Half of all nursing homes in Massachusetts are understaffed

It felt like someone was hammering an ice pick into Lynette Couture’s leg.

The 55-year-old was recovering in Plymouth Harborside Healthcare’s rehab unit last fall after a horrific car crash shattered her left leg. Doctors had drilled a metal device into her bones to reconnect them.

Couture asked staff for pain medicine three times between 9:40 and 10:40 one night in September, according to a journal where she meticulously logged her care. Her call light was still on as the clock ticked past 11:20, 11:35, 12:00, 12:10.

Still suffering from the stabbing pain, with no nurse in sight, Couture called the nursing station from her cell phone twice. But no one answered. A non-medical staffer pulling a double shift finally got a nurse to dispense the medicine at 12:15 a.m. — more than 2½ hours after she started asking for it.

“The angrier I got, the more I cried,” Couture recalled in an interview with The Light. “I made it known to everyone that walked past my room: it was excruciating.”

Couture says Plymouth Harborside was short-staffed. She was right. Like half of Massachusetts’ 341 nursing homes, it failed to meet state staffing requirements last summer.

Five years ago, state health officials set minimum staffing levels to help improve care for nursing home residents. But staffing levels in Massachusetts nursing homes are, in some ways, worse now, a New Bedford Light analysis of federal data has found.

When there isn’t enough staff, care deteriorates, experts and advocates say. Frail residents can fall when they try to get out of bed without help. They can get sick with infections from sitting in soiled diapers. Their skin can deteriorate into open wounds — bedsores — when they aren’t repositioned often enough.

The Light’s monthslong investigation uncovered:

• Half of the state’s nursing homes failed to meet one or both of the state’s minimum staffing standards at the end of last year.

• Most for-profit facilities were out of compliance with staffing standards at the end of last year. Most nonprofit facilities were in compliance.

• The state’s penalties aren’t strong enough to deter profit-seeking nursing home owners from failing to provide enough staffing, resident advocates say.

• State officials recently reduced penalties for dozens of understaffed nursing homes at the request of an industry trade group.

• The state’s minimum staffing standard for registered nurses isn’t enforced at all.

• State health inspectors have only issued a few dozen health violations for inadequate staffing since 2024, even though 251 nursing homes have dipped below the state minimums in that time.

Critics of the nursing home industry say understaffing maximizes profits. The numbers are a sign that some companies are understaffing on purpose, the critics add.

State prosecutors have targeted the owner of Plymouth Harborside for just that. The nursing home is part of the Next Step Healthcare chain, which reached a $4 million settlement with the Massachusetts attorney general in 2024 to resolve allegations that it hurt residents by deliberately cutting staff. The chain was “systemically noncompliant” with state staffing standards, prosecutors said.

Next Step did not respond to requests for comment for this story.

The Attorney General reached a similar settlement worth $2.75 million with Bear Mountain Healthcare this year to resolve allegations that residents of the chain were neglected because of chronic understaffing.

Another facility in the Next Step chain, Fall River Healthcare, spent more than a year on a federal list of the “worst of the worst” nursing homes in the country, The Light previously reported. Most of Next Step’s facilities, including Plymouth Harborside, were placed in a receivership in January, after a group of landlord companies took the chain to court over millions of dollars in unpaid rent.

“It’s amazing how indifferent state and federal regulators are to the well-being of nursing home residents,” said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care. “You see over and over the horrific outcomes that come from understaffing, and yet the regulators do nothing.”

What it’s like to live in an understaffed nursing home

Couture described a bleak experience during her seven weeks at Plymouth Harborside.

Her roommate’s mattress was breaking down from built-up urine, trash sat on the floor of the hallway for days, the facility constantly smelled like feces, and her bathroom was caked in filth and human excrement that stuck to her socks, she said.

Her wound dressings weren’t changed every day, according to her journal, even though her doctor said they should have been changed twice a day. She was reeling from the emotional trauma of her car accident. She asked for mental health support, she said, but no counselor ever came.

“There were some nurse’s aides that were helpful,” Couture said. “But they were few and far in between.”

When she was admitted as a patient there in September, Plymouth Harborside had nursing staff levels in the bottom 7% of Massachusetts nursing homes, The Light’s data analysis found.

“That nursing home was the worst experience of my life,” she said.

Staffing regulations widely flouted

In 2020, as COVID-19 ripped through Massachusetts nursing homes, then-Gov. Charlie Baker announced a package of reforms designed to support facilities and hold them accountable. It included a plan to establish staffing minimums, which went into full effect in April 2021.

The new state regulations based staffing requirements on the number of residents and the hours worked by nursing staff providing direct care. That ratio is called Hours Per Patient Day, or HPPD.

