Hiring Challenges Post SARS-CoV-2 & ICE Immigration Raids

Staffing has historically been one of the most challenging aspects both from a regulatory as well as from an administrative and fiscal perspective of nursing homes. Although the initial spur for the growth of privately owned nursing homes was led by the passage of the Social Security Act of 1935 with the Old Age Assistance, same spur brought on care quality issues and thus regulation. In this sense by late 1950s concerns about staffing as well as care quality led to Senate Investigations, i.e. the Subcommittee on Problems of Aged and Aging Reports from 1959, reporting that only a few nursing homes were high-quality, while most were “substandard, had poorly trained or untrained staff, and provided few services” 1, demonstrating that although nursing homes were proliferating, inadequate staffing was becoming the crux of poor outcomes.

Subsequently, the federal regulations slowly started trying to address these issues. First were the amendments to the Social Security Act in 1950 required states to license nursing homes, though standards were left to the individual states. 2 Despite the licensure and the initial focus as well as the findings of the 1959 report, over the next decades, evidence kept on mounting that most facilities had insufficient personnel and low care standards 2, ultimately culminating in the Omnibus Reconciliation Act (OBRA) of 1987. 3 OBRA-87 for the first time established explicit minimum federal staffing requirements requiring that every Medicare- or Medicaid-certified nursing home to have 24-hour licensed nursing coverage, including a registered nurse (RN) on duty at least 8 consecutive hours per day, 7 days a week 3 representing a federal staffing floor targeting to improve quality of care and resident outcomes. In this sense, although data demonstrated that outcomes and care quality improved post OBRA-87, debates continued whether the minimums were truly sufficient. 4

The next major push for changes to staffing requirements coincided with the SARS-CoV-2 outbreak. In 2023, the Centers for Medicare & Medicaid Services (CMS) proposed and in 2024 finalized, a new rule setting national minimum staffing ratios for nursing homes as part of the Biden Administration’s reform initiative, establishing 3.48 hours of nursing care per patient per day, with at least 0.55 hours from a Registered Nurse (RN) and 2.45 hours from a nurse aide alongside an RN on site 24-7. 5 This was the first time a specific quantitative nurse staffing threshold was imposed federally as previously, aside from the 8-hour RN rule, regulations only required “sufficient” staff without a numeric minimum.

While these requirements were scheduled for phased implementation, with full compliance not required until 2029, they faced immediate pushback. Industry groups and many state governments argued that the mandates were unrealistic given the existing workforce shortages and funding levels. In late 2024, a coalition of 20 states sued CMS to block the rule, and in early 2025, federal courts sided with the challengers with a federal judge setting aside the 24/7 RN and 3.48 HPRD provisions on a nationwide basis. 6 Thus, the federal staffing rule was halted before it could take effect and the Biden Administration’s staffing standards had been effectively nullified.

However, the crux of the matter remained that the industry and stakeholders were opposed from a mainly economical perspective in that there were not many arguments that such staffing minimums would not improve care or outcomes. In this context, CMS’s own analysis elucidated that most facilities would have needed to boost staffing to meet 3.48 HPRD with an American Health Care Association (AHCA) study estimating that 94% of nursing homes would have had to hire additional staff to the order of 102,000 new nurses and nurse’s aides at an estimated annual cost of about $6.5 billion to comply with the rule. 7,8 Labor was already the single largest component of nursing home operating costs, roughly two-thirds of an average facility’s budget on average so requiring nearly all homes to increase staff was ultimately a massive unfunded mandate. 8 Indeed, financial pressures and worker shortages have been so severe that as of 2023, four in five SNFs reported limiting new admissions due to inadequate staffing. 7 Thus from the operators’ perspective, the 2024 federal standards, however well-intentioned for resident outcomes, were untenable without increased funding.

Ultimately, the courts’ intervention gave nursing homes a reprieve from the looming mandate. However, the fundamental issue has remained that without enforceable ratios, staffing adequacy falls back to the vaguer requirement of “sufficient” staffing, a standard that, as history has demonstrated that has often failed to prevent understaffing. Many long-term care providers may have sighed in relief at the rule’s cancellation, but the underlying staffing crisis has not gone away.

