Nursing Home Understaffing: Half of Homes Use Agency Staff, What to Do

Nursing home understaffing means a facility does not have enough nurses and aides, measured in hours per resident per day (HPRD), or the right mix of registered nurses (RNs) versus aides, to meet residents’ basic care needs. The evidence is direct: systematic reviews link higher RN hours and better skill mix to fewer pressure ulcers, fewer infections, and less severe pain. Below, we walk through the scale of the problem, why it happens, and what you can do about it.

TL;DR:

• Agency staff rely more heavily on in facilities with staffing shortages, increasing costs by up to two-thirds and lowering overall quality ratings.
• Higher registered nurse hours and better skill mix are consistently associated with fewer pressure ulcers, infections, and reduced severe pain among residents.
• Understaffing often results from low wages, burnout, high turnover, and management decisions prioritizing costs over adequate staffing levels.
• Visible signs of understaffing include unanswered call bells, soiled residents, skipped meals, and unexplained wounds or injuries.
• Families should document observations, escalate concerns early, and gather evidence to support potential legal claims if harm occurs due to sustained staffing inadequacies.

Table of Contents

• Scope and key statistics on nursing home staffing shortages
• Causes and workforce drivers of understaffing
• How understaffing harms residents
• Regulation and policy gaps in nursing home staffing
• Red flags families should watch for during visits
• What families can do now to address concerns
• When understaffing crosses the line into a legal claim
• Why the staffing conversation misses the point
• How Calil Law supports families harmed by understaffing
• Sources
• FAQ

Scope and key statistics on nursing home staffing shortages

Staffing gaps in long-term care are not occasional. They are a persistent, measurable pattern that shows up in federal payroll data and in facility-level outcomes.

Between 2018 and 2022, the share of nursing homes using any agency nursing staff rose considerably, reaching about half of all facilities, according to research on staffing agency reliance. Facilities are not just short on people. They are increasingly filling those gaps with temporary staff who cost more and know the residents less.

A few numbers tell the story of why this matters:

• Agency staff cost between about half and two-thirds more per hour than directly employed staff, depending on role, according to the same analysis.
• Heavier reliance on agency staffing is linked to lower facility quality ratings.
• The Payroll-Based Journal (PBJ), the federal system that tracks HPRD, is the main tool regulators and researchers use to measure whether a facility is actually staffing at the level it claims.

HPRD matters because it is the closest thing the industry has to a common yardstick. A facility can look fully staffed on paper and still fall short in the RN hours that drive the outcomes residents and families care about most.

Causes and workforce drivers of understaffing

Understaffing rarely comes from one single failure. It is usually the product of several forces pulling in the same direction at once.

The most persistent driver is the labor market itself. Certified nursing assistants and floor nurses in long-term care are often paid less than comparable roles in hospitals, with fewer benefits and heavier physical and emotional demands. That combination drives burnout and turnover, which then forces remaining staff to cover more residents with less support, deepening the exhaustion that caused the turnover in the first place.

The COVID-19 pandemic accelerated this cycle. Facilities saw significant workforce exits, and workforce landscape research found that shortages contributed to reduced admissions and even facility closures as operators struggled to rebuild staffing levels.

Management decisions play a role too. Staffing is often the largest controllable cost in a nursing home’s budget, so some operators treat staffing levels as a lever to protect margins rather than a fixed requirement.

A few patterns tend to show up together:

• Chronic reliance on agency staff, rather than occasional use to cover a single call-out.
• High visible turnover among aides and floor nurses within the same building.
• Consistent short-staffing on evenings, nights, and weekends rather than isolated incidents.

Pro Tip: Ask how many different agency staff have worked with your loved one in the past month. Frequent, unfamiliar faces are often a stronger warning sign than a single bad day.

Agency staffing can solve an immediate coverage gap, but staff who do not know a resident’s routine, medical history, or communication style are more likely to miss subtle changes that signal a decline.

How understaffing harms residents

The research on this point is consistent, even when individual study designs vary. Facilities with more nursing hours per resident and a richer mix of RNs to aides produce measurably better outcomes.

