The danger of nursing homes defying federal staffing guidelines

Regulators have permitted thousands of nursing home across the country America USA TODAY found that the woman flouted federal staffing regulations by working all day without a registered nurse on call, according to an investigation.

Nearly They all got away with it. Only 4% were cited by government inspectors. Even fewer were fined. 

When When you add in other caregivers for nursing homes, you find that one-third of U.S. facilities failed to meet multiple benchmarks set by the federal government for nurse and aide staffing. 

LowPeople of color are more prevalent among those who have low-income. fare the worst. Their nursing homes report the lowest staffing levels, but data show they seldom get in trouble because of it.

USA TODAY’s investigation revealed that the federal government rarely enforces decades-old rules for staffing and nursing homes.

Citations and penalties remained sparse even as regulators developed three ways to measure staffing. In The spring is here They will suggest a fourth approach. 

Nursing Supporters, home workers, and home care workers march through the streets California’s Capital in June Advocate for higher industry standards, safer staffing and higher wages
Rich Pedroncelli/AP

Having Research has shown that the strongest predictor for whether residents of nursing homes will succeed is how many nurses and aides there are. When The facilities lack the staffing needed to perform essential medical tasks. Doctor’s appointments are missed, call buttons go unanswered, diapers are not changed, showers are not given and wounds are not cleaned. Dementia You can get in quicker. People You will get more sick and eventually die on your own.

The Residents and their family members can call emergency 911 to voice their despair.

“She is on the floor, and she can’t get anybody to get her off the floor,” One niece shared the story with a Louisiana dispatcher. “Can y’all do a wellness call or something? I don’t know what to do.”

On The other side of the state is a man who cannot leave his bed without assistance and defecates on his own. He Call 911

“I called” He asked for assistance and told the dispatcher. “But nobody answered.”

In His State The Union Address this year President Joe Biden promised sweeping nursing home reforms. But the government’s persistent failure to crack down on facilities that fall short of nursing home standards Could render his plan unworkable.

USA TODAY compared millions upon millions of nursing home inspection reports and timesheets from thousands of nurses to determine the federal staffing figures. It A shocking pattern of failure was discovered.

Charlene Harrington, one of the nation’s leading researchers on staffing levels and nursing home quality, USA TODAY’s analysis probably underestimated how often facilities fell short because it used a conservative standard to measure care expected from nurses and aides.

“What you’re looking at is the bare minimum,” said HarringtonProfessor emerita at The University This is California, San Francisco. And Federal regulators “not even been enforcing the bare minimum.”

Charlene Harrington
Charlene Harrington

The Problem existed before COVID-19. Among facilities that did not have a registered nurse on duty eight hours a day as required by the federal Centers For Medicare & Medicaid Services (CMS), most failed to meet that standard in all three years before the coronavirus tore through nursing homes. 

The Many nursing homes were understaffed due to the pandemic. Americans. In It left behind former certified nurse assistants Tracey Pompey It is shocking that the public hasn’t demanded better care for elderly people.

“People get desensitized to things like this,” PompeyOf Virginia. “If it happens to a child or a dog, people won’t shut up.”

Tracey Pompey of Richmond, Virginia, is an advocate and former certified nursing assistant.
Tracey Pompey This is Richmond, VirginiaShe is an advocate and a former certified nursing assistant.
Josh Morgan, USA TODAY

James Lovette-Black?, California A glimpse at the problems persists in nursing homes inspectors up to 2020 Lovette-Black said facilities often did not have enough nurses or aides to meet residents’ needs. Yet despite his best efforts, he said, “I don’t recall ever citing for staffing violations in any nursing home in my eight years.”

He He explained why to hundreds of inspectors surveyed during a 2013 study. Staffing Department leaders did not prioritize citations. Lovette-Black They were hard to back up, he said. He Among other tactics that researchers have documented, accused facilities routinely increased their staff during inspections to avoid any negative public ratings. 

The American Health Care Association, the nation’s largest trade group for nursing homes, said in a news release this summer that 94% of the country’s facilities missed minimum staffing guidelines tougher than those used in USA TODAY’s analysis.

The An email from the company stated that “the vast majority” Inspectors receive accurate information from nursing homes. ThatSenior vice president Holly Harmon However, it is not the cause.

“We firmly support transparency and accountability,” Harmon said, “and we must also foster an oversight system that recognizes good faith efforts and promotes improvement, not just penalties.”

Speaking This is Biden’s plan, she added: “A new, federal staffing mandate without the available workforce and financial resources necessary to meet it would reinforce a punitive process that hasn’t been working for decades.”