The SARS-CoV-2 pandemic threw gasoline on the fire of nursing home staffing challenges. Even before 2020, many facilities struggled with high staff turnover, with annual turnover rates above 100% for aides having been reported alongside difficulty recruiting nurses. The pandemic then caused an exodus of workers from long-term care with over 200,000 employees having left the nursing home workforce from early 2020 to 2022, the sharpest decline of any health care sector. 9 Temporary cessation of federal survey activity may have masked some of the immediate regulatory and quality related consequences of understaffing, but they also perhaps enabled facilities to operate with skeleton crews under emergency conditions, and more importantly get used to “skeleton” staffing. Indeed, federal data has shown that by the end of 2020, 1 in 5 facilities nationwide reported staffing shortages weekly. 10 Interestingly ,average staffing hours per resident did inch up slightly in 2020 from 3.7 to 3.8 HPRD, likely due in part to decreased census, but care outcomes still suffered. 10 In this context, a study of over 8,000 nursing homes elucidated that resident health outcomes worsened substantially in 2020, with, for example, the percentage of long-stay residents experiencing mobility loss jumping from 16% to 28% by Q4 2020. 10 Not surprisingly, facilities that reported staff shortages had significantly higher rates of adverse outcomes that is more functional decline, weight loss, and pressure ulcers, whereas homes with lower total staffing hours but no reported “shortage” did not see the same degree of decline. 10 Suggesting that acute shortages, i.e. having too few staff on duty, even if on average the HPRD looked adequate directly contributed to worse resident care during acute SARS-CoV-2 surges.

By the end of 2023, the staffing situation had not fully recovered. Nationally, nursing homes were still about 80,000 workers short of pre-pandemic levels, and turnover remained high 11, with most facilities struggling to hire directly and instead relying on staffing agencies. 12 The pandemic also reminded what was well established in the 1959 Senate Report that is how vital consistent staffing is to quality in that many facilities that avoided catastrophic COVID outcomes were those with more staff who could also implement infection control. Not surprisingly this lesson has continued to shape policy discussions beyond the proposals by the Biden Administration with several states since having enacted their own minimum staffing laws or bonus pay programs to attract workers.

Even as staffing struggles have mounted, the actual need for long-term care has been consistently growing. America’s population is aging rapidly in that by 2030, all Baby Boomers will be over 65, and by 2040 the 85+ population, i.e. those most likely to require nursing home-level care will soar to new heights. 13 The U.S. Department of Health and Human Services estimates that 70% of today’s 65-year-olds will require some form of long-term care services in their remaining lifetime. 14 While many will receive care at home, a significant fraction will spend time in nursing facilities. Projections suggest that by 2030 the country may need to build 3,000 new nursing homes, on top of ~15,000 existing to keep up with demand. 14 In certain “silver tsunami” states like Florida and Arizona, the senior population is expected to increase by ~40%, highlighting that this demand will not be shared equally amongst states. 14

Compounding the numbers is the fact that nursing home residents are also getting more medically complex than ever. Hospitals discharge patients quicker and sicker, meaning post-acute skilled nursing facilities now handle higher-acuity care e.g. IV medications, wound vacs, rehab for serious illness that previously might have stayed in the hospital for longer periods of time. Chronic conditions like dementia, heart failure, and renal disease are common among today’s nursing home population, often in combination, elevating the staffing needs. More RNs and trained aides are required to manage complex clinical tasks and monitoring. In short, the quality and quantity of staff needed per resident has increased alongside challenges of hiring staff and lowering staffing turnover.

