It felt like someone was hammering an ice pick into Lynette Couture鈥檚 leg.
The 55-year-old was recovering in Plymouth Harborside Healthcare鈥檚 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. 鈥� more than 2陆 hours after she started asking for it.
鈥淭he angrier I got, the more I cried,鈥� Couture recalled in an interview with The Light. 鈥淚 made it known to everyone that walked past my room: it was excruciating.鈥�
Couture says Plymouth Harborside was short-staffed. She was right. Like half of Massachusetts鈥� 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鈥檛 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 鈥� bedsores 鈥� when they aren鈥檛 repositioned often enough.
The Light鈥檚 monthslong investigation uncovered:
鈥� Half of the state鈥檚 nursing homes failed to meet one or both of the state鈥檚 minimum staffing standards at the end of last year.
鈥� Most for-profit facilities were out of compliance with staffing standards at the end of last year. Most nonprofit facilities were in compliance.
鈥� The state鈥檚 penalties aren鈥檛 strong enough to deter profit-seeking nursing home owners from failing to provide enough staffing, resident advocates say.
鈥� State officials recently reduced penalties for dozens of understaffed nursing homes at the request of an industry trade group.
鈥� The state鈥檚 minimum staffing standard for registered nurses isn鈥檛 enforced at all.
鈥� 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 with the Massachusetts attorney general in 2024 to resolve allegations that it hurt residents by deliberately cutting staff. The chain was 鈥渟ystemically noncompliant鈥� with state staffing standards, prosecutors said.
Next Step did not respond to requests for comment for this story.
The Attorney General reached a 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 鈥渨orst of the worst鈥� nursing homes in the country, The Light . Most of Next Step鈥檚 facilities, including Plymouth Harborside, were in January, after a group of landlord companies took the chain to court over millions of dollars in unpaid rent.
鈥淚t鈥檚 amazing how indifferent state and federal regulators are to the well-being of nursing home residents,鈥� said Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care. 鈥淵ou see over and over the horrific outcomes that come from understaffing, and yet the regulators do nothing.鈥�
What it鈥檚 like to live in an understaffed nursing home
Couture described a bleak experience during her seven weeks at Plymouth Harborside.
Her roommate鈥檚 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鈥檛 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.
鈥淭here were some nurse鈥檚 aides that were helpful,鈥� Couture said. 鈥淏ut they were few and far in between.鈥�
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鈥檚 data analysis found.
鈥淭hat nursing home was the worst experience of my life,鈥� she said.
Staffing regulations widely flouted
In 2020, as COVID-19 ripped through Massachusetts nursing homes, then-Gov. Charlie Baker announced a designed to support facilities and hold them accountable. It included a plan to establish staffing minimums, which 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鈥檚 analysis found widespread noncompliance with these standards.
At the end of last year, half of the state鈥檚 nursing homes were out of compliance with one or both of the state鈥檚 staffing standards. Some didn鈥檛 have enough overall nursing staff. Others didn鈥檛 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 鈥� the state鈥檚 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鈥檚 Medicaid program, has collected $58 million in penalties over five years 鈥� an average of $11.6 million a year 鈥� 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 .
In an email to The Light, Nee said 鈥渟tatewide compliance has improved significantly鈥� 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鈥� other nursing staff standard? It requires nursing homes to have a certain number of registered nurses 鈥� the staff with the most training and responsibility.
The state doesn鈥檛 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. that registered nurse staffing ratios are strongly linked to quality and safety.
鈥淵ou see all kinds of problems get worse when you don鈥檛 have the RNs,鈥� Harrington said.
Yet registered nurses are the most difficult staff to hire and retain for most nursing homes, according to a recent . 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鈥檛 include specific penalties.
The other regulation, which governs MassHealth payments, levies penalties on nursing homes that don鈥檛 have at least a 3.58 HPPD overall staffing ratio.
It doesn鈥檛 mention the registered nurse requirement.
鈥淢assHealth does not enforce the 0.508 RN HPPD requirement,鈥� wrote Nee, the MassHealth spokesperson.
Nee said that鈥檚 because the 0.508 RN HPPD requirement isn鈥檛 in MassHealth鈥檚 regulations. She did not answer The Light鈥檚 questions about why the agency doesn鈥檛 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 鈥渨orkforce challenges鈥� for nursing homes.