Medicaid Most nursing home stays are paid for by reimbursements. They pay less than Medicare. The The larger financial picture is however complicated.

Taxpayers Spend nearly $90 billion annually on Medicaid Medicare Stays at nursing homes — many of them run by companies that report double-digit profit margins. Nursing Homes also pay caregivers lower than other sectors of health care. 

Half of nursing staff — or more — turns over in a yearAccording to federal statistics about the industry, it is at least $1.2 million.

Barbara Decelles, a retired RN, had a 38-year career at skilled nursing and assisted living facilities in Wisconsin and Illinois.
Barbara DecellesRetired RN, he had a 38-year history in skilled nursing and assisted living facilities. Wisconsin Illinois.
Mike De Sisti, Milwaukee Journal Sentinel via USA TODAY NETWORK

Registered nurse Barbara Decelles For 38 years, I made the most of it in senior care centers. Wisconsin Illinois. She You can quit this year.

She’s done working 25-hour shifts, knowing she might be making mistakes, then, exhausted, driving off the road on her way home.

She’s done choosing which call light to answer and which to ignore. She’s done asking for more help and being told it doesn’t fit the budget. She’s had it with owners appearing on a busy day to celebrate the staff’s heroic work with a goofy photo-op but not extending benefits to aides or awarding raises.

Barbara DecellesBefore quitting, she was a registered nurse who worked at senior care facilities for 38 years.
Somehow, somebody is making money off of this and it certainly isn’t the caregivers. I’m tired to my soul.

But she can’t escape from the anger – that people she cared for daily declined faster and died sooner because of inadequate staffing.

“Somehow, somebody is making money off of this, and it certainly isn’t the caregivers,” Decelles said. “I’m tired to my soul.”


Understaffing has been a problem throughout decades of nursing home reforms – one that Bill Halamandaris According to leaders Congress CMS has repeatedly been ignored. 

HalamandarisRetired Capitol Hill Staffer worked on the Senate Committee On Aging As the nation’s first regulations for nursing homes, it gave wide authority to federal health officials to enforce these rules. Halamandaris The 1967 Moss AmendmentsThese were, among others, intended to result in the creation of minimum staffing levels and a subsequent crackdown.

That didn’t happen. 

“Like a lot of things, the congressional intent is lost in the bureaucracy,” Halamandaris said.

Federal Since then, regulators have created multiple methods to determine if a nursing home is adequately staffed. 

Since The late 1980s. Regulations require facilities to be available. “sufficient nursing staff” To provide care for residents and have a registered nurse on-site at all times. 

In 2001, a study by the Medicare Regulator Congress Minimum number of nurses and aides recommended.

ThenCMS used the results of another study to determine how much it would pay residents in nursing homes starting in 2011. Medicare. Reimbursements The amount of staffing that a nursing home offers for patients with similar medical requirements is what determines how much the cost of these services. It’s the formula CMS also deploys in its consumer-focused Nursing Home Care Compare tool.

That “expected” USA TODAY’s analysis found that the average staffing level is nearly always lower than 2001’s minimums. 

Regulators They have not used the 2011 or 2001 benchmarks to enforce. And USA TODAY discovered a gap between facilities who filed with the federal government and found they had broken the eighth-hour rule. 

Nicholas CastleThe leading researcher in enforcement of nursing home standard from West Virginia UniversityConcentrated enforcement efforts can also have a significant impact. For CMS and other state inspection agencies, for example, have focused on the reduction of physical restraints for many years.

Those He stated that restraints are necessary to ensure his safety. “almost disappeared.”

Long-term care advocate Richard Mollot said that even without explicit numeric staffing requirements, the federal government’s qualitative approach combined with a wide array of available staffing benchmarks should provide plenty of leverage over short-staffing.

If Inspectors “were empowered and interested, able or willing, to enforce this, I think the sufficient staffing requirement would be fine,” MollotExecutive Director of the Long Term Care Community Coalition. “But unfortunately, they’re unwilling or unable to do that.”

CMS declined multiple requests for an on-the-record interview about USA TODAY’s findings, staffing levels and oversight.

The In nursing homes across the country, timid enforcement results in daily violations America.


Cindy Napolitan66-year old Judith is an eyewitness to the meaning of short-staffing. Cheyenne Medical Lodge In Mesquite, TexasShe lives in, with her adult daughter. Both Multiple sclerosis and Napolitan’s husband, who had been their caregiver, died in 2017.

