Chronic Understaffing in Nursing Homes and Its Impact on Care

Understaffing in nursing homes is not new. It has been a documented danger since the 1980s, and the facilities have known it. The COVID-19 pandemic made it worse, and the problem outlasted the emergency. If you work in long-term care, you are living with the consequences: unsafe ratios, mandatory overtime, and turnover that never lets up.

How COVID-19 Deepened the Shortage

Nursing homes already struggled to hire and keep staff before COVID-19. Poor pay, lack of respect, unsafe conditions, and heavy workloads all got worse when the pandemic hit.

Certified nursing assistants (CNAs) make up most of the nursing home workforce and deliver most of the direct care, yet they are paid the least and carry the highest risk of work-related injury. During the pandemic they did the same physically and emotionally demanding work in more hazardous conditions, with fewer people on the floor.

Infection control collapsed on top of the staffing gap. About 20% of nursing homes did not have enough personal protective equipment in October 2020, so workers reused PPE or relied on inadequate gear while caring for residents with and without COVID-19.

Turnover was already extreme. The staff turnover rate ran at 94% based on 2017 and 2018 data. During the pandemic, nursing home staff quit at higher rates than any other healthcare workers because they would not or could not work in unsafe conditions. As of June 2022, the shortage was still severe:

• 87% of nursing homes reported moderate or high staffing shortages
• 98% had trouble hiring new staff
• 73% said staffing shortages could force them to close
• 60% were losing money
• 53% could not sustain their current costs and pace for more than a year

Decades of Low Staff-to-Patient Ratios

In 2001, the Centers for Medicare and Medicaid Services (CMS) published a study establishing the importance of minimum staff-to-patient ratios. It recommended that each resident receive at least 4.1 to 4.85 hours of direct nursing care per day, depending on length of stay, delivered by a mix of registered nurses (RNs), licensed practical nurses (LPNs), and CNAs.

Many homes never meet that standard. Poor funding, high turnover, burnout, and unsafe conditions all push staffing below the recommendation, and for years there were few consequences. A facility could fall short and stay open, and staff could keep their licenses.

Consequences land only when short staffing causes harm. Outcomes that can make nursing staff civilly or criminally liable, or cost them their licenses, include deaths, hospitalizations, emergency room visits, falls, and bedsores.

Thirty states set their own mandatory minimum hours of direct care per resident per day. All 30 mandate fewer hours than the national recommendation, and the requirements sit well below what individual residents actually need. Facilities can also apply for waivers instead of meeting the requirements in some cases.

Where Federal Law Stands

For decades, federal law did not set specific numeric staffing levels. It required long-term care facilities to provide enough licensed nurses and CNAs to meet residents' care-plan needs, a full-time RN as director of nursing, an RN as full-time charge nurse, an RN onsite eight consecutive hours a day seven days a week, and CNAs who demonstrate competency and become licensed and state-registered within four months of hire.

That changed, briefly. In April 2024, CMS finalized the first federal minimum staffing standard for nursing homes: 3.48 total nurse staffing hours per resident day, including 0.55 RN hours and 2.45 nurse aide hours, plus an RN onsite 24 hours a day, seven days a week. The rule never took effect. Two federal courts vacated its core provisions in 2025, a budget law enacted in July 2025 (Public Law 119-21) barred CMS from enforcing the standard through September 2034, and CMS issued an interim final rule on December 3, 2025 repealing it outright, effective February 2, 2026.

So as of 2026, there is again no enforceable federal minimum. States continue to set their own rules, and they do not agree. New York, Rhode Island, and Massachusetts raised their minimums, while Georgia, Oregon, and South Carolina cut theirs temporarily or permanently.

The Homes Know the Risk

Nursing homes have understood the dangers of short staffing since the 1980s, yet some deliberately hire fewer people to cut labor costs. For years, many misrepresented their payroll headcount and got away with it, until the Affordable Care Act in 2010 required daily payroll reporting to verify staffing.

That data confirmed the gap. About half of nursing homes failed to meet CMS staffing recommendations 80% or more of the time between April 2017 and March 2018. For-profit homes often fell below even the lower state thresholds, such as the 3.5 hours California requires.

LPNs are the exception. They face less of the poor pay, physical strain, and limited advancement that drive RNs and CNAs out, and homes are most likely to staff the required number of LPNs. Skilled nursing facilities pay LPNs their highest average annual salary and expect less physical labor of them than of CNAs. RNs and CNAs in nursing homes earn below-average pay, RNs have more advancement options elsewhere, and CNAs face heavier physical demands than they would in home health or assisted living.

What Drives the Shortage

• Lack of respect for the work
• Poor pay and benefits
• Limited career advancement
• Better-paying options in other industries or care settings
• Unsafe conditions and workloads

What the Shortage Causes

• High turnover
• Nurse burnout
• Unsafe working conditions
• Heavier workloads and more overtime
• Unsafe staff-to-patient ratios

What Can Be Done

There is no clean fix. Nursing homes draw most of their funding from Medicare and Medicaid, and CMS reimburses through a bundled payment: one lump sum per patient per day. With many specialties competing for a single pot of money, salaries stay low, hiring budgets stay thin, and residents may not get all the care they need for as long as they need it.

A federal law requiring 4.1 to 4.85 hours of direct care per resident would help, but it would be hard to enforce, as the short life of the 2024 rule showed. State minimums can help too, though a flat number does not account for residents who need more attention than average, and facilities have gamed the rules by hiring temporary staff right before inspection.

To cope, nursing homes may require mandatory or voluntary overtime, lean on family members and unlicensed caregivers on weekends, hire agency staff, limit new admissions, promote from within, or raise wages and bonuses. None of it breaks the cycle on its own. Turnover and burnout feed the shortage, and good CNAs, LPNs, and RNs will keep leaving for better conditions as long as the workload and the risk stay high.

The workable path forward will combine action from leadership and frontline staff. Until funding and conditions improve, nurses should back each other up, stretch the resources they have, and advocate for themselves, their coworkers, and their residents to keep harm to a minimum.