Staffing is an ongoing concern at nursing homes, but the fires are finally calming down. As Skilled Nursing News continues to monitor shifts in staffing challenges – especially with the federal staffing mandate in place – our focus has become more vigilant. Thus, we wanted to take a step back and provide our readers with a four-part series on the current state of the workforce in the sector and some critical issues in advancing progress.

As the nursing home industry heads into the last quarter of the year, some operators say they have been able to douse the flames of staffing challenges that have wreaked havoc over the past several years, although this varies depending on the size of the chain and the region.

“There are always going to be fires to put out. You will lose somebody and you’re back filling a position. But I think it’s really calmed down,” Laurel Lingle, VP of Talent Acquisition at Majestic Care, told SNN.

That said, operators aren’t ready to take a breather yet.

“We’re seeing a shift for the better, but we’re still not out of the woods knowing that the mandate is coming,” Lingle said, adding that operators are constantly assessing their staffing needs and asking, “What does it look like in the next six months to a year to two years, and how do we get there appropriately?”

In April 2024, the Centers for Medicare & Medicaid Services (CMS) issued a staffing mandate that sparked widespread criticism from providers. The rule mandates a minimum of 3.48 hours per resident per day (HPRD) of total staffing, with specific allocations for registered nurses (RN) and nurse aides and a 24/7 RN requirement. It’s regulation that some industry leaders have described as an “extinction event” due to its potential effect on operations, including mounting closures and a worsening of the crisis of access.

The industry also has lagged the rest of the health care sector in improving staffing levels following the COVID-19 pandemic; for example, the nursing home sector has yet to recover to its pre-pandemic level of employment, while the hospital sector now is employing more people than in 2019. The good news is that providers are catching up by applying unique strategies along with better pay and benefits, resulting in lower turnover rates and reduced temporary agency use.

Encouraging though the trends may be, it’s important to note that to fulfill the mandate’s requirements, 75% of nursing homes nationally will need to hire additional staff, according to the Department of Health and Human Services’ (HHS) estimates.

Indeed, over the last year, SNN has published many stories on the repercussions stemming from staffing issues that range from shutdowns, downsizing, bottlenecks at hospitals, overwhelmed and burnt out workers to difficulties with recruitment and retention. And rural and smaller nursing home chains still face an uphill battle for fulfilling positions, especially for RN openings.

This is the first article in the SNN series on the state of the nursing home workforce.

Recruitment efforts

At Diversicare Healthcare Services, as the company prepares for the staffing mandate, its recruiting and retention strategies – in place for several years now – are paying off, CEO Steve Nee told SNN.

For Diversicare – and other mid-sized to large operators that SNN spoke to – a reduction in agency usage is one key measure of progress in their efforts to stabilize and strengthen staffing.

“We have been 100% agency free in all of our buildings for over a year now [and] we’re in the throes of kind of bulking up our staffing in an effort of this [staffing mandate] going through,” Nee said. “We are all about recruiting efforts, attracting top talent, and then also closing that back door and keeping them here. We have put forth a significant amount of resources, investing in our people. And it’s not just in the form of wage adjustments.”

Diversicare is based in Brentwood, Tenn., and operates more than 46 long-term care centers with about 4,500 beds. Its facilities are mostly rural and offer a range of health care services including skilled nursing and other specialized ancillary services.

Company culture and employee wellbeing is a central part of the company’s workforce efforts, he said.

“One [focus] is getting the talent in the door, and then two, retaining and ensuring that that engagement is there, focusing on things like leadership development, career advancement, additional certifications, those types of things that matter to those people, but really tailoring those on a case by case basis,” Nee said.

For Majestic, one of the workforce initiatives that has helped speaks to the promise of stability of a full-time job along with the flexibility of hours. It’s Majestic’s in-house staffing agency, which was created in 2021, a year after COVID peaked.

“[Our internal agency] has been a huge assistance in making sure [staff members] are trained in the way we want them to be. They’re trained on our EMR. They’re trained under our guidelines, our policy. So instead of an agency worker walking in not knowing who Majestic is, these individuals are wearing our name tags, and know what our mission, vision and value is,” said Lingle.

These workers have full benefits, PTO, everything that a building employee would have except they are paid at a higher rate, she said. And the reason for the higher pay is due to travel between facilities.

“They’re given a home base building, and then they have a travel area. And they are flexible on what shift they work,” Lingle said.

