19 Frequently asked questions about long-term care staffing
Staffing in long-term care is complex, with changing regulations and ongoing financial and workforce challenges. These FAQs provide clear answers on staffing requirements, best practices, and solutions to help you confidently manage quality care.
1. What is long-term care?
Long-term care (LTC) encompasses a wide variety of services for individuals with chronic illness, disability, or cognitive impairment to meet their medical and non-medical needs for an extended period.
The following are the most common types of LTC:
- Nursing homes
- Assisted living facilities
- Skilled nursing facilities (SNFs)
- Home health care
- Rehabilitation centers
- Hospice care
- Adult day care centers
- Long-term acute care hospitals (LTACHs)
- Continuing care retirement communities (CCRCs)
- Memory care facilities
Each type of facility plays a crucial role in delivering comprehensive, compassionate care over time.
2. What are the staffing requirements for nursing homes?
The Centers for Medicaid & Medicare (CMS) requires facilities to conduct a comprehensive, data-driven assessment process to determine the necessary staffing levels, skills, and resources to meet the needs of their specific resident population across all units and shifts.
CMS surveyors assess whether facilities have conducted these assessments with all required components.
3. What is the minimum requirement for the presence of a registered nurse (RN) in a nursing home?
Nursing homes must comply with the longstanding federal baseline staffing requirements set by Congress that mandate:
- A minimum of eight consecutive hours of RN coverage per day, seven days a week
- A licensed nurse—RN or licensed practical/vocational nurse (LPN/LVN)—on duty 24 hours a day
Ensuring the right staff coverage supports quality care and regulatory compliance.
4. What is the minimum staffing level for a nursing home?
State regulations have minimum staffing standards for nursing homes that vary widely from fixed numerical amounts to wording that allows for discretion, such as “staffing must be sufficient to meet resident needs.”
Currently, at the federal level, no fixed numerical minimums are enforced.
The CMS staffing mandate in 2024 minimum nurse staffing requirements stipulated that an RN should be on-site 24 hours a day, seven days per week, and at least 3.48 hours per resident day (HPRD) of total nursing care be provided.
However, the passage of the 2025 Reconciliation Law placed a 10-year moratorium on the implementation and enforcement of the numerical CMS rule's staffing minimums.
5. How much would the 2024 CMS nursing home staffing rule cost?
The 2024 CMS staffing rule was projected to cost nursing homes $6–6.5 billion annually. To comply with the mandate, LTC facilities would have to hire 102,000 more nurses and certified nursing assistants (CNAs).
After significant industry pushback, challenges in U.S. district courts in 2025 provided divergent rulings. For now, implementation and enforcement have been delayed by law for at least a decade.
6. Which states have specific nursing home staffing laws?
Many states have specific staffing standards for LTC facilities, but some have notably higher demands. Nursing home staffing requirements by state for 2025 include these outstanding examples:
- California requires at least 3.5 hours per resident day (HPRD), and a minimum of 2.4 provided by CNAs.
- New York mandates 3.5 HPRD, 1.1 provided by a licensed nurse and a minimum of 2.2 provided by CNAs.
- Florida has a standard of 3.6 HPRD and a ratio of one CNA per 20 residents.
States often require nursing homes to meet minimum hours per resident day for total nursing staff or for specific staff categories (RNs, LPNs/LVNs, and CNAs) and have reporting or monitoring mechanisms.
All states oversee compliance with federal standards and may apply fines or administrative sanctions for non-compliance.
Nursing homes should maintain staffing ratios that are compliant with their state regulations.
Helpful resources:
7. What is HPPD or Hours Per Patient Day?
HPPD (hours per patient day)—usually called hours per resident day (HPRD) in LTC facilities—is a key staffing metric in healthcare. It measures the total hours of nursing care patients or residents receive from nursing staff in a 24-hour period.
It helps facilities analyze and monitor workforce deployment, estimate staffing needs, adjust budgeting, and ensure adequate care levels.
8. How do you calculate HPPD?
Calculating the HPPD requires counting the total number of nursing hours worked in 24 hours and then dividing it by the patient census during that period.
For this calculation, nursing hours do not count paid sick leave, vacation time, or other time not dedicated to direct care.
HPPD = Nursing hours worked in a 24-hour period / total number of residents or patients
9. How many patients can a CNA have legally?
There is no nationwide legal limit on the number of patients per CNA, and most states have not stipulated a limit. However, a few have.
- Delaware: one CNA for every seven residents during the day, one-to-10 in the evening, and one-to-15 during the night.
- Oregon: one-to-11 during the day, one-to-nine in the evening, and one-to-17 at night.
- Pennsylvania: one-to-10 during the day, one-to-11 in the evening, and one-to-15 at night.
- Florida: one CNA for every 20 residents.
10. How many nurses should be in a nursing home?
State regulations and facility assessments determine how many nurses should be on-site at any given moment in a nursing home.
