Nursing Home Staffing Requirements

Staffing is the single biggest lever for resident safety in a nursing home. It is also one of the most contested questions in federal long-term care policy. Between May 2024 and December 2025, the federal baseline for nurse staffing was rewritten, challenged in court, prohibited by Congress, and then formally repealed. This guide describes what the federal rules require today, what the 2024 CMS Minimum Staffing Final Rule tried to add, how that rule was unwound, and how a handful of states layer their own staffing minimums on in addition to the federal floor.

This is the regulatory-framework companion to our broader explainer on understaffing in nursing homes, which covers the evidence on how thin staffing translates into falls, pressure injuries, medication errors, and preventable deaths. Both pages sit under the nursing home neglect hub, which covers the federal definition of neglect and the full catalogue of harms that follow from it.

Federal Authority: The Nursing Home Reform Act and 42 CFR Part 483

Federal nursing home staffing rules trace back to the Nursing Home Reform Act of 1987, enacted as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). That statute established the core federal "sufficient staff" and licensed-nurse coverage requirements for Medicare- and Medicaid-certified long-term care facilities. CMS implements those requirements through Subpart B of 42 CFR Part 483, with the staffing rule itself at 42 CFR § 483.35.

The statutory "sufficient staff" standard

42 CFR § 483.35(a) states that a long-term care facility "must have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care, and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at § 483.71." This is a performance standard, not a numeric ratio.

42 CFR § 483.35(a)(3)–(4) adds a competency requirement: licensed nurses must have "specific competencies and skill sets necessary to care for residents' needs," and nurse aides must "demonstrate competency in skills and techniques necessary to care for residents' needs."

The Core Federal Baseline

On in addition to the "sufficient staff" performance standard, 42 CFR § 483.35 sets a handful of specific floor requirements that every Medicare- and Medicaid-certified nursing home must meet.

Licensed nurse coverage requirements

• 24-hour licensed nursing. 42 CFR § 483.35(b)(1) requires each facility to "provide services by sufficient numbers of … licensed nurses and other nursing personnel … on a 24-hour basis." This is the OBRA-era 24-hour licensed nursing services baseline.
• 8 consecutive hours of RN coverage. 42 CFR § 483.35(b)(1)(ii) requires "the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week," subject only to limited waiver provisions.
• Full-time director of nursing. 42 CFR § 483.35(b)(2) requires the facility to "designate a registered nurse to serve as the director of nursing on a full time basis."
• Charge nurse on each tour. 42 CFR § 483.35(c) requires the facility to "have a licensed nurse serving as a charge nurse on each tour of duty."

These four requirements, together with the general "sufficient staff" standard and the facility-assessment process at 42 CFR § 483.71, make up the current federal baseline. Notably, none of them is a numeric hours-per-resident-day (HPRD) floor.

The 2024 CMS Minimum Staffing Final Rule

On May 10, 2024, CMS published Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting (CMS-3442-F) in the Federal Register at 89 FR 40876. For the first time in the history of the federal nursing home program, the final rule proposed hard numeric staffing floors on in addition to the OBRA-era baseline.

Hours-per-resident-day standards

According to the CMS fact sheet for CMS-3442-F, the rule set a total nurse staffing minimum of 3.48 hours per resident day (HPRD), of which at least 0.55 HPRD had to be direct registered nurse care and at least 2.45 HPRD had to be direct nurse aide care. Hours per resident day is calculated by dividing total direct-care nursing hours worked in a day by the number of residents in the facility that day, so a 100-resident facility would have needed at least 348 nurse hours, 55 RN hours, and 245 nurse aide hours to hit the thresholds.

24/7 RN requirement

The CMS fact sheet for CMS-3442-F also required a registered nurse to be on site 24 hours per day, 7 days per week, replacing the long-standing 8-consecutive-hours-per-day RN floor for facilities subject to the new rule. CMS estimated in the rule's regulatory impact analysis that about 80 percent of nursing facilities already had RN coverage 24 hours per day, 7 days a week before the rule, though direct measurement is limited because the Payroll-Based Journal records total daily RN hours but not shift timing.

Facility assessment and phased implementation

The CMS fact sheet set a phased implementation timeline for urban facilities: Phase 1 (90 days from publication) was the new facility-assessment requirements at 42 CFR § 483.71; Phase 2 (2 years from publication) was the 3.48 total HPRD floor and the 24/7 RN requirement; and Phase 3 (3 years from publication) was the 0.55 RN HPRD and 2.45 nurse aide HPRD components. Rural facilities received a longer phase-in: 3 years for the total HPRD and 24/7 RN requirements, and 5 years for the RN and nurse aide HPRD components.

