Addressing the Nursing Home Crisis: A Comprehensive Policy and Practice Review (2025 Edition)

Addressing the Nursing Home Crisis: 2025 Edition

1. Executive Summary

The United States nursing home sector is confronting a profound and escalating crisis, characterized by a dangerous confluence of deteriorating care quality, critical workforce shortages, pervasive financial instability, and persistent ethical challenges. Decades of systemic issues, including chronic underfunding, regulatory shortcomings, and societal factors, have rendered the sector exceptionally vulnerable. Key indicators paint a stark picture: nursing facilities are closing, direct care hours per resident are declining 1, staffing levels frequently fail to meet minimum safety thresholds 2, and a significant portion of homes operate at a financial loss, particularly those heavily reliant on Medicaid reimbursement.4 Resident safety is compromised, evidenced by high rates of abuse, neglect, and preventable adverse events often linked to inadequate staffing.1

The COVID-19 pandemic served as a harsh accelerant, magnifying these pre-existing weaknesses with devastating consequences for residents and staff.8 It exposed deep flaws in infection control, exacerbated workforce burnout and turnover, and intensified financial pressures.11 The crisis is not a single problem but a complex interplay where financial constraints limit investments in staffing and quality, leading to poor working conditions, high turnover, and ultimately, compromised resident care and safety.1

Root causes are multifaceted, stemming from historical policy decisions that shaped the industry’s reliance on fragmented and often inadequate payment systems (particularly Medicaid) 16, the influence of for-profit motives potentially misaligned with care quality 19, regulatory enforcement that has often lacked sufficient teeth 22, and societal factors including an aging population with increasingly complex needs and an undervalued caregiving workforce.24 Ethical dilemmas permeate the system, from ensuring resident autonomy and dignity amidst operational pressures to the equitable allocation of scarce resources and the prevention of abuse and neglect.27

Despite this bleak landscape, innovative models of care, such as the Green House Project and the Eden Alternative, demonstrate the potential for improved quality of life, resident satisfaction, and staff retention when person-centered philosophies are implemented.31 Technological advancements in monitoring, telehealth, and AI also offer promising tools, though their deployment requires careful consideration of ethics and equity.34 International comparisons reveal that many peer nations utilize universal funding mechanisms (social insurance or tax-based) that provide more stable financing for long-term care, suggesting potential pathways for US reform.36

Addressing this crisis demands urgent, comprehensive, and multi-stakeholder action. This report synthesizes evidence to provide actionable recommendations for policymakers, healthcare providers, and advocacy organizations. Key recommendations include fundamental financing reform, particularly addressing Medicaid reimbursement adequacy; robust investments in workforce recruitment, retention, training, and compensation; strengthening regulatory oversight and enforcement effectiveness; promoting the adoption of proven innovative care models and technologies; and ensuring equity in access and quality across racial, socioeconomic, and geographic lines. Only through such a concerted effort can the nation begin to honor its commitment to providing safe, dignified, and high-quality care to nursing home residents.

1. Defining the Crisis: Dimensions and Current State (2025)
2. Overview of Key Indicators

The crisis engulfing the US nursing home sector manifests across several critical dimensions. Years of mounting pressure have culminated in a state where the quality of care provided is demonstrably declining, workforce shortages have reached critical levels, the financial viability of many facilities is precarious, and the safety and well-being of residents are frequently compromised.1 Recent events, most notably the COVID-19 pandemic, have severely exacerbated these long-standing vulnerabilities, bringing the system’s fragility into sharp focus.8 Understanding the current state requires examining trends in facility capacity, quality metrics, staffing levels, financial health, and resident safety, using the most recent available data while acknowledging potential lags in official reporting.

1. Statistical Trends and Current Data (2024-2025 Focus)

Quantitative data reveal concerning trends across the nursing home sector, suggesting a system under significant strain.

• Facility Capacity: The overall number of nursing facilities certified by the Centers for Medicare & Medicaid Services (CMS) has been contracting, showing a 5% decrease between July 2015 and July 2024.1 This trend is mirrored in the long-term care hospital (LTCH) sector, which saw closures accelerate after changes in CMS payment criteria, with a drop from 438 facilities in 2015 to 341 in July 2024, and more closures announced.39 Industry reports indicate that financial pressures and the anticipated costs of complying with new federal staffing mandates may force further closures, particularly among facilities heavily reliant on Medicaid or located in rural areas.4 Compounding this, over 60% of nursing homes reported limiting new admissions due to staffing shortages even before the mandate’s implementation, creating bottlenecks in hospital discharges and reducing access for seniors needing care.11
• Quality of Care Metrics: A critical indicator of declining care quality is the reduction in direct nursing staff time available to residents. Between July 2015 and July 2024, the average hours of nursing care—encompassing Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and nurse aides—decreased by 8%, falling from 4.13 to 3.80 hours per resident day (HPRD). This decline occurred despite the generally increasing health needs of the resident population, suggesting a growing gap between resident needs and available care resources. The decrease was driven primarily by a steep 21% drop in RN hours and an 8% decline in nurse aide hours, partially offset by a 6% increase in LPN hours over the same period.1 Concurrently, regulatory compliance has worsened. The average number of deficiencies cited per facility during surveys increased by 40%, from 6.8 in 2015 to 9.5 in 2024. Perhaps more alarmingly, the share of facilities cited for serious deficiencies—those involving actual harm or immediate jeopardy to resident health or safety—rose substantially from 17% to 28% during this timeframe.1 Commonly cited deficiencies involve failures in providing necessary care, reporting abuse or neglect, and adhering to infection control requirements.1 Research indicates a relationship between these rising deficiencies and declining staffing levels, with better-staffed homes typically receiving fewer citations.1 While CMS continues to refine its quality reporting through mechanisms like the Five-Star Quality Rating System, including recent updates and handling of data freezes related to Minimum Data Set (MDS) changes 43, the overall trend in these core quality indicators points downward.
• Staffing Levels: Current staffing levels remain a central concern. The 2024 average of 3.80 total nursing HPRD falls short of the levels identified in federal studies as necessary to avoid quality problems.1 The new CMS minimum staffing rule, finalized in April 2024, mandates 3.48 total HPRD, including 0.55 RN HPRD and 2.45 Nurse Aide (NA) HPRD, plus 24/7 on-site RN coverage.2 However, analysis of facility data from late 2023/early 2024 indicates widespread non-compliance; fewer than one in five (19%) nursing homes met all three HPRD minimums required by the rule when fully implemented.2 While nearly 60% met the interim total HPRD requirement of 3.48, far fewer met the specific RN (49%) and NA (30%) thresholds.3 Compliance varies dramatically by state, with fewer than half of facilities meeting the new standards in 45 states, and fewer than 25% meeting them in 28 states.2 For-profit facilities demonstrate particularly low compliance rates (around 11-19%) compared to non-profit or government facilities.2 Furthermore, average RN staffing hours drop significantly on weekends (around 40%), a factor CMS has begun incorporating into its Five-Star ratings to incentivize improvement.42
• Financial Health: The financial stability of the nursing home sector is precarious. While Medicare Fee-for-Service (FFS) payments often yield high margins for short-term post-acute stays (18.4% FFS Medicare margin for freestanding SNFs in 2022) 47, Medicare days constitute a small fraction (median 10%) of total resident days for most facilities.47 The majority of care, particularly long-term stays, is funded by Medicaid, which consistently under-reimburses, covering only about 82 cents for every dollar of reported cost on average.5 This reliance on inadequate Medicaid payments, coupled with rising labor and operational costs and the expiration of pandemic-related relief funds, has led to widespread financial distress.4 Industry surveys suggest over half of nursing homes operate at a loss, with average operating margins cited as deeply negative.4 MedPAC reported an average all-payer total margin of -1.4% in 2022 even with pandemic relief funds included, dropping to -4% without them.47 This financial pressure is a major barrier to investing in staffing and quality improvements.
• Resident Safety & Abuse: Elder abuse and neglect within nursing homes remain alarmingly common. Estimates suggest approximately 1 in 10 residents experience abuse 7, with some studies indicating nearly 44% report being abused.7 Disturbingly, surveys indicate a high proportion of staff (2 in 3 in one WHO report) admit to committing abuse in the past year.7 Understaffing is a significant contributing factor, increasing the risk of neglect manifesting as preventable falls, dehydration, malnutrition, and severe bedsores, as well as outright abuse due to staff stress and burnout.2 The problem is compounded by systemic underreporting, with estimates suggesting only 1 in 14 to 1 in 24 cases are officially reported.48 Furthermore, state agencies responsible for investigating complaints face significant backlogs and high staff vacancy rates, hindering timely oversight and intervention.48
• Occupancy Rates: Nursing home occupancy declined significantly following the onset of the COVID-19 pandemic, dropping by 10% (nearly 100,000 residents) nationally by mid-2020 due to deaths and reduced admissions.8 While some recovery may have occurred, rates remained below 80% as of late 2023.4 Staffing shortages further impact occupancy, forcing many facilities to limit admissions, thereby reducing access to care.11

Table 1: Key Statistics Defining the US Nursing Home Crisis (2024-2025)

 

Indicator	Statistic / Trend	Source(s)
Facility Capacity
Certified Nursing Facilities	▼ 5% (July 2015 – July 2024)	1
Facility Closures	>775 closed recently; 1,600+ potentially closing in one year (2021 est.); ongoing risk due to finances/mandate	12
Facilities Limiting Admissions	>60% (due to staffing)	11
Quality of Care
Avg. Total Nursing HPRD	3.80 (2024); ▼ 8% from 4.13 (2015)	1
Avg. RN HPRD	0.66 equiv. (based on 2015 ratio); ▼ 21% (2015-2024)	1
Avg. NA HPRD	2.22 equiv. (based on 2015 ratio); ▼ 8% (2015-2024)	1
Avg. Deficiencies per Facility	9.5 (2024); ▲ 40% from 6.8 (2015)	1
Facilities w/ Serious Deficiencies	28% (2024); ▲ from 17% (2015)	1
Staffing Mandate Compliance (vs. Final Rule)
Meet All 3 HPRD Minimums (Overall, RN, NA)	19% (as of late 2023/early 2024)	2
Meet Interim Overall 3.48 HPRD	~60% (as of late 2023/early 2024)	3
States w/ <25% Compliance (All 3 Minimums)	28 states	3
Financial Health
Avg. Operating Margin (Industry Report)	-17% (AHCA report, 2023)	4
All-Payer Total Margin (MedPAC, 2022)	-1.4% (with relief funds); -4.0% (without relief funds)	47
Medicare FFS Margin (MedPAC, 2022)	18.4%	47
Medicaid Payment-to-Cost Ratio	~0.82 (National Avg./Median, 2019 data)	5
Facilities Operating at Loss (Industry Survey)	>50%	6
Resident Safety
Estimated Abuse Prevalence	1 in 10 residents (NCEA); 44% report abuse (Cureus study)	7
Staff Admitting Abuse	2 in 3 (WHO report)	7
Abuse Case Reporting Rate	1 in 14 to 1 in 24 cases reported	48
Occupancy
National Occupancy Rate	▼ 10% (Early 2020 – Mid 2020); <80% (Dec 2023)	4

(Note: HPRD = Hours Per Resident Day; RN = Registered Nurse; NA = Nurse Aide; FFS = Fee-for-Service. Data points reflect latest available information, primarily 2022-2024, but some rely on slightly older benchmarks or estimates as indicated in sources.)

The consistency of negative trends across capacity, quality, staffing, finance, and safety underscores the systemic nature of the crisis. While official data often has a time lag, more recent industry reports and surveys frequently paint an even more urgent picture, suggesting that the pressures from inflation, expiring relief funds, and the looming staffing mandate may be intensifying the crisis in 2025 beyond what the latest comprehensive government statistics capture.4 This potential underestimation of current severity is critical for policymakers to consider. Furthermore, the simultaneous decline in care hours and rise in serious deficiencies, despite ongoing oversight efforts like the Five-Star system, points to a potential paradox.1 It suggests that current quality monitoring and reporting mechanisms may not be sufficient to counteract the powerful undertow of financial and workforce pressures, or may not fully capture the dimensions of quality most impacted by these pressures.

1. Impact of COVID-19 (Lingering Effects)

The COVID-19 pandemic had a catastrophic and disproportionate impact on nursing home residents and staff, acting as a brutal stress test that exposed and amplified the sector’s underlying vulnerabilities.8 Residents, representing less than 1% of the US population, accounted for a staggering share of COVID-19 deaths, with estimates ranging from 22% to over 35%.9 This tragedy highlighted long-standing weaknesses in infection prevention and control (IPC) practices, which were found to be widespread and persistent even before the pandemic.14 Facilities struggled with inadequate IPC expertise, staffing shortages hindering isolation protocols, lack of testing, insufficient personal protective equipment (PPE), and difficulties adapting to rapidly changing guidance.14

Even into 2025, COVID-19 continues to pose risks in long-term care facilities (LTCFs).9 Suboptimal vaccination rates among residents for COVID-19 (around 41-42% uptake for the 2024-25 vaccine as of early 2025), influenza (around 60-62%), and RSV (around 20-21%) leave this vulnerable population susceptible to ongoing surges.9 Persistent IPC challenges remain a concern.9

Beyond the direct health impacts, the pandemic inflicted deep and lasting scars on the nursing home workforce and finances. It dramatically worsened pre-existing staffing shortages, leading to massive job losses from which the sector has yet to fully recover.4 The emotional toll of witnessing widespread death and working under extreme pressure drove many caregivers out of the profession entirely.10 Financially, the pandemic increased operating costs significantly due to PPE, testing, and reliance on expensive agency staff, while simultaneously reducing revenue through lower occupancy rates from deaths and decreased post-acute admissions.4 While emergency relief funding provided a temporary lifeline, its expiration places further strain on already struggling facilities.4 Studies also indicate the pandemic slowed the pre-pandemic trend of decreasing long-term nursing home stays or deaths following hospitalization, suggesting a broader impact on care trajectories for older adults.53 Additionally, post-pandemic neuropsychiatric symptoms among residents have reportedly contributed to increased use of psychotropic medications.58 The pandemic did not create the nursing home crisis, but it undeniably acted as a powerful catalyst, making the need for fundamental reform more urgent than ever.

III. Unpacking the Root Causes

The current nursing home crisis is not a sudden phenomenon but the culmination of decades of intertwined historical developments, economic pressures, regulatory decisions, and societal shifts. Understanding these root causes is essential for formulating effective solutions.

1. Historical Evolution of the Nursing Home Industry

The modern nursing home industry is largely a product of mid-20th century public policy. Prior to the 1930s, care for the infirm elderly often occurred in public almshouses, known for poor conditions.16 The Social Security Act of 1935, specifically its Old Age Assistance (OAA) program, aimed to dismantle this system by prohibiting payments to residents of public institutions. This inadvertently spurred the growth of private “old age homes” and boarding houses, which could now profit from residents’ OAA funds.16

Post-World War II policies further shaped the sector. The Hill-Burton Act of 1946 provided grants for constructing nursing homes linked to hospitals, shifting their oversight towards the healthcare system.59 Amendments to the Social Security Act in the 1950s mandated direct payments to nursing homes (rather than beneficiaries) and required states to establish licensing programs, although standards varied widely.16 Increased federal funding for medical services, including nursing home care, through OAA and later the Kerr-Mills Act (1960), along with federal loan programs, fueled further growth of the private, often proprietary, industry.16

The passage of Medicare and Medicaid in 1965 marked a watershed moment. While Medicare focused on acute care and limited post-acute stays, Medicaid became the dominant payer for long-term nursing home care, solidifying the government’s role in financing the industry.16 This massive influx of public funds led to explosive growth in the number of nursing homes (a 140% increase by the mid-1970s) and revenues, but quality of care often lagged.17 Public outcry over poor conditions, fraud, and abuse led to increased scrutiny, including Senate hearings chaired by Senator Frank Moss starting in the 1960s.16 This pressure resulted in early federal efforts to standardize regulations through the 1967 “Moss Amendments,” which defined Skilled Nursing Facilities (SNFs) and Intermediate Care Facilities (ICFs) and authorized the Department of Health, Education, and Welfare (HEW, now HHS) to set uniform standards.16 President Nixon’s 1971 eight-point plan aimed to strengthen enforcement, increase surveyor training, and decertify substandard facilities.16

Despite these efforts, concerns about quality persisted. A pivotal moment came with the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), often called the Nursing Home Reform Act. Responding to widespread reports of inadequate care, OBRA ’87 established comprehensive federal standards for quality of care, resident assessment (the precursor to the MDS), staffing (though specific ratios weren’t mandated federally until 2024), and, crucially, a detailed Bill of Rights for residents.18 This legislation fundamentally reshaped the regulatory landscape, emphasizing resident dignity, autonomy, and the facility’s responsibility to ensure the “highest practicable physical, mental, and psychosocial well-being” of each resident.27 The historical trajectory reveals an industry heavily shaped, funded, and expanded by government policy, with regulatory efforts often reacting to, rather than proactively preventing, quality crises driven by the underlying economic structure.