Based According to the federal 2001 study, each resident should receive 2.8 hours of care daily. The The government uses a formula to pay for the home Medicare money assumes it’s offering 2.4 hours. The real number for Cheyenne Medical Lodge? Each resident can expect 1.7 hours of aide care daily, according to its most recent reports to the government.

Napolitan It was described as a struggle to get regular baths or assistance with transferring into a wheelchair. She said her daughter developed a painful pressure ulcer because a doctor’s orders to turn her every two hours were not followed. 

Cindy Napolitan moved into a skilled nursing facility with her daughter after the death of her husband.
Cindy Napolitan After her husband’s death, she and her daughter moved into skilled nursing facilities.
Cindy Napolitan

The administrator Cheyenne Medical Lodge Its operating company Foursquare HealthcareMultiple requests for comment were ignored by,

Since 2017, Texas nursing homes have reported the nation’s second-lowest staffing levels, USA TODAY found. Although More than 950 facilities reported that there were fewer nurses and aides than was expected. Medicare formula, inspectors issued citations to just 16 of them – among the country’s lowest penalty rates. 

A spokesperson for the Texas Department This is Health Human Services According to inspectors “thoroughly investigate those concerns.” But Assistant Press Officer Tiffany Young The CMS data was not updated before inspectors arrived. “are looking at staffing at that specific point in time.” 

Napolitan She has filed complaints and, when state inspectors visited her again earlier in the month, she stated that she asked them whether there had been a record number grievances at her nursing home.

“We don’t even come close,” She said. “That’s scary.” 

She’s resigned to the fact that she’ll probably be fighting for good care for herself and her daughter as long as she can still communicate. 

“I’m diplomatic; I try to be,” Napolitan said. “But there are times when you just have to say, ‘All right, enough is enough.’”

Residents USA TODAY was told by family members and residents of nursing homes that they felt trapped. No No matter where they were, they couldn’t find the right care. No They could not find anyone to fix the staffing situation, no matter who they spoke to.

In New York City, Claire Campbell She encountered low staffing levels wherever she took her mother. Grace E. Campbell.

USA TODAY’s analysis found that during her stays in two nursing homes between 2019 and 2022, the gap between actual staffing and CMS’ expected staffing ranked them in the state’s bottom third. 

Even However Claire participated on the family council at one and filed numerous complaints with the state against both facilities, she said little ever changed.

Claire Campbell took this photograph through a window at The Riverside Premier Rehabilitation and Healing Center in Manhattan as her mother Grace Campbell filled out her 2020 absentee ballot during COVID lockdown.
In 2019, Grace Campbell (right) dressed up for Halloween as
Top photo: Grace Campbell At COVID lockdown, she completed her 2020 absentee ballot The Riverside Premier Rehabilitation Healing Center In Manhattan. Bottom photo: In She dressed up for 2019 Halloween As “Grandma Noonie” – what her grandson called her.
Left: Grace Campbell At COVID lockdown, she completed her 2020 absentee ballot The Riverside Premier Rehabilitation Healing Center In Manhattan. Right: In She dressed up for 2019 Halloween As “Grandma Noonie” – what her grandson called her.
Left: Grace Campbell At COVID lockdown, she completed her 2020 absentee ballot The Riverside Premier Rehabilitation Healing Center In Manhattan. Right: In She dressed up for 2019 Halloween As “Grandma Noonie” – what her grandson called her.

In 2019, Grace Enter The Riverside Premier Rehabilitation Healing Center In Manhattan, a non-profit organization that ignored the Hudson River.

She I was still able to complete the daily crossword in The New York Times Play along “Jeopardy,” However, she was unable to stand up on her own. Instead, Claire Nurses insisted that her mother use a diaper. 

Delays She claims that diaper changes can set off a chain reaction. Her mother avoided drinking water then suffered from dehydration and urinary tract infections. 

In Send an email TO USA TODAY The Riverside Administrator Jake Hartsein These allegations were not discussed, but it was denied that residents experienced delays or omissions with their care. He CMS gave the facility a 5-star rating recently for quality measures. He We did not mention the one-star rating for staffing and inspections of health. Riverside’s overall rating down to two stars.

When If he felt his staffing levels were sufficient, Hartstein wrote: “In comparison with other skilled nursing facilities in our immediate proximity, The Riverside’s nurse aide (CNA) staffing levels are on the same level.”

After Yet another fall Grace Transferred from The Riverside To Amsterdam Nursing HomeThe early summer of 2021 saw the launch of a non-profit called. There, Grace Often, we had to wait for hours to get help to use the toilet. Claire said. She Could not lift her wheelchair above the marble threshold. 

