Proposed, Not Final: What CMS’s CARE Rule Would Change for Washington Nursing Homes

By Matthew Macklin, Managing Attorney, Stratagem Law Group. What CMS’s November 2026 deregulatory proposal would and would not change for Washington nursing homes, and what to do before comments close on January 11, 2027.

Key takeaways

• CMS published the Cutting Administrative Requirements for Excellence in Patient Care (CARE) proposed rule at 91 Fed. Reg. 72634 (Nov. 10, 2026). Comments are due January 11, 2027, at 11:59 p.m. Eastern. Nothing in it is in effect.
• For nursing homes, the proposal would end ongoing respiratory illness reporting to NHSN (keeping emergency reporting), drop the staff COVID-19 educate-and-offer requirement, excuse the Ombudsman copy of a transfer notice only for emergency hospital transfers, remove “representatives of the direct care staff” from the facility assessment, and move the Life Safety Code to the 2024 edition.
• The two-residents-per-bedroom and commode-and-sink standards would no longer attach to a building because it is “newly certified,” which CMS says would spare existing facilities from those standards after a change of ownership or a gap in operations.
• The 2024 rule’s numerical staffing minimums and 24/7 RN requirement were already repealed, effective February 2, 2026. The facility assessment survives both rules; the Medicaid payment transparency reporting would be rescinded.
• Washington’s own rules, including chapter 388-97 WAC, RCW 70.129.110, and RCW 18.51.530, are untouched and in several places already require what CMS proposes to drop.

On November 5, 2026, the Centers for Medicare & Medicaid Services released a proposed rule that would repeal or loosen federal participation requirements across the 21 provider and supplier types it reviewed, with nursing homes accounting for the largest single share of the projected savings. For Washington operators, the practical questions are what would change, what would not, and what to do before the comment period closes.

Law reviewed through November 13, 2026.

What the CARE rule is

CMS published “Medicare and Medicaid Programs; Cutting Administrative Requirements for Excellence in Patient Care” in the Federal Register on November 10, 2026. 91 Fed. Reg. 72634 (Nov. 10, 2026) (CMS-3484-P; RIN 0938-AW04; Docket No. CMS-2026-3631). The rule would amend Conditions and Requirements of Participation in 42 C.F.R. parts 403, 416, 418, 438, 442, 460, 482, 483, 485, and 494. CMS estimates average annual savings of about $320 million across the affected providers, of which $142.6 million is attributed to long-term care facilities. Id. at 72637. Comments must be received by January 11, 2027; Regulations.gov lists the closing time as 11:59 p.m. Eastern.

It is a proposal. No requirement discussed below changes until CMS publishes a final rule and its effective date arrives, and a proposal does not suspend a current obligation or a scheduled compliance date.

What would change for nursing homes

Respiratory illness reporting and COVID-19 vaccine documentation (42 C.F.R. § 483.80)

CMS proposes to remove the ongoing reporting of acute respiratory illness data (influenza, COVID-19, and RSV) to the CDC’s National Healthcare Safety Network required by § 483.80(g)(1), a requirement CMS now estimates costs facilities roughly $61 million and more than 600,000 staff hours a year. 91 Fed. Reg. at 72654.

Reporting would be required only during a Secretary-declared public health emergency, and the elements (facility census, confirmed resident and staff cases, hospitalized residents, supply and staffing shortages, and countermeasure inventories) would be activated and defined at that time, so the next emergency’s reporting would not necessarily look like today’s. Id. at 72655, 72761. Separately, the requirement to educate staff about the COVID-19 vaccine, offer it, and document those steps would be removed, while the resident-side educate-and-offer requirement stays. Id. at 72653.

One drafting point is worth a comment: the preamble says resident documentation would be consolidated into two elements, education and immunization status, but the proposed regulatory text at § 483.80(d)(3)(iv) still refers to multi-dose education and to each dose administered. Id. at 72653, 72761. The infection prevention and control program itself, the antibiotic stewardship program, and the designated infection preventionist are not changed.

Transfer notices to the Ombudsman (§ 483.15(c)(3)(i))

Today a copy of every transfer or discharge notice must go to the Office of the State Long-Term Care Ombudsman. The proposal adds one exception: “when the resident is transferred on an emergency basis to an acute care facility.” 91 Fed. Reg. at 72651, 72760. Notice to the resident and representative is not affected, and for an urgent medical transfer it must still be given as soon as practicable before the move. 42 C.F.R. § 483.15(c)(4)(ii)(D). The Ombudsman copy remains required for every other transfer and discharge.