1. Economic Drivers

Financial pressures are a central element of the nursing home crisis, stemming primarily from the structure of payment systems and the influence of ownership models.

• Medicaid Dominance and Underfunding: Medicaid stands as the financial backbone for the majority of nursing home residents, covering long-term stays for over 60% of individuals.6 However, this reliance creates inherent financial instability because Medicaid reimbursement rates, set at the state level, consistently fall short of the actual costs of providing care.6 National analyses estimate that, on average, Medicaid pays only around 82 cents for every dollar of reported nursing home cost, with significant variation across states – some paying as low as 62% of the national average rate even after adjustments.5 Nearly 40% of nursing homes receive Medicaid payments covering 80% or less of their costs.5 This chronic underfunding forces facilities to operate on thin margins, often cross-subsidizing Medicaid residents with higher payments received from Medicare post-acute stays or private payers.47 Facilities with a high percentage of Medicaid residents are disproportionately affected, exhibiting lower financial performance, lower staffing levels, and poorer quality outcomes.5 The potential for future federal or state cuts to Medicaid spending further jeopardizes access and viability, particularly for these vulnerable facilities.39 Medicaid is thus a double-edged sword: essential for access for low-income individuals, yet a primary source of the financial strain that compromises the quality of that access.
• Medicare Payment Systems: Medicare primarily covers short-term, post-acute skilled nursing care following a qualifying hospital stay, typically for up to 100 days.42 Since the Balanced Budget Act of 1997, Medicare has paid SNFs through a Prospective Payment System (PPS), currently the Patient-Driven Payment Model (PDPM) implemented in 2019, which sets per diem rates adjusted for resident acuity and needs.65 Medicare FFS margins for SNFs have historically been high (18.4% in 2022), leading the Medicare Payment Advisory Commission (MedPAC) to conclude that payments exceed efficient costs and recommend base rate reductions.47 However, because Medicare represents a relatively small share of total resident days (median 10%), these higher margins cannot fully compensate for Medicaid shortfalls across the facility.47
• For-Profit Motives and Private Equity (PE): The nursing home industry is dominated by for-profit entities, accounting for 72% of facilities in 2022.47 A growing body of research suggests a potential misalignment between the profit-maximization goals inherent in this model and the delivery of high-quality, person-centered long-term care. Studies have linked for-profit ownership, and particularly the increasing involvement of private equity (PE) firms, with concerning trends: lower staffing levels (especially among CNAs and LPNs, while sometimes maintaining RN levels potentially due to regulatory focus), higher rates of deficiencies and fines, increased reliance on debt, and complex financial arrangements like related-party transactions and sale-leaseback agreements that can extract wealth from facilities.19 Some studies even associate PE ownership with higher resident mortality rates and higher overall charges despite lower staffing investments.20 The short-term investment horizons typical of PE (aiming for exits within ~5 years) may incentivize cost-cutting over long-term quality investments.20 Transparency is also an issue, as many PE transactions fall below federal reporting thresholds, and frequent ownership changes obscure accountability.19 While not all for-profit homes perform poorly, and non-profits also face challenges (often having lower Medicaid payment-to-cost ratios 5), the evidence points to systemic risks associated with the for-profit model, especially PE, under current financial and regulatory conditions.19
• Rising Operational Costs: Beyond reimbursement pressures, nursing homes face escalating operational costs. The persistent workforce crisis drives up labor expenses, particularly reliance on costly temporary agency staff.4 The pandemic led to increased spending on PPE and infection control measures.12 General inflation and the costs associated with meeting increasing regulatory and reporting requirements also contribute to financial strain.4

1. Regulatory Landscape (Historical Context)

As noted previously, the regulatory environment for nursing homes has evolved significantly, largely in response to identified crises. OBRA ’87 remains the cornerstone, establishing comprehensive standards where few existed before.18 Early enforcement focused heavily on physical plant safety (“bricks and mortar”), gradually shifting towards assessing care processes and resident outcomes.60 However, the history of regulation is marked by a persistent tension between setting adequate standards and ensuring effective enforcement. Efforts to strengthen regulations or enforcement have often faced industry resistance, leading to delays, weakened implementation, or inconsistencies.16 For example, battles over implementing the 1967 Moss Amendment standards delayed their rollout 16, and early enforcement approaches sometimes allowed facilities long grace periods to correct deficiencies before sanctions took effect.22 This historical pattern highlights the ongoing challenge of creating a regulatory system that is both robust enough to ensure quality and consistently applied to hold providers accountable.

1. Societal Factors

Broader societal trends and attitudes significantly influence the nursing home crisis.

• Demographic Imperative: The aging of the US population, particularly the large Baby Boomer cohort now entering their late 70s and 80s, is dramatically increasing the demand for long-term care services.25 The number of Americans aged 65 and older is projected to nearly double between 2018 and 2060, reaching 95 million.74 By 2034, older adults are projected to outnumber children under 18 for the first time in US history.25 This demographic shift not only increases the sheer volume of individuals needing care but also the complexity, as older adults are more likely to have multiple chronic conditions requiring sophisticated management.1 This rising demand strains a system already struggling with capacity, workforce, and funding limitations.
• Family Caregiving Burden: Unpaid family caregivers provide the vast majority of long-term care in the US, contributing an estimated $470 billion in economic value annually.26 This reliance places an immense financial, physical, and emotional burden on families, particularly women and caregivers of color, who report higher levels of strain.76 Many Americans age 40+ anticipate needing to provide care for a loved one but feel unprepared.77 The “sandwich generation,” caring for both aging parents and children, faces unique pressures.77 Despite their critical role, family caregivers often lack adequate social and financial support, contributing to burnout and stress.26 This heavy reliance on informal care reflects, in part, the lack of affordable formal care options and gaps in the social safety net.
• Cultural Views and Ageism: Societal attitudes towards aging, dependency, and the value of care work profoundly shape the long-term care landscape. Negative perceptions or undervaluation of caregiving roles can impact caregiving decisions and exacerbate caregiver burden.26 Pervasive ageism may contribute to the systemic underinvestment in nursing home care and the low prioritization of resident well-being and rights.52 Cultural norms also influence preferences for care settings and family involvement.26
• Workforce Perceptions: The long-term care sector, particularly nursing homes, suffers from a negative public image as a desirable place to work. Factors like low pay, difficult working conditions, lack of respect, and limited career advancement contribute to difficulties in attracting and retaining staff.4 This perception issue forms a significant barrier to resolving the workforce crisis.

1. Analysis of Current US Nursing Home Policies and Regulations

The regulatory and policy framework governing US nursing homes is complex, involving multiple federal agencies, intricate funding streams, and significant state-level variation. Understanding this framework and its documented shortcomings is crucial for identifying areas needing reform.

1. Federal Oversight Roles

Several federal entities share responsibility for overseeing nursing homes participating in Medicare and Medicaid.

• Centers for Medicare & Medicaid Services (CMS): As part of the Department of Health and Human Services (HHS), CMS holds the primary federal responsibility. It establishes the health and safety standards (Requirements of Participation) that facilities must meet, sets payment rates for Medicare services (and oversees state Medicaid payment structures), monitors quality of care through data collection and public reporting (e.g., Care Compare), and oversees the state-level survey and certification process.1 CMS develops policies and guidance intended to ensure quality service for beneficiaries.46
• HHS Office of Inspector General (OIG): The OIG acts as an independent watchdog within HHS. Its role includes conducting audits, evaluations, and investigations into fraud, waste, abuse, and neglect within HHS programs, including nursing homes.79 The OIG identifies systemic weaknesses, raises concerns about issues like staffing levels, background checks, and emergency preparedness, and recommends improvements to CMS oversight.23 It also pursues criminal and civil enforcement actions against providers engaging in misconduct or providing grossly substandard care, often working with the Department of Justice on False Claims Act cases related to patient neglect.79
• Government Accountability Office (GAO): The GAO is an independent, non-partisan agency that works for Congress. It conducts evaluations and issues reports on the effectiveness and efficiency of federal programs, including CMS’s oversight of nursing homes.42 GAO reports have frequently highlighted shortcomings in areas like staffing data reporting on Care Compare, the effectiveness of enforcement sanctions, and the limitations of the Special Focus Facility program, often making specific recommendations to CMS for improvement.22

These agencies form a system of checks and balances, with CMS setting and enforcing rules, OIG investigating misconduct and systemic risks, and GAO evaluating overall program effectiveness for Congress. However, reports from OIG and GAO consistently point to gaps and weaknesses in federal monitoring and oversight.22

1. Funding Mechanisms

The way nursing homes are paid significantly influences their operations and financial stability.

• Medicare: Medicare primarily funds short-term, post-acute care in SNFs under its Part A benefit, typically following a hospitalization.42 Since 1998, payment has been based on the SNF Prospective Payment System (PPS), a per diem rate intended to cover all routine, ancillary, and capital costs.67 The rate is adjusted for geographic wage differences and resident case mix, using the Patient-Driven Payment Model (PDPM) since 2019, which classifies residents based on clinical characteristics.65 Medicare covers 100% of the cost for the first 20 days, with a significant daily copayment required from beneficiaries for days 21-100.47 While Medicare FFS spending on SNF services is substantial ($29 billion in 2022) 47, it represents only a fraction of total nursing home revenue due to the short-stay nature of Medicare coverage.47 As previously noted, Medicare FFS margins are generally high (18.4% in 2022), leading MedPAC to argue that payments exceed efficient costs and recommend a 3% base rate reduction for FY 2025.47
• Medicaid: Medicaid is the dominant payer for long-term nursing home stays, covering over 60% of residents.6 Unlike Medicare’s federally determined PPS, Medicaid reimbursement rates and methodologies are established by each state, leading to substantial variation nationwide.64 States may use cost-based methods (rates tied to reported facility costs) or price-based methods (rates set prospectively based on historical costs adjusted for inflation or other factors).64 Many states also utilize supplemental payments (like Disproportionate Share Hospital (DSH) payments, though less common for nursing homes, or Upper Payment Limit (UPL) payments) or, increasingly, State Directed Payments (SDPs) within managed care systems to bolster base rates.84 Despite these mechanisms, a pervasive issue is that state Medicaid rates frequently fail to cover the actual cost of care, averaging around 82% nationally, creating significant financial pressure.5 MACPAC and KFF regularly report on these state variations and trends, highlighting the complex and often inadequate nature of Medicaid financing for nursing homes.64
• Value-Based Purchasing (VBP): The SNF VBP program, mandated by the Protecting Access to Medicare Act (PAMA) of 2014 and implemented in FY 2019, aims to link Medicare payments to quality performance.87 Initially, it relied solely on a single measure: the SNF 30-Day All-Cause Readmission Measure (SNFRM).87 The program is funded by withholding 2% of SNFs’ Medicare FFS Part A payments each year; CMS then redistributes 60% of this withhold back to facilities as incentive payments based on their performance (achievement and improvement) on the measure(s), with the remaining 40% retained by Medicare.87 MedPAC heavily criticized the initial design for its reliance on a single measure, its failure to adequately motivate improvement across all providers (reward/penalty amounts were often small), and its lack of adjustment for social risk factors.88 In the first three years, the majority of SNFs received a net payment reduction under VBP.88 Recognizing these flaws, Congress, in the Consolidated Appropriations Act of 2021, authorized CMS to expand the program to include up to nine additional measures, beginning with the FY 2026 program year.87 CMS has finalized new measures for inclusion.87 Despite these changes, the overall uptake of VBP models specifically designed for SNFs remains limited compared to other healthcare sectors, particularly for long-stay care which is predominantly Medicaid-funded.65 Final rule updates for the FY 2025 SNF PPS include further refinements to the VBP program.67

1. Oversight and Enforcement

Mechanisms for ensuring nursing homes meet federal standards involve surveys, public reporting, and enforcement actions.

• Survey Process: State survey agencies, under contract with CMS, conduct onsite inspections (surveys) to assess compliance with federal Requirements of Participation.60 Standard surveys occur approximately annually (and unannounced), with additional surveys conducted to investigate specific complaints.23 Surveyors observe care, review records, and interview residents and staff to identify deficiencies.91 CMS provides detailed guidance (e.g., Appendix PP of the State Operations Manual) and utilizes specific software (LTCSP) for the process.93 However, OIG has identified shortcomings in the effectiveness of state survey agencies 79, and recent reports indicate significant backlogs in state inspections and high surveyor vacancy rates, potentially compromising oversight timeliness and thoroughness.48
• Five-Star Quality Rating System: Launched in 2008, this system is CMS’s primary tool for publicly reporting nursing home quality on the Care Compare website, intended to help consumers make informed choices.80 It assigns an overall star rating (1 to 5 stars) based on performance in three domains:

1. Health Inspections: Based on the number, scope, and severity of deficiencies identified during the three most recent standard surveys and recent complaint investigations, weighted more heavily for recent surveys. Ratings are calculated relative to other homes within the same state.92
2. Staffing: Based on self-reported data (Payroll-Based Journal, PBJ) on nursing hours (RN, LPN, NA) per resident day, adjusted for case mix. Recent updates incorporate weekend staffing levels.42
3. Quality Measures (QMs): Based on performance on a set of clinical quality measures derived primarily from MDS resident assessment data (e.g., falls, pressure ulcers, antipsychotic use, function).43 The overall rating starts with the Health Inspection rating and is adjusted up or down based on the Staffing and QM ratings.92 While widely used, the system faces critiques: its components may not strongly correlate with resident and family satisfaction 51; data accuracy, particularly for self-reported staffing and QM data, is a concern (though CMS conducts some audits and validation) 82; it may not capture all important aspects of quality (e.g., specialized care, staff morale) 51; and ratings can be volatile due to methodological changes or data freezes/updates.42 GAO found the information on Care Compare generally aligns with characteristics of understandability but noted limitations, such as lack of weekend staffing data (since partially addressed).42

• Enforcement Actions (Remedies): When surveys identify noncompliance, CMS and states can impose various remedies.98 Key enforcement actions include:

• Civil Monetary Penalties (CMPs): Fines imposed per day or per instance of noncompliance. The range varies based on severity, from $50-$3,000 per day for non-jeopardy deficiencies up to $3,050-$10,000 per day for immediate jeopardy or repeat deficiencies.91 However, the effectiveness of CMPs has been questioned. GAO and OIG reports found that imposed amounts are often significantly reduced through appeals or settlements, collection is frequently delayed, and the median penalties imposed are often at the low end of the allowable ranges, potentially weakening their deterrent effect.22 CMS has taken steps to strengthen CMP imposition, such as requiring immediate CMPs (without a grace period) for certain serious or repeat deficiencies, including specific harm-level citations related to resident behavior/restraints, quality of life, and quality of care.22
• Denial of Payment for New Admissions (DPNA): Prohibits Medicare/Medicaid payment for new residents admitted to the facility. This is mandatory if a facility fails to correct deficiencies within three months.98
• Termination: The most severe remedy, ending the facility’s participation in Medicare/Medicaid.22 Historically used sparingly, with concerns about lengthy processes and extensions granted.22

• Special Focus Facility (SFF) Program: This CMS program targets a small number of nursing homes nationwide (historically around 136) identified as having persistent patterns of serious quality issues.83 States select SFFs from a candidate list of the poorest performers in their state, though they have discretion in selection.83 SFFs are subject to more frequent surveys (twice as often) and face increased pressure to improve, with stricter timelines for achieving substantial compliance (around 18 months) before facing potential termination.83 GAO evaluations found the program showed some success in driving improvement for graduates, but also identified issues like inconsistent state adherence to survey frequency, vague enforcement guidance leading to variable penalties, SFFs remaining in the program far beyond the intended timeframe, and limited program size due to resource constraints.22 GAO recommended notifying candidate homes and potentially charging SFFs for extra surveys.83 SFFs also exhibit lower compliance with the new staffing mandate requirements compared to non-SFFs.3

The overall picture of oversight and enforcement suggests a system with established processes but persistent challenges in achieving consistent, timely, and impactful accountability, particularly for systemic issues rooted in financial and staffing pressures. The gap between regulatory intent and on-the-ground impact remains a significant concern.22

Table 2: Overview of Federal Nursing Home Regulations and Oversight Mechanisms

 

Component	Key Elements	Relevant Legislation/Agency	Key Snippets
Foundational Law	Establishes comprehensive quality standards, resident rights, assessment process, staffing requirements (broadly).	OBRA ’87	18
Regulatory Body	Sets specific Requirements of Participation, manages payment systems, oversees state surveys, public reporting (Care Compare).	CMS (HHS)	1
Independent Oversight	Audits, evaluations, investigations of fraud, abuse, neglect; recommends improvements to CMS.	OIG (HHS)	23
Congressional Oversight	Evaluates program effectiveness, reports on CMS performance, makes recommendations.	GAO	42
Key Requirements	Minimum staffing levels (HPRD, 24/7 RN), quality of care standards, resident rights (autonomy, dignity, participation, etc.), infection control, abuse prevention, assessment (MDS), care planning.	CMS Regulations (42 CFR 483)	1
Oversight Tools	State-led annual standard surveys & complaint investigations; public reporting via Five-Star Quality Rating System (Health Inspections, Staffing, Quality Measures).	CMS, State Survey Agencies	60
Targeted Oversight	Increased scrutiny (surveys, enforcement) for chronically poor-performing facilities.	Special Focus Facility (SFF) Program (CMS)	3
Enforcement Actions (Remedies)	Civil Monetary Penalties (CMPs), Denial of Payment for New Admissions (DPNA), Directed Plan of Correction, State Monitoring, Termination from Medicare/Medicaid.	CMS, State Survey Agencies	22
Payment Link to Quality	Medicare payment adjustments based on performance (initially readmissions, expanding measures).	SNF Value-Based Purchasing (VBP) Program (PAMA 2014, CAA 2021)	87

1. State-Level Variations

While federal regulations set a floor, states retain significant authority, leading to considerable variation in the nursing home landscape.

