In the latter half of 2023, the National Labor Relations Board (NLRB) has issued some of its most significant decisions in decades, and they affect both unionized and non-union long term care facilities. The result is that the National Labor Relations Act (NLRA) is now much broader, and the NLRB has paved the way for unions to more easily gain recognition based upon authorization cards instead of an election. This coincides with historically high levels of union organizing activity, particularly in the health care sector, and general support for unions among American workers. We discuss these developments, how the landscape has changed, and some best practices for long term care facilities in response to these developments.