CMS projected in the CMS-3442-F fact sheet that meeting both the 24/7 RN requirement and the 0.55 RN HPRD component would require nursing facilities to hire approximately 16,000 additional registered nurses nationwide.

A KFF analysis of CMS Payroll-Based Journal data (March 2024 release, reflecting Q3 2023 staffing) found that approximately 19 percent of nursing facilities had staffing levels that would have met all components of the fully implemented 2024 final rule. In the same analysis, approximately 60 percent of facilities met the 3.48 total HPRD threshold, 49 percent met the 0.55 RN HPRD threshold, and 30 percent met the 2.45 nurse aide HPRD threshold. KFF is a non-partisan health policy research organization and its analysis was built directly on CMS PBJ data.

What Happened to the 2024 Rule

The 2024 final rule never took full effect. Three separate events — a federal district court decision, an act of Congress, and a CMS repeal rule — combined to unwind the HPRD and 24/7 RN provisions between April and December 2025.

Texas district court vacatur (April 2025)

On April 7, 2025, the U.S. District Court for the Northern District of Texas vacated the rule's 24/7 RN provision and its HPRD provisions in the AHCA-Kennedy challenge (consolidated case Nos. 2:24-CV-114-Z and 2:24-CV-171-Z). According to the preamble of the December 3, 2025 repeal rule (90 FR, Dec. 3, 2025), the court concluded that CMS had exceeded its statutory authority under the Nursing Home Reform Act, which set the minimum at 8 consecutive hours of RN coverage per day. The court left the rest of the final rule, including the facility-assessment requirements, intact.

Statutory moratorium under Public Law 119-21 (July 2025)

According to Congressional Research Service Report R48633, Section 71111 of Public Law 119-21, enacted July 4, 2025, prohibits the Secretary of Health and Human Services from "implementing, administering, or enforcing" the 2024 minimum staffing standards — the 24/7 RN, 0.55 RN HPRD, 2.45 nurse aide HPRD, and 3.48 total HPRD provisions — through September 30, 2034.

Formal regulatory repeal (December 2025)

On December 3, 2025, CMS published an interim final rule, "Medicare and Medicaid Programs; Repeal of Minimum Staffing Standards for Long-Term Care Facilities" (CMS-3457-IFC), in the Federal Register. The interim final rule formally removed the 24/7 RN coverage requirement and the 0.55 RN, 2.45 nurse aide, and 3.48 total nurse HPRD requirements from 42 CFR § 483.35.

Current regulatory state (as of April 2026)

After the December 3, 2025 repeal, the federal staffing baseline reverts to the pre-2024 OBRA-era requirements in 42 CFR § 483.35: 24-hour licensed nursing presence, an RN for at least 8 consecutive hours per day 7 days per week, a full-time RN director of nursing, a licensed charge nurse per tour, and the "sufficient staff" performance standard tied to the facility assessment at 42 CFR § 483.71. There is no enforceable federal HPRD floor and no 24/7 RN requirement.

How Staffing Is Reported Under Federal Law

Even without a numeric HPRD floor, federal law requires every Medicare- and Medicaid-certified nursing home to report its staffing in detail.

Payroll-Based Journal submissions

42 CFR § 483.70(p) requires every Medicare- and Medicaid-certified facility to electronically submit direct-care staffing information — including agency and contract staff — to CMS through the Payroll-Based Journal (PBJ) system on a quarterly basis, based on payroll and other auditable data. The CMS PBJ program page documents the current submission format and deadlines.

Care Compare staffing star ratings and on-site posting

42 CFR § 483.35(g) requires facilities to post daily nurse staffing data — resident census and total hours worked by RNs, LPNs/LVNs, and certified nurse aides — in a prominent place accessible to residents and visitors, to retain the data for at least 18 months, and to make it available to the public on request. The PBJ-derived staffing numbers also drive the staffing star rating on the CMS Care Compare website, which is the main consumer-facing way to compare facilities.

State Staffing Standards That Go Beyond Federal Rules

A small number of states have enacted their own numeric staffing floors that apply on in addition to the federal baseline. A 2025 peer-reviewed study in PubMed Central (PMC12352297) using 2023 Payroll-Based Journal data found that only six states (California, Florida, Illinois, Massachusetts, New York, and Rhode Island) plus Washington, D.C., had statutory staffing mandates that exceeded the federal baseline as of the study's analysis period. The same study found that, on average, nursing homes failed to meet the 2.45 nurse aide HPRD benchmark across every facility size and ownership category, and that 11 states had average reported staffing below the 3.48 total HPRD threshold.