• Staffing Mandates: Prior to the 2024 federal rule, numerous states had already established their own minimum nursing staff requirements, but these varied widely in terms of specific HPRD levels, requirements by shift or staff type (RN, LPN, CNA), and enforcement mechanisms.24 Studies on the impact of these state mandates suggested they often resulted in only small staffing increases, primarily in facilities already near or below the new standard, although some improvements in outcomes like reduced restraint use were observed.61 The new federal rule now sets a national baseline, but states can maintain stricter standards.
• Certificate of Need (CON) Laws: Approximately 35 states and the District of Columbia maintain CON laws, which require healthcare facilities, including nursing homes in many cases, to obtain state approval before building new facilities, expanding bed capacity, or adding major services or equipment.101 The original intent was often to control healthcare costs by preventing unnecessary duplication and ensuring development aligned with community need.101 However, CON laws are controversial. Proponents argue they achieve these aims, while opponents contend they stifle competition, limit consumer choice, protect incumbent providers (potentially including lower-quality ones), increase costs, and reduce access to care.101 Research on their impact on nursing homes is mixed. Some older studies suggested CONs reduced bed growth 103, but later studies questioned their effectiveness in constraining the market or controlling Medicaid spending.103 There is evidence suggesting CON laws may negatively impact access and quality 102, and potentially hinder the growth of home and community-based services (HCBS) if applied to home health agencies.103 The National Academies report recommended eliminating CON requirements for nursing homes.52 The existence and scope of CON laws represent a significant state-level variable affecting market dynamics and potentially hindering innovation or entry of new providers.
• Medicaid Policies: As the primary payer for long-term care, state Medicaid policies are highly influential. As discussed under Funding Mechanisms, states have broad discretion in setting reimbursement rates and methodologies, resulting in dramatic differences in payment adequacy across the country.64 States also vary significantly in their adoption and funding of HCBS through Medicaid waivers (like 1915(c)) or state plan amendments, impacting the availability of alternatives to institutional care.46 The extent to which states utilize managed care models for long-term services and supports (MLTSS) also differs.64

1. Recent Policy Developments

Two major federal rules finalized in 2024 represent significant shifts in nursing home and long-term care policy.

• Minimum Staffing Standards for Long-Term Care Facilities (Final Rule, April 2024): This landmark rule establishes, for the first time, comprehensive federal minimum nurse staffing requirements for Medicare and Medicaid-certified nursing homes.3 Key components include:

• A total nurse staffing minimum of 3.48 HPRD.
• Specific minimums within that total: 0.55 HPRD for RNs and 2.45 HPRD for NAs. (The remaining 0.48 HPRD can be met by RNs, LPNs, or NAs).3
• A requirement for an RN to be on site 24 hours a day, 7 days a week.3
• Enhanced facility assessment requirements, mandating input from staff and families.3
• Staggered implementation timelines, generally giving rural facilities more time to comply than urban facilities (e.g., RN/NA HPRD requirements effective 2027 for urban, 2029 for rural).3
• Provisions for temporary hardship exemptions based primarily on workforce unavailability in the facility’s geographic area (defined as having a provider-to-population ratio at least 20% below the national average for the relevant staff type), requiring facilities seeking exemptions to document recruitment efforts and post notice of their status.2 Special Focus Facilities are ineligible for exemptions.3 The rule aims to directly address the link between low staffing and poor quality.105 However, it faces strong industry opposition centered on the immense cost (estimated at $6-6.5 billion annually by industry analyses 41) and the difficulty of hiring the estimated 102,000 additional nurses and aides needed 3 amidst existing severe shortages.11 Critics argue the mandate is unfunded (CMS states facilities are responsible for costs 50) and could force closures or census reductions, limiting access to care, particularly in rural areas and for Medicaid residents.40 Supporters, including labor unions and consumer advocates, view it as a long-overdue measure to ensure resident safety and improve job quality.109 The success of this mandate appears heavily dependent on simultaneous efforts to bolster the workforce pipeline and address funding adequacy, creating a significant implementation dilemma.2

• Ensuring Access to Medicaid Services (Final Rule, April 2024): This rule aims to improve access to and quality of Medicaid services, including HCBS.46 A key provision with major implications for the direct care workforce requires that state Medicaid programs ensure at least 80% of Medicaid payments for specific HCBS (homemaker, home health aide, and personal care services) are spent on compensation for the direct care workers furnishing these services, rather than administrative overhead or profit.46 The rule also includes requirements for states to report on payment adequacy, conduct comparative rate analyses, publish fee schedules, and establish advisory committees involving beneficiaries and workers to provide input on rates.84 These provisions aim to address low wages contributing to HCBS workforce shortages.15 However, the future implementation or potential revision of this rule could be subject to political changes.66

1. Identified Policy Shortcomings and Gaps

The preceding analysis reveals several critical shortcomings in the current policy and regulatory framework:

• Inadequate and Inequitable Financing: Chronic Medicaid underfunding remains a fundamental flaw, destabilizing providers and creating disparities in care quality based on payer source and facility location.5 The fragmented nature of funding between Medicare (short-term) and Medicaid (long-term) creates misaligned incentives.65
• Ineffective Enforcement: Despite numerous regulations, enforcement mechanisms like CMPs often lack timely and sufficient impact due to reductions, delays, and amounts that may not serve as adequate deterrents.22 The SFF program reaches too few facilities and faces implementation challenges.83 Survey processes face backlogs and consistency issues.48
• Limited Transparency: Lack of transparency regarding facility ownership structures (especially PE and chains) and detailed financial operations hinders accountability and understanding of how public funds are used.19
• Workforce Neglect: Policy has historically failed to adequately address the root causes of the workforce crisis through sufficient investment in compensation, training infrastructure, and career pathways.4
• Quality Measurement Gaps: The Five-Star system, while useful, has limitations and may not fully capture resident experience or key aspects of quality, and its data inputs face accuracy concerns.51
• Barriers to Innovation: Regulatory and financial structures, potentially including CON laws, can impede the adoption and scaling of promising person-centered care models.52
• Slow VBP Adoption: Value-based payment models specifically tailored and proven effective for the complexities of long-term nursing home care are underdeveloped and not widely implemented.65

1. Critical Workforce Challenges

The nursing home workforce crisis is arguably the most acute and pervasive challenge facing the sector, directly impacting the quality, safety, and availability of care. This crisis encompasses severe difficulties in recruitment and retention, inadequate compensation and benefits, gaps in training and education, and high levels of workload-induced stress and burnout.

1. Recruitment and Retention Crisis

• Magnitude: Nursing homes are grappling with unprecedented workforce shortages, a problem significantly intensified by the COVID-19 pandemic.10 Between February 2020 and mid-2022, the sector lost nearly 229,000 caregivers, representing over 14% of its workforce—the most severe job loss among all healthcare sectors.11 As of early 2024, employment levels in long-term care generally remained below pre-pandemic benchmarks, with nursing homes needing to recover nearly 125,000 workers just to return to February 2020 levels.1 Some estimates suggest the workforce is at levels not seen since 1994, with full recovery potentially taking until 2027.4 This shortage exists within a broader context of projected national RN shortages, making it difficult for nursing homes to compete with hospitals and other settings for limited nursing talent.3
• Turnover: Staff turnover rates in nursing homes are exceptionally high, contributing significantly to instability and inconsistency in care. While estimates vary depending on methodology, recent studies and reports indicate alarming levels. One analysis using CMS payroll data calculated mean and median annual turnover rates for hours of total nursing staff care at 128% and 94%, respectively.111 Another report cited an average staff turnover rate of 53% in 2021.4 Turnover is consistently linked to poorer quality of care, including higher rates of health inspection deficiencies and resident abuse.1 The constant churn disrupts resident-staff relationships, hinders team cohesion, and increases costs associated with recruitment and training.114 Evidence suggests that facilities with union representation tend to experience lower turnover rates.113
• Recruitment Difficulties: Facilities report significant challenges in filling open positions. Key reasons cited include a general shortage of available workers in the labor market, inability to offer competitive salaries and benefits compared to other healthcare sectors (especially hospitals), and lingering issues related to COVID-19 vaccine mandates.3 Rural facilities often face greater recruitment hurdles due to smaller labor pools, while urban facilities may face more intense job competition.2 Engaging younger workers, who may perceive nursing home work negatively or prefer other settings, is also a noted challenge.24 Traditional recruitment strategies like sign-on bonuses are reportedly becoming less effective.116
• Retention Difficulties: Keeping existing staff is as challenging, if not more so, than recruiting new ones. Nurses and aides leave nursing home jobs primarily due to low pay and inadequate benefits, high workload and stressful working conditions stemming from understaffing, lack of respect or support from management, limited opportunities for career advancement, and burnout.2 The physical and emotional demands of the job are immense.119 The pandemic exacerbated these issues, with fear of exposure and vaccine mandates contributing to attrition.116 High levels of job dissatisfaction are prevalent.4 The sheer number of nurses considering leaving their positions increased dramatically during the pandemic years.56 This constant drain of experienced staff further destabilizes care. The data strongly suggests that focusing solely on recruitment without addressing the fundamental reasons why staff leave is an inefficient “leaky bucket” approach; robust retention strategies are paramount.117

1. Compensation and Benefits

Low compensation is a primary driver of the workforce crisis.

• Wage Levels: While wages vary significantly by state, region, and facility, national data provides a benchmark. According to May 2023 Bureau of Labor Statistics (BLS) data and some 2024 estimates:

• Registered Nurses (RNs): The national median annual wage for RNs across all industries was $86,070 ($41.38/hour).119 Average RN salaries in general hospitals were around $97,000 122, while outpatient centers averaged over $102,000.122 Nursing care facilities (skilled nursing facilities) reported a mean annual wage of $87,430 in one source 122, but other estimates place the average closer to $82,000.123 This suggests nursing home RN wages may lag behind acute care settings, impacting competitiveness.
• Licensed Practical/Vocational Nurses (LPNs/LVNs): The national median annual wage was $59,730 ($28.72/hour).119 BLS data shows the mean annual wage in nursing care facilities was $63,730, slightly higher than in general hospitals ($55,380) but lower than outpatient centers ($69,630 reported in another source 125).124 Some sources report nursing facility LPN averages around $60-$67k.123
• Certified Nursing Assistants (CNAs): The national median annual wage for nursing assistants was $38,200 ($18.36/hour).119 Mean annual wages in nursing care facilities were around $38,730, slightly lower than in general medical/surgical hospitals ($40,840) and specialty hospitals ($42,180).126 Other estimates place the average CNA salary around $35,000-$36,000.123 These wages are often near or below living wages in many parts of the country, especially considering the demanding nature of the work.

• Impact of Low Pay: Inadequate wages and benefits are consistently cited as major reasons for recruitment and retention difficulties.4 Nursing homes, particularly those heavily reliant on low Medicaid reimbursements, often lack the financial capacity to offer competitive compensation packages needed to attract and retain staff in a competitive labor market.6
• State Efforts: Recognizing the link between wages and workforce stability, many states have implemented strategies such as increasing Medicaid provider payment rates with the explicit goal of boosting staff compensation.15 Some states have also established minimum wage requirements specifically for HCBS workers, and the new federal Medicaid access rule mandates an 80% pass-through of certain HCBS payments to worker compensation.15

Table 4: Nursing Home Workforce Statistics (US Averages/Ranges, 2023-2024)

 

Metric	RN	LPN/LVN	CNA	Total Nursing Staff	Source(s)
Median Annual Wage (National, All Industries, May 2023)	$86,070	$59,730	$38,200	N/A	119
Mean Annual Wage (Nursing Care Facilities, May 2023)	~$87,430*	$63,730	$38,730	N/A	122
Mean Annual Wage (General Hospitals, May 2023)	$96,830	$55,380	$40,840	N/A	122
Avg. HPRD Provided (2024)	~0.55 1	~0.95 1	~2.30 1	3.80	1
Staff Turnover Rate (Annual %)	Varies widely (e.g., 56% in one study)	Varies widely (e.g., 54% in one study)	Varies widely (e.g., 78% in one study)	Median 94% (hours); Mean 128% (hours); ~53% (staff)	4
Estimated National Shortage (vs. Mandate)	~23,000-24,000	N/A (part of total)	~77,000-78,000	~102,000	3
Key Reasons for Turnover	Low pay/benefits, workload, burnout, lack of support/respect, limited advancement	Low pay/benefits, workload, burnout, lack of support/respect, limited advancement	Low pay/benefits, workload, burnout, lack of support/respect, limited advancement	Low pay/benefits, workload, burnout, lack of support/respect, limited advancement	2

*(Note: Wage data primarily from BLS May 2023. RN wage in NHs from BLS Home Health Care Services category used as proxy, other sources vary.123 HPRD estimated based on 1 trends. Turnover rates vary significantly by study methodology. Shortage estimate based on industry analysis of federal mandate 41 vs. CMS estimate.3)

1. Training and Education

The preparation of the nursing home workforce often falls short of meeting the complex needs of residents.

• Current Standards: Federal regulations mandate a minimum of only 75 hours of initial training for CNAs and home health aides.128 While many states exceed this minimum, requirements vary significantly, with reported state minimums ranging from just 4 hours to 125 hours.128 Similarly, state requirements for nursing home administrator licensure vary widely; some states require only a high school diploma, while others mandate a bachelor’s degree.129 Federal law requires licensed nurses (RNs/LPNs) 24/7 and an RN for at least 8 hours daily, but specific advanced training in geriatrics or long-term care is not universally mandated.61
• Identified Gaps: The National Academies’ 2022 report on nursing home quality strongly criticized the adequacy of current training standards.52 It found that CNA training often focuses on basic tasks rather than developing the competencies needed to care for residents with complex conditions like dementia, multiple chronic illnesses, and behavioral health needs.52 Furthermore, the report highlighted a lack of essential content on gerontology, geriatric assessment, long-term care principles, and palliative care across the education programs for all health professionals working in nursing homes.52 Gaps also exist in training related to infection prevention and control, cultural sensitivity, diversity and inclusion, and the use of health information technology (HIT).52 The Institute of Medicine’s 2008 report, Retooling for an Aging America, also emphasized the need for improved training standards and competency-based programs for direct-care workers.131 The focus on minimum hours may obscure deeper deficits in the quality and relevance of the training content provided.
• NASEM Recommendations: To address these gaps, the National Academies committee recommended significant enhancements to education and training 52:

• Establish national minimum education and competency requirements for key leadership roles (administrators, medical directors, directors of nursing, directors of social services).
• Increase minimum training hours for CNAs and shift to competency-based training covering relevant topics (dementia, IPC, behavioral health, etc.).
• Develop pathways for current staff to meet new requirements.
• Mandate inclusion of gerontology, geriatrics, LTC, and palliative care content in all relevant health professional education programs.
• Require annual continuing education for all nursing home staff.
• Implement ongoing diversity, equity, and inclusion training.
• Provide resources and training for family caregivers.
• Develop training in core HIT competencies for leadership and staff.52

1. Workload, Stress, and Burnout

The nursing home work environment is often characterized by excessive workloads, high stress, and widespread staff burnout, which are major contributors to the turnover crisis.