There are two required ratios in the regulations. Massachusetts nursing homes must provide at least 3.58 HPPD with a combination of nurses and nurse aides. Registered nurses, who have the most education and responsibility for patient care, must provide at least 0.508 HPPD of that total.

For example, a facility with 100 residents must provide at least 358 hours of nursing care in a day. That works out to about 45 nursing staff working eight-hour shifts. At least seven of those 45 staffers must be registered nurses.

The Light’s analysis found widespread noncompliance with these standards.

At the end of last year, half of the state’s nursing homes were out of compliance with one or both of the state’s staffing standards. Some didn’t have enough overall nursing staff. Others didn’t have enough registered nurses. Some were understaffed according to both measures.

Total staffing compliance improves

Massachusetts has focused its enforcement efforts on getting nursing homes to improve their overall nursing staff levels. How is it doing?

At the end of 2025, one-third of Massachusetts nursing homes in the state were below the overall nursing staff minimum — the state’s primary staffing standard.

That level of compliance is actually an improvement from recent years. About half of nursing homes were out of total staffing compliance during parts of 2021 and 2022.

MassHealth, the state’s Medicaid program, has collected $58 million in penalties over five years — an average of $11.6 million a year — from nursing homes for not meeting the overall staffing minimum, according to Stacey Nee, a spokesperson for the agency.

That amounts to just 0.5% of the $2.3 billion in revenue that Massachusetts nursing homes received from MassHealth in 2024, according to figures provided by the Center for Health Information and Analysis.

In an email to The Light, Nee said “statewide compliance has improved significantly” in recent years because of the penalties. An improved labor market and more state funding have also helped, she said.

Nee provided statistics from past years that showed even more noncompliance than The Light found in 2025 data. From 2021 to 2024, Nee said, 53% to 74% of nursing homes failed to meet overall staffing minimums.

Advocates for nursing home residents say the current level of noncompliance is still unacceptable. They say the penalties for understaffing are still too low, and nursing home owners see them as the cost of doing business.

State minimums for registered nurses not enforced

What about Massachusetts’ other nursing staff standard? It requires nursing homes to have a certain number of registered nurses — the staff with the most training and responsibility.

The state doesn’t enforce that standard at all.

The number of facilities failing to meet the registered nurse requirement has grown over the past few years, rising from 23% when the standard was introduced to 32% at the end of last year.

Registered nurse hours are the most important care hours a facility provides, said Dr. Charlene Harrington, a registered nurse and professor emeritus at the University of California San Francisco who has studied long-term care.

Only registered nurses are trained to make care plans and identify problems like strokes or heart attacks. They also oversee other nursing staff. Research shows that registered nurse staffing ratios are strongly linked to quality and safety.

“You see all kinds of problems get worse when you don’t have the RNs,” Harrington said.

Yet registered nurses are the most difficult staff to hire and retain for most nursing homes, according to a recent statewide survey. Nursing homes reported that a quarter of registered nurse positions in nursing homes were vacant in 2024. Most nursing homes said a shortage of eligible applicants and non-competitive salaries made it hard to hire registered nurses.

Two state regulations set staffing standards for nursing homes. One regulation, overseen by the Department of Public Health, lays out both the overall nursing staff requirement and the requirement for registered nurses. It doesn’t include specific penalties.

The other regulation, which governs MassHealth payments, levies penalties on nursing homes that don’t have at least a 3.58 HPPD overall staffing ratio.

It doesn’t mention the registered nurse requirement.

“MassHealth does not enforce the 0.508 RN HPPD requirement,” wrote Nee, the MassHealth spokesperson.

Nee said that’s because the 0.508 RN HPPD requirement isn’t in MassHealth’s regulations. She did not answer The Light’s questions about why the agency doesn’t include it in the regulations, which the agency itself sets.

Katheleen Conti, a spokesperson for the Department of Public Health, told The Light in an email that the agency has not taken action to enforce the RN requirement, citing “workforce challenges” for nursing homes.

State relaxes penalties on some nursing homes, increases them for others

MassHealth recently relaxed its penalties for many facilities’ low staffing at the request of an industry trade group.

Until last year, facilities that fell below the overall staffing ratio had faced a 2% cut to their Medicaid reimbursement rate — already too light of a penalty, some resident advocates said. But in October, MassHealth replaced the flat 2% penalty with a sliding scale between 0.5% and 3%, creating escalating tiers for lower staffing levels.

The change resulted from meetings between MassHealth and the Massachusetts Senior Care Association, a trade group representing long-term care facilities, including nursing homes.