In a separate request for comment, CMS asks whether a resident should be able to opt out of the Ombudsman copy when the resident or representative initiates the discharge, with the preference documented in the medical record. 91 Fed. Reg. at 72656.

The facility assessment, and what already happened to the staffing rule (§§ 483.71, 483.35)

The May 2024 staffing rule required the facility assessment to involve direct care staff “and representatives of the direct care staff, if applicable.” 42 C.F.R. § 483.71(b)(1)(ii). CMS now proposes to strike the representatives clause; direct care staff themselves (RNs, LPNs/LVNs, and nurse aides) would still participate, and the rest of § 483.71 is retained. 91 Fed. Reg. at 72651–52, 72760.

This should not be confused with the staffing minimums. CMS already repealed the 2024 rule’s numerical minimums (3.48 total nurse hours per resident day, including 0.55 RN and 2.45 nurse aide hours) and its 24/7 onsite RN requirement in an interim final rule effective February 2, 2026, after Congress barred enforcement of those standards through September 30, 2034 and two district courts vacated them. 90 Fed. Reg. 55687 (Dec. 3, 2025); Pub. L. No. 119-21, § 71111; Am. Health Care Ass’n v. Kennedy, 777 F. Supp. 3d 691 (N.D. Tex. 2025).

Section 483.35 is back to its pre-2024 baseline, including an RN on duty at least eight consecutive hours a day, seven days a week. The facility assessment and the remaining staffing requirements were not touched by that repeal and remain in force.

Building standards: codes, windows, occupancy, and bathrooms (§ 483.90)

CMS would adopt the 2024 editions of the Life Safety Code (NFPA 101) and the Health Care Facilities Code (NFPA 99), together with NFPA 101A (2025), NFPA 13 (2022), NFPA 25 (2023), and NFPA 110 (2022), and would codify its practice of announcing voluntary “categorical waivers” that let a facility follow a newer code provision. 91 Fed. Reg. at 72761–62.

Two points here are easy to overstate. First, CMS would remove the requirement at § 483.90(a)(7) that every sleeping room have an outside window or outside door, with a 36-inch maximum sill height for buildings constructed after July 5, 2016. But CMS states that resident bedrooms “would continue to be required to provide at least one window to the outside” under the resident room standards. Id. at 72683–84; 42 C.F.R. § 483.90(e)(1)(vi). Windowless bedrooms are not on the table.

Second, the two-residents-per-bedroom standard and the requirement that each resident room have its own bathroom with at least a commode and sink currently apply to facilities that received construction or reconstruction plan approval after November 28, 2016 “or are newly certified” after that date. 42 C.F.R. § 483.90(e)(1)(i), (f).

CMS proposes to delete “newly certified,” leaving plan approval as the only trigger, and explains that the change “would exempt existing facilities from being required to meet” those standards “because the facility changed ownership or experienced a gap in operations.” 91 Fed. Reg. at 72656, 72762.

Medicaid payment transparency (42 C.F.R. §§ 438.72, 442.43)

The 2024 rule also required states to report annually, at the facility level, the percentage of Medicaid nursing facility and ICF/IID payments spent on compensation for direct care workers and support staff. The CARE rule would rescind that reporting. 91 Fed. Reg. at 72636, 72696.

A request for comment on nurse practitioners and physician assistants (§ 483.30)

CMS is not proposing a change here; it is asking a question. In a SNF the initial comprehensive visit must be made by a physician, and later required visits may alternate between the physician and an NP, PA, or clinical nurse specialist.

The statute requires that the care of every SNF resident be provided under the supervision of a physician. 42 U.S.C. § 1395i-3(b)(6). For Medicaid nursing facilities, by contrast, a state may allow a non-employee NP or PA working with a physician to perform any required physician task. 42 U.S.C. § 1396r(b)(6). CMS asks for comment on expanding the NP and PA role in SNFs “within our current statutory limitations,” including the state and local restrictions that would affect any new flexibility. 91 Fed. Reg. at 72656–57.