Because Because of the frequent delays Claire She said that she had hired an aide for her mother’s visit at the nursing home. Even However, this did not guarantee timely treatment.

On Claire’s birthday in January, Grace I called her to tell her she needed to have a bowel movement, but no one had helped. Claire A friend and I abandoned our lunch to hurry over.

Grace Campbell lived in New York's Amsterdam Nursing Home until her death in January 2022 at the age of 98. Claire Campbell says her mother had multiple falls while a resident because of understaffing. Describing the photograph, she said:
Grace Campbell lived in New York's Amsterdam Nursing Home until her death in January 2022 at the age of 98. Claire Campbell says her mother had multiple falls while a resident because of understaffing. Describing the photograph, she said:
While Living at New York’s Amsterdam Nursing Home, Grace Campbell fell on Jan. 4. She tried to move in her wheelchair after that, her daughter said, when no one answered her phone call. These Photos, from Jan. 10 Jan. 11, show the bruises.
While Living at New York’s Amsterdam Nursing Home, Grace Campbell fell on Jan. 4. She tried to move in her wheelchair after that, her daughter said, when no one answered her phone call. These Photos, from Jan. 10 Jan. 11. Show the bruises that were created.
While Living at New York’s Amsterdam Nursing Home, Grace Campbell fell on Jan. 4 After that, her daughter said, she tried to maneuver herself in her wheelchair after no one answered her call. These Photos, from Jan. 10 Jan. 11, show the bruises.

Within an hour, Grace98 years old, was killed. Her death certificate read “natural causes.”

In a statement to USA TODAY, a spokesperson for the management company with which Amsterdam Nursing Home contracts, Centers Health CareIt was said “safety and care” are the top priority.

Corporate communications director Jeff Jacomowitz said in a statement that the facility meets all state staffing requirements. Yet, Amsterdam Nursing Home was cited for insufficient staffing by the department’s inspectors in FebruaryJust weeks later, Grace’s death. 

Government Insufficient staffing is a rare offense in the State of New York. Of The facilities reported levels that were lower than those anticipated by the Medicare Formula, only 3% were cited. 

The Inspectors who visited Amsterdam It was possible. They compared daily staffing reports with the facility’s assessment of complete staffing, finding enough caregivers on just four days in January 2022. 

One nursing assistant interviewed by inspectors called the situation “a nightmare.” She According to her, she was embarrassed to answer the telephone and talk to family members about why their relative wasn’t getting out of bed that night. “I can’t take 18 people out of bed when there are only two staff,” She said. “It’s impossible.”

Inspectors A citation was also issued for insufficient staffing. The Riverside In May 2019 Grace A resident. Neither This citation is not the same as the one for Amsterdam Endorsed with fines

“Ensuring all nursing home residents receive proper care is a priority of the New York State Department of Health,”  Deputy Director This is Communications Jeffrey Hammond. He Also, inspections were noted. “are conducted in accordance with federal regulations.”

A new state law was adopted in April requires nursing homes to spend at least 40% of their revenue on staff that provides face-to-face care. 

“I reported it to everyone,” Claire Campbell This was a reference to the poor quality of care and understaffing. “From the nursing station to the medical director to the wound care director to the ombudsmen to the State of New York Department of Health. … Nobody took action.”


Part of the president’s plan to address lax enforcement of nursing home rules is to pay states to hire more nursing home inspectors and boost their pay.

InspectorsRegistered nurses often find that they can earn higher wages and travel less in the private sector. Federal The funding for nursing home enforcement is the same as 2014: it amounts to $397 million annually. Biden wants to increase that by 25%, matching inflation over the past seven years. 

Sen. Bob Casey, D-Pa., advocates for more resources for nursing home inspections.
Sen. Bob Casey, D-PaThe. advocates for more resources for nursing homes inspections.
Carolyn KasterAP

Sen. Bob Casey?, Democrat From Pennsylvania The funding increase is supported by the person who has advocated for stricter enforcement of the worst nursing homes. 

“I’ve been advocating … for years now, for not just transparency and accountability with regard to nursing homes themselves,” He stated, “but also the resources that will bring about that transparency, accountability and better performance.”

Casey Notes that January Report from the Inspector General For the Department This is Health Human Services Inspectors were found to be understaffed. A quarter of the states regularly misses the deadline set by federal law to inspect a house within 10 days of receiving safety complaints.

