Staffing shortfalls in U.S. nursing homes are still widespread despite new federal requirements — and residents are paying the price, a new study finds.
Researchers analyzing more than 1,200 facilities nationwide reported that understaffed homes saw a 22% rise in adverse events, including falls and pressure ulcers, compared with better-staffed peers. Facilities with the lowest staffing also recorded a 15% higher mortality rate. The findings were published October 28 in BMC Health Services Research and draw on federal data from 2023 to 2025, along with interviews with administrators and family caregivers across 15 states.
The study arrives as the Centers for Medicare & Medicaid Services (CMS) begins phasing in the first-ever federal minimum staffing rule. Even so, the median hours-per-resident-day (hprd) reported in 2025 — 3.12 — fell short of the 3.48 minimum, which includes at least 0.55 hprd from registered nurses. According to the analysis, 68% of facilities reported non-compliance after the rule was finalized in 2024.
What the researchers found
The mixed-methods study tracked staffing and outcomes using CMS Payroll-Based Journal and Minimum Data Set records for roughly 150,000 residents in 1,247 facilities. Homes providing fewer than 3.0 hprd had 1.8 times higher odds of hospital readmission (OR=1.82; 95% CI 1.45–2.28) and significantly more preventable harms, including a 28% increase in urinary tract infections. Among residents with dementia — 42% of the sample — low staffing was associated with 19% more behavioral incidents requiring restraints.
Rural facilities, which made up about a third of the sample, faced the steepest shortages, with staffing levels roughly 25% lower than urban counterparts. The authors cite ongoing economic pressures, wage competition from hospitals, and immigration constraints as drivers of shortages; registered nurse vacancies reached an estimated 18% nationally in 2025, up from 12% in 2022.
“Staffing is not just a numbers game — it’s the linchpin of dignity in long-term care,” lead author Dr. Elena Ramirez of Johns Hopkins said in a statement. “Without addressing shortages, we’re condemning residents to substandard care amid a demographic tsunami.”
Inside facilities: burnout, moral distress, and delayed care
Interview data from 89 administrators and 112 family caregivers painted a stark on-the-ground picture. Staff cited burnout and moral distress; one administrator described rationing care, such as bathing residents every other day instead of daily. Sixty-two percent of family members reported delayed responses to call lights and routine needs. “My mother waited 45 minutes for pain meds because there was only one nurse for 30 residents,” said one Ohio caregiver interviewed for the study.
By contrast, high-performing facilities in the top staffing quintile recorded substantially better satisfaction scores in federal surveys, the authors noted, suggesting the quality gap is not inevitable.
Rule under pressure — and what it might take to fix staffing
The CMS minimum staffing rule is being phased in over several years, with implementation delayed in parts of the country due to lawsuits from industry groups and state challenges. CMS leaders have described the standards as a baseline, not a ceiling, and warned that persistent non-compliance could bring significant penalties next year. Industry groups counter that the rule carries unsustainable costs, especially for rural homes, and say states must raise Medicaid rates to make compliance feasible.
The study recommends a package of financial and workforce strategies: federal incentives for training and career ladders, state wage subsidies for certified nursing assistants — whose turnover reached an estimated 94% in 2024 — and tying Medicaid payments to verified staffing audits. The authors also point to technology supports, such as remote monitoring and virtual aides, as potential efficiency boosts, while acknowledging that tools cannot replace core bedside staff.
Importantly, the researchers estimate that full compliance with staffing standards could avert costly hospitalizations and save roughly $4.2 billion annually, based on recent federal cost data. With 1.3 million residents in skilled nursing facilities and an aging population headed toward 80 million adults 65 and older by 2040, they argue the status quo is untenable.
Healthcare experts say the evidence adds urgency to a long-running problem. “Post-pandemic, we’ve underinvested in care workers,” said Dr. Ashish Jha in a recent broadcast interview. “This study quantifies what we knew anecdotally: low staffing kills.”
