From CNA to CEO: Skilled Nursing Lags on Internal Promotions Despite Success Stories

Bernie McGuinness, CEO of Majestic Care, always knew that he wanted a rewarding career where he could work with people and make a tangible impact.

His pursuit of such a career led him from being a certified nursing assistant (CNA) to the CEO of a nursing home company that he co-founded. Majestic Care now has 34 locations throughout Indiana, Ohio and Michigan.

“Last July, we purchased a building in Carmel, Indiana, [where] both of my grandparents on my dad’s side had passed away,” McGuinness said. “I was a new administrator in that building, and last July I got to walk in as the new CEO for that building. It was kind of a full circle.”

McGuinness is not the only skilled nursing leader who rose through the ranks from frontline caregiver to CEO. But such a path is difficult, and compared with other industries, skilled nursing lags on promoting from within.

Improving this, so that more people can follow an upward career trajectory in the industry, could be crucial in building a more stable workforce, with leaders who have deep knowledge that can inform change making efforts as nursing homes adapt for the future.

Climbing a steep ladder

As a teenager, McGuinness got a job working with children with physical and intellectual disabilities, as a camp counselor. Although he had his sights set on becoming a teacher, his supervisor recommended he consider becoming a nurse instead; he possessed the compassion and tact of a natural caretaker.

So, McGuinness got a job as a CNA in his hometown of Yorktown, Indiana. Although he was only working part-time while enrolled in college, he fell in love with long-term care immediately.

But he said he remembered thinking that he didn’t want to be a CNA forever, due to the physical and emotional demands of the job.

“I’ll still remember the first resident that ever passed away while I was taking care of them,” McGuinness said. “You know, I had just been joking with him at the dinner table … and then during the last bed check, he was gone. There is an emotional toll that takes on you. But I wanted to continue that path. I saw a real need for people in that industry.”

Eventually, McGuinness became a nurse and joined a larger, national organization in Indianapolis. He was newly married and had just started a family when a mentor approached him about going back to school to become an LPN.

“I said, ‘Well, actually, I want to be the administrator of this building,” he said, noting that the building was full of agency nurses and had been plagued with frequent administrator turnover.

He wanted to learn how to maximize the potential of the facility to keep staff coming back, and provide residents with caretakers who could anticipate their needs.

“ I was lucky enough I did an unpaid AIT [administrator in training program] for six months and was the weekend supervisor and kind of worked my way up there and became a licensed administrator,” he said.

Administrative Internship Programs offer an avenue for CNAs to make the transition to administrative or leadership positions, although they are often unpaid, adding another challenge for those with ambitions in the skilled nursing sector. Cassie Mistretta, former CEO of Senior Living Properties, worked as a CNA during her AIT program. Her nursing home administrator, whom she admired, recommended the role to supplement her income during her AIT.

“I think everybody in health care, especially health care administration, should work as a CNA first or at some point. It informed every decision I made as a leader moving forward and generated a lot of success for me as a leader in workforce management and just doing the right thing,” Mistretta said.

As for McGuinness, after working in various leadership positions and eventually overseeing operations for a range of facilities in the Midwest, he was ready to start his own company, and he founded Majestic Care in 2018.

Improving on career pathways

Dr. Jacquelyn Kung, CEO of Activated Insights, which helps senior care providers collect feedback from their employees and residents, also began her career as a frontline caregiver in a nursing home.

After working in leadership roles at a large retirement community in her twenties, Dr. Kung launched her company to better understand and address the issues which contribute to the staffing crisis in health care. Activated Insights’ work informs the annual Best Workplaces in Aging Services list in Fortune.

Dr. Kung said that due to chronic staffing shortages, SNF operators often don’t have the attention or resources to focus on improving employee experience and promoting career paths.

“Because SNFs run on such low margins, it really takes a special operator to be able to see an investment. It’s going to cost time and money. And it’s going to be at least six months before it pays back,” Kung said.

Stories like McGuinness’ are somewhat rare compared to the overall level of turnover in the industry, which McGuinness attributed to the stress of the job and the regulatory environment.

In fact, SNFs only fill about 15% of roles with internal promotions, lagging hospitals, hotels and retail. But top-performing SNFs are much more successful with internal promotions, Activated Insights data show.

“The average tenure of an administrator or director of nursing continues to decline, and with turnover at the top of the organization you will see management teams often follow leaders,” McGuinness said.

But Kung said that providers who do put significant efforts toward creating career paths and fostering retention have a significant competitive advantage over providers who do not.

“It translates into much better care outcomes,” she said. “From star ratings and incident reports to financial performance.”

A California operator launched a career paths program in 2019 with the strengths and goals for every staff member listed on cards. The CEO reviewed those cards every three to six months to make decisions about promotions, with the intention of hiring at least 30% of new positions from within.

Kung said the provider also works with supervisors to take note of skills current employees might need to build before beginning new positions, like technical skills and certifications and best management practices.

To date, the company has surpassed its 30% goal.

“They have much lower turnover than other people and their financial performance is out of the world,” Kung said. “And it’s in California, which is one of the hardest states operating.”

For employees who want to move their careers forward but don’t necessarily want to become administrators, Trilogy Health Services, which has over 130 locations, the majority of which are skilled nursing facilities, created apprenticeship programs for culinary and caregiver staff to increase their skills and their pay while staying in their roles.

The programs include training on dementia, mentorship of new employees, and culinary training.

“So, you have someone who knows your culture, who knows your residents, who knows your families, knows the other staff, and they’re upskilling, and getting paid more, they’re benefiting as well as the organization,” Kung said.

For employees looking to move forward, all of the leaders Skilled Nursing News spoke with recommended staff take opportunities when they present themselves, to grow new skills.

“I found that to be successful for me, the more loyal I was to the company, the more they invested in me. As a leader, the employees that we targeted to promote from within and invest in were employees who stuck it out with us,” Mistretta said.