State relaxes penalties on some nursing homes, increases them for others
MassHealth recently relaxed its penalties for many facilities鈥� 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 鈥� 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.
鈥淢assHealth received feedback from the industry that a graduated approach would be fairer,鈥� Nee wrote in an email.
The new rules avoid a 鈥渇inancial cliff effect,鈥� 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鈥檚 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% 鈥� a fraction of the penalty they used to face for understaffing.
Though this group of 74 facilities doesn鈥檛 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鈥檚 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鈥檛 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 鈥渦nacceptable鈥� for state health regulators to lower penalties at the industry鈥檚 request.
鈥淭hey are cozier with lobbyists for the nursing home industry and their friends than the advocates for the elderly,鈥� Montigny said. 鈥淭his is another example of the lobbying corrupting the policy.鈥�
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鈥� needs.
State penalties for health violations can be as high as per instance, depending on severity.
The department doesn鈥檛 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鈥檚 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, 鈥渁s well as look for patterns of care not being delivered appropriately due to staffing concerns,鈥� 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.
鈥淭his Massachusetts standard is modest, to say the least,鈥� said Brooks, the Consumer Voice policy director. 鈥淓ven if you鈥檙e at 3.58, you鈥檙e probably not meeting the needs of most of the residents in your nursing home 鈥� and that鈥檚 just based on science.鈥�
Extensive has that higher staffing leads to better care, especially when registered nurse staffing levels are high. Residents of nursing homes with more nurses are to bedsores, infections, and emergency room visits, studies have found.
Experts a 鈥渓andmark鈥� 2001 Medicare 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 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鈥� needs.
The coalition鈥檚 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鈥檚 341 nursing homes, 313 had overall nursing staff levels below the coalition鈥檚 target.
鈥淪taffing is the most important factor in terms of quality and safety,鈥� said Richard Mollot, executive director of the , a national advocacy group based in New York that publishes research on the nursing home industry.
鈥淲hen you see that facilities are not even being held accountable for what should be a bottom line of staffing, it鈥檚 very disheartening,鈥� he said.
Low wages in nursing homes
Wages in nursing homes are too low, and that鈥檚 one of the main reasons they鈥檙e understaffed, say resident advocates, state regulators, and the .
The average nursing staff turnover rate at nursing homes in Massachusetts is 39%. That means, on average, about four in 10 of a facility鈥檚 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鈥檚 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鈥檚 nursing home residents.
鈥淭he reality is that a nursing facility鈥檚 ability to invest in quality care and our workforce is directly tied to government funding,鈥� 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 鈥渂y as much as $47 per resident day,鈥� she wrote.
That figure comes from a 2023 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 鈥渁re an imperfect measure of what facilities should be paid.鈥�
Massachusetts spends on nursing home care each year, primarily through MassHealth insurance coverage.
鈥淭he taxpayers are getting ripped off because they aren鈥檛 getting the value of the dollars they鈥檙e paying through government subsidies,鈥� said , 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鈥檚 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 鈥� a group disproportionately made up of nonprofits. Overall, nonprofits make up 26% of the state鈥檚 nursing homes, but they account for 44% of nursing homes that complied with staffing regulations at the end of last year.
鈥淔acilities that are understaffed generally do it on purpose,鈥� he said. 鈥淭hey do it because that鈥檚 how they save money 鈥� that鈥檚 how they make profits.鈥�
The Light鈥檚 analysis found that 64% of for-profit nursing homes were out of compliance with at least one of the state鈥檚 staffing minimums at the end of last year, compared to only 18% of nonprofits.
Noncompliance with the state鈥檚 overall nursing staff minimum 鈥� the one that鈥檚 enforced with penalties 鈥� 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.
鈥淚t pays to provide substandard care,鈥� said Mollot, the Long Term Care Community Coalition director.
While many nursing homes file with slim or even negative profit margins, has that there鈥檚 to the .
Many nursing home owners set up 鈥渞elated party organizations,鈥� 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鈥檚 landlord by owning and leasing the property. Because related parties are separate companies, they don鈥檛 face the same disclosure requirements as the nursing homes themselves.
