Impact of Medicare Rescinding the 24 Hour Nursing Home RN Rule

On December 2–3, 2025, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule removing the federal requirement that Medicare- and Medicaid-participating nursing homes maintain a registered nurse (RN) on-site 24 hours per day and rescinding the minimum-hours-per-resident-day staffing floors that had been adopted in 2024. The change reverses the 2024 rule that had required a minimum of 3.48 total nursing hours per resident per day, including 0.55 RN hours per resident per day (and a 24/7 RN presence). CMS framed the repeal as a step to reduce regulatory burden and expand access in rural and tribal areas. Advocates, unions, and many families view the move as a rollback that will worsen resident safety.

This blog explains what the repeal means in practice, why less RN coverage increases the likelihood of nursing home neglect and adverse outcomes, what data and peer-reviewed research show about staffing and patient safety, practical warning signs families should watch for, and what legal options exist when neglect occurs.

“Removing a federal guarantee of around-the-clock registered nurse coverage places our most vulnerable residents at greater risk. RNs are the frontline clinicians who spot subtle changes that can mean the difference between recovery and tragedy. Families deserve better than policies that normalize understaffing.” — John J. Malm, Naperville nursing home abuse attorney

What Changed

• The 2024 minimum-staffing rule required nursing homes to provide, on average, at least 3.48 total nursing hours per resident each day: 0.55 RN hours and 2.45 nurse-aide hours. It also required an RN on-site 24/7.
• In early December 2025, CMS issued an interim final rule that removes both the minimum hours per resident day standards and the 24/7 RN on-site requirement for Medicare/Medicaid-certified facilities; the repeal takes effect under the timeline specified in the Federal Register and allows comment.

Why RN Presence Matters in Nursing Homes

Registered nurses perform assessments, detect and respond to acute changes, manage medications and complex wounds, and lead care teams. RNs are trained to recognize early signs of sepsis, dehydration, pressure injuries, failing swallowing safety, and other conditions that, if unrecognized, quickly lead to serious harm. Without sufficient RN coverage:

• Early warning signs are more likely to be missed or misinterpreted.
• Medication errors and delayed treatments increase.
• Pressure injuries, infections, and preventable hospitalizations rise.
• Nurse aides have less supervision and clinical guidance.

A substantial body of evidence links higher RN staffing and overall nurse staffing to better outcomes: fewer pressure ulcers, lower infection rates, fewer hospital readmissions, and lower mortality. Systematic reviews and national studies show consistent associations between lower nursing staffing and worse patient safety metrics.

What the Data Says Now

• National estimates published by HHS/ASPE during the 2024 rulemaking showed that before the 2024 rule roughly 59% of nursing homes met or exceeded the 3.48 HPRD benchmark; others fell short. That baseline illustrated widespread variability in staffing across facilities.
• CMS’s Nursing Home Staffing Study and PBJ (payroll-based journal) data repeatedly document large state-to-state variation and frequent understaffing relative to recommended levels. Many homes operate with RN HPRD well below the levels associated with good clinical outcomes.
• During and after the COVID-19 pandemic, staffing worsened in many places: one modeling analysis noted very high rates of understaffing during the pandemic and that in 2021 up to 94% of nursing homes were understaffed at times; subsequent recovery remained incomplete. Staffing shortages are a persistent structural problem.

How Eliminating the 24/7 RN Requirement Can Lead to Neglect

Removing guaranteed RN coverage does not by itself create neglect, but it materially increases the risk of neglect through several mechanisms:

• Less clinical surveillance: acute deterioration (infection, stroke, heart attack, sepsis) is more likely to be missed during periods without an RN.
• Weaker medication oversight: RNs cross-check orders, manage complex regimens, and often prevent dosing errors that lead to harm.
• Fewer skilled assessments: wound care, IV therapy, catheter management and fall risk assessments require RN skills; delays degrade outcomes.
• Overreliance on less-trained staff: nurse aides and licensed practical nurses (LPNs) may be asked to assume tasks beyond training without adequate supervision.
• Increased workload and burnout: fewer RNs mean higher patient loads per RN when they are on site, a proven contributor to missed care, errors, and turnover.

Collectively, these factors make neglect more likely to occur and less likely to be discovered early.

