Choosing a Facility
Nursing Home Staffing: Hours, Turnover and Why It Matters
How Much Staffing Does a Nursing Home Need, and How Do You Check It?
Federal nursing home staffing rules require enough nursing staff around the clock to meet residents' care plans, a licensed charge nurse on every shift, and a registered nurse on site at least 8 consecutive hours a day, 7 days a week. There is no federal minimum of hours per resident: the 2024 minimum staffing standards were repealed effective February 2, 2026. In August 2026 CMS data, the median home reported 3.68 nurse hours per resident per day and 44.9% nursing staff turnover.
Ask families what went wrong in a nursing home and the answer is often the same: not enough people on the floor. Call lights that go unanswered, meals that arrive cold, a parent left in bed too long. Staffing is the part of nursing home quality you can feel on a visit, and it is also one of the few parts measured from payroll records rather than self-reports.
What Federal Nursing Home Staffing Rules Require
Every nursing home that takes Medicare or Medicaid must follow 42 CFR 483.35. The core rules:
| Requirement | What the rule says |
|---|---|
| Enough staff | Sufficient nursing staff, with the right skills, to meet each resident’s assessed needs and care plan, around the clock |
| Licensed nurses | Licensed nurses on duty 24 hours a day, and a licensed charge nurse on every shift |
| Registered nurse | An RN on site at least 8 consecutive hours a day, 7 days a week |
| Director of nursing | A full-time RN director of nursing, who can double as charge nurse only in homes averaging 60 or fewer residents |
| Nurse aides | Aides must finish state-approved training and pass a competency test within 4 months, be checked against the nurse aide registry, and get a performance review every year |
| Daily posting | Staff counts and hours for each shift, plus the resident count, posted at the start of every shift |
A state can waive the 24-hour licensed nurse and RN requirements for a home that shows it can’t recruit nurses despite diligent efforts, and the federal government can waive the RN requirement for some rural homes. A home with a waiver must tell its residents.
What the federal rules don’t contain is a number. There is no required ratio of aides to residents and no minimum hours per resident. Your state’s nursing home licensing agency can tell you whether state rules add anything more.
What Happened to the 2024 Minimum Staffing Rule
In May 2024, CMS published a rule that would have added the first federal staffing minimums:
- 3.48 total nurse staffing hours per resident per day;
- 0.55 of those hours from registered nurses and 2.45 from nurse aides;
- a registered nurse on site 24 hours a day, 7 days a week.
Those minimums never took effect. According to CMS’s December 2025 rule:
- Courts. Two federal district courts, in Texas and Iowa, vacated the hours-per-resident and 24/7 RN provisions in 2025.
- Congress. Section 71111 of Public Law 119-21, signed July 4, 2025, bars CMS from implementing or enforcing those standards until September 30, 2034.
- Repeal. CMS published an interim final rule on December 3, 2025 repealing the minimums and restoring the earlier text of the rule. It took effect February 2, 2026.
So the rules in the table above are the federal rules in force today. If you read about a federal 24/7 RN requirement or a 3.48-hour minimum, that information is out of date.
How CMS Measures Staffing
Because federal rules set no minimum, the most useful staffing information is what CMS publishes. Since July 1, 2016, every nursing home has had to report its staffing to CMS through the Payroll-Based Journal, based on payroll and other auditable records. Homes report every quarter, within 45 days of the quarter’s end. The data include employees and agency or contract staff. They exclude private aides paid by families, hospice staff and feeding assistants.
From those records, CMS calculates six measures for each home:
- Total nurse hours per resident per day: registered nurses, licensed practical nurses and nurse aides combined.
- Registered nurse hours per resident per day.
- Total nurse hours on weekends, when many homes run thinner.
- Nursing staff turnover: the share of nursing staff who left over a year.
- Registered nurse turnover.
- Administrator departures over a year.
