Understaffing in Nursing Homes – A Common Cause of California Nursing Home Neglect

Posted on July 15, 2021 by bermanstaff

The decision to place a loved one in a nursing home is difficult and usually made when a family cannot afford in-home care and their loved one requires skilled or 24-hour care. You trust the nursing home to give your loved one the care they need that you cannot provide, but all too often, residents face abuse or neglect instead.

More than 64% of nursing home staff admit to committing some type of neglect or abuse against residents. Nursing home neglect occurs when a resident does not receive the services and care they need including adequate food, water, shelter, exercise, socialization, hygiene, and medical attention. Neglect may or may not be intentional, but it is commonly the result of understaffing in nursing homes in San Diego. An estimated 21% of nursing home residents are neglected at least once a year, but the true number is likely higher.

Understaffing in Nursing Homes Is a Common Problem

Understaffing has been a problem in long-term care facilities for decades, but a recent analysis of federal data revealed just how common the problem is.

Medicare recently began to gather and publish staffing data based on daily payroll records from over 14,000 nursing homes as required by the Affordable Care Act. Previously, Medicare rated facility staffing levels based on reports the facilities submitted themselves. The data shows that 70% of nursing homes have been exaggerating staffing levels and failed to report when staffing levels fell very low.

According to the analysis, most nursing homes had large and frequent fluctuations in staffing from one day to the next with noticeable staff shortages on weekends. At the average facility, the difference would have staff caring for twice as many patients on poorly staffed days than on the best staffed days. At some facilities, the difference was one CAN for every eight residents on the best days and a CNA to patient ratio of 1 to 18 on the worst days.

During a single quarter of 2017, about 25% of nursing homes in the U.S. had no RNs at work at least one day. Between 2014 and 2018, 1 out of every 8 nursing homes was cited for understaffing with too few nurses on duty.

Federal & California Nursing Home Staffing Requirements

Many families are surprised to learn that there are few requirements for nursing home staffing. Under federal law, Medicaid- and Medicare-certified nursing homes (which is most nursing homes) must meet the following staffing requirements:

  • Full-time director of nursing (DOM)
  • Licensed nurse (LPN or RN) always on duty
  • Registered nurse (RN) on duty at least 8 hours per day, 7 days per week (this can be the DOM at smaller facilities)

There are no federal requirements for staffing ratios in nursing homes for certified nurse aides (CNAs) who provide the majority of care to residents and account for most of a nursing home’s staff.

Federal guidelines also fail to set a nurse to patient ratio in nursing homes. As long as a single nurse is on duty, federal staffing requirements have been met.

Nursing homes are only required to provide at least 75 hours of training to CNAs and “provide sufficient staff and services” to maintain the highest level of physical, psychosocial, and mental well-being of patients.

The federal government has issued recommendations for nurse-to-patient staffing ratios. The recommended ratio for skilled nursing facilities is 1 RN for every 5 patients, but there is no recommended ratio for long-term care facilities.

Under these guidelines, a nursing home maintaining minimum federal nurse staff levels would only provide a resident with about 20 minutes of nursing care per day. The Centers for Medicare and Medicaid Services (CMS) recommends minimum staffing to provide each resident with at least 3 hours of total staff time per day. This includes two hours of CNA time and one hour of LPN or RN time. However, optimum staffing gives nursing home residents 3 hours of CNA time and one hour of RN or LPN time.

In 2000, the CDC reported that orderlies and CNAs accounted for two-thirds of all nursing home staff and RNs accounted for only 15% of staff time residents received.

State regulations for nursing home staffing are usually more stringent than federal regulations. Still, many fall short of recommended guidelines.

California State Regulations for Nursing Home Staffing

California adopted new nursing home staffing requirements in 2018 under California Health & Safety Code §1276.5. The new rules require skilled nursing facilities to give residents a minimum of 3.5 hours of direct care per day with at least 2.4 of the hours provided by a CNA. This is up from 3.2 hours previously. The care provided can include anything from assistance with daily tasks to changing a diaper, moving a patient to avoid bedsores, or inserting a feeding tube.