• Prevalence and Definition: Burnout, clinically defined by emotional exhaustion, depersonalization (cynicism), and a reduced sense of personal accomplishment 114, affects a large proportion of the nursing workforce. Studies indicate over half of nurses may experience moderate to high burnout symptoms 114, with significant percentages reporting high levels of emotional exhaustion.135
• Contributors: Key drivers of burnout in nursing homes include heavy workloads and high resident-to-staff ratios resulting from chronic understaffing.2 Long work hours, demanding shifts, insufficient breaks, and frequent overtime contribute to physical and emotional fatigue.133 The emotional toll of caring for frail, complex residents, including frequent exposure to death and challenging behaviors, is significant.114 Lack of support from management, poor teamwork, inadequate resources, and a stressful work environment further exacerbate the problem.118
• Consequences: Burnout is strongly linked to nurses’ intention to leave their jobs and actual turnover 2 (though one study found no association with turnover 135). This turnover further worsens staffing shortages, creating a vicious cycle.2 Beyond workforce stability, burnout negatively impacts nurses’ own physical and mental health, leading to increased absenteeism.138 Crucially, staff burnout is associated with lower quality of care, increased risk of errors, neglectful or abusive behaviors, and poorer patient safety outcomes.135

1. Documented Impact of Staffing on Resident Outcomes

A substantial body of evidence confirms the critical relationship between nursing staff levels and the quality and safety of resident care. Higher staffing levels, particularly for RNs, are consistently associated with better outcomes:

• Fewer health inspection deficiencies.1
• Lower rates of potentially preventable hospitalizations and rehospitalizations.42
• Reduced incidence of pressure ulcers.141
• Better maintenance of residents’ functional abilities (e.g., ADLs).51
• Lower rates of resident falls with major injury.44
• Decreased use of physical restraints.61

Conversely, inadequate staffing is directly linked to negative outcomes and safety risks:

• Increased risk of resident neglect, manifesting as dehydration, malnutrition, poor hygiene, and untreated bedsores.2
• Higher likelihood of resident abuse.7
• Increased risk of preventable falls.2
• Potentially higher resident mortality rates, particularly noted in studies of PE-owned facilities with reduced staffing.21

The National Academies report underscored that achieving adequate staffing has been a persistent challenge for decades.24 The data clearly positions adequate staffing not merely as a desirable goal but as a fundamental prerequisite for safe and effective care. This evidence forms the primary justification for regulatory efforts like the federal minimum staffing mandate.

1. Role of Labor Unions

Labor unions, such as the Service Employees International Union (SEIU), play a significant role in the nursing home sector, representing a notable portion of the workforce (e.g., 17.3% of homes in one 2021 study).109 Unions advocate for their members on issues central to the workforce crisis, including demanding higher wages and improved benefits, safer working conditions, enforceable staffing standards or ratios, protection against mandatory overtime, job security through grievance procedures, and greater democratic participation for workers in facility decisions.10

Recent research suggests that union presence is associated with positive outcomes related to workforce stability. A study published in JAMA Network Open found that unionization was linked to a statistically significant decrease in total nursing staff turnover (a 1.7 percentage point reduction on average). This effect was considerably larger in counties where a high proportion (>75%) of nursing homes were unionized, suggesting a broader market impact.113 Unions argue that by improving job quality, they help stabilize the workforce, which in turn supports better care.113 They have been strong proponents of the federal minimum staffing standards.109

However, unionization can also create tensions. Employers may view union demands for higher wages and benefits or stricter work rules as increasing operational costs and reducing management flexibility.113 Collective bargaining negotiations can sometimes be adversarial.145 Nonetheless, the potential for unions to improve job quality and reduce turnover suggests they could be valuable partners in addressing the workforce crisis, particularly in ensuring that increased funding translates into better jobs and that staffing standards are effectively implemented and enforced.113

Ultimately, the workforce crisis is inextricably linked to the quality crisis. Solving one requires solving the other. Addressing the multifaceted challenges of recruitment, retention, compensation, training, and burnout is not merely an operational necessity but a fundamental requirement for improving the lives of nursing home residents.

1. Examination of Ethical Concerns

The nursing home crisis is deeply intertwined with significant ethical challenges that impact residents, families, and staff. These concerns span from fundamental rights and autonomy to end-of-life decisions, protection from harm, equitable access, and the allocation of limited resources.

1. Resident Rights, Autonomy, and Dignity

The foundation of ethical care in nursing homes rests on respecting the rights, autonomy, and dignity of residents. The Nursing Home Reform Law (OBRA ’87) explicitly guarantees these rights, requiring facilities to “promote and protect the rights of each resident” with a strong emphasis on individual dignity, choice, and self-determination.27 Key federally protected rights include:

• The right to be treated with respect and dignity.
• The right to be fully informed about one’s care and health status.
• The right to participate in assessment, care planning, and treatment decisions.
• The right to refuse treatment, including medications and restraints.
• The right to privacy and confidentiality in care and communications.
• The right to voice grievances without fear of retaliation.
• The right to visits from family, friends, and others.
• The right to make independent choices regarding personal affairs (e.g., activities, schedule, physician choice).27

Autonomy, the ability to make one’s own choices and govern oneself, is crucial for maintaining quality of life and well-being in residential care.78 Older adults’ perceived autonomy—their individual sense of having opportunities to make choices about daily life—is linked to better health outcomes.149

However, exercising autonomy in a nursing home setting faces numerous challenges. Residents may feel they have little control over daily routines like grooming, bathing, or meal times.149 Individual capacity (physical and cognitive function), staff attitudes and support, facility policies and environment, and the influence of family members all impact a resident’s ability to exert autonomy.149 Staff may sometimes hinder autonomy, perhaps believing residents with cognitive impairment cannot make decisions, or prioritizing efficiency over choice, or struggling to balance a resident’s wishes with conflicting family preferences.150 Conversely, some family members express concern that an excessive focus on respecting a resident’s refusal of care (autonomy) might threaten the resident’s safety or well-being, arguing that refusals sometimes stem from underlying issues or barriers rather than deeply held values.150 This tension between promoting autonomy and ensuring safety and well-being, especially for residents with diminished capacity, represents a core ethical dilemma in nursing home care.149 Advocacy groups like the National Consumer Voice for Quality Long-Term Care and Justice in Aging, along with state Long-Term Care Ombudsman programs, play vital roles in educating residents about their rights and advocating for their protection.27

1. End-of-Life Care Practices

With an aging population and increasing prevalence of chronic illness, nursing homes are increasingly becoming sites for end-of-life (EOL) care.154 Providing high-quality EOL care, focused on preventing and relieving suffering while respecting patient wishes, presents complex ethical challenges.154 Palliative care, an approach aimed at improving quality of life for patients and families facing life-limiting illness through symptom management and holistic support, is recommended but often underutilized or inadequately implemented in nursing homes.154

Ethical dilemmas frequently arise around EOL decisions, including:

• Decision-Making Capacity: Determining when a resident lacks the capacity to make their own decisions and who should serve as the surrogate decision-maker.155
• Conflicting Preferences: Navigating disagreements between the resident’s wishes (if known), family preferences, and healthcare professionals’ recommendations regarding treatment goals (e.g., curative vs. comfort-focused).78
• Treatment Decisions: Making choices about life-sustaining treatments such as cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration (ANH), and the appropriateness of withholding or withdrawing such treatments.78
• Terminal Sedation: Considering the use of sedation to manage intractable symptoms at the very end of life.155

Advance Care Planning (ACP) and Advance Directives (ADs)—such as living wills and durable powers of attorney for healthcare—are crucial tools for promoting resident autonomy in EOL care.155 ADs allow individuals to document their preferences for future medical care should they become unable to communicate, guiding families and providers.78 Studies show ACP can improve EOL care quality, increase patient and family satisfaction, and reduce stress for surviving relatives.158 However, barriers to effective ACP persist, including lack of public awareness, reluctance to discuss EOL issues, insufficient provider training in communication, and uncertainty about prognosis.157 Furthermore, even when ADs exist, they are not always readily available or consistently followed in practice.159 Effective, culturally competent communication and shared decision-making involving the resident (when possible), family, and care team are paramount for navigating these sensitive issues ethically.78 Specific programs and frameworks, like the Gold Standards Framework or NUHELP, aim to improve EOL care delivery in nursing homes.154

1. Prevention of Abuse and Neglect

Residents have the fundamental right to be free from all forms of abuse (willful infliction of injury, intimidation, or punishment) and neglect (failure to provide necessary goods and services).7 Yet, as previously noted, abuse and neglect remain disturbingly prevalent.7 The ethical obligation to protect vulnerable residents from harm is frequently undermined by systemic factors. Understaffing is a major risk factor, leading to inadequate supervision, delayed responses, failure to meet basic needs (hygiene, nutrition, repositioning), and increased staff stress that can contribute to abusive behaviors.2 Inadequate staff training, poor management practices, and a facility culture that tolerates or fails to address problematic behavior also contribute.2 While regulatory oversight through surveys and complaint investigations exists, its effectiveness is hampered by underreporting of incidents by residents or staff (due to fear or inability), state agency backlogs, high surveyor turnover, and enforcement actions that may lack sufficient deterrent effect.22 Preventing abuse and neglect requires not only robust oversight and enforcement but also addressing the root causes related to staffing, training, and facility culture.

1. Use of Restraints (Physical and Chemical)

The use of restraints poses significant ethical concerns related to autonomy, dignity, and safety. Residents have the right to be free from physical or chemical restraints imposed for discipline or convenience, and not required to treat medical symptoms.27

• Physical Restraints: Defined as methods restricting free body movement (e.g., belts, vests, geri-chairs, sometimes bed rails) 28, their use has declined dramatically since OBRA ’87 highlighted their dangers (from over 21% in 1991 to under 5% by 2007).62 However, any use remains ethically problematic due to risks of serious physical harm (injury, pressure ulcers, muscle atrophy, strangulation, death), psychological trauma (fear, anxiety, depression), and profound loss of dignity and autonomy.28 Evidence does not support the common rationale that restraints prevent falls; in fact, they may increase injury risk.28 Ethical practice and regulations require exhausting less restrictive alternatives (e.g., environmental modifications, personalized activities, staff interventions) before considering restraints, which should only be used for documented medical necessity and under strict monitoring.62
• Chemical Restraints: This refers to the misuse of psychoactive medications, particularly antipsychotics, to control resident behavior (e.g., agitation, wandering) for staff convenience rather than for a diagnosed medical condition.29 This practice is explicitly prohibited by federal regulations but remains widespread, especially among residents with dementia.29 Antipsychotic use in older adults with dementia is associated with significantly increased risks, including falls, cognitive decline, stroke, and a nearly doubled risk of death.29 Despite these dangers and regulatory bans, enforcement has been weak, with violations often cited at “no actual harm” levels, minimizing penalties.29 CMS has relied heavily on self-reported MDS data to track antipsychotic use, which OIG found to be potentially inaccurate and an underestimate of the problem.96 The persistent misuse of chemical restraints points to deeper systemic issues: inadequate staffing levels that make managing behavioral symptoms difficult, lack of staff training in non-pharmacological dementia care approaches, and potentially financial incentives favoring medication over more labor-intensive interventions.21 This practice represents a significant ethical failure, prioritizing convenience over resident safety, rights, and well-being.

1. Equity and Access Disparities

Profound disparities based on race, ethnicity, socioeconomic status, and geography permeate the nursing home system, representing a major ethical failure in terms of justice and equity.30

• Racial/Ethnic Disparities: Research consistently shows that nursing homes serving predominantly Black and Hispanic residents tend to offer lower quality care. These facilities often have lower staffing levels (particularly RNs), higher numbers of deficiencies, higher rates of resident hospitalizations and readmissions, and lower scores on quality measures compared to facilities serving predominantly white residents.24 Black and Latino residents are disproportionately concentrated in these lower-quality facilities, a pattern not fully explained by financial status or clinical need.140 These disparities were exacerbated during the pandemic, with higher infection and death rates in facilities serving communities of color.20 These inequities are rooted in broader structural racism and systemic discrimination within the healthcare system and society.76
• Socioeconomic Disparities: Quality of care is strongly correlated with a facility’s payer mix. Facilities heavily reliant on Medicaid reimbursement, due to chronic underpayment, often struggle financially, leading to lower staffing and poorer quality.5 Residents residing in counties with lower socioeconomic status (SES) generally have access only to nursing homes with lower overall quality ratings (including staffing and clinical measures).164 Medicaid residents also experience higher mortality rates compared to privately funded residents.49 This creates a two-tiered system where ability to pay significantly influences the quality of care received.
• Geographic Disparities (Rural vs. Urban): Rural nursing homes face unique challenges that can impact access and quality. They often struggle more with staffing shortages due to smaller labor pools and difficulty competing for workers.2 Consequently, they face greater difficulty meeting staffing mandates.2 Rural facilities are often smaller, have fewer resources, are less likely to offer specialized services (like dementia units or mental health services), and may have poorer quality outcomes on some measures, such as higher rates of hospitalization and resident pain.141 Rural residents generally face broader barriers to healthcare access, including geographic isolation, transportation difficulties, and shortages of physicians and specialists.165 These disparities mean that access to high-quality nursing home care is not equitably distributed across geographic locations.

These intersecting disparities violate the ethical principle of justice, which demands fair distribution of resources and opportunities. They indicate that the burdens of the current dysfunctional system fall disproportionately on already marginalized populations.

1. Family Involvement in Decision-Making

Family members often play a critical role in the lives of nursing home residents, providing emotional support, monitoring care, advocating for needs and preferences, and assisting with instrumental tasks.167 Effective family involvement is linked to higher resident satisfaction, better psychosocial outcomes, and potentially improved adherence to care plans.167

However, fostering positive family involvement presents ethical challenges. Communication breakdowns between families and staff are common, leading to mistrust and frustration.167 Families may feel their insights are ignored or struggle to navigate the facility’s hierarchy, while staff may perceive families as demanding or interfering, particularly in understaffed environments.168 High staff turnover exacerbates these issues, disrupting relationships and requiring families to constantly re-educate new staff about their loved one’s needs.167

Ethical dilemmas arise regarding:

• Confidentiality: Balancing a resident’s right to privacy with a family’s desire or need for information, especially when the resident’s capacity is questionable.171
• Autonomy vs. Family Wishes: Navigating situations where the family’s preferences conflict with the resident’s expressed wishes or the staff’s assessment of best interest.78
• Shared Decision-Making: Determining the appropriate level of family involvement in care planning and decision-making, respecting the resident’s autonomy while acknowledging the family’s role and potential legal authority (e.g., power of attorney).78
• Trust: Building and maintaining trust between families and staff is crucial but easily undermined by poor communication, perceived lack of responsiveness, or concerns about care quality, often stemming from organizational issues like understaffing.167

Addressing these challenges requires clear communication protocols, efforts to build partnerships, adequate staffing to allow for meaningful interaction, and ethically sound processes for surrogate decision-making.167

1. Resource Allocation Ethics

Decisions about how to allocate limited resources—including staff time, funding, equipment, and access to specialized services—are inherent in healthcare and carry significant ethical weight.30 Ethical frameworks for resource allocation often draw on principles like:

• Justice: Ensuring fairness and equity in distribution, giving individuals what they are due.30 This includes considering need and ensuring vulnerable populations are not disadvantaged.30
• Beneficence: Acting for the benefit of patients.30
• Non-maleficence: Avoiding harm.30
• Utility: Maximizing overall good or benefit, often considered in population-level decisions.30
• Autonomy: Respecting individual choices.30

In practice, allocation decisions are often based on criteria such as medical need, urgency, likelihood and duration of benefit, and potential impact on quality of life.161 Basing decisions on social worth or discriminatory factors is considered unethical.161

Within nursing homes, resource allocation dilemmas manifest daily. Chronic understaffing forces implicit rationing of staff time and attention. Inadequate Medicaid funding limits the resources available for staffing, supplies, therapies, and environmental improvements, disproportionately affecting facilities serving low-income residents and contributing to care disparities.5 Decisions about who receives limited therapy slots, specialized dementia care, or more intensive nursing support involve ethical trade-offs. The phenomenon of “negative dynamics” may occur, where prioritizing immediate needs under severe constraints depletes resources or capacity needed for future quality care or prevention.173 Transparency in allocation policies and the use of objective, fair mechanisms (like triage committees during crises) are crucial for ethical justification.161 The systemic financial pressures and workforce shortages inherent in the current nursing home crisis create an environment ripe for ethically challenging resource allocation decisions that often disadvantage the most vulnerable residents.

VII. Innovative Models, Best Practices, and Technological Advancements

Amidst the crisis, various innovative approaches aim to transform nursing home care by prioritizing person-centeredness, enhancing quality of life, and improving workforce conditions. Technological advancements also offer potential tools to support these goals.

1. Person-Centered Care Models

These models shift away from traditional, institutional approaches towards creating smaller, homelike environments that emphasize resident autonomy, relationships, and meaningful life.