Thus, the long-term care sector faces a dual pressure; a surge in residents in coming years, many of whom will have greater care needs, against a backdrop of a shrinking caregiver workforce. This imbalance poses serious risks to care quality if not addressed. “Healthcare on the brink” due to the aging demographics; without major investments in the workforce or new care models, the gap between needed and available care may widen to unsustainable levels and lead to ethical conundrums of rationing. 15

From a facility perspective, the issue of staffing is financial in the short-term but beyond financial in the long-term. Despite the financial disincentives for facilities to increase staffing, a large body of research has consistently shown that better-staffed nursing homes deliver higher quality care. Higher staffing levels, especially of RNs and lower staff turnover have consistently been associated with fewer adverse events, better health outcomes, and improved safety for residents. Facilities with more nurses on duty see have shown significantly lower inappropriate medication use, with a study of over 10,000 U.S. nursing homes demonstrating that each additional hour per resident-day of RN staffing was associated with a 2.25% decrease in the rate of inappropriate antipsychotic medication use, and higher total staffing hours correlated with overall lower antipsychotic use. 16 From a clinical outcomes perspective, systematic reviews have clearly shown that increased RN hours and a richer skill mix, that is a higher proportion of RNs among nursing staff have consistently led to fewer pressure ulcers, fewer infections, and less resident pain. 17 Au contraire, facilities that were just “adequately” staffed with mainly aides but few RNs often had mixed results on outcomes. 17

Ultimately, data has shown that it’s not just the absolute number of staff, but consistency of staffing that matters. Research has shown that staffing instability, described as days with below-average staffing levels was associated with lower care quality measures, even if the facility’s overall average staffing was decent. 18 In other words, a nursing home that has intermittent short-staffed days, e.g. due to call-outs or fluctuating census performs worse on quality indicators, like falls, weight loss, or ADLs compared to one with steadier daily staffing, highlighting the need for reliability and consistency.

Not surprisingly, higher RN and therapist staffing was also linked to fewer hospitalizations and emergency visits for nursing home residents, in that an increase of 1 RN hour per resident-day was associated with a significant decrease in unnecessary emergency department visits in both long-stay and short-stay resident populations. 19

Overall, the intuitive truth is not surprising. When nursing home residents receive more hours of care from trained staff, their outcomes improve, that is fewer drugs, fewer ulcers, fewer hospital trips, and better overall well-being. Conversely, chronically understaffed facilities tend to have more falls, more infections, more untreated symptoms, and more regulatory infractions. There is also evidence that nursing homes with better staffing achieve higher ratings and family satisfaction, which can have reputational and financial benefits in the long run.

Under new Medicare payment models, poor quality can hit a facility’s bottom line. In 2019, Medicare shifted to the Patient-Driven Payment Model (PDPM) for skilled nursing facilities, tying reimbursement to resident clinical complexity and outcomes rather than purely volume of therapy or services rendered. Facilities that are inadequately staffed may struggle with PDPM in two ways: clinically, they might not be able to capture and manage all of a resident’s conditions leading to a lower acuity classification and thus lower daily payment and outcomes-wise, avoidable complications like hospitalizations or weight loss can trigger penalties or lower quality ratings that indirectly affect reimbursement. In essence, if you don’t invest in staff up front, you may pay for it later through reduced payments and performance-based adjustments. While PDPM is complex, one aspect is clear is that higher nursing needs and better outcomes are rewarded, so a facility that skimps on care may find its Medicare revenue reduced compared to a well-staffed competitor.

Beyond reimbursement, the risk of regulatory citations rises when staffing is thin. Federal law already requires “sufficient” staffing to meet all residents’ needs, and surveyors can cite facilities for non-compliance with that requirement. In recent years, regulators have become more vigilant about staffing-related deficiencies. Notably, the most serious level of violations, those causing actual harm or immediate jeopardy to residents often involve situations of egregious neglect that tie back to lack of staff. According to newly released federal data, only around 5.6% of nursing home health inspections cite harm or immediate jeopardy (the rest are lower-level issues), but these severe citations have been increasing. 20,21 In 2024, there was a significant increase in “double G” citations, indicating repeated serious noncompliance and an 18% rise in related civil monetary penalties over the prior year. 20,21 Many of these serious deficiencies, such as unchecked pressure sores, dehydration, or unsafe wandering leading to injury are directly linked to inadequate monitoring or care due to not enough staff on the floor.