“MassHealth received feedback from the industry that a graduated approach would be fairer,” Nee wrote in an email.

The new rules avoid a “financial cliff effect,” Nee said, by incentivizing facilities that are close to compliance to continue hiring.

Almost 4 in 10 of the nursing homes that were below the staffing threshold were set to receive higher penalties under the new rules, The Light’s analysis shows.

On the other hand, most facilities with substandard staffing at the end of last year were set to benefit from a lower penalty under the new rules.

Staffing data shows 74 nursing homes with an HPPD between 3.28 and 3.57, which is below the state standard. Under the old rules, all of those facilities would have faced a 2% reduction in their MassHealth reimbursement. But the new regulation cut the penalties for that staffing range to between 0.5% and 1.5%.

More than two dozen facilities are set to receive the minimum adjustment of 0.5% — a fraction of the penalty they used to face for understaffing.

Though this group of 74 facilities doesn’t have the worst staffing ratios, they tend to have worse ratings from Medicare on health inspections and quality of care. Four have been flagged for abuse and seven are candidates or participants in a special enforcement program that targets facilities with a history of serious, repeated problems, Medicare data shows.

All but five of the 74 are for-profit companies.

The state’s 40 lowest-staffed facilities would face steeper penalties under the new rules. They faced a 3% cut at the end of last year, instead of a 2% cut.

The new rules haven’t led to improvement yet. The number of nursing homes not complying with the overall staffing standard has increased in both quarters since the agency publicly announced it was changing the penalties, driven by understaffing at for-profit facilities.

State Sen. Mark Montigny, who represents New Bedford and has previously called for tougher penalties on nursing homes, called it “unacceptable” for state health regulators to lower penalties at the industry’s request.

“They are cozier with lobbyists for the nursing home industry and their friends than the advocates for the elderly,” Montigny said. “This is another example of the lobbying corrupting the policy.”

Other penalties for low-staffed nursing homes rarely used

State health officials have other ways, besides MassHealth penalties, that they could penalize nursing homes for low staffing. The Department of Public Health can also cite nursing homes for violating federal health regulations that require them to provide enough staff to meet residents’ needs.

State penalties for health violations can be as high as $27,378 per instance, depending on severity.

The department doesn’t do this often.

State health inspectors have cited only 31 nursing homes with health violations for inadequate staffing since 2024. But 251 nursing homes have been below the state minimums for at least one quarter since then, Medicare data shows.

It’s harder to penalize nursing homes this way because inspectors need more evidence. They have to review more payroll records and conduct interviews with residents, family, and staff, “as well as look for patterns of care not being delivered appropriately due to staffing concerns,” wrote Conti, the department spokesperson.

State standards are below the bare minimum, critics say

Experts on long-term care say the state minimums are well below the staffing actually needed to provide basic care, which makes the widespread noncompliance even more alarming.

“This Massachusetts standard is modest, to say the least,” said Brooks, the Consumer Voice policy director. “Even if you’re at 3.58, you’re probably not meeting the needs of most of the residents in your nursing home — and that’s just based on science.”

Extensive research has found that higher staffing leads to better care, especially when registered nurse staffing levels are high. Residents of nursing homes with more nurses are less prone to bedsores, infections, and emergency room visits, studies have found.

Experts point to a “landmark” 2001 Medicare study that said nursing homes provide the best quality care with at least 4.1 HPPD.

And resident needs have increased since 2001, the experts say, so most nursing homes today need even more staffing to provide a basic level of safe care.

The Long Term Care Community Coalition analyzes nursing home staffing based on resident assessments reported to Medicare. These assessments show how much care each resident needs based on their medical condition. The coalition combines that data with research on the time it takes to provide different types of care. The result is the number of staff hours each nursing home would need to meet its residents’ needs.

The coalition’s latest analysis found that staffing levels in Massachusetts nursing homes should range from 4.22 to 6.28 HPPD, depending on patient needs, but these benchmarks are rarely met. Of the state’s 341 nursing homes, 313 had overall nursing staff levels below the coalition’s target.

“Staffing is the most important factor in terms of quality and safety,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a national advocacy group based in New York that publishes research on the nursing home industry.

“When you see that facilities are not even being held accountable for what should be a bottom line of staffing, it’s very disheartening,” he said.

Low wages in nursing homes

Wages in nursing homes are too low, and that’s one of the main reasons they’re understaffed, say resident advocates, state regulators, and the facility owners themselves.

The average nursing staff turnover rate at nursing homes in Massachusetts is 39%. That means, on average, about four in 10 of a facility’s staff quit and have to be replaced in a given year. In 153 Massachusetts facilities, turnover is even higher than the state average.