Concrete Harms to Expect When RN Coverage Falls

• Increased pressure ulcers and wound progression because early signs are missed.
• Higher rates of preventable infections (e.g., urinary tract infections, aspiration pneumonia).
• More medication errors and adverse drug events.
• More hospital transfers for conditions that could have been treated in the facility if recognized early.
• Poorer chronic disease management (diabetes, heart failure), leading to decline.

Multiple studies and systematic reviews link these outcomes to lower RN staffing and missed nursing care.

Who is Most at Risk

• Residents with complex medical needs (IV therapy, wound care, feeding tubes, COPD, heart failure).
• Residents with dementia or communication barriers who cannot reliably report symptoms.
• New admissions and recently discharged hospital patients who require careful monitoring.
• Facilities in rural or resource-constrained areas that already struggle to recruit RNs.

What Families and Advocates Should Watch For

• Repeated delays in medication administration or missed medications.
• Worsening pressure injuries, unexplained wounds, or rapid skin breakdown.
• Recurrent, unexplained infections (UTIs, pneumonia).
• Frequent ambulance calls or hospital transfers for issues that could have been caught earlier.
• Staff frequently saying “we don’t have an RN right now” or obvious gaps in clinical care at night/overnights.
• Staff turnover so high that residents see different caregivers daily.

If you observe these signs, document dates/times, take photos (where permitted), and ask for the clinical record and care plan updates. These records often become critical evidence if legal action is necessary.

Practical Steps Families Can Take Now

• Ask the facility for its staffing plan and RN coverage schedule; request written responses.
• Demand to see the care plan and ask how the facility would monitor acute changes overnight.
• Record (date/time) instances of delayed or missed care; preserve medication administration records and incident reports.
• Contact the IDPH to file a complaint. The IDPH investigates neglect and staffing violations.
• If you suspect neglect or harm, consult an Illinois attorney experienced in nursing-home neglect and long-term care litigation. Documented evidence of understaffing, incident reports, and the resident’s medical records strengthen legal claims.

Why Families Still Have Legal Recourse

Even though CMS removed the federal 24/7 RN floor, nursing homes remain subject to other federal requirements (e.g., the condition of participation for safe and adequate care), state licensing rules, and common-law duties to provide reasonable care. Where facilities breach their duty and neglect results, families can pursue administrative complaints, state enforcement actions, and private civil claims for negligence, neglect, and wrongful death. Evidence of inadequate staffing, ignored care needs, and resulting injuries is central to these claims. Many successful actions rely on clinical records, witness statements, photos, and expert nursing testimony linking understaffing to the resident’s harm.

Frequently Asked Questions about the 24/7 RN Hour Rule Repeal

Q: Does the repeal mean nursing homes will have no RNs at all?
A: No. Many facilities will continue to staff RNs, and some state rules or facility policies may still require RNs on site. The federal change removes the guaranteed 24/7 federal floor for Medicare/Medicaid participation; actual staffing will vary by facility, ownership model, and state regulation.

Q: Can my state require 24/7 RN coverage even if CMS does not?
A: Yes. States have their own licensing and staffing standards. Families should check state nursing-home regulations and the facility’s license conditions. State survey agencies enforce licensing requirements.

Q: If my loved one is harmed after the repeal, can we sue?
A: Potentially yes. Legal claims depend on whether the facility breached its duty of care and whether that breach caused harm. Even without a federal 24/7 RN rule, plaintiffs can use clinical records, staffing schedules, incident reports, and expert testimony to prove neglect. Consult an attorney promptly.

Q: What can regulators do?
A: State survey agencies can inspect, cite, and sanction facilities for deficiencies that threaten resident health and safety. Families can file complaints with state review agencies and report suspected abuse or neglect.

Contact the Top-Rated Illinois Nursing Home Neglect Lawyers at John J. Malm & Associates

If your loved one lives in a nursing home and you are worried about staffing, missed care, or signs of neglect, do not wait. Document what you see, request staffing and clinical records, file complaints with your state survey agency, and contact the experienced Illinois nursing home abuse and neglect attorneys at John J. Malm & Associates.

Our firm represents families in Illinois and surrounding states in nursing home neglect and wrongful death claims. We evaluate staffing records, preserve crucial evidence, and consult medical experts to determine whether neglect occurred and how to hold a facility accountable. If you suspect your family member has been harmed due to understaffing or negligent care, contact our office today for a confidential consultation so we can review the facts and explain your options.