The call for culture change in nursing homes has succeeded beyond anything the reformers of 2006 could have imagined. It is now embedded in federal regulation, accreditation frameworks, foundation initiatives, and the vocabulary of every serious quality improvement effort in the field. The language won. The residents lost. That is not a paradox. It is the mechanism.
In October 2006, I published a piece asking whether the growing call for culture change in healthcare would lead to better care. I was skeptical—not of the aspiration, but of the architecture. What I did not yet have language for is what 20 years inside a changing industry has since given me: the specific name for what culture change language, in the wrong hands, does. It legitimates. It provides cover. It is possible to celebrate culture change at a conference in the morning and extract management fees from a chronically understaffed facility in the afternoon. The language does not prevent the extraction. In some cases, it enables it.
That is what I did not know in 2006. That is what the intervening years have made impossible to unknow.
What the Research Said Then, and What it Says Now
In 2006, I noted the academic literature was mixed. Some researchers saw organizational culture as inherently changeable; others argued that honest understanding was more useful than claiming transformation. The middle ground held that culture changes—but leaders’ ability to control its direction remained deeply uncertain. That middle ground has held.
‘Person-centered care did not fail those residents. The system failed them while invoking person-centered language in every document it produced.’
Two decades of research on culture change in long-term care show a consistent pattern: process changes are achievable, structural changes are difficult, and resident outcomes are modest and uneven. Scaling person-directed care results across facilities serving Medicaid-dependent residents has proven elusive in exactly the ways I suspected in 2006. Culture change initiatives have not resolved those structural conditions. In many cases, they have been deployed around them, celebrating the language of transformation, while the financial architecture of the industry moved in the opposite direction.
Person-Centered Care: The Phrase That Traveled Further Than the Idea
In 2006, I contrasted culture change—vague, contested, difficult to operationalize—with person-centered care, which I called self-explanatory and self-evident. I borrowed, to paraphrase Oliver Sacks’s formulation: it is not the disease that has a person, but a person who has a disease. That language has since traveled into places I did not anticipate. It is codified in federal regulations, embedded in CMS guidance, present in care-planning mandates and the vocabulary of every serious quality initiative in the field.
Massachusetts data indicate that a substantial share of nursing facilities—approximately one-third, based on recent analyses of the Centers for Medicare & Medicaid Services’ Staffing Data Submission Payroll Based Journal, operate below minimum staffing thresholds recommended in 2024, standards grounded in the principle that person-centered care requires an adequate ratio of human attention to human need.
National evidence shows that for-profit facilities are more likely to have lower staffing levels and higher rates of deficiencies, including those related to staffing. The consequences are not evenly distributed: residents in lower-staffed facilities are disproportionately Medicaid beneficiaries and more likely to come from communities of color and from households with limited resources to supplement care. Studies further show that facilities serving higher proportions of Black residents tend to have fewer resources, lower staffing levels, and poorer outcomes, reinforcing structural inequities embedded in the long-term care system.
Person-centered care did not fail those residents. The system failed them while invoking person-centered language in every document it produced. That is not irony. That is function.
The Extraction Problem Culture Change Cannot Solve
What I did not anticipate in 2006 was the specific form structural obstruction would take. The past two decades have seen the accelerated entry of private equity into nursing home ownership, with mechanisms now well documented: Operating Company (OpCo)/Property Company (PropCo) splits separating operations from real estate, related-party management fees paid to affiliated entities, LLC structures that distribute ownership while concentrating profit and obscuring accountability. A facility can report operating losses—claiming inability to improve staffing, while simultaneously paying millions annually to entities controlled by the same ownership group.
‘The pioneers who built the movement meant something real by it. The industry absorbed the language and kept the model.’
This is not a culture problem. It is an extraction problem. And the distinction is not semantic. If this is a culture problem, the intervention is education, leadership development, and reform initiatives. If this is an extraction problem, the intervention is ownership disclosure, related-party transaction limits, and regulatory enforcement that current frameworks have been systematically weakened to avoid delivering. The culture change movement, whatever its intentions, did not produce those structural interventions. What it produced was a vocabulary of transformation that operators could adopt without altering the financial architecture underneath it. The pioneers who built the movement meant something real by it. The industry absorbed the language and kept the model.
What the Slow Work Actually Requires
I ended my 2006 piece with a conditional: only by keeping our sights on person-centered care would culture change serve any useful purpose in promoting the slow work of reform. That conditional has not expired. But the slow work now has a clearer map of what it must navigate.
The residents I am thinking of are not abstractions. They are the 1.2 million Americans in nursing facilities who depend upon Medicaid for their care—the person in a memory care unit whose needs are managed by an understaffed night shift, the person whose care plan uses the vocabulary of person-centered care and whose experience of that care is shaped by a staffing ratio that has not improved in a decade.
For them, the question I asked in 2006 was never really about culture. It was always about power and who holds it, who profits from its exercise, and who bears the cost when it is used against the people it was supposed to serve. Twenty years of accumulated language has not answered that question. It has deferred it. Naming the deferral honestly is where the slow work must begin.
James Lomastro, PhD, has more than 40 years’ experience as a senior administrator in healthcare, human services, behavioral health, and home- and community-based services. He was a surveyor at the Commission on Accreditation of Rehabilitation Facilities surveying throughout the United States and Canada. Lomastro is a member of the Coordinating Committee of Dignity Alliance Massachusetts.
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