In Let us know if you have any letters for state officials in the fall Casey A third of nursing home owners are behind on their annual inspections. Some The state’s are doing worse than the rest.

Inspectors Several employees also reported dissatisfaction with their jobs. The Survey of hundreds of nursing home inspectors from 10 states in 2013 There has been a lot of pressure from the industry and elected officials to alter inspection results. 

In September, SEIU Healthcare Pennsylvania union members went on strike over stagnant negotiations with nursing home owners. The union had advocated for the state to toughen its minimum staffing standards and increase funding so nursing homes could hire more workers to comply with those rules.
In September, SEIU Healthcare Pennsylvania Union members went on strike against stagnant negotiations between nursing home owners and union workers. The The union pushed for tougher staffing standards and increased funding to ensure that nurses homes have more workers who can comply with the rules.
Brian Myszkowski, USA TODAY NETWORK

“We are being crushed by political influence of the nursing home groups,” One inspector wrote.

Some Inspectors stated that they would recommend stiffer penalties or fines to their bosses if necessary. “downcode” Their reports. Reversal “throws out things you work so hard on can be discouraging,” Another inspector wrote.

Dean LernerAn attorney who oversees regulatory enforcement Iowa for nearly a decade, said he once expanded the state’s team of nursing home inspectors because they “were so understaffed.” But, he said, the incoming governor cut those positions before anyone could start.

Sometimes CMS’ own guidance has created confusion. 

The federal manual given to states to train their inspectors for years told them they should not investigate staffing levels unless the inspector had first found that care standards were not met. It’s like handing out speeding tickets only to drivers who crash.

After regulations changed in 2016, this guidance was updated. This allowed inspectors to inspect staff at all times and not need to link low staffing with poor care. But The rare number of citations and observations by inspectors suggest that some still believe they need examples for care violations.

That’s not the only barrier confronted by inspectors. Nurses USA TODAY was informed that they were threatened with termination if the inspectors do not hear them out. Others Fears that they may be held personally responsible if poor care is caused by staffing levels beyond their control are real.

Nurses They also admitted that they had falsified their staffing data and called in extra workers when they knew inspectors were coming. Academic research has found staffing spikes around inspection days.

Lovette-BlackRetired California state inspector, recalled seeing the same staffing-related problems – “frequent falls or pressure injuries or infections,” he said – year after year at the same facilities. By The nurse homes would be returned to compliance if they submitted paperwork proving that their staff had been retrained or had modified staffing schedules. 

“A year later when you went back, they would have slipped back into their bad practices,” He said. “There still wasn’t enough CNAs. Wasn’t enough licensed nurses.

“Nothing really changes. The culture doesn’t change.”


After David JonesAfter suffering a stroke at the age of 71, he was referred to a Virginia He will be in a nursing home for physical therapy for a few more weeks to regain the use of his leg. He He and his wife chose Glenburnie Rehab Nursing Care CenterA facility located near their predominant Black Neighborhood in Richmond. 

The It was made easier by the proximity Jones’ elderly wife and daughter – a nurse’s aide – to spend time with him daily. After Retired as a hospital janitor. Jones He had always loved to travel and was particularly fond of fishing trips in the countryside. Friends Other family members visited him at the nursing home.

Low Nursing homes with a high percentage of residents who are not white require extra staffing. That Includes many amenities Virginia Like Glenburnie RehabAbout half of the residents live in this area. Black.

Last year, Only 7% Virginia Staffing levels were met in facilities housing large numbers of people of color They were expected to work based on the Medicare The reimbursement formula is used since 2011.

At Virginia Facilities with more residents of colour, only 7% met their staffing requirements based upon the Medicare Payment formula Among All other nursing homes VirginiaThis mark was reached by 30%.

Yet Only eight staffing citations were ever issued to any nursing home. Virginia Last year. Three They went to predominantly Black homes.

Kimberly BeazleyDirector of the Virginia The office responsible for overseeing inspections and licensing nursing homes, stated that the division has had a higher turnover rate than other departments in the past. She According to the report, 30% of all inspector positions are currently vacant.

But Beazley She said that she doesn’t believe vacancies have affected inspection quality, but only quantity inspectors can do them. Asked She asked if the state was issuing enough staffing violations citations, and she answered yes. “We have followed all CMS’ guidance.”

Researchers Researchers have linked the inequalities in staffing to higher-profit ownership of nursing home facilities in Black Communities and the fact that there is more Black Residents pay for their accommodation with MedicaidThis lowers the cost of nursing home care. Some Are too young Medicare; others end up there beyond the usual 21 days covered by that benefit.