Facilities adjust the ratio depending on acuity and facility resources, and actual staffing may vary widely due to ongoing workforce challenges.
11. How do you calculate the staff-to-patient ratio?
The staff-to-patient ratio is commonly calculated using nurse-to-patient ratios or hours per resident day (HPRD). The nurse-to-patient ratio indicates the number of patients assigned to a nurse during a shift (e.g., one nurse to three patients would show as 1:3), while HPRD divides total nursing hours per patient day.
Best practices recommend adjusting ratios based on patient acuity and clinical environment rather than fixed values. Adequate staffing improves safety, reduces missed care such as medication errors, and enhances nurse well-being.
PRN staffing platforms, such as Nursa, help maintain adequate nurse-to-patient ratios and hours per patient day.
12. How to calculate nurse staffing needs effectively?
Tools are available to help healthcare facilities accurately estimate and plan nurse staffing levels that promote quality patient care and operational efficiency.
- Care Dependency Scale (CDS or PAS): A tool that measures levels of the patients’ dependency on care in 15 areas, each with five gradations, ranging from completely dependent to independent.
- Resident Assessment Protocols (RAPS): A set of clarification aids for 18 geriatric care issues and corresponding trigger systems, which alert the caregiver to clinical problem areas.
- Functional Assessment of the Care Environment for Older People (FACE): A tool to inform decisions on care objectives and the distribution and assumption of tasks.
13. Why are nursing homes so short-staffed?
The aging population and increased longevity have intensified healthcare demand, especially in nursing homes. Other factors include the following:
- The nursing workforce is also aging, limiting potential educators and, therefore, the number of new nursing students entering the field.
- Turnover in nursing has risen due to burnout, unmet expectations, and stress and violence in healthcare settings.
- Many nurses reduce hours or leave during childbearing years.
Appropriate staffing based on healthy nurse-patient ratios and acuity levels boosts nurse job satisfaction, retention, and patient safety.
14. What is payroll-based journal reporting?
Payroll-Based Journal (PBJ) is a CMS electronic reporting system that requires LTC facilities to report direct care staffing information each quarter. Reports must include actual hours worked by each employee per calendar day. Administrative or non-care staff are not reported.
Mastering PBJ reporting and accuracy is essential for the facility to qualify for the five-star CMS rating system. PRN staffing platforms like Nursa provide access to local healthcare workers to maintain adequate hours per patient day and quality of care.
15. How many hours can a nurse be mandated to work?
Although there is no federal maximum shift length, most states restrict nursing shifts to 12 hours with mandatory rest periods to promote nurse and patient safety.
Furthermore, several states restrict mandatory overtime, while others leave it up to facilities’ discretion. Please consult the relevant state labor laws or nurse practice acts for precise rules in a particular state.
Related: How facilities can cut down on nurse overtime costs
16. What is the turnover rate for nursing home employees?
Nursing homes continue to face an intensely challenging environment in 2024-2025, with overall nursing staff turnover as high as 54 percent for one-star facilities, while even five-star homes face a substantial 44 percent turnover.
These numbers reflect the difficulty of retaining staff and the broader strain these facilities endure, managing high patient needs amidst workforce shortages and limited resources.
Fill schedule gaps and cover staff call outs with Nursa’s per diem staffing.
17. How short-staffed are nursing homes on average?
On average, nursing homes run over 40 percent short of the recommended level of RNs on duty, as reported for 2024. This is significantly higher than the 10-20 percent shortages reported in acute care facilities.
Read: Understanding the nursing shortage in 2025
18. Is understaffing illegal in nursing homes?
It can be, if it violates federal or state minimum standards and jeopardizes resident safety.
Understaffing in nursing homes is not always a standalone legal violation. It often contributes to other violations of laws or regulations and can lead to legal liability.
Nursing homes are legally bound to provide adequate care and staffing to ensure residents' safety and well-being.
If residents suffer harm from understaffing—such as preventable falls, bedsores, infections, missed care, or neglect—nursing homes can be held civilly liable. The damages may include medical costs, pain, and suffering resulting from inadequate care.
Civil lawsuits for neglect, administrative fines, and even loss of operating licenses are possible outcomes for understaffed nursing homes.
Related: Understand the hidden costs of understaffing in nursing
19. How can technology help in LTC staffing?
Healthcare staffing platforms like Nursa provide fast, flexible access to local per diem nurses to cover scheduling gaps on demand.
With built-in credential verification, background checks, and integration with scheduling systems, Nursa simplifies workforce management while supporting staff retention.
Facilities using the platform also have the option to transition trusted per diem nurses into permanent roles without incurring hire-away fees, gradually strengthening their core team.
Staffing shortages, high turnover, and increasing care needs create immense challenges for nursing home managers and schedulers. Nursa’s staffing software platform offers reliable, on-demand support to connect you to the nurses you need for safe coverage and quality care. Leveraging this digital solution allows facilities to navigate workforce instability with greater confidence and agility.
Sources:
.png)
.png)