CMS adjusts the hours for how much care each home’s residents need, so a home caring for sicker residents is expected to staff more. It counts someone as having left after a gap of at least 90 days with no hours, among staff who had worked at least 120 hours in a 90-day period, so occasional fill-in workers don’t skew the number.
Who Counts as Nursing Staff
CMS groups payroll hours into three kinds of nursing staff:
- Registered nurses: the director of nursing, RNs with administrative duties, and RNs giving care.
- Licensed practical or vocational nurses: including those with administrative duties.
- Nurse aides: certified nurse aides, aides in training and medication aides.
Together these make up “total nurse staffing.” Hours per resident per day is simply the total hours those staff worked in a day divided by the number of residents that day. A home with 100 residents at the national median of 3.68 hours would log about 368 nursing hours in a day, shared across day, evening and night shifts.
CMS reports registered nurse hours separately and gives them as much weight in the staffing rating as total nurse hours: up to 100 points each. A home can have plenty of aide hours and still be thin on RN hours, so look at both numbers.
4+ Stars for Staffing: Nursing Homes by State
CMS Care Compare lists 5,245 nursing homes in this group (4+ stars for staffing) across 53 states and territories, data from August 2026. Pick a state for its nursing homes, cities and senior care rules.
What the National Numbers Show
In August 2026 CMS data:
| Measure | National median |
|---|---|
| Total nurse staffing hours per resident per day | 3.68 |
| Registered nurse hours per resident per day | 0.58 |
| Nursing staff turnover | 44.9% |
In plain terms, the median home provides a little over three and a half hours of nursing time per resident each day, all nurse and aide time combined, and a little over half an hour of that from registered nurses. Close to half of nursing staff at the median home leave within a year.
Across the country, 5,245 homes had 4 or 5 stars for staffing, and 6,751 homes had nurse turnover below the national median. The Nursing Home Comparison tool puts these measures side by side for up to three homes you’re considering.
Why Staffing and Turnover Matter
CMS’s own rating guide cites research finding a clear link between nurse staffing levels and quality of care, and growing evidence that higher turnover is associated with poorer care. When the same aides care for your parent day after day, they learn how your parent likes to be helped, notice small changes sooner, and communicate better with family.
That’s why staffing has its own star rating and can move a home’s overall rating up or down by a star. A home that reports no registered nurse hours on a day with residents, or fails a CMS staffing audit, gets 1 star for staffing. The star ratings guide explains the scoring.
Staffing also shows up in inspection reports. Citations for not having enough staff, or for not posting daily staffing, are worth asking about. The inspection reports guide shows how to find them.
How to Check Staffing Yourself
The payroll data tell you about past quarters. Your visit tells you about today.
- Read the daily posting. Every certified home must post, at the start of each shift, how many RNs, licensed practical nurses and certified nurse aides are on duty, their hours, and the number of residents. Divide residents by aides for a rough sense of each aide’s load. The home must keep these postings for 18 months and show them to you on request, so ask for a few weekend and night shifts too.
- Visit more than once. Medicare suggests a second visit on a different day and at a different time, because staffing can change in the evening and on weekends.
- Watch the floor. How long do call lights stay on? Are residents waiting for help at meals? Do staff seem rushed, or do they stop to talk?
- Ask Medicare’s staffing questions. Is a licensed nurse there 24 hours a day, and an RN at least 8 hours a day, 7 days a week? Has the administrator or director of nursing changed in the past year? Will the same aides care for your parent day to day?
- Ask about agency use. How much of the staff comes from agencies, and do agency staff get the same orientation?
The how to choose a nursing home guide has the full Medicare checklist.
When Staffing Seems Short After Admission
If your parent already lives in the home and care is slipping, write down specifics: dates, times, how long a call light stayed on, missed meals or medications. Raise it with the director of nursing or administrator, and bring it to a care plan meeting.
