Beyond Stroke Survival

A Journey of Care

Caregivers Face Nursing Home Challenges

Nursing homes face a crisis not due to staffing shortages but financial decisions prioritizing profits over care.

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When my mother first got sick, a social worker sat across from me and told me he couldn’t find her a bed. Not in our city. Not in a nearby county. He suggested sending her out of state.

Out of state. Away from her friends, her family, everything familiar to her to die from her stroke, in a place where no one who loved her could easily reach her. I refused. But I have never stopped thinking about the families who didn’t have that choice. Who were pressured and had to watch their person disappear into a facility hours away because the system had nothing left to offer them close to home.

That was my introduction to the nursing home crisis. And what I have learned since then is that the story we are being told about why this is happening, that there simply aren’t enough workers, is not the whole truth. Not even close.

Why This Matters to Every Stroke Caregiver Right Now

Before we get into the data, I want to be direct about what is actually at stake for those of us doing this work every day.

The nursing home system is not just where people go to live long-term. For family caregivers, it is the backup plan. It is the answer to the question we carry quietly and rarely say out loud: what happens if I can’t do this anymore? What happens when I get sick, when I reach my limit, when my own body gives out from the weight of it all?

For most of us, that backup plan is not available. The facilities closest to home have wait lists stretching six months, a year, sometimes longer. According to KFF, the average waiting period for Medicaid programs targeting seniors was 15 months in 2025 — and in some states the wait stretches into years. More than 60% of nursing homes nationwide have been forced to limit new patient admissions, impacting hospitals trying to free up beds and preventing seniors from accessing the care they need. BrmmlawPubMed Central

And respite care, the short-term relief that lets a caregiver take a breath, handle a medical emergency of their own, or simply sleep for one uninterrupted night, is increasingly impossible to find. Among the nation’s 63 million family caregivers, more than 1 in 3 rank respite care as their top service need. But the facilities that would provide it are the same ones turning people away at the door. Center for American Progress

This is not an abstract policy problem. This is the reality inside every caregiver’s home, right now, today.

The Word “Shortage” Is Doing a Lot of Work

We are told, repeatedly, that the reason nursing homes can’t take more patients is a staffing shortage. Not enough workers. A pipeline problem. Something systemic and sad and essentially nobody’s fault.

Here is what the data actually shows.

In 2023, nursing homes saw total net revenues of $126 billion and profits of $730 million. The average nursing home profit margin is nearly 9%, a margin most hospitals would covet. These are not struggling businesses scraping by and unable to afford more staff. These are highly profitable operations that have made a calculation: it is cheaper to be understaffed and pay the occasional fine than it is to hire and retain adequate workers. Congress.gov

71% of nursing homes in this country are for-profit. Fines for dangerously low staffing levels are viewed by these operators as merely a part of the cost of doing business. Congress.gov

That is not a staffing shortage. That is a business decision being dressed up as a workforce crisis.

What the People Living Inside These Facilities Say

If you want to cut through the industry talking points, ask the residents.

A survey of over 120 nursing home residents found that 88% stated their facilities lacked the staff necessary to meet their needs. Not a third. Not half. Nearly nine out of ten residents living in these facilities said there were not enough people to take care of them. United States Senate Committee on Finance

At some facilities, the CNA-to-patient ratio swings from one CNA for every eight residents on the best-staffed days to one CNA for every eighteen residents on the worst days, most commonly on weekends, when staffing is routinely and deliberately cut. The same person, in the same bed, receiving wildly different levels of care not because of a workforce that doesn’t exist — but because the facility chose not to schedule it. Catherine Cortez Masto

These are people who cannot get to the bathroom on their own. People who cannot call for help without a call light being answered. People whose families placed them in these facilities trusting that someone would be there. And the industry’s response to a survey showing 88% of residents feel understaffed is to lobby against minimum staffing requirements and win.

The Rule That Could Have Changed Everything, Disappeared

In 2024, after decades of research and advocacy, the Centers for Medicare and Medicaid Services finalized a rule requiring nursing homes to meet minimum staffing standards for the first time in the program’s history. It was a modest rule, the minimum threshold was still below what federal studies identified as necessary for basic adequate care but it was a start.

In December 2025, CMS formally repealed that rule. Today, nursing homes are not subject to any federal minimum staffing ratios. Staffing levels are governed largely by individual state rules and nursing home management decisions. Senate

Ten years. The most profitable segment of the long-term care industry successfully argued it needed ten more years before being held to a minimum standard of care for the most vulnerable people in this country. And they won that argument while sitting on $730 million in annual profits.

Where Did the Workers Actually Go?

Here is the piece that makes the “shortage” framing collapse completely.

Nurses and CNAs are not disappearing. They are being driven out of an industry that has decided their labor is a line item to be minimized rather than a workforce to be invested in.

