Skilled Nursing Update: CMS Proposes Significant Regulatory Relief for Skilled Nursing Facilities

On November 5, 2026, the Centers for Medicare & Medicaid Services (“CMS”) released a sweeping proposed rule aimed at reducing administrative requirements across Medicare- and Medicaid-participating providers. The proposed Cutting Administrative Requirements for Excellence in Patient Care (“CARE”) rule would revise numerous Conditions of Participation and Requirements for Participation. For skilled nursing facilities (“SNFs”), the proposal includes several significant changes involving respiratory illness reporting, COVID-19 vaccination requirements, transfer and discharge notices, facility assessments, physical environment standards and Medicaid payment transparency reporting.

CMS estimates that the rule as a whole would save approximately $320 million annually. For long-term care facilities specifically, CMS estimates average annual savings of approximately $142.6 million.

Importantly, these changes are proposed and are not yet effective.

Existing Facilities Could Receive Important Relief Following a Change of Ownership or Certification Gap

The CARE proposal contains a particularly important physical environment change for transactions involving existing nursing facilities.

Current requirements generally provide that nursing facilities newly certified after November 28, 2016, may have no more than two residents per bedroom and must provide each resident room with its own bathroom containing at least a commode and sink. CMS acknowledges that these requirements may create significant obstacles when an existing facility changes ownership or reopens following a gap in operations because a new provider may otherwise be treated as newly certified and face substantial renovation requirements.

CMS proposes to tie these standards instead to the date that state and local authorities approved the facility’s building construction or reconstruction plans. As a result, an existing facility would not become subject to the more recent room occupancy and bathroom requirements merely because of a change of ownership or lapse and restoration of certification.

CMS Would Eliminate Routine Respiratory Illness Reporting

CMS proposes to eliminate the ongoing respiratory illness reporting requirement at 42 C.F.R. § 483.80(g), which currently requires nursing facilities to report specified respiratory illness information on an ongoing basis.

Under the proposal, facilities would no longer be required to routinely report this data outside a public health emergency. CMS would, however, preserve its authority to require specified reporting during a future Secretary declared public health emergency. The data that CMS could require during such an emergency would include facility census, confirmed resident cases, hospitalizations, confirmed staff infections, supply and staffing shortages and information concerning medical countermeasures and therapeutics.

The proposal would not eliminate the broader infection prevention and control requirements at § 483.80. Facilities would remain responsible for maintaining an infection prevention and control program, antibiotic stewardship program and designated infection preventionist, among other requirements.

Staff COVID-19 Vaccine Education, Offering and Documentation Requirements Would End

CMS also proposes to remove the federal requirement that nursing facilities educate staff regarding COVID-19 vaccination, offer the vaccine to staff and document those activities.

Resident requirements would remain. Facilities would continue to be required to educate residents or their representatives about COVID-19 immunization and offer the vaccine, subject to medical contraindication or refusal. CMS also proposes to streamline the resident documentation requirements so that documentation would focus on education and immunization status.

Emergency Hospital Transfers Would No Longer Require Ombudsman Notice

One of the more operationally significant proposals would modify § 483.15(c)(3)(i). Currently, facilities generally must send the State Long-Term Care Ombudsman a copy of resident transfer or discharge notices, including notices associated with emergency transfers.

CMS proposes an exception when a resident is transferred on an emergency basis to an acute care facility. Facilities would still be required to notify the resident and resident representative of the transfer and reasons for the move, but they would no longer have to send the Ombudsman a copy of the notice for the emergency transfer.

CMS explains that emergency-transfer notices have generated substantial paperwork for facilities and Ombudsman offices without necessarily furthering the original purpose of protecting residents against inappropriate transfers and discharges.

CMS is separately seeking comments on whether residents should be permitted to opt out of Ombudsman notification when the resident or resident representative initiates a discharge.

CMS Would Scale Back the Facility Assessment Participation Requirement

CMS proposes another change to the facility assessment requirements at § 483.71. Under the current rule, certain categories of individuals must be actively involved in conducting the facility assessment, including direct care staff and representatives of direct care staff, if applicable.