Systematic reviews of nurse staffing and resident outcomes associate higher RN hours and better skill mix with fewer pressure ulcers, fewer nursing home associated infections, and less moderate to severe pain. A broader evidence review reaches a similar conclusion: higher nurse staffing is probably associated with fewer pressure ulcers, and the evidence points the same direction for infections and pain even where individual studies vary in strength.

The link goes beyond physical wounds. Causal analysis of staffing changes found that every 15-minute increase in nurse HPRD reduced antipsychotic use by about 1.51 residents, and modeling of the 2024 federal staffing standards projected a significant reduction in residents on antipsychotic medications nationally, reducing use by around 9.6%. Antipsychotics are sometimes used as a chemical restraint when there are not enough hands to manage a resident’s distress through attention and redirection instead.

Simulation results indicate omitted clinical care falls below a low threshold near approximately 1.0 licensed nurse HPRD and total nurse HPRD of 3.8 to 4.6.

CMS Nursing Home Staffing Study, June 2023

The mechanism behind these numbers is straightforward. When staff are stretched thin, basic activities of daily living get delayed or skipped, medications go out late, monitoring for changes in condition becomes rushed, and transfers between bed, chair, and bathroom happen too quickly to be done safely.

Regulation and policy gaps in nursing home staffing

Federal rules set a floor, but that floor has long been a subject of debate, and enforcement does not always catch facilities that fall below it.

The CMS Nursing Home Staffing Study found that increasing licensed nurse staffing reduces delayed or omitted clinical care, and its simulations suggest that total nurse staffing between roughly 3.8 and 4.6 HPRD keeps omitted care under 10% in many scenarios. The catch is that feasibility and cost vary widely by facility, which is part of why federal minimums have moved slowly and unevenly.

A few structural issues shape how these rules play out in practice:

• Proposed federal minimum staffing standards have faced delays, phase-in periods, and legal challenges that slow implementation.
• States vary considerably in their own staffing minimums and how strictly they enforce them, so a facility that is compliant in one state might fall short of another state’s requirements.
• PBJ data relies on facility self-reporting, and survey inspections happen periodically rather than continuously, which leaves gaps between when understaffing occurs and when a regulator documents it.

The result is a system where the research on what staffing levels prevent harm is fairly clear, but the regulatory mechanisms meant to enforce those levels lag behind the evidence. Families often end up as the most consistent, real-time monitor of whether a facility is actually meeting its residents’ needs, regardless of what the paperwork says.

Red flags families should watch for during visits

Some signs of understaffing are obvious the moment you walk in. Others take a few visits to notice because they build slowly over time.

1. Call bells go unanswered for long stretches, or you hear them ringing repeatedly with no response.
2. Residents appear soiled, unwashed, or in the same clothes across multiple visits at different times of day.
3. Meals are skipped, cold, or left untouched because no one was available to help a resident eat.
4. New pressure ulcers or wounds appear without a clear explanation from staff.
5. Personal belongings go missing repeatedly, which often points to rushed, understaffed shift changes rather than theft alone.
6. Small injuries recur, like bruises or skin tears, suggesting rushed transfers or inadequate supervision.
7. Mood or behavior changes emerge, including new withdrawal, agitation, or confusion that staff cannot explain.

Pro Tip: Keep a simple log with the date, time, what you observed, and which staff member you spoke with. A pattern documented over weeks carries far more weight than a single complaint.

What families can do now to address concerns

Escalation works best when it follows a clear sequence, starting inside the facility and moving outward only if the response falls short.

1. Raise the issue directly with floor staff first, since some problems are simple miscommunications that get fixed on the spot.
2. Request a care planning conference with the director of nursing or administrator if the issue is recurring rather than a one-time lapse.
3. File a written grievance through the facility’s formal complaint process and keep a copy for your own records.
4. Contact your state’s survey agency or file a complaint with CMS if the facility does not resolve the issue, including dates, times, staff names, and any photos you have taken.
5. Reach out to your local long-term care ombudsman, an independent advocate whose role is specifically to help residents and families navigate these disputes.
6. Preserve evidence as you go, including medical records, photos of injuries, and copies of every complaint you file, in case you need to consult an attorney later.

When understaffing crosses the line into a legal claim

Persistent, documented understaffing can support a negligence, elder-abuse, or wrongful-death claim when it can be shown that the facility owed a duty of care, breached that duty by failing to staff adequately, and that the breach caused a specific, identifiable harm.