California

California Health and Safety Code § 1276.65 requires skilled nursing facilities to provide a minimum of 3.5 direct care service hours per patient day (DHPPD), of which at least 2.4 must be performed by certified nurse assistants. California Department of Public Health All Facilities Letter 18-27 describes how the department conducts unannounced compliance audits and may issue administrative penalties for noncompliance.

Our California nursing home complaint guide walks through how to file a California-specific complaint with CDPH.

Florida

Florida Statute § 400.23(3)(a) requires nursing homes to maintain a minimum weekly average of 3.6 hours of direct care per resident per day, including at least 2.0 hours by certified nursing assistants and at least 1.7 hours by licensed nursing staff. The statute also bars facilities from staffing below one CNA per 20 residents.

New York

New York Public Health Law § 2895-b requires every nursing home to maintain a daily average of 3.5 hours of care per resident per day, of which at least 2.2 hours must be provided by a certified nurse aide and at least 1.1 hours by a licensed nurse. The statute took effect January 1, 2022, and the New York State Department of Health may impose civil penalties for each day of noncompliance, assessed quarterly using federal Payroll-Based Journal data.

See our New York nursing home complaint guide for the New York Department of Health's complaint pathway.

Illinois

The Illinois Nursing Home Care Act (210 ILCS 45) and the Illinois Department of Public Health regulations at 77 Ill. Adm. Code Part 300 set staffing minimums for Illinois long-term care facilities and authorize IDPH to assess penalties for noncompliance with the state's direct-care staffing ratios. Our Illinois nursing home complaint guide covers the IDPH complaint process.

Training and Certification Requirements

Federal rules also govern how long nurse aides must be trained before they can provide direct care and how often they must demonstrate competency after that.

Federal nurse aide training minimums

Under 42 CFR § 483.152(a)(1), a nurse aide training and competency evaluation program must consist of "no less than 75 clock hours of training," and § 483.152(a)(2) requires that the training include at least 16 hours of supervised practical training. 42 CFR § 483.152(b) further requires that nurse aides receive at least 16 hours of training in specified topic areas — communication and interpersonal skills, infection control, safety and emergency procedures, residents' rights, and basic personal-care skills — before any direct contact with a resident.

In-service education and the state nurse aide registry

42 CFR § 483.35(d)(7) requires the facility to ensure that nurse aides complete a performance review every 12 months and receive regular in-service education based on those reviews. 42 CFR § 483.95 sets the broader in-service requirement at no less than 12 hours per year for nurse aides. 42 CFR § 483.156 requires each state to maintain a nurse aide registry.

How Staffing Requirements Translate Into Resident Care

Staffing rules are the input side of a care system whose outputs are hands-on tasks: repositioning, feeding, medication passes, bathing, toileting, wound care, and response to call lights. When the number of licensed nurses and nurse aides on shift falls below what the resident population's acuity requires, those tasks get delayed, skipped, or rushed. The result is a set of harms the federal neglect framework already recognizes.

Our understaffing article lays out the peer-reviewed evidence on those outcomes in detail. Several of the cluster's harm-specific pages, including malnutrition, dehydration, and medication errors, connect specific neglect harms back to the staffing conditions that make them more likely. Readers looking at the broader facility-level consequences may also want to see the nursing home abuse hub, since chronic understaffing has been cited by federal oversight bodies as a contributing factor to both neglect and abuse.

How Families Can Verify a Facility's Staffing

Families do not need to rely on a facility's marketing materials to understand its staffing. Federal law gives them three concrete tools.

• Ask to see the daily posted staffing data. Under 42 CFR § 483.35(g), every certified facility must post its daily nurse staffing numbers — resident census and hours worked by RNs, LPNs/LVNs, and certified nurse aides — in a place accessible to residents and visitors, and must keep those records for at least 18 months. Families have the right to request this information directly.
• Look up the facility on Care Compare. The CMS Care Compare website publishes each facility's staffing star rating, which is built from Payroll-Based Journal submissions required by 42 CFR § 483.70(p). Compare the facility's total nurse HPRD, RN HPRD, and nurse aide HPRD to the national and state averages shown on the page.
• Check state-specific minimums where they apply. In California, Florida, New York, Illinois, and a few other states, the facility is also subject to a numeric state HPRD floor. If Care Compare shows reported hours below that state floor, the state survey agency can investigate a noncompliance complaint.

If a facility's staffing looks chronically below state or federal expectations and you are worried about a specific resident, our guide on how to report nursing home neglect walks through the state survey agency, Long-Term Care Ombudsman, and Adult Protective Services pathways. Our Texas nursing home complaint guide is another example of a state-specific pathway in a state that does not have a numeric HPRD floor.

If you believe harm has already occurred and you want to understand legal options outside the regulatory system, you can also speak with an attorney about a civil claim. That conversation is independent of any complaint you file with a survey agency or ombudsman.