Rural Nursing Homes Foresee Financial Strain, Fear Failure To Qualify for Exemptions from CMS’ Staffing Mandate

Nursing homes in states with large rural communities have long struggled to grapple with workforce issues, and for most of these rural providers there seems to be no end in sight, making fulfilling the federal government’s staffing mandate an impossibility.

For such communities, registered nurses (RNs) are especially hard to recruit, and statistics paint a grim picture on the ability of facilities in regions like Nebraska, for example, to become eligible for the staffing rule’s exemptions. Moreover, many providers happen to like the staffing model adjusted to suit their unique regional needs.

That said, these rural communities are trying their best to counter the staffing issues through better educational, training and retention efforts, but say they need additional help and funds.


Jalene Carpenter, president and CEO of the Nebraska Health Care Association said that the 24/7 registered nurse (RN) staffing requirement is particularly impractical for Nebraska, which has a considerable number of rural facilities.

“Having a 24/7 RN requirement is not at all feasible,” Carpenter told Skilled Nursing News.

The existing state regulations allow facilities to staff according to the unique needs of their residents, a model that Carpenter believes ensures better care than a one-size-fits-all mandate. She criticized the inflexible federal mandate for not accommodating the diverse needs of different facilities and residents.


“I would also say Nebraska had what we felt was a very good model, where the regulations are very clear: your staff should meet the residents’ needs, and every facility was unique,” she said. “So, having this one-size-fits-all approach is not something that we support, and we believe it is actually not best for the residents or the providers.”

The story is not so different for rural communities in the Northeast. The majority of nursing homes in New Hampshire are in rural areas and will struggle to meet the requirements of the staffing mandate, according to Brendan Williams, president and CEO of the New Hampshire Health Care Association.

“We cannot afford to have the federal government erase the small progress we have made at the state level,” Williams said in a press release.

An analysis by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) found that the unfunded federal mandate would cost New Hampshire nursing homes $30.4 million a year.

And Nebraska and New Hampshire are just two of the many states scrambling to figure out how the mandate will play out for more rural facilities.

Ineligibility for exemption waivers

Despite the hope that exemption waivers might provide some relief, Carpenter revealed a stark reality.

“Based upon our national affiliates’ analysis, there is no single facility in Nebraska that would be eligible for the waiver,” she said.

She said the criteria for these waivers, which include being in a workforce shortage area and falling 20% below the national average in staffing, do not apply to any Nebraska facilities.

Carpenter added that 95% of these facilities do not currently meet the 24/7 RN requirement, and some counties don’t even have an RN residing within their borders. This shortage is exacerbated by the state’s overall workforce deficit, which makes it impossible to comply with the new mandate.

Efforts to recruit and retain nurses include doubling scholarship funds and collaborating with immigration and refugee organizations, but these measures are long-term solutions that won’t address the immediate crisis, she said.

On a more hopeful note, Carpenter highlighted legislative efforts aimed at blocking the staffing mandate. Senator Deb Fischer and other federal delegates from Nebraska have introduced legislation to counteract the mandate.

“We are very supportive of the fact that all of our federal delegation has been incredibly supportive as well as our governor’s office. We can continue to appreciate that support, because this [mandate] would be a huge burden. Not just when it comes to the facility level of finding staff and paying staff, but there’s also going to be a fiscal burden that is going to be for the state of Nebraska, to be able to pay for this increase.”

Moreover, on the national level, the American Health Care Association (AHCA) and several Texas-based providers filed a lawsuit against federal agencies last week, in an attempt to get the staffing mandate dismissed altogether. And, legal experts told Skilled Nursing News that the lawsuit has a strong likelihood of succeeding.

Meanwhile, at the facility level in rural communities, there are efforts underway to stay afloat.

One notable example is Burwell Community Memorial Health Center in Nebraska. Initially struggling with debt and outsourced management, the center managed a turnaround by emphasizing local services, strong management, and a commitment to staff well-being.

Administrator Tim Groshans credited the not-for-profit model and a focus on competitive salaries, benefits, and facility improvements for their success. The center’s efforts include offering attractive pay rates, housing options for employees, and comprehensive health insurance coverage to retain skilled staff.

Additionally, the University of Nebraska Medical Center (UNMC) is building a new health care education facility to train more nurses and healthcare workers, particularly for rural areas.

“I can’t stress enough how committed our facilities are to quality,” Carpenter said. “And we believe that following an individualized approach where every facility staff to meet the residents needs is a much better approach than this so I can’t stress enough that they have their commitment to quality. This unfortunately, is not a path to quality for our state. It is an immediate path to closure.”

Closely monitoring timelines

Meagan English, chief people officer at Oregon-based Marquis Companies, said rural facilities can prepare for the mandate’s implementation by closely monitoring timelines, requirements, and community assessments to understand qualifications for waivers and grants. These resources can aid in staff development, she added. 

She acknowledged that this process is particularly challenging for rural communities, which face higher risks, and stressed the need to identify current resources and potential local talent for growth.

“I think for rural communities, it is going to be harder and trickier,” she said. “There is a real risk for all of our communities, especially rural ones. So, figuring out right now what you can be doing, who you have in your midst to grow, and what resources might be available is really, really hard.”

Sally Cantwell, senior VP of Organizational Development at Utah-based PACS, said another pathway for rural facilities is turning CNAs into nurses through partnerships and transparent career pathways. 

“Identify your needs in space,” she said. “What are they? Where are your strengths, can you grow from within? Can you get CNAs more simply than you can nurses? So, turn your CNAs into your nurses with those partnerships that are so valuable.”

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