There are 146 employees within the Majestic Staffing program who are called upon to fulfill positions on an as-needed basis, much like a temporary agency.

Further evidence that operators are reducing agency usage – and bringing down associated costs – has come from recent earnings calls and financial reports from major publicly traded companies in the sector, such as Sabra Health Care REIT (Nasdaq: SBRA) and Omega Healthcare Investors (NYSE: OHI).

Temporary staffing not only incurs higher costs but can also lead to inconsistent care and lower overall patient satisfaction. As noted in recent reports, these agencies often provide workers with less familiarity with the specific needs and protocols of individual facilities, which can negatively impact the quality of care.

Majestic’s internal agency has really helped in eliminating use of external agency workers,  reducing the wage expense of $5 million a month during the pandemic to about $200,000 currently.

Majestic has also had better luck in securing permanent employees. The rate for converting applicants to care team members is around 78% currently, Lingle said.

“So if we get somebody in front of us, we’re able to secure them into a role [more successfully],” she said.

Other organizations are implementing centralized recruiting, and leaders in the space said these are crucial to effective recruiting.

“We’ve got centralized recruiting initiatives, with regional recruiters assisting locally or [we use] centralized platforms to find and source staff,” Mark Hancock, executive vice chairman at PACS Group, told SNN earlier this year.

Retention efforts

Retention efforts are also being bolstered by increased investments in training and professional development. Facilities are recognizing that providing career advancement opportunities can help reduce turnover and build a more dedicated workforce. Moreover, some operators are partnering with educational institutions to create pipelines for new talent, aiming to address the long-term staffing needs of the sector.

Along with these efforts, programs to strengthen facility leadership, commonly known as Administrators-in Training (AIT) programs, are underway at many operators from PACS Group (NYSE: PACS) to Health Dimensions Group (HDG). Leaders at these organizations told SNN that the strong leaders provide training and stability to frontline workers.

Meanwhile, career ladder programs have helped both Majestic and PACS.

“We’ve also got training development programs that provide opportunities for tuition reimbursement or continued education programs. This allows nurses to enhance their skills, stay current, stay trained, and progress in their career paths,” Hancock said.

PACS said its AIT program aims to target turnover among these roles, especially because turnover on the top causes massive ripple effects in just about every area of the company.

Companies like the PACS Group are also applying a decentralized model to their AIT program to create a balance between onerous federal and state requirements while also making the experience as individualistic as possible.

Building the frontline workforce continues to be crucial for the nursing home sector as the industry faces the federal minimum staffing mandate. Some operators like Schmidt Wallace Healthcare have found a way to graduate thousands of certified nurse aides while remaining a small regional provider, while others work closely with academic institutions in the area.

Subsequent articles in this series will discuss AIT programs in greater depth, cover the efforts to grow the frontline worker pipeline as well as share updates and progress with the Dwyer Workforce Development model, which aims to expand the labor pool for nurse aides and advance their careers by addressing the real-life challenges they face and that often contribute to their leaving the nursing home workforce.

Fires still raging for some nursing homes

For many rural operators of nursing homes, staffing shortages are still raging.

According to Kimberly Green, COO of Diakonos Group, an Oklahoma-owned and operated long-term care provider, staffing shortages in rural nursing homes are dire and stubborn.

Diakonos shut down a facility in 2021 in the Oklahoma town of Medford, and after transforming it into a specialized skilled nursing facility focused on geriatrics and psychiatric care, it still struggled to attract sufficient staff, she told NPR.

Green’s efforts to address the staffing crisis included international recruitment, where she offered to sponsor the relocation of 50 registered nurses (RNs) and their families to the U.S. However, only 10 RNs took up the offer. The recruitment agency eventually withdrew, citing the non-competitive salaries and the unattractiveness of rural Oklahoma as key reasons for their failure.

The lack of exposure to long-term care in nursing education and the more attractive pay and benefits offered by hospitals contribute to the shortage, Green said.

A new AHCA report points to a grim picture for worsening access to care, sharing that 774 facilities closed their doors between February 2020 and July 2024, displacing over 28,000 residents. Now, more than 66% of facilities are concerned that if their workforce challenges persist they may have to close their facility, the report states.

These sobering statistics make understanding the state of the nursing home workforce, as well as innovative approaches to improvement, particularly pressing.