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Three- and four-bed nursing home rooms should be phased out

Meanwhile, though, state policy makers should allow nursing homes to continue operating in a financially sustainable way.

A woman walked to her room at a senior care home in Calistoga, Calif.Eric Risberg/Associated Press

Would you want to share a bedroom with two strangers?

Most adults past their college dorm days would probably answer no. Yet in Massachusetts, many older residents are living in three- and four-bed rooms due to aging nursing homes that were built without the benefit of modern health standards.

Those outdated rooms should be phased out. But it is incumbent on state policy makers and nursing homes to find a way to do that while allowing nursing homes to continue operating in a financially sustainable way. If nursing homes are forced to close — a danger highlighted by the recent announcement that four Western Massachusetts nursing homes will shutter — that does a major disservice to patients, their families, and the community.


Studies have shown that single-occupancy rooms are best for nursing home residents, though some may prefer to live with a spouse or friend. Residents living in single-occupancy rooms tend to have lower rates of infectious diseases, better sleep patterns, fewer medication errors, and a greater sense of privacy and control, according to a 2021 report by national health care consulting firm Health Management Associates.

The Biden administration has talked about the need to phase out nursing home rooms with more than two beds. Federal rules require nursing homes built after 2016 to have no more than two residents per room. While older nursing homes may have up to four residents, the Centers for Medicare and Medicaid Services has urged facilities to consider updating spaces to have no more than double occupancy.

In Massachusetts, the Baker administration aggressively pursued similar reforms, first raising the possibility of eliminating multi-bed rooms in 2016. The nursing home industry lobbied against the shift. In its fiscal 2018 budget, the Legislature tried to prohibit the administration from imposing new construction standards on older facilities, but then Governor Charlie Baker vetoed the language.


In September 2020, during the COVID-19 pandemic, Baker offered to invest $140 million into nursing homes as long as they complied with certain standards, including eliminating three- and four-bed rooms. In March 2021, the Department of Public Health issued regulations requiring all long-term care facilities to eliminate three- and four-bed rooms by April 30, 2022, with waivers available for facilities that made a “good faith effort” to comply but could not meet the deadline.

Thirty-one long-term care facilities sued to overturn the regulations. All applied for hardship waivers — arguing that physical facility constraints prevented them from expanding — and were denied. The facilities said in a court complaint filed in Suffolk Superior Court in June 2022 that 800 beds would need to be taken out of commission under the new rules, of which 585 were occupied. The lawsuit argues that it would be disruptive to residents to transfer them elsewhere. It would also threaten nursing homes’ financial viability, since they entered into payment contracts relying on revenue from having three or four residents per room. The facilities collectively would lose $54 million if they had to eliminate those beds, leading to 436 staff layoffs, according to the lawsuit. The facilities say there are infection-control measures that can prevent the spread of disease other than removing beds.

“These are facilities that have been successfully operating in their communities for decades, providing a valued service to their residents, jobs for workers, in proximity to [residents’] families,” said Howard Sollins, an attorney representing the nursing homes. “The viability of these facilities is being jeopardized.”


The lawsuit’s warning that some facilities may close may be prescient. The Northeast Health Group on Feb. 7 notified the Department of Public Health that it plans to close four Western Massachusetts nursing homes: Chapin Center in Springfield; Governor’s Center in Westfield; and Willimansett Center East and West in Chicopee.

There are multiple factors that can contribute to nursing homes’ financial woes, from low Medicaid reimbursement rates to staffing challenges. But officials at the Pennsylvania-based health system blamed occupancy requirements. Combined, the four nursing homes had to reduce capacity from 448 beds to 314 beds, which led to financial insolvency, Northeast Health Group chairperson Ann Mullen DelCollo wrote to the Department of Public Health. While a judge temporarily suspended the two-bed rule for nursing homes involved in the litigation, Northeast Health Group is not a plaintiff.

The four homes vary in quality. Governor’s Center has one star in federal Medicare rankings and scores poorly on state performance metrics. Willimansett Center East and West are four- and five-star nursing homes, respectively, and Chapin Center has three stars.

The decision to shut down four homes in one county worries area legislators. Springfield Representative Bud Williams asked acting Health and Human Services Secretary Mary Beckman to suspend the two-bed mandate until March 1, 2024, to give the Legislature time “to fully explore options” regarding that requirement and a rule capping reimbursement rates for providers. With Kate Walsh becoming secretary in less than two weeks, Williams wrote to Beckman, “it would be premature for the Healey-Driscoll Administration to proceed with the closure of these facilities without a full review of the regulation and the adverse consequences to the patients, the families, the employees, and the economic impact to the region, with a projected loss of 362 jobs.”


West Springfield Representative Michael Finn said until now, lawmakers didn’t appreciate the severity of the regulation’s impact. “I think it’s incumbent upon us as legislators … to look at the regulations that were put in place during those real chaotic moments at the height of COVID and see if those rules should still apply, and if they should, what can we do to prop up an industry that’s so important,” he said.

There may be ways to make better use of the state’s nursing homes. According to federal data compiled by Dignity Alliance Massachusetts, a coalition of senior and disability rights advocates, the average daily occupancy rate of Massachusetts nursing homes in December was 76 percent. Some beds may be empty due to staffing, COVID-related admissions freezes, or regulatory issues.

Yet at the same time, hospitals are having trouble getting patients into nursing homes. The Massachusetts Health and Hospital Association reported in January that hospitals statewide had 594 patients awaiting beds in skilled nursing facilities — although many were waiting for reasons other than bed availability, like insurance barriers, lack of a guardian, COVID status, or a need for specialized services.


Paul Lanzikos, a cofounder of Dignity Alliance Massachusetts, said some closures of low-quality homes may be warranted, but it should be done rationally. “Having four facilities close precipitously in one region is chaotic,” he said.

The Massachusetts Senior Care Association, which represents nursing homes, has suggested convening experts to recommend ways to mitigate infections other than removing beds. The group also suggests using COVID recovery money to fund construction projects related to creating more private rooms or developing specialized care units.

Long-term, three- and four-bed rooms should be phased out. In the short term, the Healey administration should work with nursing homes to move toward that goal in a way that harms patients the least.

Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.