CMS proposes to remove the requirement involving representatives of direct care staff, while continuing to require participation by direct care staff themselves, including RNs, LPNs/LVNs and nursing assistants. CMS states that requiring facilities to ensure the active involvement of third-party representatives over whom the facility may have no employment or contractual authority is operationally burdensome.

CMS Proposes Major Updates to Life Safety and Physical Environment Standards

CMS proposes replacing the currently incorporated 2012 editions of the NFPA Life Safety Code (NFPA 101) and Health Care Facilities Code (NFPA 99) with the 2024 editions. For nursing facilities, CMS also proposes adopting the 2022 edition of NFPA 13 for sprinkler installation, the 2023 edition of NFPA 25 for sprinkler inspection, testing and maintenance, and the 2022 edition of NFPA 110 governing emergency and standby power systems.

Among other changes, CMS would remove the federal requirement at § 483.90(a)(7) requiring an outside window or door in every resident sleeping area and the associated 36-inch windowsill requirement. Nursing facilities would still be required to provide at least one outside window in resident bedrooms under the separate physical environment requirement.

CMS also proposes authority to permit facilities, through categorical waivers announced in subregulatory guidance, to follow particular provisions of newer Life Safety Code or Health Care Facilities Code editions when CMS determines that the newer provision provides an equal or superior means of protecting safety.

Medicaid Payment Transparency Reporting Would Be Rescinded for Nursing Facilities

CMS also proposes to unwind the Medicaid institutional payment transparency reporting requirements adopted as part of the 2024 nursing home staffing rule.

Specifically, CMS proposes eliminating requirements for states to report, at the facility level, the percentage of Medicaid nursing facility payments spent on compensation for direct care workers and support staff. CMS explains that nursing facilities receive funding from multiple sources and that accurately allocating staff compensation specifically to Medicaid residents could require burdensome tracking. CMS states that it instead intends to explore whether existing sources such as Payroll-Based Journal data, Minimum Data Set information, Medicare cost reports and Medicaid claims and encounter data can provide useful estimates.

The proposal would therefore effectively remove the Medicaid institutional payment transparency reporting requirement for nursing facilities.

CMS Is Asking Whether NPs and PAs Should Have a Greater Role in SNFs

Beyond the proposed regulatory amendments, CMS is expressly seeking comments about expanding the role of nurse practitioners (“NPs”) and physician assistants (“PAs”) in SNFs, especially regarding visits currently required to be performed by physicians.

CMS acknowledges an important statutory limitation: federal law requires the care of every SNF resident to be provided under physician supervision, and unlike the Medicaid nursing facility provisions, the Medicare SNF statute does not provide the same authority to delegate all required physician tasks. Existing § 483.30 generally requires the initial comprehensive SNF visit to be performed by a physician, while subsequent required visits may alternate with visits by a PA, NP or clinical nurse specialist.

CMS nevertheless asks for feedback regarding ways NPs and PAs could address access and workforce challenges within existing statutory limits.

Practical Takeaways

The CARE rule is only a proposal, so facilities should not change existing compliance activities based on the proposal. Instead, SNF operators should consider:

• Identifying policies and workflows that would be affected by the proposed changes, particularly NHSN respiratory reporting, emergency-transfer Ombudsman notices and staff COVID-19 vaccination documentation;
• Involving facilities and life-safety personnel in evaluating the proposed transition to the 2024 NFPA standards; and
• Considering whether to submit comments regarding physician, NP and PA services, Ombudsman notice requirements, facility assessments or other provisions important to facility operations.

The proposed rule is scheduled for publication in the Federal Register on November 10, 2026.

Providing Comments

SNFs should review the Proposed Rule’s changes to determine the potential impact on their operation and determine whether to submit a comment to support, question, clarify or challenge any of the proposed changes. Comments are due sixty days after publication.

If you have any questions, would like assistance preparing public comments, or would like additional information about this topic, please contact:

• Brian Jent at (317) 977-1402 or bjent@hallrender.com;
• Ellie Tucker at (314) 228-7508 or etucker@hallrender.com;
• Sean Fahey at (317) 977-1472 or sfahey@hallrender.com;
• Robert Markette at (317) 977-1454 or rmarkette@hallrender.com;
• Todd Selby at (317) 977-1440 or tselby@hallrender.com; or
• Your primary Hall Render contact.