Jobs in nursing homes are hard work. Staff help residents with many daily needs, including bathing and using the bathroom. They manage the difficult, sometimes violent, behaviors that come with mental decline later in life. They oversee unique care plans for each resident, which can include a wide range of shifting medications and treatments. One mistake can cause lasting harm.

Nurse aides are the backbone of the nursing home industry, but many other jobs pay more and come with less responsibility. The median hourly wage for a nurse aide in Massachusetts was $22.44 last year, according to the Bureau of Labor Statistics. By comparison, landscaping workers made $23.40, and customer service representatives made $23.61.

The median registered nurse makes $49.03 an hour in Massachusetts, but national data shows that their wages are generally higher in hospitals than nursing homes.

What’s the path to higher wages for nursing home workers? The industry and resident advocates disagree on the answer.

The industry group that advocates for nursing homes in Massachusetts says the state needs to pay more to facilities. That would happen through MassHealth, the payer for most of the state’s nursing home residents.

“The reality is that a nursing facility’s ability to invest in quality care and our workforce is directly tied to government funding,” wrote Tara Gregorio, president of the Massachusetts Senior Care Association, in an email.

Increased government funding has helped the industry raise wages by 40% over the past five years, but the industry needs even more money, she said. Massachusetts underfunds nursing home care “by as much as $47 per resident day,” she wrote.

That figure comes from a 2023 federal report on Medicaid payments to nursing homes, which analyzed the average cost of providing care to Medicaid-insured residents compared to the average rate states paid for that care.

But the report had limitations. The data came from 2019 and did not cover all types of MassHealth plans, nor all payments to nursing homes. And although the report compared costs to Medicaid payment rates, it notes that costs “are an imperfect measure of what facilities should be paid.”

Massachusetts spends billions of dollars on nursing home care each year, primarily through MassHealth insurance coverage.

“The taxpayers are getting ripped off because they aren’t getting the value of the dollars they’re paying through government subsidies,” said Dick Moore, a former state senator who is now part of Dignity Alliance Massachusetts, a coalition of senior and disability advocacy organizations.

For-profit nursing homes more often understaffed

Advocates for nursing home residents reject the industry’s arguments that it needs more government funding. They blame profit-seeking facility owners.

Brooks, the Consumer Voice policy director, pointed out that dozens of nursing homes in Massachusetts do hire enough staff — a group disproportionately made up of nonprofits. Overall, nonprofits make up 26% of the state’s nursing homes, but they account for 44% of nursing homes that complied with staffing regulations at the end of last year.

“Facilities that are understaffed generally do it on purpose,” he said. “They do it because that’s how they save money — that’s how they make profits.”

The Light’s analysis found that 64% of for-profit nursing homes were out of compliance with at least one of the state’s staffing minimums at the end of last year, compared to only 18% of nonprofits.

Noncompliance with the state’s overall nursing staff minimum — the one that’s enforced with penalties — is rare among nonprofits. Just 6% of nonprofits failed to reach 3.58 HPPD at the end of last year, compared to 45% of for-profits.

“It pays to provide substandard care,” said Mollot, the Long Term Care Community Coalition director.

While many nursing homes file public cost reports with slim or even negative profit margins, research has found that there’s more to the story.

Many nursing home owners set up “related party organizations,” separate companies they control and outsource services to. A related party can charge the nursing home to provide staff or management, or it may even act as the nursing home’s landlord by owning and leasing the property. Because related parties are separate companies, they don’t face the same disclosure requirements as the nursing homes themselves.

The latest cost reports from 2024 show some examples of Massachusetts nursing homes paying related parties for services. Southshore Health Care Center in Rockland paid more than $2 million to companies owned by one of the nursing home’s owners, paying rent and a variety of fees for management, payroll, drugs, and other services. Briarwood Rehabilitation and Healthcare Center in Needham paid more than $4 million to related parties for expenses that included “Executive Fees” and “Consulting Fees.”

At Life Care Center of Leominster, over $1 million went to the nursing home owner’s companies, mainly for insurance. One line item included $4,528 for “Interior Designs.”

Researchers say this is a common business strategy in the nursing home industry, allowing some owners to turn public funding into profits while providing substandard care.

“All the research is showing these nursing homes are making a ton of money and taking the money out through their related party organizations,” said Harrington, the nurse and San Francisco professor emeritus. “They hide their profits in these related party companies.”

Massachusetts nursing homes are required to spend at least 75% of their revenue on direct care expenses, such as paying nurses and aides and buying food for residents. But one in five of the state’s nursing homes failed to meet that spending threshold during the year that ended in June 2025, according to a MassHealth report.