California does not set a specific staff to resident ratio in nursing homes. Some states do have a nurse to patient ratio law in nursing homes. Oklahoma, for instance, requires one direct care staff member for every seven residents. Some states combine staffing ratios in nursing homes with a minimum amount of direct care per day.

Despite the important step California has taken to ensure residents receive more direct care, skilled nursing facilities can be granted a waiver.

Soon after the new staffing requirement went into effect, more than half of nursing homes in California asked for an exemption. Some have been repeatedly cited for inadequate staffing. This includes nursing homes owned by Shlomo Rechnitz who controls 1 out of every 14 nursing home beds in California. His facilities have asked for a waiver, yet he has faced several state and federal probes related to quality issues and understaffing.

Why Are There Staffing Shortages in Nursing Homes?

The issue of understaffing in San Diego nursing homes is complicated. California has the largest nursing shortage in the country with a deficit of 44,500 registered nurses – three times the next state. However, this does not tell the whole story when it comes to nursing homes.

Registered nurses and licensed practitioner nurses account for a small share of the staff in most nursing homes. Instead, most direct care to patients is usually provided by certified nursing assistant (CAN), an unlicensed paraprofessional and entry-level healthcare worker. Nursing homes rely on this generally low-paid labor to provide most care to patients.

Understaffing in nursing homes is also a vicious cycle. It doesn’t just harm patients; it also increases work-related nursing injuries, burnout, poor morale, call offs, and high turnover rates. Staff who are forced to work longer and harder, and may be underpaid, don’t just quit and change facilities; they leave the industry completely or move on to higher-paying hospital jobs and contribute to shortages of qualified staff.

According to the CMS Nursing Home Compare star rating system, for-profit nursing homes usually have lower quality of care and lower staffing levels than nonprofit nursing homes.

Labor is a major expense for any skilled nursing facility. For-profit facilities may rely more heavily on lower-paid CNAs than RNs and LPNs. The median salary for a nursing aide is just $12.78 nationwide ($26,590 per year) and $16.13 in California. In exchange, they have one of the most physically and emotionally demanding jobs that requires lifting and moving patients, cleaning and dressing patients, assisting with toileting and feeding, and more.

While a business should certainly make a profit, this requires balancing staffing levels and other costs against quality of care and safety. When staff levels are dropped to minimum levels or lower, it harms staff and may lead to dangerous neglect of the residents in their care.

Nursing Home Understaffing Is More Common at For-Profit Facilities

At the heart of most understaffed nursing homes in California is profit.

About 70% of all nursing homes in the United States are for-profit. Numerous studies have shown that nursing homes frequently put profits ahead of their residents. In 2017, more than 15,600 nursing homes in the U.S. generated $166 billion in revenue. That’s more than the U.S. hotel industry.

While nonprofit nursing homes also seek to improve efficiency and boost revenue, unspent revenue is invested in services and facilities. With for-profit facilities, anything that doesn’t cover operating expenses and obligations can be distributed to the owners.

Private Equity-Owned Nursing Homes Are Particularly Concerning

One of the most dangerous practices in the industry involves private equity (PE) investment groups which own about 10% of all nursing homes. These firms profit by purchasing businesses, reducing costs or improving efficiency to boost apparent value, then selling them later. PE firms may use the following strategy to maximize profits:

  • The private equity firm purchases the nursing home
  • The facility’s buildings and real estate is placed in a separate holding company and leased back to the nursing home
  • Companies also owned by the investment group take over services at the facility like laundry, supplies, and management
  • The nursing home may seem like it is financially struggling and barely covering expenses while the investors are making money from all the companies providing services
  • The nursing home becomes saddled with debt to pay off the lenders that financed the purchase of the facility

This complex ownership structure makes it difficult to determine who is responsible for the facility’s quality of care and liable for damages when a resident is hurt. The for-profit company will also claim it has no money, even though they have extracted all the money from the operation through lease agreements and management or service contracts. To make matters even worse, the companies are private which makes it difficult to assess their finances and operations.

