America’s nursing homes are under growing strain because demand is rising while hiring and retention lag behind, putting day-to-day resident care at risk.
Federal regulators note there are nearly 1.2 million residents living in Medicare and Medicaid-certified long-term care facilities, and CMS has responded by setting nationwide minimum staffing standards (including 3.48 hours per resident day total nurse staffing, with 0.55 RN hours and 2.45 nurse aide hours) to reduce unsafe care in facilities that can’t staff consistently.
The workforce math is tight even before you account for turnover: the largest institution-based long-term care industry skilled nursing care facilities employed about 1.5 million people as of July 2024, yet staffing remains hard to stabilize because these jobs are demanding and often lower-paid than other healthcare roles.
Nursing assistants alone numbered nearly 1.4 million in May 2024, with 492,000 working in nursing care facilities, and an average hourly wage of $19.84—a key reason facilities struggle to compete for workers.
In the broader labor market, the U.S. Chamber reports the country is still missing 1.7 million Americans from the workforce compared to February 2020, which makes it even harder for nursing homes to fill entry-level roles quickly.
Immigration can be part of a practical, lawful staffing strategy because it expands the pool of qualified applicants for essential, hands-on roles that are persistently hard to fill domestically.
The U.S. Department of State explains that Employment Third Preference (EB-3) includes “unskilled workers (Other Workers)” for jobs requiring less than two years of training or experience, and these cases generally require an employer-filed petition and labor certification, an option that can support nursing homes seeking stable long-term hires.
This matters because federal projections show long-term services and supports demand keeps climbing: HRSA projects overall LTSS demand will grow 40% (2023–2038), and demand for nursing assistants is projected to grow 44%, a signal that the staffing gap won’t solve itself without multiple supply pathways, including international hiring where lawful and appropriate.
Why Nursing Homes Are in Crisis
America’s nursing homes are in crisis largely because the U.S. population is aging faster than the workforce needed to care for it.
According to the U.S. Census Bureau, by 2030 all baby boomers will be age 65 or older, meaning 1 in 5 U.S. residents will be retirement age, dramatically increasing demand for long-term care services.
At the same time, the U.S. Bureau of Labor Statistics (BLS) shows that while nursing care facilities employ a significant share of healthcare workers, employment growth has not kept pace with demand.
In 2024, there were nearly 1.4 million nursing assistants nationwide, but only about 492,000 worked in nursing care facilities, leaving many facilities understaffed despite rising patient needs.
BLS projections also indicate that openings for nursing assistants will average over 211,800 per year through the next decade, driven by both growth and replacement needs, highlighting how severe and ongoing the staffing gap has become.
Compounding the problem, most nursing homes are struggling to recruit and retain workers in an extremely tight labor market.
Industry data cited by the American Health Care Association (AHCA) shows that 94% of nursing homes report open positions, with particularly acute shortages of registered nurses and certified nursing assistants.
High turnover makes the situation worse: CNA turnover rates have exceeded 50% annually in many facilities since the pandemic, disrupting continuity of care and driving up costs.
Financial leaders in the sector warn that staffing pressures are now directly limiting access to care. A Ziegler CFO survey found that 25% of single-site nursing homes and 18% of multi-site operators have been forced to limit new admissions because they cannot staff safely.
Together, these trends explain why the nursing home industry is under sustained strain and why long-term solutions, including workforce expansion through lawful immigration pathways — are increasingly part of the national conversation.
The Impact on Quality of Care
Staffing shortages have a direct and measurable impact on the quality of care residents receive in nursing homes.
According to the U.S. News & World Report’s latest Best Nursing Homes rankings, fewer than 20% of the nation’s approximately 15,000 nursing homes earned a “High Performing” rating, and staffing levels were one of the most significant factors preventing facilities from achieving top scores.
U.S. News relies heavily on Centers for Medicare & Medicaid Services (CMS) staffing and quality data, which shows that many facilities fall below recommended nurse staffing hours per resident.
CMS has repeatedly warned that inadequate staffing is associated with higher rates of falls, pressure ulcers, infections, and hospital readmissions, all of which are tracked through the federal Nursing Home Care Compare system.
Federal oversight agencies have reinforced these findings with hard data.
The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) has reported that insufficient staffing is a key contributor to preventable adverse events in skilled nursing facilities, noting that nearly 1 in 5 Medicare beneficiaries experienced harm during a nursing home stay, much of it linked to poor monitoring and delayed care.
When there are too few caregivers on shift, residents may wait longer for assistance with basic needs such as toileting, mobility, or medication administration, increasing risks of injury and decline.