• Green House Project: Launched in the early 2000s, the Green House model radically redesigns the nursing home environment and staffing structure.31 Key features include:

• Environment: Small, self-contained homes typically housing 10-12 residents, each with a private bedroom and bathroom, centered around a shared living room, open kitchen, and dining area.31
• Staffing: Utilizes “universal workers” called Shahbazim (typically CNAs with additional training in areas like cooking, activities, and dementia care) who work in self-managed teams within a specific home, providing a wide range of personal care, clinical support, and household tasks.31 RNs and other clinical professionals support multiple homes.31
• Philosophy: Focuses on empowering residents with choice and control over their daily lives (e.g., waking times, meals, activities) and fostering deep relationships between residents and consistent staff.31
• Evaluation Findings: Research suggests significant positive outcomes compared to traditional nursing homes:

• Quality of Life/Care: Residents report higher quality of life across domains like privacy, dignity, autonomy, and food enjoyment; maintain self-care abilities longer; experience less decline in late-loss ADLs; and have lower rates of depression and being bedfast.31 Medicare spending per resident is significantly lower, potentially due to reduced hospitalizations.176 Clinical quality appears comparable despite less direct RN supervision within the home.31 The model also proved effective in mitigating COVID-19 spread.177
• Staffing: Staff report higher job satisfaction and likelihood of staying.31 The model delivers more direct care time per resident (23-31 minutes more per day) and significantly more non-care engagement time (4x higher) without increasing overall staffing hours compared to traditional models.31
• Family Satisfaction: Families report higher satisfaction with amenities, care, and environment.31
• Financials: Capital costs can be lower than other “culture change” models, operating costs are generally comparable to traditional homes, and occupancy rates (both overall and private pay) tend to be higher.31

• Eden Alternative / Pioneer Network: The Eden Alternative, developed in the 1990s by Dr. Bill Thomas (also creator of Green House), is a philosophy focused on combating the “three plagues” of nursing home life: loneliness, helplessness, and boredom.33 Key principles include creating a human habitat with plants, animals, and children; fostering close relationships; empowering residents with choice and staff with decision-making authority; and promoting meaningful activity.32 The Pioneer Network is a broader movement advocating for culture change and person-directed care, encompassing various approaches including Eden.33

• Evaluation Findings: Research on Eden implementation shows:

• Quality of Life/Care: Potential to reduce resident loneliness, boredom, and helplessness; lower rates of depression reported in some studies.181 Evidence regarding impact on clinical outcomes (e.g., functional status, infection rates, medication use) is mixed, with some studies finding significant improvements (e.g., reduced restraint use 184) while others found limited or no significant differences compared to traditional homes.180
• Staffing: Organizations implementing Eden report lower staff turnover and increased staff satisfaction.32 Staff empowerment is a key factor.183
• Family Satisfaction: One study reported significant improvement in family satisfaction after Eden implementation.185

• Implementation: Successful adoption requires strong leadership commitment, sustained staff training, and involvement of residents, families, and staff in decision-making.183 The principle-based approach allows flexibility.33

These models demonstrate that alternative approaches focusing on environment, relationships, and empowerment can yield significant benefits. However, their relatively limited adoption highlights systemic barriers. Widespread implementation likely requires changes in financing, regulation, and workforce development policies to support these fundamentally different ways of operating.31

1. Specialized Models

• Dementia Villages (e.g., Hogeweyk): Originating in the Netherlands with the De Hogeweyk village, this model creates a self-contained, secure neighborhood specifically for people with advanced dementia.186 Key elements include:

• Environment: A village-like setting with houses, streets, squares, shops (grocery store, cafe), gardens, and other amenities, allowing residents to move freely within a safe perimeter.186
• Living Arrangements: Small-scale group living, typically 6-7 residents per house, often with distinct “lifestyle” themes (e.g., urban, traditional, cultural) to match residents’ backgrounds and preferences.189 Residents have private rooms but share common living spaces.190
• Care Approach: Focuses on “normal life” and social participation, de-emphasizing the medical aspects of care. Staff (including shopkeepers, etc.) are trained in dementia care but wear street clothes, fostering a less institutional atmosphere.186 Emphasis is placed on resident autonomy, choice, and participation in daily activities (cooking, shopping).186
• Evaluation/Outcomes: Comprehensive, rigorous evaluations are still limited.187 However, Hogeweyk itself reports a dramatic reduction in antipsychotic medication use (from 50% historically to under 10%) since adopting the village model.186 Evidence supports the benefits of specific design elements used in dementia villages, such as small-scale, homelike environments and access to gardens, which are associated with reduced behavioral symptoms and agitation.186 The model holds potential for improving quality of life and reducing behavioral challenges.190
• US Applicability/Challenges: Despite significant media attention, dementia villages remain rare in the US.192 Major barriers include the high cost of development and operation (often requiring substantial government funding or private investment) 186, navigating existing US regulations designed for traditional facilities, translating the “village” concept culturally and architecturally, and overcoming community resistance (NIMBYism) and stigma associated with dementia.192 Implementing such models requires strong leadership, specialized staff training, and potentially higher staffing ratios.187

1. Technology in Eldercare

Technological advancements offer a range of tools with the potential to improve care efficiency, safety, resident independence, and quality of life, although ethical and equity considerations are paramount.

• Telehealth and Remote Monitoring: Telehealth platforms enable remote consultations with physicians and specialists, potentially improving access to care, especially in rural areas or for residents with mobility limitations.34 Remote patient monitoring systems, using wearable sensors or ambient devices, can track vital signs, activity levels, sleep patterns, and other health indicators, allowing for early detection of changes, proactive interventions, and potentially reducing hospitalizations and emergency visits.34 Evidence suggests home telemonitoring can decrease readmissions.193
• Smart Homes and Environmental Sensors: Integrating sensors (motion, door, bed, environmental) into living spaces can enhance safety and support independence.34 These systems can automatically detect falls, monitor for wandering, remind residents to take medication, control lighting and temperature, and alert caregivers or emergency services in case of anomalies.34
• Artificial Intelligence (AI): AI algorithms can analyze the vast amounts of data generated by sensors, wearables, and electronic health records (EHRs) to provide deeper insights and predictive capabilities.35 Potential applications include:

• Risk Prediction: Identifying residents at high risk for falls, pressure ulcers, infections, hospital readmissions, or cognitive decline based on patterns in their data.35
• Early Diagnosis: Assisting in the early detection of conditions like dementia or delirium through analysis of speech patterns, imaging, or clinical data.35
• Personalization: Tailoring care plans, interventions, and alerts based on individual resident needs and real-time status.34
• Decision Support: Providing clinicians with evidence-based recommendations or alerts.35

• Robotics: Robots are being developed for various roles in eldercare:

• Assistive Robots: Providing physical assistance with tasks like lifting, mobility support (robotic walkers, exoskeletons), personal hygiene, and household chores.34
• Monitoring Robots: Mobile platforms equipped with sensors to monitor residents’ vital signs, activity, and environment, potentially interacting via voice or touch screen.197
• Social/Companion Robots: Designed to provide companionship, engage residents in conversation or activities (games, reminiscence therapy), and alleviate loneliness and social isolation. Positive effects have been noted, particularly with pet-like robots for residents with dementia.193

• Effectiveness and Challenges: Systematic reviews indicate that technology-assisted interventions can positively impact physical and cognitive functioning, health management, quality of life, and independence among older adults.34 However, significant challenges remain. The evidence base for many specific AI applications is still developing and may lack rigorous validation against clinical standards.35 Technology acceptance and usability can be barriers for both older adults and staff, requiring user-friendly design and adequate training.193 Critical ethical concerns regarding privacy, data security, autonomy (e.g., potential for over-monitoring or algorithmic bias), and the potential for technology to replace human interaction must be addressed.35 Furthermore, the high cost of some technologies and the digital divide raise equity concerns, risking exacerbation of existing disparities if access is not universal.35 Realizing the benefits of technology requires careful, ethical implementation, robust governance, user-centered design, and attention to equitable access.

1. Policy Experiments and Best Practices

Beyond specific models and technologies, certain practices emerge as beneficial. Empowering frontline staff through self-managed teams and consistent assignments, as seen in Green House and Eden, appears crucial for both staff retention and resident well-being.31 State-level policy experiments, such as enhanced funding for HCBS through initiatives like the American Rescue Plan Act investments or state-specific programs, aim to rebalance long-term care away from institutions.15 Workforce development initiatives funded by states or implemented through partnerships (e.g., mentorship/apprenticeship programs) seek to address pipeline issues.15 Integrating technology like wearables for chronic condition monitoring is also seen as a best practice in some settings.73

Table 6: Comparison of Innovative Care Models

 

Feature	Green House Project	Eden Alternative	Dementia Village (e.g., Hogeweyk)	Traditional Nursing Home (Baseline)
Environment	Small (10-12 res.), self-contained home; private rooms/baths; central living/kitchen	Focus on creating “human habitat” with plants, animals, children within existing or modified structures	Secure, small-scale village/neighborhood; themed houses (6-7 res.); access to shops, cafes, outdoor spaces	Larger institution; often shared rooms; centralized dining/activities; clinical atmosphere
Staffing Model	Universal workers (Shahbazim) in self-managed teams; consistent assignment; RNs support multiple homes	Empowered staff teams; focus on relationships; consistent assignment encouraged	Trained staff (incl. non-care roles) in street clothes; focus on normalcy; potentially higher staff ratios	Hierarchical structure; task-oriented care; variable staff assignment; RNs/LPNs/CNAs with distinct roles
Care Philosophy	Person-directed; maximize autonomy/choice; deep relationships; meaningful life	Combat loneliness, helplessness, boredom; person-directed care; spontaneity; growth	Normalize life; social participation; maximize freedom within secure environment; de-emphasize medical model	Medical/custodial model; focus on safety/tasks; scheduled routines; often limited autonomy
Reported QOL Outcomes	Improved (privacy, dignity, autonomy, food); less depression/being bedfast	Potential reduction in loneliness, boredom, helplessness; lower depression (some studies)	Potential for improved well-being, reduced behavioral symptoms (based on elements/anecdotes)	Variable; often cited issues with QOL, institutional feel
Reported Clinical Outcomes	Maintained self-care longer; fewer ADL declines; lower Medicare costs/hospitalizations; comparable quality; good COVID mitigation	Mixed results; some studies show reduced restraints, others find limited clinical benefit vs. traditional	Reduced antipsychotic use reported by Hogeweyk; evidence supports benefits of design elements (small scale, gardens)	Baseline for comparison; high rates of adverse events, hospitalizations, antipsychotic use often reported
Staff Outcomes	Higher satisfaction; lower turnover (reported)	Lower turnover; increased satisfaction (reported)	Requires specialized training; potentially improved satisfaction due to model	High turnover; high burnout; low satisfaction commonly reported
Family Outcomes	Higher satisfaction	Improved satisfaction (some studies)	Qualitative reports suggest positive family experiences	Variable; common complaints about communication, care quality
Cost/Financials	Lower capital costs (vs. other culture change); comparable operating costs; higher occupancy	Can be implemented in existing structures; potential cost savings via lower turnover	High initial development cost; funding often relies on government/specific sources	Baseline operating/capital costs
Challenges	Scalability, financing, regulatory adaptation, workforce training	Sustaining culture change, leadership commitment, measuring impact consistently	High cost, regulatory hurdles (US), scalability, NIMBYism, need for robust evaluation	Systemic issues: underfunding, workforce crisis, poor quality, institutional nature
Sources	31	32	186	(Implicit baseline from crisis description)

VIII. International Perspectives: Comparative Analysis

Examining long-term care (LTC) systems in other high-income countries provides valuable context for understanding the unique challenges and potential alternative approaches for the US nursing home sector. While no single international model is perfectly transferable, comparing funding mechanisms, service delivery, staffing, and outcomes can offer important lessons.

1. Overview of LTC Models in Selected Countries

LTC systems vary significantly across developed nations:

• Netherlands: Features a universal social insurance system (Long-Term Care Act, Wlz) covering extensive LTC services, including nursing home care and HCBS. Delivery is primarily through private, non-profit providers. The system emphasizes choice, providing flexible cash benefits or services-in-kind.36 The Netherlands generally performs well on access to care metrics and is known for innovative models like the Hogeweyk dementia village.38 Spending on LTC is relatively high.201
• Germany: Also utilizes a mandatory universal social insurance model for LTC, established in the 1990s. It offers beneficiaries a choice between cash benefits (often used to pay informal caregivers) and in-kind services from contracted providers (both non-profit and for-profit).36 Access is based on assessed need, though benefit levels may not cover full costs.201
• Japan: Implemented a mandatory public Long-Term Care Insurance (LTCI) system in 2000, funded through premiums and taxes. It covers both institutional and community-based services, with a strong policy emphasis on preventing institutionalization.36 Benefits are typically service-based rather than cash payments.36 Japan faces immense pressure from its rapidly aging population.38
• Scandinavia (e.g., Sweden, Norway, Denmark): These countries typically rely on tax-funded, universal systems where municipalities have significant responsibility for organizing and delivering LTC services.38 There is a strong emphasis on providing HCBS to enable aging in place.38 Spending and staffing levels are generally high compared to other OECD countries.201 Benefit structures can vary; Norway, for instance, has relatively rigid service-based benefits.36
• United Kingdom: The National Health Service (NHS) provides universal healthcare funded through taxes, but social care (including LTC) is separate, means-tested, and administered by local authorities.38 This leads to significant variation in access and eligibility, with many individuals facing high out-of-pocket costs. Compared to peer nations, the UK has relatively lower administrative health spending but also fewer hospital beds, doctors, and nurses per capita, and performs below average on some health outcomes.203

1. Comparison of Funding, Staffing, Regulation, and Outcomes

Comparing the US system to these international models highlights key differences:

• Funding: The most striking difference lies in funding philosophy. While the US relies heavily on means-tested Medicaid for LTC, supplemented by significant out-of-pocket spending and limited private insurance, countries like Germany, Japan, and the Netherlands utilize universal social insurance models, and Scandinavian countries primarily use general taxation.36 This universal approach generally provides more stable and equitable financing, reducing reliance on individual wealth or impoverishment to access care. The US spends a higher percentage of its GDP on healthcare overall compared to most peer nations but a lower percentage on social services, which include aspects of LTC support.203 This disparity in financing structure is a fundamental driver of the instability and inequity seen in the US LTC system.
• Staffing: While comprehensive comparative data on nursing home staffing levels and compensation across all these countries is limited in the provided snippets, Scandinavian countries are generally understood to have higher staffing ratios. The UK notably has fewer nurses and doctors per capita than many comparable countries.204 The US struggles with low staffing and compensation linked to funding constraints, a problem potentially less acute in systems with more robust universal funding.
• Regulation: Oversight approaches vary, with some countries having more centralized control (e.g., national standards in Germany, Japan) and others more decentralized (e.g., municipal responsibility in Scandinavia, state variations in the US).
• Outcomes: Despite having the highest overall healthcare spending, the US consistently lags behind many peer nations on key health outcomes like life expectancy and prevalence of chronic conditions.203 Americans also report greater difficulty affording healthcare compared to counterparts in other wealthy nations, even older adults with Medicare coverage.205 Countries like the Netherlands perform notably well in ensuring timely access to care.200

Table 7: Comparative Overview of International LTC Systems (US vs. Selected Countries)

 

Feature	United States	Netherlands	Germany	Japan	Sweden/Norway (Illustrative)
Primary Funding	Medicaid (means-tested), Medicare (short-term post-acute), Private Pay/Insurance	Universal Social Insurance (Wlz)	Universal Social Insurance	Universal Social Insurance (LTCI)	General Taxation (primarily)
Coverage	Means-tested for LTC (Medicaid); near-universal for acute (Medicare >65)	Universal	Universal	Universal	Universal
Key Delivery Characteristics	Mix of for-profit (dominant), non-profit, govt.; fragmented health/social care; growing HCBS but institutional bias remains	Primarily private non-profit providers; integrated care efforts	Mix of non-profit & for-profit providers; choice of cash or in-kind services	Mix of provider types; strong focus on prevention/HCBS; service-based benefits	Municipal responsibility; strong HCBS focus; high public provision/funding
Reported Strengths	Innovation in private sector (e.g., some tech); Medicare post-acute benefit (though limited duration)	High access; flexible benefits; innovation (e.g., Hogeweyk)	Universal coverage; choice of benefit type	Universal coverage; strong HCBS focus	Universal access; high service levels; strong HCBS
Reported Challenges/Weaknesses	Funding instability (Medicaid underfunding); high out-of-pocket costs; access inequities; quality concerns; workforce crisis; fragmentation	High cost/spending	Benefit levels may be insufficient; coordination issues	Rapidly aging population pressure; benefit rigidity	High tax burden; potential sustainability concerns
Sources	(Report Sections II-VI)	36	36	36	36

1. Potential Lessons Learned for the US System

International comparisons offer several potential avenues for US LTC reform:

• Universal Financing: The prevalence of universal social insurance or tax-funded LTC systems in peer nations suggests the feasibility of moving away from the US’s means-tested, crisis-driven model. Exploring options for a broad-based federal LTC benefit, funded through social insurance contributions or taxes, could provide more stable, adequate, and equitable financing, reducing reliance on impoverishment for Medicaid eligibility and alleviating pressure on providers.52
• Workforce Investment: Countries with more robust LTC systems often invest more heavily in their workforce. Strategies observed internationally or implied by better funding include higher compensation standards potentially linked to national funding mechanisms, standardized national training requirements, and clearer career pathways, which the US could adapt to address its workforce crisis.52
• Integration of Health and Social Care: Many comparator countries have systems where health and social care, including LTC, are more closely integrated, often under municipal or regional responsibility (Scandinavia) or within a unified insurance framework. This contrasts with the US fragmentation between Medicare, Medicaid, and social service programs. Greater integration could improve care coordination and efficiency for individuals with complex needs.
• Balancing Institutional and Community Care: While the US has increased focus on HCBS, the “institutional bias” in Medicaid still exists.206 Learning from countries with strong infrastructures and funding streams supporting HCBS could help the US further rebalance its LTC system towards community-based options, aligning with most individuals’ preferences.103
• Regulatory Approaches: Examining how other countries regulate quality, staffing, and market entry (e.g., absence of CON-like laws in some) might offer insights into balancing safety assurance with flexibility for innovation.