The latest from 2024 show some examples of Massachusetts nursing homes paying related parties for services. Southshore Health Care Center in Rockland more than $2 million to companies owned by one of the nursing home鈥檚 owners, paying rent and a variety of fees for management, payroll, drugs, and other services. Briarwood Rehabilitation and Healthcare Center in Needham more than $4 million to related parties for expenses that included 鈥淓xecutive Fees鈥� and 鈥淐onsulting Fees.鈥�
At Life Care Center of Leominster, over $1 million the nursing home owner鈥檚 companies, mainly for insurance. One line item included $4,528 for 鈥淚nterior Designs.鈥�
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.
鈥淎ll the is showing these nursing homes are making a ton of money and taking the money out through their related party organizations,鈥� said Harrington, the nurse and San Francisco professor emeritus. 鈥淭hey hide their profits in these related party companies.鈥�
Massachusetts nursing homes are 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鈥檚 nursing homes failed to meet that spending threshold during the year that ended in June 2025, according to a .
The number of facilities not complying with the spending requirement has increased, not decreased, since the state started enforcing the standard, . 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.
鈥淚f nursing homes were so broke, why are people wanting to buy them and invest in them?鈥� 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鈥檚 current penalties for understaffed facilities 鈥� payment cuts ranging from 0.5% to 3% 鈥� aren鈥檛 high enough.
鈥淯ntil the financial penalties outweigh maintaining the status quo of noncompliance, nothing will happen,鈥� 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.
鈥淭hat would get their attention,鈥� he said.
Harrington said facilities should face fines for each day that their staffing doesn鈥檛 reach standards 鈥� 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.
鈥淵ou shouldn鈥檛 be allowed to take more residents and then make the situation worse,鈥� 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鈥檛 meeting state staffing ratios. Medicare鈥檚 website shows staffing ratings that use a broader set of measures to compare each nursing home to state and national averages, but it doesn鈥檛 include markers that clearly note whether a nursing home is meeting state staffing minimums.
In fact, The Light鈥檚 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鈥檚 told The Light that staffing needs to improve, but they didn鈥檛 endorse the advocates鈥� solutions.
State Sen. Thomas Stanley (D-Waltham) said the nursing home industry faces severe financial challenges that prevent it from paying competitive wages.
鈥淓nforcing staffing minimums is more difficult when the workforce isn鈥檛 there,鈥� he said.
Stanley said the state 鈥渄efinitely should look at鈥� increasing fines on understaffed nursing homes. But, he added, 鈥渋t鈥檚 very difficult because there鈥檚 fewer and fewer people getting into the field. That鈥檚 a big challenge.鈥�
Stanley said the solution is to provide more funding for nursing homes. He noted that the state鈥檚 law created training grants for workers and a forgivable loan fund to help nursing homes cover major costs.
He said he didn鈥檛 support admissions freezes on understaffed nursing homes.
鈥淲here would these people go if you cap the number of residents that could go in there?鈥� he said.
State Rep. Patricia Jehlen (D-Somerville), Stanley鈥檚 co-chair, said she found the widespread lack of compliance with staffing minimums depressing.
鈥淚 think we should all be worried,鈥� 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鈥檛 sure if the state鈥檚 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 鈥渟hamefully puts their balance sheets over the welfare of vulnerable people.鈥�
He said the Legislature has provided enforcement tools and funding to improve staffing, but they either haven鈥檛 been used by regulators or have been 鈥渃orrupted by insidious industry lobbying and bureaucratic indifference.鈥�
鈥淚t鈥檚 shameful and despicable,鈥� 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.
鈥淭here are people that get a pretty good salary to fight those things, so I don鈥檛 know how viable that would be,鈥� he said.
The Massachusetts Senior Care Association $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鈥檚 still healing from her car accident, but she can get around by herself slowly with a cane or walker now. And she鈥檚 been reunited with her dog, a cockapoo named Peanut.
Looking back on her time at Plymouth Harborside, Couture said she knows she didn鈥檛 make many friends 鈥� she complained, loudly and often, when she didn鈥檛 get the care she needed. Not all of her neighbors in the nursing home had the capacity to advocate for themselves so forcefully.
鈥淚t really opened my eyes to how the elderly are treated, and what they go through on a daily basis,鈥� she said.
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This reporting was supported by a grant from the Fund for Investigative Journalism.
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