But while there are glimmers of hope for a better future, the situation for many of the nearly 1.2 million residents of some 15,000 nursing homes across America is worse than before the pandemic’s start, according to interviews with dozens of nursing home professionals, workers and residents.

In a nursing home near Dallas, resident Cindy Napolitan, 66, reports call lights going unanswered, diapers not being changed, dinners going cold at the table while residents wait to be fed, and a lack of clean towels to shower with. Late last year, she watched as it took more than two hours for nurses to start performing cardiopulmonary resuscitation on her comatose neighbor. “She didn’t make it,” Napolitan says. In her almost five years of living in nursing homes, she says, care levels are the worst they’ve ever been.

“Nothing has really improved,” says Charlene Harrington, a longtime nursing home researcher at the University of California, San Francisco. “In fact, in most ways, residents are worse off than they were before the pandemic.”

The primary reason: A large-scale exodus of workers over the past three years has made worse what was already an understaffed situation in many of America’s nursing homes. Today, record-high staffing shortages and an unprecedented level of underqualified staff are leaving residents with even less care than before COVID’s arrival.

Also, the lagging rate of COVID booster shots among nursing home residents is allowing the virus to linger, causing more deaths than necessary and preventing residents from a return to regular programming.

A class action lawsuit filed by AARP Foundation lawyers in September against one of the largest for-profit nursing home operators in Illinois, the Alden Group, illustrates the present state of nursing homes, lawyers say. People living in six different facilities claim Alden has intentionally provided insufficient numbers of registered nurses, certified nursing assistants (CNAs) and other workers who provide direct care to residents. The practice has led to neglect, preventable injuries and illnesses, the lawsuit says. States set minimum staffing standards, but Alden is charged with lying on reports of staffing levels, in some cases falsifying documents while requiring residents to sign illegal agreements preventing them from suing when injuries occur because of understaffing.

“I actually think these practices have gotten worse recently, after the pandemic,” says Kelly Bagby, vice president of litigation at AARP Foundation. “That’s why we’re seeking a court order to put an immediate stop to them.” Alden did not respond to a request for comment.

That’s not to say advocates for the nursing home industry and others are out of hope. “On the federal level, what the president has proposed is much more significant than anything for decades maybe,” says Eric Carlson, an attorney at the advocacy group Justice in Aging. “If there hadn’t been a pandemic, would this action be happening at the level it is right now? I don’t think so.”

Plus there are pockets of positive change at the state level. New York, Rhode Island, Massachusetts and others recently increased minimum staffing requirements for their nursing homes. Iowa has launched an apprenticeship program enabling high school students to become CNAs before graduation, and Illinois has pledged additional tuition reimbursement for students training in nursing home careers. Ironically, it took the disaster of a pandemic to make such potential positive change possible.

Richard Mollot, the executive director of the Long Term Care Community Coalition, agrees. “I think that COVID brought much-needed attention to the nursing home sector, much more than we’ve seen,” he says. “I think that it’s now part of the dialogue and that people really saw how much needs to be done. I think that is a good thing. We’ll see.”

The U.S. nursing home industry has been shrinking for decades, with the nationwide resident population going from 1.6 million in 1997 to 1.3 million in 2019, even as the number of Americans over 80 has surged. Occupancy rates also dropped, from 88 percent to 81 percent, during the same period. The primary reason for the declines: Consumers have been increasingly opting for less institutionalized care, either in home- and community-based settings or assisted living facilities.

The pandemic appears to have accelerated that decline, slashing the resident population by a further 13 percent and causing another 8 percent drop in occupancy rates. Heightened death rates in these facilities are partly to blame, researchers say, alongside the decision by many families to pull loved ones out of nursing homes once they learned of the issues they were facing.

That’s actually seen as good news by advocates like Harrington. “Nursing homes are, generally, not of sufficient quality,” she says. “We’re seeing the population narrow because people realize it’s risky to go into these facilities … and I think that’s for the best.”

Staffing has fallen at a similar pace. Between January 2020 and November 2022, the industry shed about 215,600 jobs, according to data from the U.S. Bureau of Labor Statistics. That’s about 14 percent of its total workforce—a figure that far outpaces losses in other health care sectors. “The nursing home sector is probably in the worst situation I’ve seen in 35 years,” says Jacci Nickell, chief of senior living services at Volunteers of America National Services, a nonprofit operating more than 20 senior living communities throughout the U.S. “We’ve had staffing stresses before, but I had no idea how bad they really could be.”

The mass exodus has mainly occurred among certified nursing assistants, who many refer to as the “backbone” of the nursing home workforce. CNAs provide around 90 percent of direct resident care—lifting, bathing, toileting, dressing and feeding. In 2020, as COVID-19 cases soared in their workplaces, their job became one of America’s most deadly.

Poor conditions have been the norm for decades, says Sylvia Abbeyquaye, 48, who worked in U.S. long-term care after emigrating from Ghana more than 20 years ago. “COVID-19 was just the last straw,” she says. She quit her role as the director of nursing at a 120-bed nursing facility in Brookline, Massachusetts, after being hospitalized with the virus following an outbreak in her workplace in April 2020. She hasn’t returned to a job in a nursing facility.