CMS data further shows that facilities with higher staffing levels consistently score better on quality measures, underscoring that staffing shortages are not just a workforce issue, but a patient safety and public health concern that directly affects the well-being of millions of elderly and vulnerable Americans.
A Strained Workforce With No Relief in Sight
The nursing home workforce remains under extreme pressure, with national data showing that shortages are not easing but becoming entrenched.
According to analysis cited by the American Health Care Association (AHCA), the nursing home sector experienced an estimated 7.6% decline in its workforce between 2020 and 2023, representing more than 120,400 caregivers lost nationwide, and staffing levels still have not returned to pre-pandemic baselines.
Nearly 99% of nursing homes continue to report open positions, confirming that vacancies are widespread and persistent rather than isolated to certain regions.
The U.S. Bureau of Labor Statistics (BLS) further underscores the challenge, projecting that nursing assistants alone will see over 211,800 job openings each year on average over the next decade due to both employment growth and the need to replace workers leaving the occupation.
This constant churn makes it extremely difficult for facilities to stabilize staffing or build experienced care teams.
Turnover remains one of the most damaging forces behind the crisis, especially among certified nursing assistants (CNAs), who provide the majority of hands-on resident care.
Industry surveys summarized by Skilled Nursing News and AHCA show that annual CNA turnover rates frequently exceed 50%, meaning many facilities must replace more than half of their aide workforce every year.
At the same time, the pipeline of new workers is constrained. The American Association of Colleges of Nursing (AACN) reports that U.S. nursing schools turned away over 65,000 qualified applicants in a single year, primarily due to shortages of faculty, clinical training sites, and budget limitations, reducing the flow of new nurses into long-term care settings.
Similar capacity limits affect CNA and allied health training programs, especially in rural and underserved areas.
Together, high turnover, shrinking training capacity, and sustained vacancies demonstrate that nursing home labor shortages are structural and long-term, not a short-term disruption that will resolve without significant policy, workforce, and immigration-based interventions.
What Federal Labor Data Tells Us
Federal labor data makes clear that employment growth in long-term care is not keeping pace with rising demand from an aging population.
The U.S. Bureau of Labor Statistics (BLS) reports that skilled nursing care facilities employed approximately 1.5 million workers in mid-2024, making them one of the largest institutional healthcare employers in the country, yet employment growth in this sector has lagged behind other healthcare settings such as hospitals and outpatient care centers.
While overall healthcare employment has rebounded strongly since the pandemic, BLS notes that long-term care providers continue to face slower hiring momentum due to persistent recruitment and retention challenges.
This imbalance is especially concerning because demand for long-term services is projected to rise sharply as the share of adults age 65 and older continues to expand nationwide.
Nursing assistants illustrate this mismatch between workforce size and actual staffing needs. According to BLS, nursing assistants were the third-largest healthcare occupation in the United States, with nearly 1.4 million workers nationwide in 2024, and about 492,000 of them employed in nursing care facilities.
Despite these large numbers, vacancies remain widespread. BLS projects an average of 211,800 nursing assistant job openings each year through the next decade, driven by both employment growth and exceptionally high replacement needs as workers leave the field
This data shows that even a sizable workforce is not enough when turnover is constant and new entrants cannot keep up, leaving nursing homes chronically understaffed despite strong and ongoing demand for care.
Labor Shortages Across the Economy
The staffing challenges facing nursing homes are part of a much larger labor shortage affecting nearly every sector of the U.S. economy.
According to the U.S. Chamber of Commerce, the United States is still short approximately 1.7 million workers compared to pre-pandemic labor force levels, even as job openings remain elevated nationwide.
Federal employment data reinforces how persistent this problem has become. The U.S. Bureau of Labor Statistics (BLS) shows that while overall job growth has continued, many industries still struggle to fill essential positions, particularly those involving physically demanding or lower-wage work.
In its Job Openings and Labor Turnover Survey (JOLTS), BLS consistently reports millions of unfilled jobs across the economy, alongside elevated quit rates that signal workers are leaving roles faster than employers can replace them.
The U.S. Chamber of Commerce also highlights that states with aging populations and strong service economies are suffering the most severe shortages, including many states with high concentrations of nursing homes and long-term care facilities.
This broader labor environment explains why nursing homes are not just facing a sector-specific issue, but are competing in a national labor market that simply does not have enough workers to meet demand without additional workforce solutions, including lawful immigration.