If it isn’t fixed, contact your state’s Long-Term Care Ombudsman, who can advocate for your parent, or file a complaint with the state survey agency, which inspects nursing homes. The residents’ rights and ombudsman guide explains both. If short staffing leads to neglect or harm, see the abuse and neglect warning signs guide, and call 911 if anyone is in immediate danger.
Staffing and Who Pays
Staffing rules are the same whether a resident pays privately or relies on Medicaid. Medicare covers only short-term skilled stays; long-term care is paid by Medicaid, private funds, long-term care insurance or veterans’ benefits. Because Medicaid-funded residents may have fewer homes with open beds, it pays to check staffing on every home on a short list. The guide to paying for a nursing home, the Medicaid eligibility guide and the long-term care insurance guide cover the options.
To compare staffing at real homes, search the nursing home finder, open your state page, or start with a large city such as Los Angeles, Cincinnati or Louisville.
Frequently Asked Questions
Is There a Federal Nurse-to-Resident Ratio for Nursing Homes?
No. Federal rules require sufficient staff to meet each resident's needs, licensed nurses around the clock, and a registered nurse at least 8 consecutive hours a day, but they set no fixed ratio or hours per resident. Your state's nursing home licensing agency can tell you whether state rules add anything more.
What Happened to the 2024 Nursing Home Staffing Rule?
The May 2024 rule would have required 3.48 total nurse staffing hours per resident per day and a registered nurse on site 24 hours a day. Two federal district courts vacated those provisions in 2025, Congress barred CMS from enforcing them until September 30, 2034, and CMS repealed them in a rule published December 3, 2025, effective February 2, 2026.
Can a Nursing Home Use Agency Staff?
Yes. Agency and contract staff count in the payroll data CMS uses for staffing measures. They must meet the same competency rules: a nursing home may not use anyone as a nurse aide on a temporary, per diem or leased basis unless they meet the federal training and competency requirements.
How Do I See How Many Staff Are Working Today?
Ask to see the daily staffing posting. A certified nursing home must post, at the start of each shift, the number of registered nurses, licensed practical or vocational nurses and certified nurse aides on duty and their hours, plus the resident count, in a prominent place. It must keep those postings for at least 18 months and show them to the public on request.
Does High Turnover Mean a Bad Nursing Home?
Not by itself, but CMS treats it as a warning sign. CMS's rating guide cites growing evidence that higher staff turnover is associated with poorer quality of care, which is why turnover makes up part of the staffing star rating. Ask the home why staff leave and what it is doing to keep them.
Are Private Aides the Family Hires Counted in Staffing Data?
No. CMS's staffing measures exclude private duty nursing staff paid by a resident or family, as well as hospice staff and feeding assistants. If your parent has a private aide, the home's own staffing should still meet your parent's care plan.
More on Choosing a Facility
- Choosing a Nursing HomeRatings, inspections, staffing and the questions to ask on a visit
- Star Ratings ExplainedWhat each Care Compare star rating measures and its limits
- Inspection ReportsDeficiencies, scope and severity, fines and where to find reports
- Antipsychotic UseThe FDA warning for dementia, CMS's measure and what to ask
- Abuse Warning SignsWarning signs, CMS's abuse icon and who to call
- Residents' RightsFederal residents' rights and the free ombudsman program
This guide explains long-term care in plain language from official sources. It isn't medical, legal or financial advice; a doctor, your state Medicaid agency or an elder law attorney can advise on your situation.
Sources
- eCFR: 42 CFR 483.35, Nursing services
- Federal Register: Repeal of Minimum Staffing Standards for Long-Term Care Facilities (90 FR 55687, December 3, 2025)
- CMS: Nursing Home Five-Star Quality Rating System, Technical Users' Guide (September 2026)
- CMS: Staffing Data Submission, Payroll Based Journal
- Medicare.gov: Nursing home checklist
- Medicare.gov: Long-term care
- CMS Provider Data Catalog: Nursing Home Provider Information (August 2026)