Tetyana ShippeeAssociate Director of Research at the Center For Healthy Aging Innovation The University This is MinnesotaAccording to the report, the disparities in COVID-19 death rates brought attention to an important niche of nursing home research: The health and quality of life consequences of structural racism in policies or practices.

“Nursing homes are the most racially segregated aspect of health care,” She said. People She stated that white residents will be more likely to have positive outcomes in a facility. “Regardless of your health profile, you’re going to have worse quality of care.”

Tracey Pompey, a nurse’s aide in Virginia As a nurse on-call in many facilities, I witnessed the disparities for over 30 years.   

A photograph of David Leland Jones is displayed in front of his ashes in the home of his daughter, Tracey Pompey, in Richmond, Va.
A photograph taken by David Leland Jones It is displayed in front his ashes in the house of his daughter. Tracey PompeyIn Richmond, Va.
Josh Morgan, USA TODAY

“No one is being held accountable for what is happening in these facilities,” PompeyCo-founder and vice president, the advocacy group Justice Change For Victims This is Nursing Facilities. “I saw firsthand how patients are treated, how horrible the staffing levels are.” 

David Jones It is Pompey’s father. She Writing a complaint regarding his care was a way to see the system from a completely new perspective. GlenburnieIn which she explained how she felt that nurses and aides failed to properly address his serious symptoms during the hours leading to his death, and she did not inform his family as required.

The administrator at Glenburnie Multiple requests for comment were ignored.

USA TODAY discovered that this was true in every quarter of 2017 Glenburnie timecards reported fewer nurses and aides on hand than expected based on the federal reimbursement formula. At The time of Jones’ 2015 stay, federal regulators used a previous system to track staffing levels. That self-reported data shows Glenburnie We are short of registered nurses and aides who can assess residents’ medical conditions.

Since 2015: The nursing home was not cited for staffing shortfalls.

On His fifth day at the facility. Jones They complained of stomach pain. His The swelling was felt in the belly. For hours he vomited stool, according to a 74-page state report. Each of his complaints were documented by a nurse. The Facility also stated that he hadn’t had a stool in the past four days. 

An The facility’s X-rays showed the results Jones’ intestines were twisted, but no change in care was ordered beyond giving him giving him oral medications for stomach acid and constipation, along with a probiotic, according to the state report. No One did an abdominal exam.

Tracey PompeyCo-founder of advocacy organization Justice Change For Victims This is Nursing Facilities
We feel that had they gotten him to the hospital sooner, things could’ve been different. Somebody should’ve said, ‘Something’s wrong.’

Ten A few hours later, around 2:30 AM, a registered nursing assistant asked an aide to continue with the shift. Jones After she dialled 911, his family was called. When According to the state report, she was reunited with EMTs. Jones He was all alone, lying face down on the ground.

His Before he could be taken into an ambulance, his heart stopped.

An Inspector issued citations Glenburnie Related to Jones’ death: failing to notify family about a change in condition, failing to maintain a resident’s well-being, and not keeping complete medical records.

An audit of the facility’s time-stamped charts shows that there was a manager who had made changes Jones’ record days after his death to describe check-ins and care – some of which the review indicates the facility was unable to back up with additional documentation or that did not match staff interviews. 

Reflecting recently, Pompey remains frustrated that the facility was not fined for her father’s death. And It is unclear if the lack of training or understaffing was a factor.

“We feel that had they gotten him to the hospital sooner, things could’ve been different,” She said. “Somebody should’ve said, ‘Something’s wrong.’”


When Biden Vice President, The Obama In 2016, the administration had an opportunity to make the rules for nursing home more clear. Academics and advocates were calling for numeric staffing minimums to be written into new federal rules — and for those minimums to be enforced.

The administration chose a different path.

“We agree that sufficient staffing is necessary,” CMS wrote The Federal Register. “However, we do not agree that we should establish minimum staffing ratios at this time.”

InsteadThe agency determined that nursing home managers would need to conduct an audit. “facility assessment” listing how many workers the facility would have on hand, a number they’re supposed to develop based on the medical conditions of residents. 

Staff levels at American nursing homes have changed little in recent years, USA TODAY found. Low staffing strained the care system years before the COVID-19 pandemic arrived.
Staff Levels at American USA TODAY discovered that nursing homes have not changed much in recent years. Low The care system was already understaffed years before the COVID-19 pandemic.

Little changed. USA TODAY discovered that staffing levels in nursing homes have decreased by 9.4% since 2017 when assessments were first conducted. And Penalties for understaffing are rare.