Hospitals and critical access hospitals: not purely deregulatory, and one date that comes first

For hospitals, the proposal would remove the annual transfer-protocol training at § 482.43(c) and the emergency services readiness training at § 482.55(c)(3), both currently in effect, as well as the obstetric staff training at § 482.59(c) and the obstetric QAPI requirements at § 482.21(b)(4) and (e), which take effect January 1, 2027.

Critical access hospitals would see parallel changes to their own conditions, such as § 485.618(e)(2). 91 Fed. Reg. at 72638–43. The package is not entirely deregulatory: CMS would replace the obstetric training paragraph with a new patient-rights standard requiring informed consent before birth tissue is collected, including disclosure of any financial compensation to the hospital or a third party. Id. at 72646–48.

Because January 1, 2027 arrives ten days before the comment period closes, hospitals and CAHs should keep preparing for the obstetric QAPI and training requirements unless CMS takes separate, legally effective action to delay them.

What Washington law still requires

A federal repeal does not repeal state law, and several of the requirements CMS would relax have Washington counterparts that stand on their own. Washington nursing homes must maintain an effective infection control program under WAC 388-97-1320, and outbreak reporting to the local health jurisdiction under the notifiable conditions rules in chapter 246-101 WAC does not depend on NHSN. Washington sets its own transfer and discharge notice rules: RCW 70.129.110 requires written notice at least thirty days in advance, or as soon as practicable when urgent medical needs require an immediate move, and every notice must include the name, address, and telephone number of the state long-term care ombuds; WAC 388-97-0120 requires written notice to the resident, the surrogate decision maker, the family, and the department. None of that depends on § 483.15.

The building rules are where the gap between federal relief and state law is widest. WAC 388-97-2400 requires each resident bedroom to be on an exterior wall with a transparent glass window and, in a new building or addition, a sill no more than three feet above the floor. WAC 388-97-2420 caps bedrooms at four beds and, for a new building, addition, or change of use with plans submitted after September 1, 1995, at two beds. WAC 388-97-2700 requires a new-construction toilet room to be directly accessible from each resident room and to serve no more than two bedrooms.

Ownership changes carry their own state obligation: RCW 18.51.530 requires written notice to each resident or guardian at least sixty days before a change of ownership or management, separate from the department’s licensing process. And on practitioner visits, WAC 388-97-1260 already lets an ARNP or physician assistant alternate required visits for Medicare residents after the initial physician visit and perform any required physician task for Medicaid residents when not employed by the facility and working in collaboration with a physician. Any federal expansion would have to be read against that rule and Washington scope-of-practice law with at least NPs being “full-practice.”

What to do before January 11, and what to do after

Before January 11, the only decision with a deadline is whether to comment and on what. CMS has asked specific questions that Washington operators can answer from their own records: the cost and staff hours of NHSN reporting, how discharge notices and Ombudsman communications actually work, what would make the facility assessment less burdensome, and where NP and PA involvement has improved access.

A short comment that gives CMS specific evidence to evaluate, including the inconsistency in the proposed vaccine-documentation text, does more than a form letter. Hospitals and CAHs should treat the January 1 obstetric compliance dates as live.

After January 11, the work is mapping and patience. Map each proposed change against the WAC and RCW provisions above before anyone changes a workflow. Have a life-safety consultant review what the 2024 code editions would require of the physical plant, since newer editions add requirements as well as remove them.

Parties to a pending sale of an older building should address in the agreement how the occupancy and bathroom standards will be handled if the rule is, or is not, final before closing; whether those standards apply today turns on how the transaction is structured and surveyed, including whether the buyer accepts assignment of the provider agreement under 42 C.F.R. § 489.18, and on the building’s construction and certification history, not on the sale itself. And keep complying. NHSN reporting, Ombudsman copies, and staff vaccine education remain surveyable until a final rule takes effect.

Conclusion: read the proposal for what it is

The CARE rule would remove real paperwork from Washington nursing homes, and the occupancy and bathroom change could matter to anyone taking over an older building. It would not change what Washington law requires, it would not revive or further alter the staffing mandate, and it changes nothing today.

If your organization is weighing a comment, a transaction, or a survey response touched by this proposal, we are glad to help; contact us at info@stratagemlawgroup.com or through our contact page.

Frequently asked questions

Is anything in the CARE rule in effect now?