Studies into private equity ownership of nursing homes have revealed some serious and common consequences.

This case study was done on the private equity firm Fillmore Capital which purchased Beverly Enterprises, an operator of 300 assisted living and nursing homes in 21 states. The firm divided the chain of nursing homes into individual LLCs to reduce liability and significantly reduced per-resident staffing hours below the industry standard for nursing homes in California, among other changes.

A separate study found that many quality metrics, including overall five-star ratings and nursing home staffing ratios, decline immediately after a private equity takeover.

A recent working paper by the National Bureau of Economics made an even more startling conclusion: patients begin to die more often once private equity firms take over nursing homes. The researchers found patients who stayed in a skilled nursing facility after an acute hospital stay had a 10% higher chance of dying than average if they went to a private equity-owned facility. The study made several conclusions:

  • During the 12-year sample period, they estimated about 20,150 Medicare recipients died due to private equity ownership.
  • When a PE firm acquires a nursing home, the number of hours front-line nurses spend providing basic services is reduced. These services are not medically intensive but critical and include infection prevention measures and bed turning.
  • There was a 50% increase in the use of antipsychotic medications for patients in private equity-owned facilities. It’s possible, although certainly not proven, that this is an attempt to offset short staffing in nursing levels.

Private equity investment in nursing homes, already a known concern, came into the spotlight during the COVID-19 pandemic. It’s also on the rise with $1 billion invested between 2010 and 2014 but $5.3 billion invested in these deals between 2015 and 2020.

The Dangers of Understaffed Nursing Homes – How Understaffing Increases the Risk of Neglect & Abuse

Nursing home abuse and neglect is a frighteningly common problem. In many cases, it is not the result of intentional mistreatment or abuse but nursing home understaffing – a problem that can be easily solved.

Neglect is not always the result of uncaring RNs and CNAs. When the CNA to patient ratio in nursing homes is too high, staff are simply stretched too thin and overworked. They are forced to prioritize some duties over others and may be unable to take steps necessary to correct trip hazards, prevent infection, maintain safe and sanitary conditions, or assist with daily tasks. They are also more likely to make mistakes.

Because understaffing in nursing homes leads to burnout and high turnover rates among RNs and CNAs, facilities often need to recruit new staff urgently and may hire unqualified staff. Without the right training and being assigned too many patients and tasks, it’s inevitable that quality of care will decline. This can easily give way to neglect when residents do not receive proper care and suffer psychological, emotional, or physical harm.

Higher nurse staff levels in nursing homes is one of the most important things a facility can do to improve quality of care and life. The ratio of RNs to patients has the biggest impact, but the number of licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and certified nursing assistants (CNAs) is also vital to facility quality. Research shows the following benefits of higher nurse staffing:

  • Lower number of deficiencies
  • Reduced emergency room use
  • Lower rehospitalization rates
  • Fewer bedsores
  • Reduced use of restraints
  • Less overuse or improper use of antipsychotics
  • Lower mortality rates
  • Reduced weight loss and dehydration
  • Improved activities of daily living
  • Fewer infections
  • Reduced pain

Here are some of the serious and life-threatening effects of short staffing in nursing homes beyond general reduced quality of medical care.

Falls & Physical Injuries

It is estimated that 50% to 75% of nursing home residents fall each year, twice the rate of seniors living in the community. More than one-third of fall injuries happen to nursing home residents who are unable to walk. About 20% of nursing home falls result in a serious injury such as a fracture which can reduce the resident’s quality of life, mobility, and overall health. Every year, nearly 1,800 nursing home residents die from a fall.

Lack of training and nursing home understaffing are major factors in many falls.

Environmental hazards like wet floors, a raised bed, or a poorly maintained wheelchair are the cause of 16-27% of nursing home falls. These hazards may be the result of staff who are not trained to recognize fall hazards or staff who do not have time to inspect and address hazards.