Even at the less severe end, citations for failure to have sufficient staff are not uncommon. For example, in Iowa one nursing home was cited five separate times in a 9-month period for insufficient staffing though tellingly never being fined. 22 Nationwide, more than 400,000 deficiencies were recorded over three years since SARS-CoV-2, and facilities racking up over $560 million in fines for various violations 20,21 making it clear that regulators and the public are paying closer attention to staffing. In short, if you don’t pay for the staff up front, you may pay for the consequences later; through lower PDPM reimbursement, lost revenue from admission bans, fines, and legal liability.

On the other side of the medallion, addressing the staffing shortfall will likely require policy and societal changes, including greater support for the direct care workforce. One important facet of LTC staffing is the role of immigrant workers. Immigrants have historically been a backbone of long-term care in the U.S., and that trend is increasing. As of 2023, 28% of direct care workers, i.e. nursing assistants, home health aides, and nurses providing long-term care were immigrants, about a 15% increase since 2018. 23 In nursing homes specifically, about 21% of staff were found to be foreign-born, and in home care the proportion was even higher, i.e. over one in three. 23 Immigrant workers, including many women from Africa, the Caribbean, South Asia, and Latin America have helped fill these chronic labor gaps in these difficult, lower-paid jobs. Research has found that immigrants don’t just plug workforce holes; they improve care access. Communities with higher immigration levels have a greater share of seniors able to age in place at home or be placed in long-term care facilities, thanks to the abundant nursing aides 24 conversely, stringent immigration enforcement has been linked to worsening staffing shortages in nursing homes 25. Recently policy shifts and enforcement actions have begun to disrupt the very workforce pipeline that many nursing homes depend on, raising the specter of sudden staffing implosions. In early 2025, the federal government rescinded a 2021 policy that had designated healthcare facilities like nursing homes as off-limits for immigration raids. Making the possibility of audits of employee I-9 paperwork to identify any staff without valid work authorization a reality. The result of such an audit can be devastating, as facilities would be forced to terminate workers en masse who cannot immediately prove legal status. In other words, a single audit letter can suddenly wipe out a chunk of a nursing home’s caregivers, leaving administrators scrambling to maintain care.

Even absent formal audits, the stepped-up enforcement climate is already chilling the direct-care workforce. Providers nationwide report that some immigrant employees have simply stopped coming to work, not because they lack papers, but because of fear.  And a significant subset of long-term care workers are potentially at risk with recent estimates suggesting that around 15% of immigrant home-care aides are undocumented, meaning thousands of caregivers could be removed from the labor pool if enforcement intensifies. 26,27

Concrete examples from the field illustrate how quickly the situation can deteriorate. In Florida, the CEO of a senior living community saw ten staff members suddenly lose their work permits in a single day when a humanitarian parole program for certain migrants was terminated. The CEO was given less than 24 hours’ notice that these employees’ legal authorization to work had vanished, sending her team into a frenzy to cover the now-empty shifts. Worse, the CEO stated that the facility expected to lose 30 more workers within weeks due to an upcoming expiration of Temporary Protected Status (TPS) for immigrants from Haiti. 27 Across in Georgia, another operator, relies on foreign-born employees for one-third of staff reported that eight of his nursing aides were forced to leave after their TPS was revoked. 27

Beyond direct deportations, the legal immigration pipeline for new healthcare workers has also constricted, compounding the problem. Nursing homes, home health agencies, and assisted living facilities had counted on a steady influx of newcomers from abroad to fill the hundreds of thousands of new caregiving jobs America will need in the next decade. That influx is now in jeopardy with refugee admissions having been largely halted at the federal level. 27

All of these immigration pressures threaten to make a bad staffing situation suddenly far worse. On one hand, regulators and the public are holding facilities accountable for safe staffing and expecting them to have contingency plans for sudden shortages. On the other hand, immigration authorities are now creating exactly the kind of sudden shortage scenario that no amount of internal planning can easily withstand. A surprise ICE audit or a batch of visa expirations can empty a shift just as surely as a SARS-CoV-2 outbreak or natural disaster. In that sense, immigration enforcement has become a new form of unpredictable disruption to which nursing homes must adapt. The prospect of an unannounced ICE audit or a sudden TPS expiration wiping out a third of a facility’s aides overnight is not hypothetical, it is happening now, and it can unravel even the most carefully balanced staffing matrix. Every administrator now needs to factor this threat into emergency staffing plans: if a portion of your caregiving staff were to vanish next week due to an immigration action, how would your facility cope?