As workers have fled, the health of residents has deteriorated. Bedsores, weight loss, depression and the use of antipsychotic medication—conditions commonly associated with low staffing ratios—have all increased during the pandemic, according to an analysis of federal data by the National Consumer Voice for Quality Long-Term Care. COVID-19 deaths among nursing home residents—also exacerbated by low staffing—totaled more than 160,000 as of November, according to the federal government, representing about 15 percent of all virus deaths nationwide.

The nursing home industry is pushing back on the federal proposal to establish mandatory staffing levels, saying it’s unachievable and unaffordable under current government funding. “We would love to hire more nurses and nurse aides,” Mark Parkinson, president and CEO of the American Health Care Association (AHCA /NCAL), a national association of more than 14,000 nursing and assisted living facilities, said in a statement. “However, we cannot meet additional staffing requirements when we can’t find people to fill the open positions, nor when we don’t have the resources to compete against other employers.”

That’s likely true for some providers, given Medicaid’s current reimbursement rates. Research shows that these government payments, which 62 percent of nursing home residents nationwide rely on to fund their stays, don’t cover the full cost of care in many states, leaving providers to leverage other sources of payment to offset losses.

But the true state of the industry is difficult to discern because many nursing home owners have lacked transparency, advocates say. Roughly 70 percent of nursing homes in America are for-profit enterprises.

“Some nursing homes report high profits and others are siphoning profits out into other companies that they own, including management and property companies,” says UCSF’s Harrington, who investigates nursing home finances. “But we have no idea where the money is going because we don’t have transparency.”

Before putting more taxpayer dollars into the system, the Centers for Medicare & Medicaid Services, which is tasked with rolling out President Biden’s nursing home plan, is trying to identify unscrupulous providers pulling money out of care for profits. But it’s a slow process, Harrington says. CMS recently started making ownership data publicly available, but “it’s not accurate or complete yet,” she says. And getting it to that stage is “going to take a lot of time.”

Until then, staffing remains sparse. And complaints about residents going unchecked and unfed for hours are mounting, according to Marjorie Moore, the executive director of Voyce, an advocacy group for people living in long-term care. “Across the country, the hours of care per day are just way, way, way too low,” she says, “and that’s really scary.”

At the beginning of the pandemic, to combat rising staffing shortages, the Trump administration issued nursing homes a blanket waiver letting them onboard nurse aides who hadn’t completed the required training of at least 75 hours within four months of employment. Many states adopted a temporary nurse aide (TNA) program, allowing workers to be hired after substantially less training, often only eight hours online.

“We brought these people in who had no idea what they were doing,” Mollot says, “just when residents needed high-quality care the most.” The Biden administration lifted the blanket waiver in June 2022, citing concern that it had contributed to poor health outcomes for residents.

But extended waivers are being granted to states, counties or facilities that can’t access training or testing programs because they’re either fully booked or unavailable in the area.

It’s unknown how many of the industry’s roughly 470,000 nurse aides are currently uncertified, but industry observers suggest it’s the majority. “I’d guess it’s closer to 90 percent than 10 percent,” attorney Carlson says.

Despite this, the industry is lobbying to allow waiver extensions for another two years, maybe even permanently, if a study finds them effective in alleviating staffing burdens. Such extensions would “prevent further devastating job losses, in turn protecting access to care for our nation’s seniors,” said Holly Harmon, senior vice president of quality, regulatory and clinical services at the AHCA/NCAL, in a statement. AARP disagrees, and has called for a wide range of job improvements, like paid leave, improved training and increased pay, to help retain staff.

One area of nursing homes that experts generally agree has seen some improvement over the course of the pandemic is COVID-19 infection prevention and control. The vast majority of the credit, however, goes to one tool in particular: vaccines. They’re “a miracle,” says Carol Silver Elliott, president and CEO of the Jewish Home Family, a nursing home provider in New Jersey.

The drops in cases and deaths that vaccines spurred have allowed operators to slowly reintroduce daily routines, which were disrupted during the public health emergency. At the Jewish Home Family, visitation, communal dining, group activities and excursions have all come back, Elliott says. “We’re a whole lot more normal than we have been for a few years, so I’m grateful for that.”

But vaccination is not a one-and-done fix. “It’s an ongoing process,” says R. Tamara Konetzka, a professor of public health sciences at the University of Chicago. “And we need to keep up for it to work effectively.” Recently, though, nursing homes haven’t, which leaves this population on “shaky ground.”

As of mid-November, only 45 percent of nursing home residents and 22 percent of staff nationwide were up to date on vaccines, according to AARP’s Nursing Home COVID-19 Dashboard. So, while deaths still remain way down from the heights of the pandemic, the virus is continuing to circle through many facilities, killing hundreds of residents nationally per month. It’s also preventing a proper return to daily life, says Morgan Katz, M.D., an infectious disease expert at Johns Hopkins University School of Medicine. “Many of the facilities I work with are on outbreak status on a regular basis,” she says, which restricts residents’ freedoms and schedules.

That’s why it is so important to capture the moment created by the pandemic and harness public outrage, health professionals and advocates say. And there are some signs that is happening. “What we need is really a lot of political will,” Konetzka says. “There’s probably more political will right now than we’ve seen in decades, so that’s good.”