The 2024 requirements for 24/7 RN coverage and minimum hours per resident day for RNs and nurse aides were officially rescinded as of February 2, 2026. Currently, thirty-six states have some type of minimum staffing requirements. Attorneys general from eighteen states are asking CMS to consider a new staffing rule for certain for-profit nursing homes (NHs)  demonstrating high-risk financial and ownership practices. 1

 In 1985, I became a director of nursing (DON) in southern California because I was curious about how so few RNs could effectively take care of many residents. I now wish that I had first read Bruce C. Vladeck’s 1980 seminal book “Unloving Care: the Nursing Home Tragedy.2 It would have helped me understand then what is now clear to me. That is - that the industry has always been structured as a mostly private enterprise that benefited from its relative detachment from the mainstream healthcare system, although this is changing.

As a professional nurse, Vladeck’s insight has helped me understand why the NH industry has consistently resisted implementation of policies to advance excellence in nursing practice. For example, in 1965, when the original conditions of participation were written for federal Medicare and Medicaid program participation, RNs were not distinguished from licensed vocational and practical nurses (LVNs/LPNS)  for their unique contributions to nursing care. Instead, the two types of nursing skill mix were termed as ‘licensed nurses.” This enabled the industry to employ LVNs/LPNs as perfect substitutes for RNs, even though RN education and licensure focuses uniquely on comprehensive clinical assessment and coordination of nursing care. The practical reality is that RNs cost more money to employ than LVNs/LPNs. Also, researchers have demonstrated that RN staffing levels are associated with better outcomes.3  

This is not to suggest that there are not excellent LVNs/LPNs, nor, on occasion, that they might even be better clinicians than an individual RN. But the reality is that RNs’ education and federal/state scopes of practice are different from that of LVNs/LPNs. While RNs perform physical and technical care, they are supposed to be competent in solving complex care management and delivery issues. They can do this only if their employers create a work environment that enables them to demonstrate their professional agency.3

The approach of focusing on “licensed nurses” also exploited a fundamental tension existing within the nursing profession. 3 While this may seem like an “in the professional weeds” for physicians, this staffing practice has adversely affected nursing practice. Since 1948, professional nursing has struggled to establish itself as an applied science. It has behaved in ways that created internal tensions between university-prepared RNs and other nursing members of the nursing skill mix. Tensions remain among RNs who work in or have an interest in advancing nursing home quality. For example, members of the American Academy of Nursing (AAN); the National Association of Directors of Nursing (NADONA); and the American Association of Post-Acute Care Nursing (AAPACN) are not united. As a member of each organization, this lack of unity limits their capacity to most effectively advocate for nursing home quality, in my opinion. 

So, given all of this, what is a way forward – a way to stay hopeful as professional RNs and concerned consumers? Here are some suggestions, with an acknowledgement that those who are currently employed in NHs may face significant resistance in acting on these suggestions.

1. Actively support the meaningful implementation of the facility assessment regulation (42 CFR § 483.71), particularly within AAN, NADONA, and AAPACN.

2. Use the “Nursing Home Guide to Adjusting Nurse Staffing for Resident Case-Mix as a guide. (https://doi.org/10/10.1111/jgs.19501).4

3. Support efforts by the eighteen state attorneys general who are working with CMS to advance nurse staffing legislation. 

4. Continue to educate the public about the adverse impact of private equity firm ownership in California.

5. Promote greater professional partnership between Medical Directors and DONs.

6. Encourage DONs to establish greater respect for the practice of paraprofessionals in NHs, (i.e. including the understanding that RNs cannot solve clinical problems without the observations and data collection of these nursing staff members) and use such information to create practice improvements.

References

1. Skillednursingnews.com/2026/02/18-states-urge-cms-to-consider-nursing home

2. Vladeck, BC (1980). Unloving care: The nursing home tragedy. Basic Books, Inc. New York

3. Dellefield ME & Madrigal C. Nursing leadership-Transforming the work environment in nursing homes. Nurs Clin North Am 2022 Jun; 57(2): 299-314. Doi: 10.1016/j.cnur.2022.02.008

4. Harrington CA, McLaughlin RA, Saliba D, Halifax E, Mollot RJ, Romano PS, Tancredi DJ, Mukamel DB. Nursing home guide to adjusting nurse staffing for resident case-mix. Journal of the American Geriatrics Society, May 02, 2025