Nursing Home Staffing Mandates: Why They Miss the Point

A Moment to Step Back

Today, I read two very different articles about the same issue. One, published by The New York Times, framed the failure of the federal nursing home staffing mandates through the lens of political influence. Another post from the provider perspective, argued just as firmly that the mandate was already legally and legislatively dead long before the events highlighted by the Times.

Both articles focus on facts.

Both tell part of the story.

And both, in their own way, fall short.

What struck me most was not that the authors disagreed—but that the conversation itself felt incomplete. Too narrow. Too quick to sort a complex reality into opposing sides.

This is not a debate about two sides of the same coin. It is more akin to two tiles among the many of a Rubik’s Cube.

Staffing, quality, funding, regulation, workforce expectations, leadership capacity, physical environments, and organizational culture are all interdependent. You cannot turn one without affecting the others. And when we react to any single issue in isolation, we miss how tightly these elements are bound together in real nursing homes.

Could we all slow the conversation down and reflect—carefully and honestly—on what decades inside nursing homes have impressed upon me about staffing, culture, and care? My hope here is not to necessarily persuade, but to invite reflection. Because real solutions in this field have never come from reaction. They come from understanding.

Nursing Home Staffing Mandates Miss the Point: A View From Inside Nursing Homes

Staffing has always been among the greatest challenges in nursing homes.

I say that as someone who has spent more than 30 years as an owner, administrator, and consultant in the profession. Long before COVID, long before CMS nursing home staffing mandates, long before staffing became a national talking point, it was already a significant pain point among those of us responsible for care in the nursing home.

For nursing homes that rely heavily on Medicaid, the challenge has been structural for decades. Reimbursement rates have historically lagged behind actual costs, and wages have followed suit. The system responds exactly as designed: when funding is constrained, staffing suffers.

COVID Changed the Labor Market—Permanently

COVID didn’t create the problem. It exposed and intensified it.

During the first year or two of the pandemic, staffing moved from difficult to catastrophic. Hospitals, travel and staffing agencies aggressively recruited caregivers.

Hospitals have resources nursing homes simply do not:

• • Larger administrative teams

• • HR departments

• • Marketing and recruiting budgets

• • Benefit packages that could be adjusted quickly

Staffing agencies and travel nurse companies entered the labor market aggressively, raising pay rates and offering flexibility that nursing homes could not match. Nurses and CNAs who had been loyal to their facilities for years were suddenly presented with options that paid more, offered control over schedules, and reduced emotional burden.

For many, it was not a hard decision to exit the nursing home.

This wasn’t just a labor shift—it was a fundamental change in expectations. Staff learned that their skills were portable, negotiable, and in demand elsewhere.

The Reality Inside Nursing Homes

Most nursing homes—especially small, locally owned homes—operate with very lean administrative structures. Leadership is often limited to a small group of people wearing multiple hats, making daily survival decisions while trying to keep residents safe and staff supported.

When COVID infections finally declined, many facilities were left with:

• • 50–60% of pre-COVID occupancy

• • Burned-out staff who had quit or moved on

• • Employees lost to higher-paying agency work

• • Layoffs driven by low census

• • And yes—staff members who died

It was gut-wrenching.

Those who left largely did not return. The trauma of COVID left a lasting imprint that many of us have not fully emotionally processed, even today.  I don’t say this lightly. I say it from personal experience.

We Want More Staff—But They Don’t Want Us

Let me be clear.

Nursing homes want more staff. We want more RNs. We want more LPNs. We want more CNAs.

But they do not want us.

We raise hourly wages and they come—for four to six weeks—and they leave. The work is physically and emotionally hard. When staffing falls short because of call-offs, the burden compounds. Each shift becomes heavier than planned, and morale erodes quickly.

Smaller homes, especially family-owned ones, embedded deep in their communities, have nowhere to send their frustration. There is no escalation path. No internal task force. No corporate safety net.

Why Mandates Made Things Worse

CMS nursing homes staffing mandates were presented as a solution, but for many nursing homes they felt like another nail in the coffin.

The mandate assumed:

• • Workers existed who could be hired

• • Facilities had resources to recruit and retain them

• • Enforcement would somehow create supply

In reality, the best most facilities could do was recruit based on immediate needs and resources while hoping for a miracle.

Many have turned to staffing agencies—not because they want to, but because they have no choice. And anyone who has worked in a nursing home knows the truth: agency staff, through no fault of their own, rarely provide the same level of care as someone who knows the residents, the routines, and the culture of the building.

This is not a staffing numbers problem alone. It is a system and culture problem.

You Can’t Mandate What the System Can’t Support

Trying to fix nursing home staffing with a mandate is like giving a starving person a new set of clothes and nothing to eat.

The appearance of action improves.

The underlying problem gets worse.

Until reimbursement, workforce development, and structural support are addressed honestly, mandates will continue to fail—not because nursing homes don’t care, but because the system does not give them the tools to succeed.

There is very little an outside organization or advocacy group can tell those of us who live this every day about what’s broken. We already know.

We are not resisting improvement. We are surviving reality.

What We Lost: Culture Change and Systems Thinking

My perspective is also shaped by my involvement with the Pioneer Network, Louisiana’s culture change movement, and my academic training in gerontology. I have seen practices that work. I have watched buildings transform when leadership, staff, environment, and residents are aligned around person-centered care.

But much of that progress was decimated by COVID. Even before the pandemic, CMS had begun shifting its focus. At one point, there was a genuine, concerted effort by CMS to encourage, support, and train nursing home leaders to change culture inside their buildings. CMS funded Quality Improvement Organizations (QIOs) to provide hands-on assistance. Regulations were updated to emphasize person-centered care. The intent mattered—and in many places, it showed.

Then COVID arrived, and everything narrowed.

The regulatory lens tightened almost exclusively around compliance, documentation, and task completion. Infection control was critical—no one disputes that—but the broader understanding of how nursing homes actually function began to disappear from policy thinking.

Nursing Home Residents Do Not Live in a Vacuum

Nursing home residents do not exist independently of the systems that surround them.

Regulations and mandates that focus narrowly on care tasks and paperwork will never fix what is fundamentally a systems problem. Quality care does not emerge from a single lever being pulled harder.

It is built on four interdependent elements:

1. Resident-centered care
2. Employee satisfaction
3. Physical environments that support both residents and staff
4. Adequate and reliable funding

These elements must move together.

You cannot mandate staffing without addressing workforce sustainability.

You cannot demand better outcomes without supporting the people delivering care.

You cannot increase documentation and oversight without draining time and morale.

And you cannot starve the system financially and expect innovation to survive.

Even increased funding alone does not solve this if it is disconnected from workforce development, culture, and infrastructure.

This is not a simple equation. It is a sophisticated balancing act—one that culture change leaders understood well.

Why Mandates Miss the System

Culture change was never about a single regulation or staffing ratio. It was about rethinking how care is delivered, how staff are valued, how environments function, and how leadership supports daily work.

COVID didn’t just strain staffing—it collapsed the balance.

Facilities were forced into survival mode. Training stopped. Innovation paused. Leadership bandwidth disappeared. QIO support faded into the background as enforcement and emergency response took over.

In that environment, adding rigid staffing mandates was not reform—it was overload.

You cannot regulate your way out of a broken ecosystem.

The Path Forward Requires Memory—and Humility

Those of us who lived through this do not resist improvement. We remember what worked. We remember what was lost. And we know that no single mandate—no matter how well intentioned—can substitute for a system designed to support human beings on both sides of care.

If policymakers want real improvement, they must return to systems thinking, not just compliance thinking.

Staffing is not the problem. It is a symptom.