RICHMOND, Va. — As regulators observe worsening care and conditions in nursing homes, some advocates are pushing for stricter measures to improve staffing levels at facilities. However, a federal mandate that would've required just that was met with resistance from industry groups and top attorneys in more than a dozen states including Virginia.
Tracey Pompey, who formed the advocacy group Justice and Change for Victims of Nursing Facilities after her father died in a Henrico nursing home, has been pushing for strengthened oversight of the industry for years.
“There needs to be strict enforcement in these nursing facilities," Pompey said. "There's no accountability."
Not only was her family impacted by a tragic nursing home experience, she also spent 30 years working as a nursing assistant.
One of the takeaways from that time, she said, was having to care for residents with limited help and resources.
“I’ve taken care of 15 to 20, patients before, because the facility would keep you short staffed," Pompey said.
Last year, under the Biden administration, the Centers for Medicare and Medicaid Services established a rule to address staffing issues.
The former president claimed nursing homes would "chronically under-staff" facilities, resulting in "poor, substandard care that endangers residents" which can lead to preventable injuries such as falls and bedsores.
“This is a very hands-on profession. Residents need help bathing, dressing, eating, transferring, all kinds of things, and you need people there to do that," said Toby Edelman, a senior policy attorney with the non-profit Center for Medicare Advocacy.
While Edelman said she hoped CMS would have developed a more robust staffing rule, she supported the finalized measure.
CMS' rule called for facilities to provide a total of 3.48 hours of nursing care per resident per day, with a specific breakdown of how much time should come from a registered nurse and nurse aide.
The rule also required facilities to have a registered nurse on site 24 hours a day, seven days a week.
“Residents can get sick in the middle of the night. They're not just going to get sick during normal business hours, so the importance of having registered nurses who are able to do assessments and figure out what is going on with residents is very important," Edelman said.
CMS said the move "affirmed its commitment to hold nursing homes accountable for providing safe and high-quality care for the nearly 1.2 million residents living in Medicare- and Medicaid-certified long-term care facilities."
According to a 2024 study by the federal government, the national average hours of care per resident per day was 3.78, above the proposed minimum standard of 3.48.
The study found that for-profit facilities were most likely not to meet the standards, and Edelman said the rule would have the largest impact on low-rated nursing homes that CMS has designated as understaffed and poor performers on inspections.
For example, CMS data showed that the 1-star Colonial Heights Rehabilitation and Nursing Center, where 18 employees were recently charged in an elder abuse investigation, provides two hours and 46 minutes of care per day, much below the national average.
“It would make a difference definitely in the most poorly performing facilities," Edelman said.
According to CMS, the agency would give facilities multiple years to begin implementing the changes in phases and allow some facilities to qualify for exemptions from the rule based on factors such as geographical location and workforce circumstances.
But the rule has faced significant backlash.
Virginia's Attorney General Jason Miyares joined a lawsuit with other Republican attorneys general across the country who are attempting to stop the CMS rule from taking effect.
Mirayes called the measure “another example of Washington bureaucrats imposing sweeping mandates without considering the devastating impact on our communities.”
He said it would impose hundreds of thousands of dollars in costs on states, force already struggling nursing homes out of business, and result in fewer options for residents and families looking for nursing home care.
Meanwhile, the industry group, Virginia Healthcare Association (VHCA) which represents the interests of nursing homes across the state, said CMS chose "an illogical approach to solving the nursing crisis by requiring specific, mandated nursing levels while nursing homes are still grappling with a historic labor crisis and there’s a growing caregiver shortage."
VHCA conducted a survey among its members in late 2024, and according to feedback from 165 nursing homes and assisted living facilities, an overwhelming majority reported vacancies of nursing staff.
Combined with the staffing shortages, most facilities also reported receiving a lack of applications from qualified candidates and maintaining a waitlist for new admissions.
"Virginia’s nursing homes are desperately trying to hire more nurses and nurse aides, but we cannot find qualified individuals to fill open positions. Underfunded Medicare and Medicaid payment systems are at the root of staffing difficulties. Nursing homes need more resources to better compete for health care workers and offer higher paying jobs. If nursing homes are unable to increase their workforce, facilities will likely need to further limit the number of residents they serve," said VHCA spokesperson Amy Hewett.
With President Trump taking office, Edelman worries his administration will drop the CMS staffing rule altogether.
"I think everybody is assuming that the rule is going to get dropped, because this has been the biggest priority of the nursing home industry-- to get rid of this rule now," Edelman said.
The New York Times reported in December that one of the industry groups leading the legal challenge against the CMS rule was hopeful that President Trump would rescind the staffing mandate.
In Virginia, a lawsupported by the VHCA is set to take effect this July requiring minimum staffing standards be set with penalties for those who don't meet them.
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