Now below order Biden CMS will propose minimum requirements for every nursing role next year as President. It says this should motivate facilities to improve. It New rules or enforcement could take many years.

“Having something that’s more objective and numerical … would be useful for increased enforcement relative to the existing, more qualitative standard,” Hannah Garden-MonheitSpecial assistant to the president, from the National Economic Council. 

But Data also show that just because numbers are recorded on the books, it does not mean they will be enforced.

In Due to the lack of federal minimum staffing levels, 35 states decided to create their own with varying results. Few Rules for nurses and aides were created. None The federal regulators recommend that you adhere to the 2001 minimum staffing requirements. 

OregonA resident needs at least 2.46 hours per day of nursing and aide care.

The USA TODAY discovered that the northwestern state has the lowest number of facilities reporting low staffing, and the highest enforcement rates. Last Year, less than half Oregon According to the federal payment formula, nursing homes had less staff than they expected. Inspectors issued citations to 44% This is those that did – more than six times higher than the U.S. average. 

“Staffing is something we care deeply about in Oregon as inadequate staff is often the cause of safety and quality of care issues,” Department of Human Services Communications Manager Elisa Williams Send it as an email

Balloons are left outside a room at The Oaks at Sherwood Park nursing home in Keizer, Ore. The state is more likely than most to issue citations to facilities who report low staffing levels, according to USA TODAY's analysis.
Balloons Are left outside of a room The Oaks At Sherwood Park nursing home in Keizer, Ore. The USA TODAY’s analysis found that states are more likely than other to issue citations against facilities that report low staffing levels.

Louisiana Also, the state also created its own staffing regulations. However, more nursing homes fail to meet their expectations. This suggests that state rules may not be a panacea if they aren’t enforced. It Each resident must receive at least 2.35 hours of daily care from nurses, aides, and sometimes ward clerks. 

Last Year, 1 in 10 Louisiana According to the reimbursement formula, CMS did not expect that nursing homes would have as many employees as they had. The state also has the nation’s lowest levels of daily RN care in the five years reviewed: 16 minutes per resident compared with 38 minutes nationwide, a total that counts nurses working in administrative jobs.

Yet Five facilities were cited as having short-staffing. Zero They were cited for failing to have a registered nurse on call at least eight hours per day, despite 78% of the population being aware. Louisiana’s nursing homes fell short at least once.

The Louisiana Department This is Health An emailed statement stated that every inspection includes a review on staff levels. Inspectors When investigating particular cases of poor health care, it is important to also examine the staffing. Citations The department email stated that the emails were issued. “if there is sufficient evidence.” 


Jacinda Gaston She often smelled urine as she got off the elevator to begin her shift on the fourth level. Alden LakelandAnonymous Uptown Chicago nursing home.

Residents One of the people who spoke could tell her that they’d been in dirty diapers for at least eight hours. Urine and stool ran up people’s backs to their necks and the entire bed had to be changed. 

She It was a blessing that another aid shared the load, said the woman.

“You have to make the decision: ‘What room can I get to first?’ Knowing in the back of your head there are people who are going to have to wait even longer,” GastonThe facility’s aide for five months in this year,. “Then you have the people who don’t understand. They’re constantly on their call light. By the time you get to them, they’re in tears.”

Two inspection reports from this year document the understaffing at Alden Lakeland. In February, the director of nursing told inspectors that the fourth floor was supposed to have at least five certified nursing assistants to care for the 74 residents – not two. 

The nursing home is one of six facilities named in a class action lawsuit recently filed against The Alden Network, among the largest nursing home operators in Chicago. Gaston has volunteered as a witness for the plaintiffs.

In a statement to the Chicago Tribune, Alden officials said they do not comment on pending litigation but wrote that the company “vigorously denies any and all allegations of wrongdoing.”

Jacinda Gaston, a certified nursing assistant in training from the Chicago area, questions whether minimum staffing requirements at nursing homes and state changes to Medicaid rates will make any difference without tougher enforcement of rules.
Jacinda GastonA certified nursing assistant in training at the Chicago Are there minimum staffing requirements in nursing homes? State changes? Medicaid Rates will not make a difference without stricter rules enforcement.
Mustafa Hussain USA TODAY

Alden’s vice president of policy and public relations, Janine SchoenUSA TODAY asked the owner if they believe that staffing is adequate. Lakeland. Instead, she focused on the company’s recruiting efforts, which she described as expansive, and called for action from the state and national capitals.

