Two federal courts. Two defeats for nursing home residents. One critical reform effort now hanging in the balance.
A federal judge in Iowa vacated essential parts of the first-ever federal nursing home staffing mandate — a decision that stripped away a requirement for 24/7 registered nurse coverage and daily minimum staffing hours. This decision came just weeks after a federal judge in Texas issued a similar ruling, marking the second major blow to the Biden administration’s attempt to raise the bar for safety and accountability in America’s nursing homes.
Together, the rulings leave residents more vulnerable than ever.
A Brief History: Why the Staffing Mandate Was Created
The push for federal staffing standards began in earnest in early 2022, when the Biden administration announced its plan to “crack down on unsafe nursing homes.” The announcement came just ahead of the State of the Union address and in direct response to widespread failures during the COVID-19 pandemic, which claimed the lives of more than 200,000 nursing home residents and staff — nearly a quarter of all U.S. COVID-19 deaths.
In its sweeping reform plan, CMS committed to establishing minimum staffing levels, requiring:
- A registered nurse (RN) on duty 24/7
- At least 3.48 total nursing hours per resident per day, including minimums for RNs and nurse aides
The initiative also promised to phase out crowded multi-resident rooms, reduce the inappropriate use of antipsychotics, track corporate ownership, and tie payment rates to staffing and resident satisfaction.
This was the first time in U.S. history that the federal government proposed enforceable, measurable staffing minimums for every Medicare- and Medicaid-funded nursing facility — moving beyond vague “sufficiency” language and into the realm of enforceable standards.
The First Blow: Texas Court Tosses the Rule
On June 17, 2024, Judge Matthew Kacsmaryk of the U.S. District Court for the Northern District of Texas delivered the first fatal hit. In a sweeping ruling in favor of the American Health Care Association, LeadingAge, and several nursing home providers, the court invalidated the staffing mandate on the grounds that CMS had overstepped its legal authority.
Judge Kacsmaryk wrote that only Congress has the power to set staffing standards that override the existing statutory language, which requires an RN for 8 hours per day, not 24. He called the CMS rule “a 20th-century solution” and criticized it as a one-size-fits-all measure that failed to account for local staffing realities, especially in rural areas.
Industry leaders celebrated. At the AHCA Quality Summit in Atlanta, the room gave a standing ovation when the ruling was announced. LeadingAge and AHCA executives proclaimed the decision a “major victory” and called on Congress to block the rule permanently.
But for residents and advocates, the ruling was devastating. As Sam Brooks, policy director for the National Consumer Voice for Quality Long-Term Care, said: “This modest rule would prevent nearly 14,000 pressure ulcers, reduce hospitalizations, and make the lives of hundreds of thousands of nursing home residents better.”
The Second Blow: Iowa Court Echoes Texas
Just weeks later, U.S. District Judge Leonard T. Strand in Iowa followed suit. Like his Texas counterpart, Judge Strand ruled that CMS exceeded its authority by imposing rigid RN staffing requirements and hourly care minimums.
This ruling added fuel to the industry’s campaign against the mandate, with states and nursing home associations hailing it as a win for “flexibility” and “local solutions.”
But from the perspective of resident safety, this is a dangerous rollback.
As attorney Donna MacKenzie of Olsman MacKenzie Peacock noted: “Removing these safeguards means going back to a system where facilities can legally operate without a registered nurse on duty overnight or on weekends — precisely when emergencies happen. That’s not innovation. That’s regression.”
What’s at Stake
Both rulings gut the core of the staffing rule, but they do not affect other reforms — such as transparency on ownership, reporting of staffing levels, or public posting of whether a facility meets staffing expectations. Still, without enforceable minimums, these reforms lose teeth.
This legal battle is far from over. CMS has already filed a notice of appeal in at least one of the cases. But with a new administration potentially unwilling to defend the rule, and with Congress showing signs of bipartisan discomfort — particularly from rural lawmakers — the rule’s future remains in jeopardy.
Final Thoughts
For decades, the nursing home industry has said it “wants to do better.” Yet when finally faced with a requirement to be better, it sued — and won. Twice.
These court decisions reflect not just a legal setback but a moral one. At Olsman MacKenzie Peacock, we believe staffing saves lives. Our clients’ stories — of missed medications, ignored infections, and preventable deaths — are not isolated. They are systemic. And they are exactly what the staffing mandate was designed to prevent.
We will continue to fight for higher standards, real accountability, and the right of every nursing home resident to receive safe, dignified, and professional care.
If you believe your loved one has suffered due to inadequate staffing, contact us. Our commitment is to the residents and families who trusted these facilities to care for them — and were let down. We will keep holding these companies accountable, one case at a time.