While direct importation of any single model is impractical due to differing political, economic, and social contexts, the principles of universalism, adequate funding tied to costs, investment in workforce, and integration of services offer valuable guideposts for US policymakers seeking fundamental reform. The US system’s outlier status in its financing structure appears strongly linked to the severity of its current crisis.

1. Synthesis and Actionable Recommendations
2. Summary of Key Findings

The analysis presented in this report reveals a US nursing home system in a state of critical distress, characterized by deeply interconnected failures across multiple domains. Key findings include:

1. Deteriorating Quality and Safety: Despite regulatory efforts, key quality indicators such as direct nursing care hours per resident have declined, while serious safety deficiencies and rates of resident abuse and neglect remain alarmingly high. Understaffing is a primary driver of these safety failures.
2. Pervasive Workforce Crisis: Severe shortages, extremely high turnover rates, and widespread burnout plague the nursing home workforce. This instability is fueled by inadequate compensation (linked to low Medicaid reimbursement), demanding workloads, insufficient training, and lack of professional support and advancement opportunities.
3. Chronic Financial Instability: The sector’s heavy reliance on Medicaid, which consistently reimburses below the cost of care, creates chronic financial pressure. This is particularly acute for facilities serving predominantly low-income residents and undermines the ability to invest in necessary staffing and quality improvements. For-profit ownership models, especially private equity, introduce additional financial complexities and potential conflicts between profit motives and resident care.
4. Policy and Regulatory Shortcomings: Current federal and state policies suffer from inadequate funding mechanisms (Medicaid), inconsistent and sometimes ineffective enforcement of quality standards, gaps in transparency regarding finances and ownership, and regulatory frameworks that can stifle innovation (CON laws). Recent initiatives like the federal staffing mandate, while well-intentioned, face significant implementation challenges without concurrent funding and workforce solutions.
5. Significant Ethical Lapses: The system frequently fails to uphold residents’ rights to autonomy and dignity, struggles with ethical EOL care decisions, and exhibits profound inequities in access and quality based on race, socioeconomic status, and geography. The misuse of chemical restraints persists as a symptom of systemic failures.
6. Untapped Potential of Innovation: Proven person-centered care models (Green House, Eden) and emerging technologies offer significant potential to improve quality of life and care efficiency, but systemic barriers hinder their widespread adoption and equitable implementation.

The COVID-19 pandemic acted as a powerful catalyst, exposing and exacerbating these long-standing, intertwined problems. Addressing the nursing home crisis requires comprehensive, systemic reform that tackles the root causes across financing, workforce, regulation, and care delivery simultaneously.

1. Evidence-Based Recommendations

Based on the synthesis of evidence, the following actionable recommendations are proposed, targeted towards key stakeholder groups:

For Policymakers (Federal – Congress, CMS, HHS):

1. Reform Long-Term Care Financing:

• Address Medicaid Adequacy: Mandate that state Medicaid payments cover the actual cost of providing high-quality nursing home care, potentially by establishing federal minimum standards for rate-setting methodologies, adjusting the Federal Medical Assistance Percentage (FMAP) for LTC, or providing dedicated federal funds tied to rate increases.5 Ensure payment rates explicitly support required staffing levels and competitive wages.
• Explore Universal LTC Coverage: Initiate concrete steps, including feasibility studies and pilot programs, towards designing and implementing a universal, federally administered long-term care benefit (social insurance or tax-funded) to provide stable, equitable financing and reduce reliance on means-tested Medicaid and out-of-pocket spending.52
• Refine Medicare Payments: Re-evaluate the SNF PPS (PDPM) and VBP program to better align payments with the costs of high-quality care, potentially incorporating measures relevant to long-stay residents and adjusting for social risk factors. Consider MedPAC’s proposed SNF Value Incentive Program (VIP) framework.47 Avoid drastic cuts that could further destabilize facilities reliant on Medicare cross-subsidization without addressing Medicaid shortfalls.
• Mandate Financial Transparency: Require detailed, audited, public reporting of facility-level finances, including revenues by payer source, expenditures (especially on staffing, administration, related-party transactions), and ownership structures (including PE involvement).19

1. Invest Robustly in the Workforce:

• Expand the Pipeline: Significantly increase funding for programs that support nursing education, training, and recruitment, including scholarships, loan forgiveness programs targeted at LTC careers, and partnerships between educational institutions and LTC providers.52
• Ensure Livable Wages and Benefits: Link federal funding (Medicare/Medicaid) to requirements for competitive wages and benefits for all nursing home staff. Support wage pass-through mechanisms similar to the HCBS Access Rule.15
• Implement National Training Standards: Adopt and fund the implementation of NASEM-recommended national minimum education and competency-based training standards for administrators, DONs, medical directors, social service directors, and significantly enhance CNA training requirements, including content on dementia, behavioral health, and palliative care.52
• Support Career Advancement: Fund programs creating career ladders and specialization opportunities for direct care workers, particularly CNAs, to improve retention and professionalization.4
• Facilitate Ethical International Recruitment: Streamline processes for ethically recruiting qualified international nurses, ensuring fair labor practices and appropriate credentialing..73

1. Strengthen Regulation and Oversight:

• Enhance Survey Process: Increase funding to state survey agencies to eliminate backlogs, increase survey frequency where needed, ensure adequate surveyor training and retention, and improve consistency in deficiency citation.48
• Make Enforcement More Effective: Increase CMP amounts to reflect inflation since 1994, limit penalty reductions during appeals, expedite the collection process (e.g., through payment withholding pending appeal), and apply sanctions more consistently and rigorously, particularly for repeat or serious violations.22 Expand and strengthen the SFF program.22
• Improve Public Reporting: Refine the Five-Star system by adding validated measures of resident and family experience, staff turnover (including weekend levels), and potentially structural measures like HIT adoption; increase the weight of staffing measures; improve the validity of MDS-based QMs; and facilitate comparison across facilities with common ownership.42 Ensure data accuracy through expanded audits.82
• Increase Oversight of Ownership Models: Develop specific oversight mechanisms for chain and PE-owned facilities, scrutinizing related-party transactions, staffing patterns across commonly owned facilities, and financial practices like sale-leasebacks.19 Deny licensure based on patterns of poor quality across multiple facilities under common ownership.52
• Promote Technology Adoption: Provide financial incentives and technical assistance to support nursing home adoption of certified, interoperable EHRs and other beneficial technologies.52

1. Promote Quality, Ethics, and Equity:

• Support Person-Centered Care: Use payment models and regulatory flexibility to encourage adoption of proven person-centered care models (e.g., Green House, Eden principles).52
• Protect Resident Rights: Strengthen enforcement of resident rights, particularly regarding freedom from inappropriate physical and chemical restraints, informed consent, and participation in care planning.27 Increase funding and support for Long-Term Care Ombudsman programs.52
• Advance Health Equity: Target funding and quality improvement initiatives towards facilities serving high proportions of racial/ethnic minorities and Medicaid residents. Mandate collection and public reporting of quality and access data stratified by race, ethnicity, and socioeconomic status to monitor and address disparities.52
• Fund Research: Increase funding for research on effective care delivery models, optimal staffing configurations, quality improvement strategies, and the impact of different financing and ownership structures.52

For Policymakers (State):

1. Increase Medicaid Reimbursement: Adjust Medicaid rates to adequately cover the reasonable costs associated with providing high-quality care, including compliance with federal staffing standards and competitive wages.5 Implement value-based payment methodologies that reward quality outcomes and sufficient staffing.15
2. Strengthen State Oversight: Ensure state survey agencies are fully funded, staffed with well-trained surveyors, and conduct timely, thorough inspections and complaint investigations.48
3. Rebalance LTC Towards HCBS: Expand access to Medicaid HCBS waivers and state plan services as viable alternatives to institutional care, and provide robust support for family caregivers.46
4. Review/Reform CON Laws: Evaluate the impact of existing CON laws on nursing home access, quality, and innovation, and consider repeal or significant modification to reduce barriers to entry and competition.52
5. Support Workforce Initiatives: Partner with educational institutions, providers, and labor organizations to implement state-level recruitment campaigns, training programs, wage enhancements, and career ladder initiatives.15

For Healthcare Providers/Institutions (Nursing Homes):

1. Invest in and Empower the Workforce: Make workforce stability a top strategic priority. Offer competitive wages and comprehensive benefits. Improve working conditions by ensuring manageable workloads, providing necessary resources and support, fostering a culture of respect, and actively addressing burnout. Implement evidence-based retention strategies such as structured mentorship programs, clinical ladders, recognition programs, and opportunities for professional development and input into care decisions.4
2. Embrace Person-Centered Care: Adopt philosophies and practices that prioritize resident autonomy, dignity, and individual preferences. Implement elements of models like Eden or Green House, such as consistent staff assignment, decentralized decision-making, and creating a more homelike environment. Actively involve residents and families in care planning and daily life.31
3. Prioritize Safety and Quality Improvement: Implement robust QAPI programs with leadership commitment. Strengthen IPC practices and maintain rigorous emergency preparedness plans.9 Focus relentlessly on reducing preventable adverse events like falls, pressure ulcers, and infections.
4. Adopt Enabling Technology: Invest in and effectively utilize EHRs to improve documentation and care coordination. Explore telehealth for specialist access and remote monitoring technologies where appropriate to enhance safety and efficiency, ensuring ethical implementation.34
5. Uphold Ethical Standards: Ensure rigorous adherence to all resident rights. Implement clear policies and provide ongoing staff training on ethical EOL care, ACP, and the appropriate use (and non-use) of restraints, emphasizing non-pharmacological approaches for behavioral symptoms.27 Foster an ethical culture that encourages reporting of concerns without fear of retaliation.

For Advocacy Organizations and Consumer Groups:

1. Advocate for Systemic Policy Reform: Continue pushing for federal and state policy changes addressing inadequate funding (especially Medicaid), robust staffing standards with supporting resources, effective oversight and enforcement, workforce investments, and enhanced transparency.27
2. Empower Consumers and Families: Develop and disseminate resources educating residents and families about their rights, how to identify quality care, navigate the system, and effectively voice concerns or complaints.27
3. Support Ombudsman Programs: Advocate for increased funding and authority for state and local Long-Term Care Ombudsman programs to ensure they have the resources to effectively represent resident interests.52
4. Demand Transparency: Advocate for greater public access to information on facility performance (beyond current ratings), ownership structures, financial data, and staffing levels (including agency use and turnover).19
5. Champion Health Equity: Highlight and advocate for policies specifically designed to eliminate racial, socioeconomic, and geographic disparities in access to and quality of long-term care.76

1. Prioritization and Implementation Considerations

Implementing these comprehensive recommendations requires a coordinated, sustained effort from all stakeholders. Addressing the foundational issues of financing (particularly Medicaid adequacy) and workforce (supply, compensation, training, retention) must be prioritized, as progress in other areas (quality improvement, technology adoption, model innovation) is contingent upon a stable financial and human resource base.

Reforms should be phased strategically, recognizing the potential costs and political challenges. Collaboration between federal and state governments, providers, payers, educators, labor unions, and consumer advocates is essential. Building public awareness and political will is critical to overcome inertia and industry resistance to significant change. The cost of inaction—continued poor quality, preventable harm, workforce collapse, and widening inequities—is far greater than the investment required to build a long-term care system that truly honors the dignity and needs of older Americans and supports the essential workers who care for them.