No. It is a proposed rule with a comment deadline of January 11, 2027. Every requirement it would change remains in force until CMS publishes a final rule and the effective date arrives.

Would nursing homes still have to send transfer notices to the Ombudsman?

Yes. The proposal excuses the Ombudsman copy only when a resident is transferred on an emergency basis to an acute care facility. Notices to the resident and representative, and Ombudsman copies for all other transfers and discharges, would continue. CMS is separately asking whether residents who initiate their own discharge should be able to opt out of the Ombudsman copy.

Does the proposal change the nursing home staffing mandate?

No. The numerical staffing minimums and the 24/7 RN requirement were repealed by an interim final rule effective February 2, 2026. The CARE rule touches two other pieces of the 2024 rule: it removes direct care staff representatives from the facility assessment and rescinds Medicaid payment transparency reporting. The facility assessment itself and the baseline staffing requirements in § 483.35 remain.

Would windowless resident bedrooms become permissible?

No. CMS would remove the outside window or door requirement in § 483.90(a)(7), but it states that resident bedrooms would still need at least one window to the outside, and WAC 388-97-2400 independently requires an exterior transparent glass window.

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This article is provided by Matthew Macklin and Stratagem Law Group for general informational and commentary purposes only. It is not legal advice, does not address any specific facts or circumstances, and does not create an attorney-client relationship between the reader and Stratagem Law Group or any of its attorneys. Laws, regulations, and enforcement priorities change. Readers should consult qualified counsel regarding their specific situation before acting on any information contained here.

Related reading: No Hearing, No Rule: How to Challenge a Washington Agency Rule and Remove, Then Dismiss: The Medicare Advantage Jurisdictional Two-Step and the Limits of § 405(h) Channeling.

Sources

• 91 Fed. Reg. 72634 (Nov. 10, 2026), Medicare and Medicaid Programs; Cutting Administrative Requirements for Excellence in Patient Care (CMS-3484-P): https://www.govinfo.gov/content/pkg/FR-2026-11-10/pdf/2026-22812.pdf
• CMS fact sheet, “Medicare and Medicaid Programs; Cutting Administrative Requirements for Excellence in Patient Care (CARE) (CMS-3484-P)” (Nov. 5, 2026): https://www.cms.gov/newsroom/fact-sheets/medicare-medicaid-programs-cutting-administrative-requirements-excellence-patient-care-care-cms-3484
• Regulations.gov docket CMS-2026-3631 (comment period ends Jan. 11, 2027, 11:59 p.m. ET): https://www.regulations.gov/document/CMS-2026-3631-0001
• 90 Fed. Reg. 55687 (Dec. 3, 2025), Repeal of Minimum Staffing Standards for Long-Term Care Facilities (interim final rule, effective Feb. 2, 2026): https://www.govinfo.gov/content/pkg/FR-2025-12-03/pdf/2025-21792.pdf
• Pub. L. No. 119-21, § 71111 (July 4, 2025): https://www.congress.gov/bill/119th-congress/house-bill/1/text
• 42 C.F.R. §§ 483.15, 483.30, 483.35, 483.71, 483.80, 483.90, 489.18 (eCFR): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• RCW 70.129.110, Disclosure, transfer, and discharge requirements: https://app.leg.wa.gov/rcw/default.aspx?cite=70.129.110
• RCW 18.51.530, Notice of change of ownership or management: https://app.leg.wa.gov/rcw/default.aspx?cite=18.51.530
• WAC 388-97-0120, 388-97-1260, 388-97-1320, 388-97-2400, 388-97-2420, 388-97-2700 (chapter 388-97 WAC, Nursing homes): https://app.leg.wa.gov/wac/default.aspx?cite=388-97
• Chapter 246-101 WAC, Notifiable conditions: https://app.leg.wa.gov/wac/default.aspx?cite=246-101

Matthew Macklin, Managing Attorney, Stratagem Law Group, PLLC

Matthew T. Macklin is the Managing Attorney of Stratagem Law Group, PLLC, a Washington business, healthcare, and nonprofit law firm. A former healthcare executive and a licensed nursing home administrator since 2011, he served on the Washington State Board of Nursing Home Administrators from 2021 to 2026 and represents providers, businesses, and nonprofit boards across Washington. Connect with him on LinkedIn.