Why American Workers Aren’t Filling These Jobs
Many American workers are choosing not to enter or remain in nursing home jobs because the work is physically demanding, emotionally taxing, and often less competitive in pay compared to other options in today’s labor market.
According to the U.S. Bureau of Labor Statistics (BLS), the median hourly wage for nursing assistants was $19.84 in 2024, while jobs in retail, warehousing, and logistics — which are often less physically strenuous — can offer similar or higher pay with more predictable schedules.
Nursing home roles also involve lifting patients, working overnight or weekend shifts, and managing high resident-to-staff ratios, which contributes to burnout and attrition.
The BLS Job Openings and Labor Turnover Survey (JOLTS) consistently shows elevated quit rates in healthcare support occupations, signaling that workers are leaving these roles faster than employers can replace them.
As a result, facilities increasingly rely on older workers delaying retirement, part-time staff, or expensive temporary agency labor to fill gaps.
Geography further intensifies the problem, particularly in rural and underserved areas.
The U.S. Chamber of Commerce reports that labor shortages are most severe in states with aging populations and smaller working-age labor pools, many of which also have a high concentration of nursing homes and long-term care facilities.
Rural communities often lack nearby nursing schools or CNA training programs, limiting the pipeline of new workers. This challenge is compounded by national training constraints: the American Association of Colleges of Nursing (AACN) reports that U.S. nursing programs turned away more than 65,000 qualified applicants in a single year due to shortages of faculty, clinical placements, and funding.
Even when nursing homes offer wage increases, sign-on bonuses, or tuition assistance, these structural barriers make it difficult to recruit enough American workers to meet demand, helping explain why staffing shortages persist despite aggressive domestic hiring efforts.
How Immigration Can Be Part of the Solution
Immigration already plays a measurable and essential role in sustaining the U.S. healthcare and caregiving workforce, particularly in long-term care settings that struggle to attract enough domestic workers.
According to the U.S. Census Bureau, immigrants make up nearly 18% of the U.S. healthcare workforce, despite representing a smaller share of the overall population, and they are especially concentrated in direct care roles such as nursing assistants, home health aides, and personal care aides.
These are the same roles nursing homes report as hardest to fill. When positions remain vacant, the consequences are immediate: facilities may be forced to limit admissions, reduce services, or rely on temporary staffing agencies, which can cost two to three times more per hour than permanent staff and significantly strain operating budgets. Industry surveys and financial reports show that persistent vacancies and agency dependence are major contributors to rising costs and reduced access to care, particularly in rural and underserved communities where the labor pool is already limited.
A structured, lawful immigration strategy can help stabilize staffing by expanding the pool of reliable long-term workers.
The U.S. Department of State confirms that the Employment-Based Third Preference (EB-3) “Other Workers” category allows U.S. employers to sponsor foreign nationals for jobs requiring less than two years of training or experience, provided the employer completes the labor certification process demonstrating a shortage of available U.S. workers.
This makes EB-3 a practical option for nursing homes seeking certified nursing assistants, direct care aides, and support staff. At EB3.Work, we publish active EB-3 job opportunities in healthcare and long-term care so foreign applicants can connect with employers facing chronic shortages.
This approach helps facilities diversify their labor pool and reduce turnover while giving workers a lawful path to permanent employment. However, immigration policy exists within a broader workforce debate: as CMS minimum staffing standards are phased in, policymakers continue to weigh patient safety requirements against the reality that many facilities cannot meet these standards without expanded workforce pipelines, including immigration-based hiring.
Together, these dynamics show why immigration is increasingly viewed not as a replacement for domestic hiring, but as a necessary complement to sustain quality care in America’s nursing homes.
What Care Facilities Can Do
While immigration can expand the labor pool, care facilities must also strengthen their domestic workforce strategies to improve recruitment and retention. Compensation is a critical factor. According to the U.S. Bureau of Labor Statistics (BLS), the median hourly wage for nursing assistants was $19.84 in 2024, which is lower than many alternative service-sector jobs that require less physical and emotional strain.
The U.S. Chamber of Commerce has noted that employers facing severe labor shortages are increasingly using higher wages, better benefits, and predictable schedules to compete for workers, particularly in healthcare and caregiving roles.
Facilities that invest in competitive pay, health benefits, childcare assistance, and retention bonuses are more likely to reduce turnover, which is especially important given that CNA turnover rates often exceed 50% annually, driving up recruitment and training costs.
Training and workforce development are equally important but remain constrained nationwide.
The American Association of Colleges of Nursing (AACN) reports that U.S. nursing schools turned away over 65,000 qualified applicants in a recent year due to shortages of faculty, clinical placements, and funding, limiting the pipeline of new nurses entering long-term care.