The number of facilities not complying with the spending requirement has increased, not decreased, since the state started enforcing the standard, reports show. Facilities face a payment penalty of 0.5% to 5%.

Critics of the nursing home industry say evidence of profit extraction refutes the industry argument that nursing homes need more public funding to provide enough staff.

“If nursing homes were so broke, why are people wanting to buy them and invest in them?” said Moore, the former state senator who now advocates for residents with Dignity Alliance Massachusetts.

State should ratchet up penalties, advocates say

Resident advocates say the state’s current penalties for understaffed facilities — payment cuts ranging from 0.5% to 3% — aren’t high enough.

“Until the financial penalties outweigh maintaining the status quo of noncompliance, nothing will happen,” Brooks said.

Moore suggested hiking the penalties up to 7.5% to 10% for facilities with a two-star Medicare quality rating, and 10% to 15% for facilities with a one-star Medicare quality rating.

“That would get their attention,” he said.

Harrington said facilities should face fines for each day that their staffing doesn’t reach standards — rather than the quarterly penalties the state currently uses. She suggested daily fines of $2,000 to $3,000.

The state could impose admissions freezes or refuse to cover the cost of care for new residents while facilities are understaffed, advocates said.

“You shouldn’t be allowed to take more residents and then make the situation worse,” Brooks said.

The advocates also called for more transparency.

Moore said the state needs to make it easier for the public to see which homes aren’t meeting state staffing ratios. Medicare’s website shows staffing ratings that use a broader set of measures to compare each nursing home to state and national averages, but it doesn’t include markers that clearly note whether a nursing home is meeting state staffing minimums.

In fact, The Light’s analysis found that 22 Massachusetts nursing homes that violated state staffing standards during the latest quarter of data currently have an above-average staffing rating from Medicare.

Legislators react

The two co-chairs of the Massachusetts Legislature’s Committee on Aging and Independence told The Light that staffing needs to improve, but they didn’t endorse the advocates’ solutions.

State Sen. Thomas Stanley (D-Waltham) said the nursing home industry faces severe financial challenges that prevent it from paying competitive wages.

“Enforcing staffing minimums is more difficult when the workforce isn’t there,” he said.

Stanley said the state “definitely should look at” increasing fines on understaffed nursing homes. But, he added, “it’s very difficult because there’s fewer and fewer people getting into the field. That’s a big challenge.”

Stanley said the solution is to provide more funding for nursing homes. He noted that the state’s 2024 long-term care law created training grants for workers and a forgivable loan fund to help nursing homes cover major costs.

He said he didn’t support admissions freezes on understaffed nursing homes.

“Where would these people go if you cap the number of residents that could go in there?” he said.

State Rep. Patricia Jehlen (D-Somerville), Stanley’s co-chair, said she found the widespread lack of compliance with staffing minimums depressing.

“I think we should all be worried,” she said.

In the future, she said declining state revenue and federal Medicaid cuts could make it harder for state health officials to enforce standards against nursing homes and pay them high enough rates to provide quality care. She said she wasn’t sure if the state’s current staffing penalties are the reason why staffing levels are still so low.

Montigny, the New Bedford state senator, said in a written statement to The Light that the nursing home industry “shamefully puts their balance sheets over the welfare of vulnerable people.”

He said the Legislature has provided enforcement tools and funding to improve staffing, but they either haven’t been used by regulators or have been “corrupted by insidious industry lobbying and bureaucratic indifference.”

“It’s shameful and despicable,” he said.

Nursing home rules come from the Legislature and the Department of Public Health. Moore, the former state senator, was pessimistic that the Legislature would hike penalties for understaffing.

“There are people that get a pretty good salary to fight those things, so I don’t know how viable that would be,” he said.

The Massachusetts Senior Care Association spent $352,557 on state lobbying last year, disclosures show.

How the elderly are treated

Lynette Couture left Plymouth Harborside in October and moved in with a friend in Wareham.

She’s still healing from her car accident, but she can get around by herself slowly with a cane or walker now. And she’s been reunited with her dog, a cockapoo named Peanut.

Looking back on her time at Plymouth Harborside, Couture said she knows she didn’t make many friends — she complained, loudly and often, when she didn’t get the care she needed. Not all of her neighbors in the nursing home had the capacity to advocate for themselves so forcefully.

“It really opened my eyes to how the elderly are treated, and what they go through on a daily basis,” she said.

---

This reporting was supported by a grant from the Fund for Investigative Journalism.

---

This story was originally published by The New Bedford Light and distributed through a partnership with The Associated Press.