Nursing Home Staffing Mandates: Why Minimums Are Not the Maximum Solution

The well-being of over one million residents in U.S. nursing homes hinges significantly on adequate staffing levels. However, the debate surrounding nursing home staffing mandates is complex. While minimum staffing standards aim to ensure a baseline level of care, they may not always be the optimal solution for maximizing resident well-being and quality of care. In fact, understaffing in nursing homes is one of the biggest factors leading to nursing home abuse and neglect. Understaffing leads to inadequate attention from staff, meaning residents are more likely to get hurt through falls, dehydration, malnutrition, or bedsores.

The Push for Minimum Staffing Standards

For years, advocates and lawmakers have pushed for stricter nursing home staffing requirements. The argument is simple: more staff means better care. Insufficient staffing levels compromise those responsibilities and lead to preventable injuries and hospitalizations. A recent study revealed that increasing the hours registered nurses (RN) spend with assisted living residents with Alzheimer’s disease and related dementias is linked to a decrease in injury-related emergency department (ED) visits. This finding underscores the direct impact that adequate staffing has on resident health outcomes.

In 2024, the Centers for Medicare & Medicaid Services (CMS) finalized a rule mandating minimum staffing levels for nursing homes participating in Medicare and Medicaid. The rule required a minimum of 3.48 hours of nursing care per resident per day (HPRD), including 0.55 HPRD from registered nurses (RNs) and 2.45 HPRD from nurse aides. It also required 24/7 on-site RN coverage.

However, in December 2025, the Trump administration repealed the Biden-era nursing home staffing mandate, citing concerns that the regulations would disproportionately harm rural communities.

The Problem with a “One-Size-Fits-All” Approach

While the intention behind minimum staffing mandates is laudable, a rigid, “one-size-fits-all” approach may not be the most effective way to improve care quality across the board. There are several reasons why minimums are not the maximum solution:

Ignoring Resident Acuity: Minimum staffing levels often fail to account for the varying needs of residents. A facility with a high concentration of residents requiring complex medical care will need more staff than a facility with primarily independent residents. A 2024 study recommended a range from 4.29 total HPRD for a facility with a low acuity overall census to 6.77 HPRD for one with the highest acuity census.
Focusing on Quantity Over Quality: Simply increasing the number of staff does not guarantee better care. The competency, training, and experience of staff members are equally important. Prioritizing numbers over qualifications can lead to a decrease in the quality of care provided.
Exacerbating Staffing Shortages: The healthcare industry, particularly long-term care, already faces significant staffing shortages. Mandating minimum levels can strain resources, potentially leading to increased burnout among existing staff or forcing facilities to close, especially in rural areas.
Financial Strain: Implementing minimum staffing standards can be costly for nursing homes, potentially leading to cuts in other essential services or impacting the financial viability of facilities, especially those in underserved communities.

The Consequences of Understaffing

Understaffing in nursing homes can have devastating consequences for residents, leading to:

Increased Risk of Neglect: Inadequate supervision can result in residents being left unattended, leading to malnutrition, dehydration, falls, and bedsores.
Higher Likelihood of Abuse: Overworked and stressed staff members may be more prone to abusive behavior.
Medication Errors: Insufficient staffing can lead to missed doses, incorrect dosages, and improper timing of medications.
Poor Hygiene: Residents may not receive adequate assistance with personal care, leading to poor hygiene and increased risk of infections.
Decreased Resident Satisfaction: Lower levels of social interaction and engagement can result in social isolation and lowered satisfaction with their living situation.

A Better Approach: Comprehensive Solutions

Instead of relying solely on minimum staffing mandates, a more comprehensive approach is needed to address the challenges in nursing home care. This includes:

Acuity-Based Staffing Models: Implementing staffing models that adjust to the specific needs and acuity levels of residents in each facility.
Investing in Staff Training and Development: Providing ongoing training and professional development opportunities to enhance the skills and competency of nursing home staff.
Improving Wages and Benefits: Offering competitive wages and benefits packages to attract and retain qualified staff, reducing turnover rates.
Enhancing Oversight and Enforcement: Strengthening regulatory oversight and enforcement mechanisms to ensure that facilities are meeting quality standards and addressing instances of neglect or abuse.
Supporting Innovation and Technology: Encouraging the adoption of innovative technologies and care models to improve efficiency and enhance resident care.
Addressing Systemic Issues: Tackling broader issues such as low Medicaid reimbursement rates and lack of financial accountability that contribute to staffing challenges.

Legal Recourse for Understaffing Issues

When understaffing leads to neglect or abuse, residents and their families have legal options. A nursing home abuse lawsuit can help recover compensation for injuries, medical expenses, and other damages. It can also hold negligent facilities accountable for their actions and help prevent future harm to other residents.

Conclusion

While minimum staffing mandates may seem like a straightforward solution to improve nursing home care, they are not a panacea. A more nuanced and comprehensive approach is needed, one that considers resident acuity, staff qualifications, systemic issues, and innovative solutions. By moving beyond minimums and focusing on a holistic strategy, we can create a long-term care system that truly prioritizes the well-being and quality of life for all residents.