When residents do not receive enough direct care hours, they may not receive the exercise or physical therapy they need. This can cause muscle weakness and reduced function that makes a fall more likely. Poor staffing levels can even mean a resident is left alone in a situation that causes them to fall, such as sitting in a chair when they have poor balance and mobility.

It is not uncommon for nursing home residents to suffer fall-related injuries when they are dropped or rolled out of a bed. Certified nursing assistants have a higher injury rate than any other occupation, including construction workers. Many of their injuries happen when attempting to move or lift patients.

While some facilities supply equipment or lifting machines to assist with this task, CNAs often report that the machines are non-functional or they do not have enough. This equipment also requires special training. Sometimes CNAs are forced to attempt to move residents alone when the task requires two staff members.

Learn more about nursing home falls and what to do if your loved one has suffered a serious fall.

Infections & Disease

Residents living in understaffed nursing homes in California are at a higher risk of infection. This can be due to insufficient incontinence care, residents who are not moved often enough and develop bedsores, inadequate infection prevention, and improper catheter care, among other deficiencies.

Common nursing home infections that may be related to high nursing home staffing ratios include:

  • Urinary tract infections (UTIs)
  • Pneumonia
  • Skin infections
  • Scabies infections
  • COVID-19
  • Food poisoning
  • MRSA
  • Sexually transmitted infections (STIs)
  • Sepsis
  • Respiratory infections
  • Influenza
  • Gastroenteritis


Pressure sores or bedsores are one of the most common but serious complications in nursing homes. They are also a warning sign of neglect, usually due to understaffing.

Residents most at risk of developing a bedsore are those who are immobile, incontinent, obese, malnourished, and/or suffer from vascular disease or nerve damage. A pressure ulcer can develop rapidly, sometimes in a matter of hours in the most vulnerable patients. This means preventing and treating bedsores requires patients receive enough direct care hours to:

  • Perform regular skin assessments
  • Frequently change the resident’s position
  • Perform proper incontinence care
  • Ensure the bed is elevated correctly and the patient has proper support

When CNAs are overworked and caring for too many patients, they may be forced to prioritize what they do and who they help. Patients can be left in one position for too long and develop a bedsore that rapidly worsens and triggers a cascade of complications such as infection, hospitalization, and disability.

Learn more about bedsores and nursing home neglect and what you should do if your loved one develops a pressure ulcer in a nursing home.

Malnutrition & Dehydration

Nursing home residents require proper nutrition and hydration, but this can be a challenge even with proper staffing. Many residents require help eating, have special dietary requirements that must be managed, and need to be monitored for vitamin deficiencies. Medications and health conditions can make eating a challenge, cause a loss of appetite, or make the resident unable to remember if they have even eaten.

Nursing home understaffing means residents may not get the help or monitoring they need. Malnutrition and dehydration may not be noticed before the resident suffers real harm.

About 20% of nursing home residents are malnourished. Seniors with dementia are at a very high risk of malnutrition and dehydration which can increase their susceptibility to bedsores and other complications.

Avoidable Hospitalization

When staffing ratios in nursing homes are too high and staff are unable to provide basic needs to residents, infection, worsening health, and injury can all lead to avoidable hospitalization.

Hospitals are discharging patients sooner which means nursing homes are handling increasingly frail patients with intensive medical needs. Understaffed nursing homes are often unprepared to handle serious complications after hospitalization or may cause new complications.

One out of every 5 Medicare patients sent to a nursing home from a hospital are hospitalized again within 30 days, usually for something preventable such as infection, medication errors, and dehydration. This is a rehospitalization rate 27% higher than the overall Medicare population.

To make matters worse, nursing homes are financially rewarded in this scenario. Only 11% of nursing home residents are covered by Medicare compared to 75% covered by Medicaid, yet about 30% of nursing home revenue comes from Medicare. Medicare does not cover long-term care, but it does cover a limited stay in a nursing home after discharge from a hospital.