Attorneys evaluating these cases typically look for staffing records and PBJ data showing hours actually worked, incident reports and medical records documenting the harm, and witness statements from staff, other residents, or visiting family members. The NCEA’s guidance on nursing home neglect defines neglect as including a facility’s failure to provide the staffing, supplies, or training necessary to prevent harm, which is often the starting point for these claims.

If your loved one has suffered a serious injury, a repeated pattern of neglect, or died in circumstances connected to inadequate staffing, gather what documentation you can and speak with an attorney promptly. Every state sets its own deadlines for filing these claims, and waiting too long can close that door permanently.

Why the staffing conversation misses the point

Most coverage of nursing home understaffing treats it as a resource problem: not enough workers, not enough money, not enough time. That framing is not wrong, but it lets facilities off the hook too easily. The research is clear that specific staffing levels produce specific, preventable harms, from pressure ulcers to unnecessary antipsychotic use. That is not an abstract resourcing issue. It is a set of choices about where money goes once it is available.

The conventional advice, tour the facility and ask about staff-to-resident ratios, is useful but incomplete. A ratio on a brochure means little if agency turnover is high or if staffing dips predictably on nights and weekends. What actually protects your loved one is watching for patterns over time and treating your own observations as data, not just worry.

If you take one thing from the research, it is this: the facilities that consistently staff at the levels the evidence supports are not doing something extraordinary. They are doing what should be baseline. Families should not have to become amateur investigators to confirm that baseline is being met, but until enforcement catches up with the research, that is often the reality.

— Jorge

How Calil Law supports families harmed by understaffing

When understaffing leads to a pressure ulcer that turns into sepsis, a fall that could have been prevented with proper supervision, or a death that never should have happened, the legal path forward depends on solid documentation and a firm willing to try the case, not just settle it quietly.

The firm is led by an experienced trial lawyer and mediator, and reviews each case personally rather than handing it off to a call center. If a facility’s understaffing caused serious harm to your loved one, our nursing home and elder abuse practice and wrongful death practice are built for exactly these situations.

To evaluate your case, we typically request:

• Staffing records and any available PBJ data for the facility during the relevant time period.
• Medical records, incident reports, and photos documenting the injury or decline.
• A timeline of your visits, observations, and any complaints you already filed.

Reach out through our personal injury practice page to request a free case review.

This article is general information, not a substitute for advice from a qualified doctor. Consult a qualified healthcare professional about your own circumstances before acting on anything here.

Sources

• Association of nurse staffing and resident outcomes: systematic review (PubMed)
• Nursing homes increasingly rely on staffing agencies for direct care nursing (PMC)
• Evidence review on nurse staffing and outcomes (NCBI Bookshelf)
• Research on staffing and antipsychotic use (Wharton WP2025-03)
• Nursing home staffing study (CMS, June 2023)

FAQ

How can families deal with understaffing at a nursing home?

Start by raising concerns directly with floor staff and, if the problem continues, request a meeting with the director of nursing or administrator. Document every incident with dates, times, and staff names, and escalate to your state survey agency or long-term care ombudsman if the facility does not resolve the issue internally.

What are common red flags of understaffing in a nursing home?

Watch for unanswered call bells, residents left soiled or unwashed, skipped or cold meals, and unexplained pressure ulcers or bruises. Recurring small injuries and sudden mood or behavior changes are subtler signs that often point to the same underlying problem.

What does understaffing actually mean in a nursing setting?

Understaffing means a facility does not have enough nursing staff, measured in hours per resident per day, or lacks the right mix of registered nurses and aides to meet residents’ basic care needs safely. Research shows that higher RN hours and better skill mix are tied to fewer pressure ulcers, infections, and less severe pain.

What are the consequences of inadequate nursing home staffing?

Inadequate staffing is linked to more pressure ulcers, infections, and severe pain, along with delayed medications and rushed, unsafe transfers. Causal analysis also found that low staffing increases antipsychotic use, since medication is sometimes used in place of the attention residents actually need.

Recommended

• Nursing Home/Elder Abuse
• What Is a Negligent Supervision Claim?