Expanding CNA training programs, offering tuition assistance, and creating clear career ladders from aide to licensed nurse can help facilities build a more stable workforce over time.
At the same time, partnering with reputable international recruitment agencies and lawful employment-based immigration programs allows nursing homes to supplement domestic hiring when shortages persist.
Federal labor certification rules administered by the U.S. Department of Labor are designed to ensure that international recruitment only occurs when qualified U.S. workers are not available, creating a balanced approach that protects domestic labor while allowing employers to meet critical staffing needs.
Together, these strategies show that solving nursing home staffing shortages requires both sustained investment in U.S. workers and thoughtful use of global talent pathways.
How Immigration Can Help Address the Nursing Home Staffing Crisis
Step 1: Identify chronic workforce gaps that cannot be filled domestically
Nursing homes must first document persistent labor shortages.
BLS data shows that nursing assistants are the third-largest healthcare occupation, yet facilities still face an average of 211,800 job openings per year through the next decade due to growth and turnover.
These numbers demonstrate that domestic supply alone is not meeting demand.
Step 2: Use lawful employment-based immigration pathways
Employers can turn to legal options such as the EB-3 Other Worker category, which requires an employer-filed petition and labor certification confirming no sufficient U.S. workers are available.
This pathway allows nursing homes to recruit caregivers, aides, and support staff in a structured, compliant manner while meeting federal labor protections.
Step 3: Recruit and retain internationally trained workers for long-term stability
Foreign-born workers already play a vital role in U.S. healthcare.
According to federal workforce analyses, immigrants make up a significant share of nursing assistants and home health aides, particularly in long-term care settings where turnover exceeds 50% annually.
EB-3 workers typically seek long-term employment and permanent residency, which helps facilities reduce churn and stabilize staffing.
Step 4: Combine immigration with workforce development efforts
Immigration works best alongside investments in training, wages, and career pathways.
This is critical because U.S. nursing schools turned away over 65,000 qualified applicants in a single year due to faculty and capacity shortages, limiting domestic supply growth.
A combined approach helps nursing homes meet CMS staffing standards while improving quality of care and resident outcomes.
Frequently Asked Questions- The Growing Crisis in America’s Nursing Homes and How Immigration Can Help
1) Why are America’s nursing homes in a staffing crisis right now?
America’s nursing homes are under pressure because the number of older adults who need daily care is growing faster than the workforce needed to support them.
Federal regulators estimate there are nearly 1.2 million residents living in Medicare and Medicaid-certified long-term care facilities, which means the system is huge and needs consistent staffing every day.
At the same time, many nursing homes struggle to hire and keep enough caregivers because the work is demanding and turnover is high.
Pay is another challenge, especially for nursing assistants, who often earn around $19.84 per hour on average and can find other jobs with similar pay but less physical strain.
The broader labor market also makes it harder because the country is still missing about 1.7 million workers compared to February 2020.
When nursing homes cannot fill shifts, it affects how quickly residents get help with basic needs like bathing, moving safely, and taking medications.2) What does the new CMS minimum staffing rule mean for residents and families?
CMS set nationwide minimum staffing standards because consistent staffing is closely tied to safe care in nursing homes.
The rule includes a total of 3.48 nurse staffing hours per resident per day, with 0.55 hours from registered nurses (RNs) and 2.45 hours from nurse aides, aiming to reduce unsafe conditions where residents don’t get timely help.
For families, the goal is simple: fewer missed care tasks and better day-to-day attention for loved ones.
For facilities, the rule can be tough because many are already struggling to recruit staff, especially in rural areas and places with smaller labor pools.
Meeting these standards often requires hiring more people and reducing reliance on expensive temporary staffing.
Over time, stronger staffing levels can support better outcomes like fewer falls, infections, and avoidable hospital trips.
The rule also pushes nursing homes to prove they can deliver safe care consistently, not just on good days.3) How do staffing shortages actually affect quality of care in nursing homes?
When there are not enough caregivers on shift, residents may wait longer for help with basics like toileting, getting out of bed safely, or receiving medications on time.
These delays can lead to real risks, including falls, pressure sores, infections, and worsening health that could have been prevented with closer monitoring.
Public quality data and rankings often show staffing is one of the main reasons many facilities don’t score at the top level.
Short staffing also hurts consistency, because residents see new faces all the time when turnover is high, and that disrupts routine care.