Over 138,000 nurses left the workforce between 2022 and 2024. The most common reasons, aside from retirement, were stress, burnout, workload, understaffing, inadequate pay, and workplace violence. The median salary for a nursing aide nationwide is just $12.78 an hour, that’s $26,590 a year, for one of the most physically and emotionally demanding jobs that exists. You are lifting bodies, managing incontinence, absorbing grief and confusion and the daily indignities of illness, and you are being paid less than many retail workers. American Medical AssociationCatherine Cortez Masto

Staff who are forced to work longer and harder while underpaid don’t just quit and move to a different facility. They leave the industry completely, contributing to what the industry then calls a shortage of qualified workers. The facilities create the conditions that drive workers out, and then use the empty positions as evidence that there aren’t enough workers to hire. It is a cycle entirely of their own making. Catherine Cortez Masto

And simultaneously, hospitals are laying off the workers who left nursing homes for better conditions. In July 2025, over 100 CNAs at a Providence Swedish facility in Everett, Washington received layoff notices. Health systems including UC San Diego Health and Kaiser Permanente announced similar workforce reductions, citing financial pressures and concerns over federal reimbursement changes. The New Republic

Nursing homes claiming they cannot find staff. Hospitals laying off the staff that exists. Nearly 40% of RNs and 41% of LPNs reporting an intent to leave the workforce entirely within the next five years, citing the same reasons as those who already left. Brookings

This is not a pipeline problem. This is a treatment problem. And caregivers and their loved ones are absorbing the consequences of it every single day.

The Generation That Is Coming and the Math That Doesn’t Work

Here is the part that should alarm every single person reading this, whether you are a caregiver today or simply someone who expects to grow old in this country.

By 2040, the Census Bureau projects there will be just three potential family caregivers for every person age 80 or older, down from six in 2025. That is a 50% drop in the available caregiver pool in just 15 years, at the exact same time that the number of adults over 85 is projected to triple by 2050. ASHA

The Baby Boomer generation is the largest in American history. They are aging right now, today, and they are going to need care on a scale this country has never seen. The nursing home system, already turning people away, already operating with staffing ratios that 88% of residents say are inadequate — is not remotely prepared for what is coming.

Supporting our nurses and CNAs is not just compassion. It is infrastructure. If we do not treat the people who provide care as the essential workforce, paying them living wages, giving them manageable patient loads, protecting them from the burnout that is driving them out of the profession, then there will not be enough of them left to care for the wave of need that is already on its way.

“Even the patchwork that did exist is getting shredded,” said Nicole Jorwic of Caring Across Generations, describing the state of caregiver support policy following recent Medicaid cuts. That is the honest assessment of where we are. And for caregivers who are already stretched past their limit, already unable to find respite, already being told that the closest facility has a six-month wait. It is personal. Center for American Progress

What You Can Do?

Get on wait lists now, not when you’re in crisis. Given current wait times averaging 15 months or more, beginning the process of exploring nursing home and respite options now — even as a precaution — may be the most protective thing you can do for yourself and your loved one. Call facilities near you and ask specifically about both long-term placement and short-term respite availability.

Check real staffing data before you trust a facility’s reputation. The federal government’s Care Compare tool rates nursing homes on actual payroll-based staffing data. A facility with high profits and low staffing scores is telling you something important with those numbers.

Ask your state legislators about staffing minimums. With federal standards now repealed, states are the last line of defense. Eighteen states currently have no minimum direct care staffing requirement at all. Your state representative has direct power over whether that changes — and a phone call from a constituent carries real weight. United States Senate Committee on Finance

Advocate for fair wages for direct care workers. This one feels distant until you understand that the person who would have cared for your mother — or for you — left the profession because they couldn’t afford to stay. Supporting wage legislation for CNAs and home health aides is not separate from your interests as a caregiver. It is directly connected to whether care will be available when you need it.

Know your respite care options. Medicaid-funded respite care is available in some states through Medicaid waivers and state plan options, though eligibility requirements and hour caps vary significantly by state. Contact your state’s Area Agency on Aging or visit archrespite.org to find out what programs exist in your area. The National Family Caregiver Support Program also provides funding for respite services in every state. Crowell & MoringCenter for American Progress

File a complaint if you see understaffing harm a resident. Contact your state’s Long-Term Care Ombudsman program at theconsumervoice.org/get_help. These complaints create public records and are one of the few accountability mechanisms that remain.

When that social worker suggested sending my mother out of state, he wasn’t being cruel. He was describing the reality of a system that had already run out of room. But the reason it had run out of room was not inevitable. It was the result of choices — choices made by profitable corporations, choices made by legislators, choices made by a regulatory environment that just gave the industry a decade-long pass on accountability.

The nurses and CNAs who want to do this work are out there. They left because the conditions were impossible and the pay was insulting. The Baby Boomers who will need care are coming whether the system is ready for them or not. And the family caregivers who are already stretched to the breaking point, who need respite care that doesn’t exist and backup plans that have six-month wait lists, cannot absorb much more.

This is not a staffing shortage. This is a choice. And as caregivers, as voters, and as the people who are going to be left holding the consequences of that choice, we deserve to call it what it is.

Sources

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