “measure most closely linked to the quality of care residents receive.” In September 2023, the Centers for Medicare and Medicaid proposed a rule for minimum staffing standards for nursing homes. The rule that was finalized in April 2024 required facilities to have 3.48 hours of staff for each patient each day, with set periods for RNs and nursing aides. Just one-fifth of all nursing homes already were in compliance with the mandate; the others had five years to enforce it.
Mark Parkinson, the head of the American Health Care Association, the nursing home industry’s major association, responded that because the mandate did not include increased funds for nursing homes, it threatened “to shut down more nursing homes, displace hundreds of thousands of residents, and restrict seniors’ access to care.” Nursing home advocates first argued that the standards were too low but became the mandate’s staunch defenders after Trump’s election generated fears that he would refuse to enforce it.
Evidence suggests that they were right to worry. The nursing home industry has placed increasing pressure on the new administration to rescind the regulations. On April 15, the New York Times listed the nursing home staffing regulation as one of the many rules Trump intended to either repeal or stop enforcing as part of what he calls the “deconstruction of the overbearing and burdensome administrative state.” He may not need to take any specific action to cancel the staffing mandate because a Texas judge vacated it earlier in the month. Most observers conclude that the administration is unlikely to appeal that decision.
Of course, even the most rigorous regulations can only do so much. Five states, including California, Florida, Massachusetts, New York, and Rhode Island, already have laws on the books requiring nursing homes to have a minimum number of staff. Because the states rely on underfunded inspectors for enforcement and lack penalties for noncompliance, however, many facilities have fewer workers than required. Nevertheless, nursing homes in those states have higher staffing levels and better quality of care than facilities in other states.
Readers wishing to read Biden’s 2022 State of the Union address or the factsheet that followed will discover that the Trump administration has removed the relevant pages from the government website. But the regime cannot so easily whitewash the problems that continue to plague the nursing home industry and threaten to become more severe in the years ahead. Without adequate staffing levels, nursing homes are no more prepared for a pandemic than they were in January 2020.
Sources:
Emily K. Abel, Elder Care in Crisis: How the Social Safety Net Fails Families (NYU Press, 2022).
Carol Davenport, “Inside Trump’s Plan to Halt Hundreds of Regulations,” New York Times, April 16, 2025.
Charlene Harrington, et al., “Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 through 2016,” KFF, April 3, 2018.
Sushant Joshi, “Staffing Shortages, Staffing Hours, and Resident Deaths in US Nursing Homes during the COVID-19 Pandemic,” Journal of the American Medical Directors Association, 24, no. 8 (August 2023).
Jordan Rau, “Why Nursing Home Residents Still Suffer Despite Tough State Laws,” New York Times, July 12, 2024.
“Minimum Staffing Standards for Long-Term Care Facilities,” Federal Register, May 10, 2024.
Center for Medicare Advocacy, “Federal Court in Texas Vacates President Biden’s Staffing Rule for Nursing Homes,” April 10, 2025,
https://medicareadvocacy.org
Nancy Ochieng and Priya Chidambaram, “Nursing Facility Staffing Shortages during the COVID-19 Pandemic,” KFF, April 4, 2022.
Michael L. Barnett and David C. Grabowski, “Nursing Homes Are Ground Zero for COVID-19 Pandemic,” JAMA Health Forum, March 24, 2020.