Skilled nursing facilities play a vital role in the United States health care system, particularly for older adults who need rehabilitation or postacute care after a hospital stay. For decades, these facilities have served as a bridge between hospitals and home, ensuring patients recover safely while receiving medical supervision and therapy. However, the COVID-19 pandemic has permanently altered this sector in ways that are only now becoming clear.
A recent investigation published in JAMA Internal Medicine reveals that the true capacity of skilled nursing facilities in the United States has declined significantly since the pandemic began. While official counts of licensed beds show only modest reductions, the number of beds that facilities can actually staff and operate has fallen much more sharply. These declines have had measurable consequences for hospitals, patients, and communities, particularly in rural areas.
This article explores the findings of this research, explains why traditional measures of nursing home capacity can be misleading, and examines how staffing shortages and reduced operating capacity are reshaping access to care for older adults.
Skilled nursing facilities, often referred to as SNFs, provide 24 hour medical care, rehabilitation services, and assistance with daily activities. They are distinct from assisted living facilities because they deliver clinical care under physician supervision. Nearly one in five Medicare patients discharged from hospitals rely on SNFs for recovery.
Capacity in these facilities is usually described in terms of licensed beds. Licensed beds represent the maximum number of residents a facility is permitted to house under state and federal regulations. However, having a license does not guarantee that a bed is usable. Staffing levels, financial constraints, and operational challenges determine whether a bed can actually be filled.
The study introduces a more realistic measure called operating capacity. This metric estimates how many residents a facility can safely care for based on its recent maximum census, which reflects real world staffing and resource limitations. This distinction is critical for understanding what has happened since the pandemic.
The study analyzed data from more than 15,900 skilled nursing facilities across the United States using Centers for Medicare and Medicaid Services records from 2018 through 2024. Several important trends emerged.
First, the total number of licensed skilled nursing beds declined by about 2.5 percent between 2019 and 2024. On its own, this change might appear manageable. However, when examining operating capacity, the decline was far more pronounced. Facilities were able to care for approximately 5 percent fewer residents by the end of 2024 compared with pre pandemic levels. At the lowest point in early 2021, operating capacity had fallen by nearly 15 percent.
Second, the number of open beds available for new admissions also decreased. By 2024, there were roughly 3,800 fewer beds available nationwide on an average day compared with 2019. This represents a reduction of more than 5 percent in the system’s flexibility to absorb new patients.
Third, these changes were not evenly distributed. One quarter of U.S. counties experienced declines in skilled nursing facility operating capacity of more than 15 percent. Rural counties were especially affected, with many losing more than a quarter of their functional capacity.
One of the most significant contributors to reduced operating capacity has been widespread staffing shortages. During the pandemic, skilled nursing facilities experienced unprecedented workforce losses. Burnout, illness, early retirement, and competition from hospitals and staffing agencies made it difficult to retain nurses and aides.
According to the study, counties with larger declines in skilled nursing facility capacity reported more frequent staffing shortages. For every one percentage point drop in operating capacity, there was a corresponding increase in reported shortages. The strongest associations were seen for nurses and nursing aides, who are essential for safe resident care.
Importantly, these relationships were not observed when capacity was measured using licensed beds alone. This suggests that traditional bed counts fail to capture the realities facilities face on the ground. A facility may hold a license for 100 beds but only have enough staff to safely operate 80 of them.
Reduced skilled nursing facility capacity does not only affect nursing homes. It has ripple effects throughout the health care system, particularly for hospitals.
Hospitals depend on skilled nursing facilities to discharge patients who no longer require acute care but cannot safely return home. When SNF capacity is limited, hospitals are forced to keep patients longer than medically necessary.
The study found that hospitals located in areas with larger declines in nearby skilled nursing facility capacity experienced longer average hospital stays. There was also a notable increase in the proportion of patients who remained hospitalized for 28 days or more, which is an indicator of severely delayed discharge.
In addition, patients who were eventually discharged to skilled nursing facilities often had to travel farther from their homes. This trend reflects a scarcity of available beds nearby and can disrupt family involvement, continuity of care, and patient satisfaction.
Geography played a major role in how skilled nursing facility capacity changed after the pandemic. Rural counties were significantly more likely to experience large losses in operating capacity compared with urban and suburban areas.
These counties tend to have older populations, lower population density, and fewer health care alternatives. When a skilled nursing facility reduces capacity or closes units in a rural area, there may be no nearby replacement. This forces patients to travel long distances for care or remain in hospitals longer.
The findings raise concerns about equity and access, particularly as the U.S. population continues to age. Rural communities already face challenges related to hospital closures and limited health care infrastructure. Declines in skilled nursing facility capacity further strain these systems.
One of the most important contributions of this research is its demonstration that licensed bed counts alone are an inadequate measure of skilled nursing facility capacity.
Occupancy rates, which divide current census by licensed beds, can also be deceptive. If a facility closes beds informally due to staffing shortages but does not surrender its licenses, occupancy rates may appear low even though the facility is operating at its true limit.
The study’s operating capacity approach offers a more accurate picture by reflecting what facilities can realistically handle. Policymakers, hospital administrators, and planners may need to adopt similar measures to assess system readiness and identify areas at risk.
The decline in skilled nursing facility operating capacity has important implications for health policy. Simply increasing the number of licensed beds will not solve the problem if facilities cannot recruit and retain staff to operate them.
Potential policy responses include investments in workforce development, improved wages and working conditions for nursing home staff, and targeted support for rural facilities. Transparency around staffing levels and operational capacity could also help hospitals plan discharges more effectively.
The study also suggests that health systems need better real time data on staffed and usable beds, similar to reporting requirements introduced for hospitals during the pandemic. Without accurate data, capacity constraints remain hidden until they cause delays and disruptions.
While the findings are compelling, the authors note several limitations. Staffing shortages were self reported by facilities, which may introduce reporting bias. The analysis was observational, meaning it cannot establish cause and effect with certainty. Other changes during the study period, such as Medicare payment reforms, may also have influenced facility behavior.
Additionally, the study did not fully assess whether some patients who would have gone to skilled nursing facilities instead received care at home or in assisted living settings. Further research is needed to understand how care patterns have shifted.
The COVID-19 pandemic has left a lasting mark on the U.S. skilled nursing facility sector. While licensed bed counts suggest only modest declines, the actual capacity to care for patients has dropped significantly due to staffing shortages and operational constraints. These reductions have contributed to longer hospital stays, delayed discharges, and increased travel distances for vulnerable patients.
As the nation prepares for continued population aging, understanding and addressing these capacity challenges is critical. Measuring what facilities can truly provide, rather than what they are licensed to offer, is a necessary step toward building a more resilient and equitable postacute care system.
McGarry BE, Wilcock AD, Gandhi AD, et al. Changes in U.S. Skilled Nursing Facility Capacity Following the COVID-19 Pandemic. JAMA Internal Medicine. Published online January 12, 2026. DOI: 10.1001/jamainternmed.2025.7197
This article is intended for informational and educational purposes only. It summarizes and interprets findings from a published research study and does not constitute medical, legal, or policy advice. Readers should consult qualified health care or policy professionals for guidance specific to their situation.
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