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Staffing In California Nursing Homes: A Crisis in Care

Over the past two years, California nursing homes received approximately $470 million in increased Medicaid/Medi-Cal reimbursements. Approximately $163 million of these funds were required to be passed through to nursing home workers in the form of salary and benefit increases; $53.8 million was earmarked to improve staffing levels. Initial audits by the Department of Health Services have shown that roughly one-third of the facilities did not pass through these funds to direct care workers and many others failed to pay overtime or health benefits.

While nursing assistants (certified or not) comprise the largest part (70%) of the direct care hours in California's nursing homes, their wages comprise less than 50% of the total salaries for direct care. And while CEO compensation for nursing home chains increased 80% during the last three years, the hourly average wage for nursing assistants in California is approximately $7.50 an hour.

Understaffed and Underpaid

In California, a CNA can be required to care for anywhere from eight to 20 residents during a shift. California requires 3.2 nursing hours per patient per day. While many facilities meet this requirement on paper, many do not meet the hours in fact. The average staff turnover rate in California nursing homes is close to 80% for for-profit facilities and somewhat lower for non-profit facilities. With poverty level wages, few health or retirement benefits and no opportunities for advancement, nursing home chains continue to make unprecedented profits while relying on underpaid CNAs to do the bulk of the work. Is it any wonder that nursing homes are having a hard time attracting and keeping qualified staff?


In California, a cosmetologist must have 1600 of training before they can perform pedicures or manicures; a dog groomer must have hundreds of hours of training. Yet staff who care for our most vulnerable populations are only required to have 100 hours of on-the-job training and 60 hours of classroom training—training that in most cases is provided by the facility where they work. As one study noted, "There is a crisis in staffing in nursing homes, and it's getting worse." With no mandated staff to patient ratio and no uniform training, underpaid, untrained staff continue to be the biggest factors in inadequate care.

Impact on Care

Nursing homes continue to accept sicker and more dependent residents, and HMOs continue to prematurely discharge severely ill patients into nursing homes. California's CNAs find themselves ill-prepared in the face of short staffing and inadequate training.

The result is devastating for both CNAs and nursing home residents. The impact on care cannot be overstated. When nursing homes do not have enough staff, the residents suffer: malnutrition, dehydration, falls, bedsores, infections and incontinence. The majority of nursing home quality of care problems can be attributed to inadequate staffing and inadequate training.

Blaming the Victims

Almost every hearing on nursing home abuse and neglect results in renewed efforts to monitor nurses' aides There have been no initiatives, however, to track nursing home owners with a history of inadequate care. There have been few initiatives to reclaim federal and state Medicare and Medicaid dollars given to nursing home chains who refuse to hire adequate staff. While there is no question that staff with criminal histories should not be working in nursing homes, corporate nursing home owners with a history of substandard care should not be allowed to operate them.

Make no mistake, the blame for poor care in California's nursing homes should be placed directly on the shoulders of those corporate chains who profit from poor care.