It can also increase stress for the staff who remain, which raises burnout and makes more people quit. In some cases, nursing homes limit new admissions simply because they cannot staff safely. In plain terms, staffing is not just a business issue, it directly shapes resident safety and daily well-being.4) Why aren’t enough American workers taking these nursing home jobs?
Many American workers avoid or leave nursing home roles because the work can be physically exhausting and emotionally intense.
Nursing assistants often lift and move residents, work nights or weekends, and manage heavy workloads when staffing is low.
Even when facilities raise wages or offer bonuses, they still compete against other jobs that may offer similar pay with less stress and more predictable schedules.
Another problem is that turnover stays high, which creates a cycle where new workers enter, feel overwhelmed, and leave.
Training pipelines can also be limited, especially in smaller towns where there may not be enough nearby programs. Nursing schools face capacity constraints too, which reduces the flow of new nurses into the system.
All of this adds up to a long-term workforce gap that domestic hiring alone has struggled to solve.5) How can immigration realistically help fix nursing home staffing shortages?
Immigration can help because it expands the pool of qualified people who are ready and willing to work in essential, hands-on care roles.
Nursing homes are dealing with structural shortages and high turnover, so adding lawful hiring pathways can make staffing more stable over time.
One option discussed in this context is the Employment-Based Third Preference (EB-3) category, including “Other Workers,” which is designed for jobs that require less than two years of training or experience and requires an employer petition and labor certification.
This matters because demand for long-term services is projected to keep rising, and demand for nursing assistants is expected to grow sharply in the coming years.
Many immigrant workers are looking for long-term stability and a legal path to permanent work, which can reduce constant churn for employers.
Immigration is not a substitute for improving wages and working conditions, but it can be a practical complement when domestic supply is not keeping up.
Used responsibly and lawfully, it helps facilities maintain safe staffing while supporting better continuity of care for residents.6) What should nursing homes do besides immigration to improve staffing and care?
Facilities need a “both-and” strategy: improve domestic recruitment and retention while using lawful immigration options when shortages persist.
Raising pay matters, but so do predictable schedules, better benefits, supportive supervisors, and realistic resident-to-staff ratios that reduce burnout.
Nursing homes can also build career pathways, such as helping aides become medication techs or nurses through tuition support and training partnerships.
Reducing turnover is crucial because replacing staff constantly is expensive and weakens care consistency for residents.
Facilities can also invest in onboarding and mentorship so new hires are more likely to stay past the first difficult months.
Immigration works best when paired with these improvements, because a better workplace helps every worker, U.S.-born and immigrant, deliver stronger care.
In the end, stabilizing staffing is one of the fastest ways to protect resident safety and improve quality scores, family trust, and long-term sustainability.
Final Thoughts
The nursing home staffing shortage is not the result of a single failure, but the convergence of long-term demographic, labor, and policy trends.
Demand for care is accelerating as the population ages, with the U.S. Census Bureau projecting that by 2030, adults age 65 and older will outnumber children for the first time in U.S. history, dramatically increasing the need for long-term services and supports.
At the same time, workforce supply is constrained. The U.S. Bureau of Labor Statistics (BLS) projects an average of 211,800 job openings for nursing assistants each year over the next decade, largely driven by high turnover and replacement needs rather than new growth alone.
These figures underscore that staffing challenges are structural and ongoing, not temporary disruptions that will resolve without sustained intervention.
Expanding lawful immigration pathways can play a meaningful role in stabilizing the workforce, particularly for essential, entry-level caregiving roles.
The U.S. Department of State explains that the Employment-Based Third Preference (EB-3) “Other Workers” category allows U.S. employers to sponsor foreign workers for jobs requiring less than two years of training or experience, provided they complete the labor certification process to show a lack of available U.S. workers.
This pathway aligns closely with the needs of nursing homes, which rely heavily on certified nursing assistants, aides, and support staff.
As HRSA projections show long-term services and support demand is expected to grow 40% between 2023 and 2038, relying solely on the domestic workforce is unlikely to meet future care needs without supplemental labor sources.
Ultimately, lasting solutions will require a balanced and coordinated approach. Investments in wages, training capacity, and career advancement are essential to attract and retain U.S. workers, especially given that nursing schools turn away tens of thousands of qualified applicants each year due to faculty and funding shortages.
At the same time, immigration-based recruitment can responsibly fill persistent gaps while complying with federal labor protections enforced by the U.S. Department of Labor.
By aligning workforce development, thoughtful policy support, and legal immigration pathways like EB-3, the United States can begin to address one of its most urgent care workforce challenges and help ensure that nursing home residents receive the safe, consistent, and dignified care they deserve.