“We need our leaders in Springfield and Washington to focus on actionable solutions to attract more caregivers to the industry rather than punitive acts that fail to solve the underlying labor shortage,” Schoen wrote. 

Complaints About Alden Lakeland They were subject to inspections more frequently than the federal minimum requirement of at least once a year and every three months. Since 2012: Inspectors were present 28 times, and they issued 90 citations.

Residents Go They can sleep for months in their bed, without having to shower, and even without changing their diapers for weeks. In These reports cover a period of 11 years Alden Lakeland He was only fined once.

Their Reports have documented abuse, broken bones, head wounds, medication errors, pressure ulcers that threatened lives, residents with dementia wandering unsupervised, improper use of physical restraints, cloudy catheter tubes, mice infestations and staff members providing care beyond the scope of their licenses. 

Residents They slept for months in their beds, wore no diapers for weeks and went without showers for weeks.

In These reports cover a period of 11 years Alden Lakeland He was only fined once. In 2016 Facility paid $1,991 to cover the failure to report abuse or neglect. Three years later, inspectors issued the same citation but no fine when the facility did not investigate how a resident’s femur had snapped.

Until this year, none of Alden Lakeland’s citations were for short-staffing. 

Overall, Illinois USA TODAY found that nursing homes had the lowest levels of staffing across five years. Last An astounding 91% of nursing homes failed to meet the standards set by the government in 2005 Medicare formula. 

The state also has been more likely than most to issue staffing citations against nursing homes, USA TODAY’s analysis found – which still meant inspectors wrote up only 14% of facilities whose timesheets showed they had missed the expected staffing level.

Given The increased focus on federal and state officials has led to an increase in the Illinois Department This is Public Health “anticipates increased inquiry into staffing” During inspections, spokesperson Michael Claffey.

Last year, Alden Lakeland There were fewer nurses and aides than in most nursing homes in the state. The facility provided 2.7 hours of care per day for residents, which is similar to the figures reported by the facility in previous years.

That’s 1.1 hours less care than the staffing the nursing home should have based on the Medicare What is the reimbursement formula? Medicare Medicaid’s 2001 report found essential to avoid medical errors. 

The Latest staffing data Alden Lakeland They are even lower.

GastonThe former Alden Lakeland Aide, stated that she once found a resident suffering from dementia in a shower room. He They had been there for at least three hours. Twice, Gaston Remembers that a resident had left the building without being noticed.

Mary Anne MillerRetired physical therapist, who worked at Alden Lakeland In 2018 and 2019,
I couldn’t work there after a while because it was too heartbreaking. It’s not because the staff isn’t trying. It’s just because there’s not enough staffing.

Mary Anne MillerRetired physical therapist, who worked at Alden Lakeland In 2018 and 2019, the resident described her daily struggle for help to get from bed to a wheelchair in order to attend therapy. 

Like Gaston, Miller He has offered to testify in opposition The Alden Network In the pending lawsuit.

“I couldn’t work there after a while because it was too heartbreaking,” She said. “It’s not because the staff isn’t trying. It’s just because there’s not enough staffing.”

Illinois Recent reforms were enacted by lawmakers to improve staff quality and productivity. The State has increased its minimum staffing levels and made changes Medicaid To encourage staff to increase their wages and pay them more

At Alden Lakeland, five inspection reports from this year noted the same kinds of poor care documented in dozens of earlier visits. ButThree citations were issued by regulators for insufficient staffing for the first-ever time.

In MayTwo people were found by a state inspector alone in the dining room. One was eating with their fingers. Both Significant cognitive impairments and difficulties swallowing were common. Under medical order, they were to be monitored to ensure they not only ate enough but didn’t inhale food into their lungs or choke to death.

An aide informed the inspector that “there’s not enough staff” To help or watch them eat. 

The Inspector deemed it an isolated incident and issued a ticket that would not trigger a penalty: “Minimal harm.”

Contributing: Maria Clark Claire Withycombe, USA TODAY Network; Lauren Formosa, Jared Sweet Audrey Whitaker, Grand Valley State University.

This report received support from the Economic Hardship Reporting Project.

Jayme Fraser Nick Penzenstadler are reporters on the USA TODAY investigations team. Contact Jayme at [email protected], @jaymekfraser on Twitter FacebookYou can also call it on Signal WhatsApp at (541) 362-1393. Contact Nick at [email protected] or @npenzenstadler, or on Signal (720) 507-5273 Jeff Kelly Lowenstein Is the Padnos/Sarosik Endowed Professor This is Civil Discourse At Grand Valley State University. 

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