Medicare provides a reimbursement of $523 per day for skilled nursing care after hospital discharge, but only for up to 100 days. Medicaid pays just $214 per day. If a resident is currently being covered by Medicaid at the lower rate but is hospitalized, they can return as a Medicare patient with the much higher daily reimbursement.

Medication Errors

About 90% of nursing home residents take at least one prescription every day. Inadequate training and understaffing in nursing homes in California are both leading causes of medication mistakes. These errors can include failure to administer medication, improper administration technique, and multiple doses.

Learn more about nursing home medication mistakes and what you should do if you suspect your loved one has been harmed by medication errors.

Nursing Home Staff Abuse

The effects of short staffing in nursing homes extend beyond neglect. A high CAN to patient ratio in nursing homes, emotional demands of the job, and poor relationships with coworkers and supervisors increase the risk of burnout, neglect, and even abusive behavior toward residents.

The effects of burnout, understaffing, and the difficulty of a nursing job on quality of care and patient treatment has been well studied. Studies have found several risk factors for staff developing abusive behavior toward residents:

  • Burnout, a state in which staff experience reduced personal accomplishment, cynicism or depersonalization, and emotional exhaustion
  • Emotional dissonance, or a discrepancy between emotions that are required and what is felt, which is strongly linked to burnout
  • Poor work conditions
  • Inadequate training for their job
  • Work overload when CNAs must care for a large number of residents, do overtime, or work long shifts
  • Low level of perceived control over their interactions with residents and other staff
  • Perceived lack of appreciation and low pay

An analysis of 9 studies in six countries found that 64% of nursing home staff (two out of every three) self-reported abusing residents in the past year. Almost 33% of the self-reported abuse was psychological or emotional abuse, such as yelling at a resident. 9% was physical abuse and 12% was neglect.

Low staffing levels can directly contribute to burnout and work overload. This makes staff more likely to experience an emotional dissonance in which they may treat residents like objects and lack empathy. Staff who report low pay and a lack of appreciation, when overworked and stressed, may also experience hostility toward residents.

Wandering or Elopement

About 60% of people with dementia wander or become lost at least once, but many experience these episodes multiple times. It’s believed that wandering happens when the person is trying to get back somewhere or looking for something when they are confused about where they are.

The most dangerous form of wandering is elopement. This refers to a patient leaving the nursing home and wandering outside where they may get hurt or even die.

Elopement should never happen. Nursing homes have a duty to ensure the safety and security of residents. Residents should be assessed for the risk of elopement so a plan can be made to prevent this. Preventing wandering requires not only security measures such as disguising exits and door alarms but also adequate supervision. Sadly, it is not uncommon for poorly trained, shorthanded nursing home staff to not even realize a resident has eloped for hours.

Resident-to-Resident Abuse

When most people think of nursing home abuse, they envision direct abuse by staff. However, abuse can come from other residents.

How common is resident-on-resident abuse in nursing homes? It may be more common than abuse by staff. A large survey of nurse aides in ten states found that 94% saw residents grabbing, pushing, or punching each other, 91% witnessed psychological abuse or aggression, 97% witnessed yelling and verbal abuse, and 77% saw residents exposing body parts to others in the past three months.

Not all resident-on-resident abuse, such as verbal abuse, can be prevented. However, serious abuse from other residents may be related to nursing home understaffing and inadequate supervision. Adequate staffing makes it easier to avoid overcrowded common areas and monitor residents to watch for potential abuse. Proper monitoring can also prevent serious abuse such as sexual abuse committed by other residents.

How to Report an Understaffed Nursing Home & Suspected Neglect

Neglect is just one of many types of nursing home abuse, but it can be one of the most serious. Do you suspect your loved one is being neglected due to understaffing? Do you notice staffing issues at the facility? There are several important steps you can take to protect your loved one.

If you believe your loved one is at risk of imminent harm, call 911 or call your local police department. Otherwise, file a complaint with the California Department of Public Health (DPH) Licensing and Certification Division. This division enforces nursing home regulations, performs investigations, and investigates complaints.