While there is no silver bullet for the workforce crisis, innovation can help “do more with less.” In an era when every extra pair of hands is invaluable, technology and analytics offer ways to support the existing staff and maintain quality. For example, adopting a real-time clinical surveillance system can significantly enhance a facility’s ability to catch problems early, even with limited staff. Clearpol Clinical is one such solution that many nursing homes are turning to. The Clearpol platform ingests live data from leading post‑acute EHRs such as PointClickCare and MatrixCare and begins 24/7 analysis within hours of activation, functioning as a digital sentinel that never calls in sick. Its machine‑learning engine continuously parses vitals, progress notes, labs, and medication profiles; the instant the system detects a pattern suggestive of clinical deterioration nit pushes a high‑priority alert to the dashboard before the problem blossoms into harm or surveyor‑noted Immediate Jeopardy. Clearpol’s algorithms flag documentation gaps in real time and auto‑generate compliance reports, so administrators can correct omissions while the chart is still warm, not three months later when the statement of deficiencies lands on their desk. In short, the software acts as an ever‑vigilant clinical and regulatory co‑pilot: “always survey‑ready,” to use its own tag line. This kind of proactive monitoring acts as a force-multiplier for your clinical team: a single nurse can oversee more residents when an AI co-pilot is analyzing data 24/7 and highlighting where attention is needed most.

Early adopters report that the system’s automated risk stratification and on‑demand analytics freed enough licensed‑nurse hours per month to cover the loss of one full‑time aide, precisely the kind of slack that can spell the difference between resilience and collapse when immigration enforcement suddenly shrinks the roster. Moreover, because Clearpol archives every alert, intervention, and resolved deficiency, it furnishes a defensible audit trail that can be handed to state inspectors as proof of continuous quality oversight, no late‑night scramble to reconstruct who knew what and when. For facilities now forced to plan for the unplannable, pandemic surges yesterday, immigration crackdowns today, climate‑driven evacuations tomorrow, embedding an AI guardian into daily operations is rapidly shifting from novelty to necessity.

Staffing will likely remain a central challenge in nursing home care for the foreseeable future. Historically, the sector has weathered scrutiny and cycles of reform, but the fundamental supply of caregivers relative to the growing needs of an aging society is an unprecedented concern. Meeting this challenge will require multi-pronged efforts from policy changes that fund higher wages and training, to immigration reforms and education pipelines for new healthcare workers, to technological aids that enhance what staff can do. Regulators may have paused the push for federal staffing ratios, but the message is clear that expectations on quality and safety are only rising. Providers who stay complacent do so at their peril: the data show that understaffing not only harms residents but also leads to citations, lawsuits, and financial pain.

On the other hand, providers who innovate and invest in their workforce can turn the staffing challenge into an opportunity for excellence. By fostering a stable, well-supported staff and equipping them with smart tools, a nursing home can deliver superior care even under tight constraints. The coming years will test the resilience and creativity of long-term care leaders. Now is the time to fortify your facility to ensure you have plans for staffing surges and shortages, embrace technologies like Clearpol that help you maintain quality with lean staffing, and advocate for systemic support to strengthen the caregiver pipeline. Nursing homes that prepare today for the workforce realities of tomorrow will be best positioned to thrive in this evolving landscape, providing safe, compassionate care to those who need it most. In this environment, diligence and innovation are not just buzzwords they are the lifelines that will sustain long-term care through the challenging decades ahead.

If your organization has not yet stress‑tested its clinical surveillance capabilities against a scenario in which a third of the evening shift disappears after an I‑9 audit, now is the time. Schedule a Clearpol Clinical demonstration today and see how real‑time monitoring, automated documentation review, and predictive analytics can harden your facility against the abrupt staffing shocks that the current enforcement climate all but guarantees. When the next unanticipated shortage hits, will your residents still receive the right care at the right moment and will your documentation prove it? Let Clearpol ensure that the answer is unambiguously yes. 

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