Works cited

1. A Look at Nursing Facility Characteristics Between 2015 and 2024 – KFF, accessed April 9, 2025, https://www.kff.org/medicaid/issue-brief/a-look-at-nursing-facility-characteristics/
2. 2024 Nursing Home Staffing Ratios | Is Your Loved One Safe?, accessed April 9, 2025, https://www.nursinghomeabusecenter.com/blog/nursing-home-minimum-staffing-requirements-2024/
3. A Closer Look at the Final Nursing Facility Rule and Which Facilities Might Meet New Staffing Requirements | KFF, accessed April 9, 2025, https://www.kff.org/medicaid/issue-brief/a-closer-look-at-the-final-nursing-facility-rule-and-which-facilities-might-meet-new-staffing-requirements/
4. The 4 Top Pain Points for U.S. Nursing Home Providers in 2025 – Pharmbills` Blog, accessed April 9, 2025, https://pharmbills.com/blog/the-4-top-pain-points-for-u-s-nursing-home-providers
5. Assessing Medicaid Payment Rates and Costs of Caring for the Medicaid Population Residing in Nursing Homes: Final Report | ASPE, accessed April 9, 2025, https://aspe.hhs.gov/reports/assessing-medicaid-payments-costs-nursing-homes
6. Financial Challenges Continue To Affect Nursing Homes, Emphasizing Need For Higher Medicaid Reimbursement Rates – AHCA/NCAL, accessed April 9, 2025, https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Financial-Challenges-Continue-To-Affect-Nursing-Homes,-Emphasizing-Need-For-Higher-Medicaid-Reimbursement-Rates.aspx
7. Nursing Home Abuse – Common Signs, Types, & More, accessed April 9, 2025, https://www.nursinghomeabusecenter.com/nursing-home-abuse/
8. Strengthening Nursing Home Policy for the Postpandemic World – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/strengthening-nursing-home-policy-postpandemic-world
9. COVID-19 Risks in Nursing Homes Persist in 2025, accessed April 9, 2025, https://assure-test.com/covid-19-risks-in-nursing-homes-persist-in-2025/
10. Healthcare Insights: The Crisis At Nursing Homes – The ILR School – Cornell University, accessed April 9, 2025, https://www.ilr.cornell.edu/scheinman-institute/blog/john-august-healthcare/healthcare-insights-crisis-nursing-homes
11. Historic Staffing Shortages Continue To Force Nursing Homes To Limit New Admissions, Creating Bottlenecks at Hospitals and Reducing Access To Care For Seniors – AHCA/NCAL, accessed April 9, 2025, https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Historic-Staffing-Shortages-Continue-To-Force-Nursing-Homes-To-Limit-New-Admissions,-Creating-Bottlenecks-at-Hospitals-and-.aspx
12. Nursing Homes Face Imminent Closures Without Financial Support from Congress, accessed April 9, 2025, https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Nursing-Homes-Face-Imminent-Closures-Without-Financial-Support-From-Congress.aspx
13. COVID-19 Pandemic Impact on Nursing Homes Financial Performance – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10958812/
14. Evolution and Landscape of Nursing Home Care in the United States – NCBI, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK584647/
15. Medicaid cuts could worsen home care worker shortage: KFF – Healthcare Dive, accessed April 9, 2025, https://www.healthcaredive.com/news/medicaid-cuts-worsen-home-care-worker-shortages-kff/740539/
16. History of Federal Nursing Home Regulation – NCBI, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK217552/
17. How Government Created and Shaped the U.S. Nursing Home Industry – Smith Scholarworks, accessed April 9, 2025, https://scholarworks.smith.edu/cgi/viewcontent.cgi?article=1011&context=soc_facpubs
18. Long-Term Care in the United States: A Timeline – KFF, accessed April 9, 2025, https://www.kff.org/medicaid/timeline/long-term-care-in-the-united-states-a-timeline/
19. 2024-03-19 Spotlight: For-profit nursing homes are cutting corners on safety and draining resources with financial shenanigans − especially at midsize chains that dodge public scrutiny – Dignity Alliance Massachusetts, accessed April 9, 2025, https://dignityalliancema.org/2024/03/18/2024-03-29-spotlight-for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-%E2%88%92-especially-at-midsize-chains-that-dodge-public-scrutiny/
20. THE IMPACT OF PRIVATE EQUITY ON NURSING HOME CARE: RECOMMENDATIONS FOR POLICYMAKERS – The Roosevelt Institute, accessed April 9, 2025, https://rooseveltinstitute.org/wp-content/uploads/2021/04/RI_NursingHomesandPE_IssueBrief_202104.pdf
21. How Patients Fare When Private Equity Funds Acquire Nursing Homes | NBER, accessed April 9, 2025, https://www.nber.org/digest/202104/how-patients-fare-when-private-equity-funds-acquire-nursing-homes
22. Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents – GAO, accessed April 9, 2025, https://www.gao.gov/products/gao-07-241
23. nursing home enforcement: the use of civil money penalties – GovInfo, accessed April 9, 2025, https://www.govinfo.gov/content/pkg/GOVPUB-HE-PURL-gpo74763/pdf/GOVPUB-HE-PURL-gpo74763.pdf
24. Nursing Home Staffing Shortages and the New Federal Nursing Home Standards – Altarum, accessed April 9, 2025, https://altarum.org/news-and-insights/nursing-home-staffing-shortages-and-new-federal-nursing-home-standards
25. The Graying of America: More Older Adults Than Kids by 2035 – U.S. Census Bureau, accessed April 9, 2025, https://www.census.gov/library/stories/2018/03/graying-america.html
26. Societal perceptions of caregivers linked to culture across 20 countries: Evidence from a 10-billion-word database – ResearchGate, accessed April 9, 2025, https://www.researchgate.net/publication/352903536_Societal_perceptions_of_caregivers_linked_to_culture_across_20_countries_Evidence_from_a_10-billion-word_database
27. Residents’ Rights – National Consumer Voice, accessed April 9, 2025, https://ltcombudsman.org/issues/residents-rights
28. Physical Restraint Use in Nursing Homes—Regional Variances and Ethical Considerations: A Scoping Review of Empirical Studies – PubMed Central, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10419255/
29. “They Want Docile”: How Nursing Homes in the United States Overmedicate People with Dementia | HRW, accessed April 9, 2025, https://www.hrw.org/report/2018/02/05/they-want-docile/how-nursing-homes-united-states-overmedicate-people-dementia
30. Administrative Ethics and the Allocation of Scarce Resources | OJIN, accessed April 9, 2025, https://ojin.nursingworld.org/link/f28f16b9c63a40dea54093dceb2a76fe.aspx
31. Evaluating THE GREEN HOUSE® Model, accessed April 9, 2025, https://thegreenhouseproject.org/wp-content/uploads/Evaluating_The_Green_House_model.pdf
32. Home: Well-being is a human right. The Eden Alternative®, accessed April 9, 2025, https://www.edenalt.org/
33. The Eden Alternative – ACCESS Health International, accessed April 9, 2025, https://accessh.org/wp-content/uploads/2024/10/Chris-Perna-Eden-Alternative-Updated.pdf
34. Exploring the Effectiveness of Technology-Assisted Interventions for Promoting Independence in Elderly Patients: A Systematic Review – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11545332/
35. New Horizons in artificial intelligence in the healthcare of older people – Oxford Academic, accessed April 9, 2025, https://academic.oup.com/ageing/article/52/12/afad219/7479755
36. U.S. and Global Approaches to Financing Long-Term Care: Understanding the Patchwork – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/publications/issue-briefs/2023/feb/us-global-financing-long-term-care-patchwork
37. 2020 – International Profiles of Health Care Systems – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/sites/default/files/2020-12/International_Profiles_of_Health_Care_Systems_Dec2020.pdf
38. Literature Review of International Models of Social Care – Scottish Parliament, accessed April 9, 2025, https://www.parliament.scot/-/media/files/committees/health-social-care-and-sport-committee/full-report-international-models-of-social-care.pdf
39. Medicare Advantage, Medicaid Cuts Deemed Devastating for Nursing Homes at House Hearing, accessed April 9, 2025, https://skillednursingnews.com/2025/03/medicare-advantage-medicaid-cuts-deemed-devastating-for-nursing-homes-at-house-hearing/
40. ‘Massive Holes’: Nursing Homes Fear Medicaid Funding Collapse as House Passes GOP Bill, accessed April 9, 2025, https://skillednursingnews.com/2025/02/massive-holes-nursing-homes-fear-medicaid-funding-collapse-as-house-passes-gop-bill/
41. AHCA/NCAL: Nursing Home Staffing Rule Will Cost $6.5B Annually, Require 102000 Extra Clinicians, Displace a Quarter of Residents, accessed April 9, 2025, https://skillednursingnews.com/2024/05/ahca-ncal-nursing-home-staffing-rule-will-cost-6-5b-annually-require-102000-extra-clinicians-displace-a-quarter-of-residents/
42. Medicare: Additional Reporting on Key Staffing Information and Stronger Payment Incentives Needed for Skilled Nursing Facilities [Reissued with revisions on Aug. 10, 2021.] – GAO, accessed April 9, 2025, https://www.gao.gov/products/gao-21-408
43. Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users’ Guide | CMS, accessed April 9, 2025, https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf
44. Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Public Reporting | CMS, accessed April 9, 2025, https://www.cms.gov/medicare/quality/snf-quality-reporting-program/public-reporting
45. CMS Posts Updated Five-Star Quality Rating Program Technical User’s Guide, accessed April 9, 2025, https://www.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Posts-Updated-Five-Star-Quality-Rating-Program-Technical-User%E2%80%99s-Guide–.aspx
46. Fiscal Year 2024 Financial Report – CMS, accessed April 9, 2025, https://www.cms.gov/files/document/cms-financial-report-fiscal-year-2024.pdf
47. Skilled nursing facility services – MedPAC, accessed April 9, 2025, https://www.medpac.gov/wp-content/uploads/2024/03/Mar24_Ch6_MedPAC_Report_To_Congress_SEC.pdf
48. Nursing Home Abuse Statistics | Statistics on Elder Abuse in 2025, accessed April 9, 2025, https://www.nursinghomeabusecenter.com/nursing-home-abuse/statistics/
49. [UPDATED 2025] Nursing Home Abuse Statistics, accessed April 9, 2025, https://www.bbga.com/practice-areas/nursing-home-abuse/u-s-nursing-home-abuse-statistics/
50. CLA Estimates $6 Billion Annual Cost for Nursing Home Staffing Mandate, accessed April 9, 2025, https://www.claconnect.com/en/resources/articles/24/cla-estimates-6-billion-annual-cost-for-nursing-home-staffing-mandate
51. The Nursing Home Five Star Rating: How Does It Compare to Resident and Family Views of Care? | Request PDF – ResearchGate, accessed April 9, 2025, https://www.researchgate.net/publication/275371127_The_Nursing_Home_Five_Star_Rating_How_Does_It_Compare_to_Resident_and_Family_Views_of_Care
52. Summary – The National Imperative to Improve Nursing Home Quality – NCBI Bookshelf, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK584660/
53. COVID-19 Pandemic Increased Long-Term Nursing Home Stay or Death Across All Groups, accessed April 9, 2025, https://www.ajmc.com/view/covid-19-pandemic-increased-long-term-nursing-home-stay-or-death-across-all-groups
54. Staff Shortages, Employee Burnout Are At Crisis Levels In Nursing Homes, accessed April 9, 2025, https://kffhealthnews.org/morning-breakout/staff-shortages-employee-burnout-are-at-crisis-levels-in-nursing-homes/
55. Nursing Homes Data Dashboard | NHSN – CDC, accessed April 9, 2025, https://www.cdc.gov/nhsn/ltc/ltc-report-overview.html
56. Nursing Shortage Fact Sheet – American Association of Colleges of Nursing, accessed April 9, 2025, https://www.aacnnursing.org/news-data/fact-sheets/nursing-shortage
57. Staffing Mandate Analysis – AHCA/NCAL, accessed April 9, 2025, https://www.ahcancal.org/Data-and-Research/Pages/Staffing-Mandate-Analysis.aspx
58. Senior Care Policy Brief: Lasting Impacts of COVID-19 on Nursing Homes, accessed April 9, 2025, https://nursinghome411.org/policybrief-mar17-2025/
59. How’d We Get Here? The History of Nursing Homes | Next Avenue, accessed April 9, 2025, https://www.nextavenue.org/history-of-nursing-homes/
60. Nursing home regulation: History and expectations – PMC – PubMed Central, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4195121/
61. Effects of State Minimum Staffing Standards on Nursing Home Staffing and Quality of Care, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC2669632/
62. Freedom from Unnecessary Physical Restraints – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/scletter09-11.pdf
63. Medicaid Cuts Could Jeopardize Access to Critical Long-Term Care Services for People with Disabilities and Older Adults – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/blog/2025/medicaid-cuts-could-jeopardize-access-critical-long-term-care-services-people
64. Estimates of Medicaid Nursing Facility Payments Relative to Costs | MACPAC, accessed April 9, 2025, https://www.macpac.gov/wp-content/uploads/2023/01/Estimates-of-Medicaid-Nursing-Facility-Payments-Relative-to-Costs-1-6-23.pdf
65. VALUE-BASED PAYMENT AND SKILLED NURSING FACILITIES: – Duke-Margolis Center for Health Policy, accessed April 9, 2025, https://healthpolicy.duke.edu/sites/default/files/2021-05/Margolis%20SNF.pdf
66. Medicaid: What to Watch in 2025 – KFF, accessed April 9, 2025, https://www.kff.org/medicaid/issue-brief/medicaid-what-to-watch-in-2025/
67. Skilled Nursing Facility PPS – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf
68. Key Issues in Long-Term Services and Supports Quality – KFF, accessed April 9, 2025, https://www.kff.org/medicaid/issue-brief/key-issues-in-long-term-services-and-supports-quality/
69. The Growth of Private Equity in US Health Care: Impact and Outlook – NIHCM Foundation, accessed April 9, 2025, https://nihcm.org/publications/the-growth-of-private-equity-in-us-health-care-impact-and-outlook
70. Americans want action on consolidation, private equity in healthcare, federal report finds, accessed April 9, 2025, https://www.fiercehealthcare.com/ai-and-machine-learning/americans-want-action-consolidation-private-equity-healthcare-federal
71. Improving Nursing Home Staffing Levels Can And Must Be Done, accessed April 9, 2025, https://medicareadvocacy.org/nursing-home-staffing-levels/
72. Second Nursing Home Report Explores Impacts of Economic Crisis, accessed April 9, 2025, https://www.claconnect.com/en/resources/blogs/second-nursing-home-report-explores-impacts-of-economic-crisis
73. Long Term Care 2025 Trends and Outlook – Provider magazine, accessed April 9, 2025, https://www.providermagazine.com/Articles/Pages/Long%20Term%20Care%202025%20Trends%20and%20Outlook.aspx
74. The Future of the Long Term Care Industry – LTC Consumer, accessed April 9, 2025, https://ltcconsumer.com/the-future-of-the-ltc-industry/
75. Societal perceptions of caregivers linked to culture across 20 countries: Evidence from a 10-billion-word database – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8248619/
76. Reimagining and Transforming Long-Term Care – ASA Generations, accessed April 9, 2025, https://generations.asaging.org/reimagining-and-transforming-long-term-care
77. Long-Term Care in America: Americans’ Outlook and Planning for Future Care, accessed April 9, 2025, https://www.longtermcarepoll.org/long-term-care-in-america-americans-outlook-and-planning-for-future-care-2/
78. The Ethics of Endings: Unpacking End of Life Care Challenges, accessed April 9, 2025, https://www.downersgrovehc.com/blog/end-of-life-care-ethical-issues
79. Nursing Homes | Office of Inspector General | Government Oversight, accessed April 9, 2025, https://oig.hhs.gov/reports/featured/nursing-homes/
80. Five-Star Quality Rating System – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/health-safety-standards/certification-compliance/five-star-quality-rating-system
81. Enforcement Actions | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services, accessed April 9, 2025, https://oig.hhs.gov/fraud/enforcement/?type=cmp-and-affirmative-exclusions
82. GAO-23-105312, NURSING HOMES: CMS Offers Useful Information on Website and Is Considering Additional Steps to Assess Underlying, accessed April 9, 2025, https://www.gao.gov/assets/gao-23-105312.pdf
83. GAO-10-197, Poorly Performing Nursing Homes: Special Focus Facilities Are Often Improving, but CMS’s Program Could Be Strengthened, accessed April 9, 2025, https://www.gao.gov/assets/a302123.html
84. Medicaid Budget Survey 2024-2025 – Provider Rates and Taxes – KFF, accessed April 9, 2025, https://www.kff.org/report-section/50-state-medicaid-budget-survey-fy-2024-2025-provider-rates-and-taxes/
85. Directed Payments in Medicaid Managed Care | MACPAC, accessed April 9, 2025, https://www.macpac.gov/wp-content/uploads/2024/10/Directed-Payments-in-Medicaid-Managed-Care.pdf
86. Methodological Approaches for Analyzing Use and Spending in Medicaid Long-Term Services and Supports: A Comparative Review | MACPAC, accessed April 9, 2025, https://www.macpac.gov/wp-content/uploads/2024/10/Methodological-Approaches-for-Analyzing-Use-and-Spending-in-Medicaid-Long-Term-Services-and-Supports-A-Comparative-Review.pdf
87. The Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/quality/nursing-home-improvement/value-based-purchasing
88. Mandated report: Evaluating the skilled nursing facility value-based purchasing program – MedPAC, accessed April 9, 2025, https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/default-document-library/jun21_ch4_medpac_report_to_congress_sec.pdf
89. Is the Value-Based Purchasing program on its way out? What SNFs need to know – Inovalon, accessed April 9, 2025, https://www.inovalon.com/blog/is-the-value-based-purchasing-program-on-its-way-out-what-snfs-need-to-know/
90. Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Updates to the Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2025, accessed April 9, 2025, https://www.federalregister.gov/documents/2024/08/06/2024-16907/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities
91. Medicare and Medicaid Programs; Civil Money Penalties for Nursing Homes, accessed April 9, 2025, https://www.federalregister.gov/documents/2010/07/12/2010-16927/medicare-and-medicaid-programs-civil-money-penalties-for-nursing-homes
92. Fact Sheet: Nursing Home Compare Five-Star Quality Rating System – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/consumerfactsheet.pdf
93. Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process – CMS, accessed April 9, 2025, https://www.cms.gov/files/document/revised-long-term-care-ltc-surveyor-guidance-significant-revisions-enhance-quality-and-oversight-ltc.pdf
94. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities – CMS, accessed April 9, 2025, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/SOM107ap_pp_Guidelines_ltcf.pdf
95. The Five-Star Nursing Home Rating System – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/scletter09-18.pdf
96. Nursing Home Environment and Resident Safety – NCBI, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK584652/
97. Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Ref: QSO-19-08-NH DATE: March 05, 2019 TO – CMS, accessed April 9, 2025, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-08-NH.pdf
98. Nursing Home Enforcement – CMS, accessed April 9, 2025, https://www.cms.gov/medicare/health-safety-standards/enforcement/nursing-home-enforcement
99. CMS Increases Mandatory Enforcement to Protect Nursing Home Residents, accessed April 9, 2025, https://medicareadvocacy.org/cms-increases-mandatory-enforcement-to-protect-nursing-home-residents/
100. Balancing Safety & Dignity: Guide to Nursing Home Restraint & Seclusion Policies, accessed April 9, 2025, https://protectseniors.com/articles/balancing-safety-and-dignity-a-guide-to-restraint-and-seclusion-policies-in-nursing-homes
101. Certificate of Need State Laws – National Conference of State Legislatures, accessed April 9, 2025, https://www.ncsl.org/health/certificate-of-need-state-laws
102. Advancing Certificate-of-Need Reform in Tennessee | PERI Policy Study, accessed April 9, 2025, https://peri.mtsu.edu/tn_conreform/