You can also report neglect to your local ombudsman. An ombudsman will serve as an advocate to help you make sure your loved one is cared for, suspicions are investigated, and action is taken.

Here are resources for reporting neglect and an understaffed nursing home.

Liability for Nursing Home Neglect Due to Understaffing

When a resident suffers physical, psychological, emotional, or sexual abuse due to neglect or abuse, the nursing home may be held liable if the neglect was caused by:

  • Understaffing
  • Inadequate staff training
  • Medication mistakes
  • Negligent hiring practices
  • Breach of regulatory or statutory requirements

When nursing home staff are negligent, the facility can generally be held liable for the negligent actions within the scope and course of the staff member’s job.

Depending on the type of neglect or abuse, civil lawsuits and criminal charges can be brought against nursing home staff, administrators or supervisors, and the owner or operator of the nursing home.

Victims of neglect or family members can hold a negligent nursing home accountable by filing a claim for nursing home neglect, pursuing a personal injury lawsuit against the facility, or filing a wrongful death and/or survival action. Learn more about your legal rights and liability for neglect below.

Contact Berman & Riedel, LLP for a Free Consultation

If your loved one has been hurt or even killed by a negligent and understaffed nursing home, our law firm is prepared to help. Berman & Riedel, LLP has earned a reputation throughout the state for being an unyielding advocate for nursing home residents and their families. We specialize in complex California elder abuse and nursing home litigation with case results that speak for themselves. Our main office is located in San Diego, but our firm represents clients in abuse and neglect cases throughout California.

Contact our law office for a free consultation with a prominent San Diego nursing home neglect lawyer to discuss your case.

Nursing Home Staffing FAQ

How many patients can a CNA have in a nursing home?

The average CNA to patient ratio in nursing homes is 1 CNA to 9 to 14 residents on weekdays and 1 CNA to 10 to 17 residents on weekends. In some states, CNAs may have 20 or even 50 patients during a shift.

Is understaffing illegal in nursing homes in San Diego?

Nursing home understaffing that fails to give patients the required amount of direct care per day is a violation of California Health & Safety Code §1276.65. It is also a violation of the Patient’s Bill of Rights which requires that the facility have “adequate” personnel.

What are the minimum staffing requirements for nursing homes in San Diego, CA?

California does not set a minimum staff-to-patient ratio for nursing homes. Instead, the state requires each patient receive at least 2.4 hours of direct care by a CNA per day and a total of 3.5 hours of direct care daily.

How many California nursing homes are understaffed?

California hasn’t had the chronic and widespread nursing shortages common in other states. In late 2020, just 2% of nursing homes reported nurse shortages compared with 18.5% of nursing homes nationwide.

Why are nursing homes so understaffed?

Nursing home understaffing is often a cost-saving measure by for-profit nursing homes that rely on lower-paid CNAs caring for more patients than higher-paid licensed nurses and lower staff ratios. However, short staffing is not always an intentional way to save money; some facilities cannot afford all the aides and nurses they need and must stretch existing staff. Nursing homes also receive patients with more intensive medical needs after hospital discharge than they used to.

About Berman & Riedel, LLP firm managing partner attorney William M. Berman:

Attorney William M. Berman focuses his practice in the areas of catastrophic personal injury, wrongful death and elder abuse and neglect. Strictly a plaintiffs’ dedicated firm, he never represents insurance companies in the defense of claims. Mr. Berman’s firm remains staunchly committed to helping those who have suffered serious injury or loss due the negligence, intentional misconduct or wrongful acts of others. Mr. Berman has grown his firm to what is considered one of the largest and most successful elder abuse/neglect practices within California. Through his continued successes in handling claims involving nursing home and elder abuse and neglect, Mr. Berman remains a prominent figure in advocating on behalf of this vulnerable class of citizens.
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Remember that the insurance company is not on your side, even if the insurance adjuster seems sympathetic and you receive a settlement offer. If you are being blamed for your accident or sustained serious injury, a lawyer will help you protect your rights and build the strongest case possible. This includes calculating the full value of your current and future losses.

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