In the early months of the COVID-19 pandemic, the nation’s attention focused on the brutal toll the virus took on those in nursing homes.

Those residents were the most vulnerable – older, sicker and living in close quarters. In the first year of the pandemic, nearly one in every 10 people living in a nursing home died from COVID.

Those deaths turned a spotlight on a corner of health care usually in the shadows. It exposed the neglect of residents, the lack of staff, the low pay for aides, weak government oversight and the callousness of some owners who milked nursing homes for profits at the expense of decent care.

One hoped-for result of the exposure was that there would be a state and national effort to provide better care for the elderly. But as the fourth anniversary of the pandemic arrives, nursing homes – and long-term care facilities in general – have seen little change in the nation or in North Carolina.

“The things we are concerned about now are holdovers from before the pandemic,” said Bill Lamb of Friends of Residents in Long Term Care, an independent, nonprofit organization.

“The pandemic laid bare all the weaknesses,” he said. “We had that attention, but it has been harder to sustain.”

Federal and state nursing home funding has improved, but given the underfunding in the past and recent inflation, nursing homes still struggle to provide quality care. In some ways, conditions are more challenging because the strong post-pandemic economy has made it harder to hire and keep aides and nurses. And COVID is still around.

Adam Sholar, CEO of the NC Health Care Facilities Association, said nursing homes have raised pay and added recruitment and retention bonuses, but staff levels have declined. “In North Carolina, the industry is down more than 10% of its workforce since the start of COVID — there are roughly 4,300 fewer employees today,” he said.

Labor shortages affecting nursing homes are not confined to the homes themselves. A high vacancy rate at the state Department of Health and Human Services (DHHS) is hindering the ability of its Division of Health Service Regulation (DHSR) to inspect nursing homes and respond to residents’ complaints. The General Assembly’s failure to spend more on state employees, and specifically public health workers, has left North Carolina nursing home residents more vulnerable to poor treatment or neglect than before the pandemic.

DHHS said in a statement: “Retention and recruitment of nursing home inspectors has been especially challenging due to low wages, the required travel and significant and stressful workload. … This means a smaller workforce is struggling to respond to a growing number of complaints and severity of deficiencies found in nursing homes.”

The department, which logged 3,484 complaints about nursing homes in 2022, said: “Without additional investigators and more funding to increase the pay for existing and future nursing home investigators, DHSR’s ability to timely survey nursing homes and investigate complaints will continue to worsen.”

Compounding the problems of low funding for nursing operations and their oversight has been a rise in private equity firms. The firms often cut quality to boost profits from Medicare and Medicaid funding.

Lamb said improving nursing homes is impeded by a shortage of labor and a lack of clarity about where the money already being spent is ending up.

“We would advocate for more regulators,” he said, “but we can’t fill the positions we already have.”

Meanwhile, Lamb said, pumping more money into the system may not help if it goes toward profits instead of patient care. “There needs to be more transparency and accountability about how the public dollars are actually used in facilities,” he said.

Four years after COVID compelled the public to see the shame of how the nation treats its oldest and most vulnerable citizens, nursing home care and its oversight may actually be worse. The government and voters should insist that we make it better.