103. The Impact of Certificate-of-Need Laws on Nursing Home and Home Health Care Expenditures – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4916841/
104. Advocating for Older Adults in 2025—Health and Long-Term Services & Supports, accessed April 9, 2025, https://justiceinaging.org/advocating-for-older-adults-in-2025-health-and-long-term-services-supports/
105. Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule (CMS 3442-F), accessed April 9, 2025, https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid-0
106. Section Review-2024-March/April 2024 – Massachusetts Bar Association, accessed April 9, 2025, https://www.massbar.org/publications/section-review/section-review-article/section-review-2024-march-april-2024
107. Analysis: Final Nursing Home Staffing Rule Would Require 102,000 Additional Caregivers, Cost $6.5 Billion Per Year – AHCA/NCAL, accessed April 9, 2025, https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Analysis-Final-Nursing-Home-Staffing-Rule-Would-Require-102,000-Additional-Caregivers-Cost-$6.5-Billion-Per-Year.aspx
108. CMS finalizes minimum staffing standards for nursing homes | AHA News, accessed April 9, 2025, https://www.aha.org/news/headline/2024-04-22-cms-finalizes-minimum-staffing-standards-nursing-homes
109. SEIU’s Henry applauds new nursing home staffing standards, Medicaid access rule: ‘It is time to put care workers, residents and consumers first’, accessed April 9, 2025, https://www.seiu.org/2024/04/seius-henry-applauds-new-nursing-home-staffing-standards-medicaid-access-rule-it-is-time-to-put-care-workers-residents-and-consumers-first
110. Historic Staffing Standards: Let’s Make This Happen! – Service Employees International Union (SEIU), accessed April 9, 2025, https://www.seiu.org/blog/2023/9/historic-staffing-standards-lets-make-this-happen
111. High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information, accessed April 9, 2025, https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.00957
112. High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information, accessed April 9, 2025, https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00957
113. New Research On Health Care Staff Turnover And Quality Of Care At Nursing Homes, accessed April 9, 2025, https://www.pbjcentral.com/new-research-on-health-care-staff-turnover-and-quality-of-care-at-nursing-homes/
114. Impact of nurse burnout on organizational and position turnover – PMC – PubMed Central, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC7532952/
115. Nursing Staff Retention, Turnover Intention, and Job Satisfaction in California Nursing Home Facilities – ScholarWorks | Walden University Research, accessed April 9, 2025, https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=17211&context=dissertations
116. Assessing Recruitment and Retention Issues in Long-Term Care Facilities in New York City – Center for Health Workforce Studies, accessed April 9, 2025, https://www.chwsny.org/wp-content/uploads/2022/10/Martiniano-2022-UHF-Poster.pdf
117. Systematic Review of Retention of Direct-Care Workers in Long-term Care Facilities – ScholarWorks | Walden University Research, accessed April 9, 2025, https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=2458&context=dissertations
118. Factors Impacting Retention of Aged Care Workers: A Systematic Review – MDPI, accessed April 9, 2025, https://www.mdpi.com/2227-9032/11/23/3008
119. Nursing Assistants and Orderlies : Occupational Outlook Handbook, accessed April 9, 2025, https://www.bls.gov/ooh/healthcare/nursing-assistants.htm
120. Characteristics of effective interventions to optimise retention for early career nurses: a scoping review | medRxiv, accessed April 9, 2025, https://www.medrxiv.org/content/10.1101/2024.12.18.24319204v2.full-text
121. Strategies to Reduce Employee Turnover in Nursing Homes – ScholarWorks | Walden University Research, accessed April 9, 2025, https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=16829&context=dissertations
122. Registered Nurses – Bureau of Labor Statistics, accessed April 9, 2025, https://www.bls.gov/oes/current/oes291141.htm
123. 2024 Nurse Salary Guide, RN, LPN & CNA Pay Rates – TAG MedStaffing, accessed April 9, 2025, https://www.tagmedstaffing.com/2024-nurse-salary-guide/
124. Licensed Practical and Licensed Vocational Nurses – Bureau of Labor Statistics, accessed April 9, 2025, https://www.bls.gov/oes/2023/may/oes292061.htm
125. 2024–2025 LPN Salary: Figures & Salaries by State | IntelyCare, accessed April 9, 2025, https://www.intelycare.com/career-advice/lpn-salary-facts-figures-salaries-by-state/
126. Nursing Assistants – Bureau of Labor Statistics, accessed April 9, 2025, https://www.bls.gov/oes/2023/may/oes311131.htm
127. Nursing Salary Insights for RNs, LPNs and CNAs – Aequor, accessed April 9, 2025, https://www.aequor.com/resources/nursing-salary-insights-for-rns-lpns-and-cnas/
128. Training Standards for Personal Care Aides Across States: An Assessment of Current Standards and Leading Examples, accessed April 9, 2025, https://www.advancingstates.org/sites/default/files/Report-TrainingStandardsforPCAsAcrossStates.pdf
129. The Nursing Home Workforce – NCBI, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK584659/
130. The National Imperative to Improve Nursing Home Quality – LeadingAge Wisconsin, accessed April 9, 2025, https://leadingagewi.org/media/110619/report-on-quality-of-care-in-nursing-homes-4-22.pdf
131. The National Landscape of Personal Care Aide Training Standards – UCSF Health Workforce Research Center on Long-Term Care, accessed April 9, 2025, https://healthworkforce.ucsf.edu/sites/healthworkforce.ucsf.edu/files/Report-The_National_Landscape_of_Personal_Care_Aide_Training_Standards.pdf
132. Wide-Ranging Systemic Changes Needed to Transform Nursing Homes to Meet Needs of Residents, Families, and Staff, accessed April 9, 2025, https://www.nationalacademies.org/news/2022/04/wide-ranging-systemic-changes-needed-to-transform-nursing-homes-to-meet-needs-of-residents-families-and-staff
133. The Effects of Nurse Burnout on Patient Experiences – Scientific Research Publishing, accessed April 9, 2025, https://www.scirp.org/journal/paperinformation?paperid=120178
134. Impact of nurse burnout on organizational and position turnover – ResearchGate, accessed April 9, 2025, https://www.researchgate.net/publication/345991596_Impact_of_nurse_burnout_on_organizational_and_position_turnover
135. Burnout in UK care home staff and its effect on staff turnover: MARQUE English national care home longitudinal survey – Oxford Academic, accessed April 9, 2025, https://academic.oup.com/ageing/article/49/1/74/5607680
136. Influence of Workload on Primary Care Nurses’ Health and Burnout, Patients’ Safety, and Quality of Care: Integrative Review – MDPI, accessed April 9, 2025, https://www.mdpi.com/2227-9032/8/1/12
137. Association of Work Schedules With Nurse Turnover: A Cross-Sectional National Study, accessed April 9, 2025, https://www.ssph-journal.org/journals/international-journal-of-public-health/articles/10.3389/ijph.2023.1605732/full
138. Nurses’ burnout and quality of life: A systematic review and critical analysis of measures used – PMC – PubMed Central, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8994939/
139. Experienced Nurses: Improving Retention by Implementing Strategies Found in Research and, accessed April 9, 2025, https://nursing.jhu.edu/wp-content/uploads/2023/10/Matta_H_Abstract.pdf
140. Racial Disparities in Nursing Facilities—and How to Address Them – Justice in Aging, accessed April 9, 2025, https://justiceinaging.org/wp-content/uploads/2022/09/Racial-Disparities-in-Nursing-Facilities.pdf
141. Rurality and Nursing Home Quality: Evidence From the 2004 National Nursing Home Survey | The Gerontologist | Oxford Academic, accessed April 9, 2025, https://academic.oup.com/gerontologist/article/51/6/761/818971
142. About – SEIU Healthcare 1199NW, accessed April 9, 2025, https://www.seiu1199nw.org/about/
143. About – Service Employees International Union (SEIU) – Fighting for Unions for All so every worker can bargain for a better life., accessed April 9, 2025, https://www.seiu.org/about/
144. The Role of Labor Unions in Creating Working Conditions That Promote Public Health, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4880255/
145. Union Organizing Trends in the Healthcare Industry | Insights – Holland & Knight, accessed April 9, 2025, https://www.hklaw.com/en/insights/publications/2010/10/union-organizing-trends-in-the-healthcare-industry
146. What do health care unions do? A response to Manthous – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC11090101/
147. Residents’ Rights Fact Sheets (Set of 50) – The Consumer Voice, accessed April 9, 2025, https://theconsumervoice.org/product/residents-rights-fact-sheet/
148. Celebrating Residents’ Rights Month: Advocating for Dignity and Respect | ACL Administration for Community Living, accessed April 9, 2025, https://acl.gov/news-and-events/acl-blog/celebrating-residents-rights-month-advocating-dignity-and-respect
149. Older people’s perceived autonomy in residential care: An integrative review – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8151558/
150. A qualitative study of family members’ perspectives regarding decision-making for nursing home residents’ care – ResearchGate, accessed April 9, 2025, https://www.researchgate.net/publication/381612451_A_qualitative_study_of_family_members’_perspectives_regarding_decision-making_for_nursing_home_residents’_care
151. Full article: A qualitative study of family members’ perspectives regarding decision-making for nursing home residents’ care – Taylor & Francis Online, accessed April 9, 2025, https://www.tandfonline.com/doi/full/10.1080/17482631.2024.2370545
152. Nursing Homes – Justice in Aging, accessed April 9, 2025, https://justiceinaging.org/issues/nursing-homes/
153. The Consumer Voice: Home, accessed April 9, 2025, https://theconsumervoice.org/
154. NUrsing Homes End of Life care Program (NUHELP): developing a complex intervention, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8234765/
155. Ethical considerations at the end-of-life care – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC7958189/
156. End-of-Life Care in the Nursing Home – Is a Good Death Compatible with Regulatory Compliance – Center for Practical Bioethics, accessed April 9, 2025, https://www.practicalbioethics.org/wp-content/uploads/2021/11/End-of-Life-Care-in-the-Nursing-Home-1.pdf
157. Improving end-of-life care – CEConnection, accessed April 9, 2025, https://nursing.ceconnection.com/ovidfiles/00006205-201609000-00004.pdf
158. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial | The BMJ, accessed April 9, 2025, https://www.bmj.com/content/340/bmj.c1345
159. Advance Directives at End-of-Life: Nursing Home Resident Preferences for Artificial Nutrition – Digital Commons @ West Chester University, accessed April 9, 2025, https://digitalcommons.wcupa.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1009&context=nurs_facpub
160. Proposed Nursing Home Regulations Could Put Residents at Risk, accessed April 9, 2025, https://www.americanbar.org/groups/law_aging/publications/bifocal/vol-41/volume-41-issue-1/sweeping-regulations-proposed-for-nursing-homes-could-threaten-r/
161. Allocating Limited Health Care Resources – Code of Medical Ethics, accessed April 9, 2025, https://code-medical-ethics.ama-assn.org/ethics-opinions/allocating-limited-health-care-resources
162. Financial Compensation and Ethical Issues in Health Care | OJIN, accessed April 9, 2025, https://ojin.nursingworld.org/table-of-contents/volume-3-1998/number-1-june-1998/compensation-and-ethical/
163. Disparities in Health and Health Care: 5 Key Questions and Answers – KFF, accessed April 9, 2025, https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/
164. Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings – PubMed, accessed April 9, 2025, https://pubmed.ncbi.nlm.nih.gov/29983361/
165. Healthcare Access Disparities among Rural Populations in the United States – Ballard Brief, accessed April 9, 2025, https://ballardbrief.byu.edu/issue-briefs/healthcare-access-disparities-among-rural-populations-in-the-united-states
166. Rural Health Disparities Overview, accessed April 9, 2025, https://www.ruralhealthinfo.org/topics/rural-health-disparities
167. The Role of Family Involvement in Long-Term Care | Blog – St. James Rehab, accessed April 9, 2025, https://www.stjamesrehab.com/blog/the-role-of-family-involvement-in-long-term-care
168. Family involvement in nursing homes: an interpretative synthesis of literature, accessed April 9, 2025, https://www.researchgate.net/publication/361483613_Family_involvement_in_nursing_homes_an_interpretative_synthesis_of_literature
169. Family involvement in nursing homes: an interpretative synthesis of literature – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9527362/
170. Family Involvement in Residential Long-Term Care: A Synthesis and Critical Review – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC2247412/
171. Ethical Issues Associated with Family Involvement in Patient Care: A Scoping Review, accessed April 9, 2025, https://internationaljournalofcaringsciences.org/docs/49.cameron.pdf
172. Nursing Ethical Considerations – StatPearls – NCBI Bookshelf, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK526054/
173. Sustainability principle for the ethics of healthcare resource allocation, accessed April 9, 2025, https://jme.bmj.com/content/47/2/90
174. An Ethics Framework for Making Resource Allocation Decisions Within Clinical Care: Responding to COVID-19 | Request PDF – ResearchGate, accessed April 9, 2025, https://www.researchgate.net/publication/343863718_An_Ethics_Framework_for_Making_Resource_Allocation_Decisions_Within_Clinical_Care_Responding_to_COVID-19
175. Fair Allocation of Critical Care Resources – UNC Center for Bioethics, accessed April 9, 2025, https://bioethics.unc.edu/old-pages/fairly-allocating-scarce-medical-resources/
176. The Impact of Green House Adoption on Medicare Spending and Utilization – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC5338209/
177. The Big Idea Behind A New Model Of Small Nursing Homes – Health Affairs, accessed April 9, 2025, https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.00081
178. The Green House Model of Nursing Home Care in Design and Implementation – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC5338211/
179. Research – Green House Project, accessed April 9, 2025, https://thegreenhouseproject.org/resources/research/
180. What Health and Aged Care Culture Change Models Mean for Residents and Their Families: A Systematic Review | The Gerontologist | Oxford Academic, accessed April 9, 2025, https://academic.oup.com/gerontologist/article/56/2/e12/2952875
181. The impact of the Eden Alternative on quality of life of nursing home residents, accessed April 9, 2025, https://digitalcommons.unl.edu/dissertations/AAI3126962/
182. THE CHANGING FACE OF LONG-TERM CARE: LOOKING AT THE PAST DECADE – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6339528/
183. Beyond the Basics: Effects of the Eden Alternative Model on Quality of Life Issues, accessed April 9, 2025, https://www.researchgate.net/publication/8480393_Beyond_the_Basics_Effects_of_the_Eden_Alternative_Model_on_Quality_of_Life_Issues
184. Influence of the Eden Alternative™ on the Functional Status of Nursing Home Residents, accessed April 9, 2025, https://www.researchgate.net/publication/304015222_Influence_of_the_Eden_Alternative_on_the_Functional_Status_of_Nursing_Home_Residents
185. Impact of the Eden Alternative on family satisfaction – PubMed, accessed April 9, 2025, https://pubmed.ncbi.nlm.nih.gov/15894248/
186. How “dementia villages” work – YouTube, accessed April 9, 2025, https://www.youtube.com/watch?v=LN_–egst3s&pp=0gcJCfcAhR29_xXO
187. Dementia Villages: Innovative Residential Care for People With Dementia | CDA-AMC, accessed April 9, 2025, https://www.cda-amc.ca/dementia-villages-innovative-residential-care-people-dementia
188. Dementia Villages – Position Statement | CDA-AMC – Canada’s Drug Agency, accessed April 9, 2025, https://www.cda-amc.ca/dementia-villages-position-statement
189. Inspiring Dutch village for those with Dementia – Opera Beds, accessed April 9, 2025, https://operabeds.com/blogs/news/dutch-dementia-village
190. Dementia Village Viability Within the Current U.S. Healthcare System – NHSJS, accessed April 9, 2025, https://nhsjs.com/2024/dementia-village-viability-within-the-current-u-s-healthcare-system/
191. The Hogeweyk village: rethinking normalcy for people living with dementia – The Lovepost, accessed April 9, 2025, https://www.thelovepost.global/the-hogeweyk-village-rethinking-normalcy-for-people-living-with-dementia/
192. Why Dementia Village Projects Like the Dutch Hogeweyk Remain Rare in the U.S., accessed April 9, 2025, https://seniorhousingnews.com/2024/06/12/why-dementia-village-projects-like-the-dutch-hogeweyk-remain-rare-in-the-u-s/
193. Innovative Assisted Living Tools, Remote Monitoring Technologies, Artificial Intelligence-Driven Solutions, and Robotic Systems for Aging Societies: Systematic Review, accessed April 9, 2025, https://aging.jmir.org/2019/2/e15429/
194. Innovative assisted living tools, remote monitoring technologies, artificial intelligence-driven solutions, and robotic systems for aging societies: Systematic review – Adelphi University, accessed April 9, 2025, https://scholarlyworks.adelphi.edu/esploro/outputs/journalArticle/Innovative-assisted-living-tools-remote-monitoring/991004360700106266
195. (PDF) Innovative Assisted Living Tools, Remote Monitoring Technologies, Artificial Intelligence-Driven Solutions, and Robotic Systems for Aging Societies: Systematic Review – ResearchGate, accessed April 9, 2025, https://www.researchgate.net/publication/337638395_Innovative_Assisted_Living_Tools_Remote_Monitoring_Technologies_Artificial_Intelligence-Driven_Solutions_and_Robotic_Systems_for_Aging_Societies_Systematic_Review
196. Artificial Intelligence (AI) and Robotics in Elderly Healthcare: Enabling Independence and Quality of Life – PMC, accessed April 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10474924/
197. Robots for Elderly Care: Review, Multi-Criteria Optimization Model and Qualitative Case Study – MDPI, accessed April 9, 2025, https://www.mdpi.com/resolver?pii=healthcare11091286
198. Enhancing Elderly Health Monitoring: Achieving Autonomous and Secure Living through the Integration of Artificial Intelligence, Autonomous Robots, and Sensors – MDPI, accessed April 9, 2025, https://www.mdpi.com/2079-9292/12/18/3918
199. The Dementia Village: Between Community and Society – Care in Healthcare – NCBI, accessed April 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK543750/
200. Mirror, Mirror 2021: Reflecting Poorly | Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
201. Global Report on Long-Term Care Financing – WHO/OMS: Extranet Systems, accessed April 9, 2025, https://extranet.who.int/kobe_centre/sites/default/files/WHO_Report_Draft_Juen2022_r.pdf
202. International Profiles of Health Care Systems – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2017_may_mossialos_intl_profiles_v5.pdf
203. Spending, Use of Services, Prices, and Health in 13 Countries – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-global-perspective
204. Comparing the NHS to the health care systems of other countries: five charts, accessed April 9, 2025, https://www.kingsfund.org.uk/insight-and-analysis/blogs/comparing-nhs-to-health-care-systems-other-countries
205. Health Care Affordability for Older Adults: How the U.S. Compares to Other Countries – Commonwealth Fund, accessed April 9, 2025, https://www.commonwealthfund.org/publications/issue-briefs/2024/dec/health-care-affordability-older-adults-how-us-compares-other-countries
206. Affordable, Accessible Health Care – AAHD, accessed April 9, 2025, https://aahd.us/2025/02/affordable-accessible-health-care/