Healthcare complianceRead at source, 24 September 2026

Nursing Home Staffing Ratios in 2026: Federal Rules, the CMS Repeal and State Minimums

This page is for nursing home administrators, directors of nursing and staffing coordinators. As of September 2026 there is no federal nurse-to-resident ratio for nursing homes. The CMS minimum staffing rule of 2024 (3.48 total nurse staffing hours per resident day and a registered nurse on site 24/7) was repealed effective February 2, 2026, after two federal courts vacated parts of it and Congress barred its enforcement until September 30, 2034. What still applies federally is “sufficient” nursing staff, an RN for at least 8 consecutive hours a day, 7 days a week, a full-time director of nursing, daily staffing posting and a facility assessment. State law is where the numbers are: New Jersey, for example, requires one certified nurse aide to every eight residents on the day shift.

Nursing home staffing ratios: the short version

“Ratio” is used loosely for two different kinds of rule, and it helps to separate them before reading any statute:

• Hours per resident day (HPRD). Total hours of direct care worked in a 24-hour period, divided by the resident census. California, New York, Florida and Pennsylvania all set HPRD floors. The 2024 CMS rule used HPRD too.
• Staff-to-resident ratios by shift. A minimum number of staff on duty per number of residents on a given shift, such as one aide per eight residents on days. New Jersey and Pennsylvania set these; Florida sets a floor of one CNA per 20 residents and one licensed nurse per 40.

An HPRD rule can be met with an uneven schedule across the day. A shift ratio cannot. That difference changes how you build a schedule, and how many people you need to hire for evenings and nights.

The CMS minimum staffing rule: what it required and what happened to it

CMS published the final rule on May 10, 2024, effective June 21, 2024. As the 2025 repeal summarizes it, the rule required “3.48 total nurse staffing HPRD, 0.55 RN HPRD, and 2.45 NA HPRD” and an RN on site 24 hours a day, 7 days a week. It was phased in: the 24/7 RN requirement by May 11, 2026 for non-rural facilities and May 10, 2027 for rural ones, and the RN and nurse aide HPRD minimums by May 10, 2027 (non-rural) and May 10, 2029 (rural).

None of those dates arrived with the rule intact. The December 3, 2025 interim final rule gives the sequence:

• Courts. In American Health Care Association v. Kennedy (N.D. Tex. 2025), the court found HHS exceeded its statutory authority, relying on the major questions doctrine, and vacated the HPRD and 24/7 RN provisions. The decision was appealed to the Fifth Circuit on June 2, 2025. In Kansas v. Kennedy (N.D. Iowa, June 18, 2025), a second court also vacated provisions of the rule.
• Congress. Public Law 119-21, section 71111, signed July 4, 2025, bars HHS from implementing, administering or enforcing the minimum staffing standards until September 30, 2034.
• Repeal. CMS then repealed the 24/7 RN requirement, the 3.48, 0.55 and 2.45 HPRD minimums and the HPRD definition, effective February 2, 2026, and restored the earlier wording of 42 CFR 483.35.

Kept from the 2024 rule: the stronger facility assessment at 42 CFR 483.71 and the Medicaid institutional payment transparency reporting. The current eCFR text of 483.35 matches that: no HPRD numbers, no 24/7 RN.

What federal rules still require

For Medicare and Medicaid certified facilities, 42 CFR 483.35 as it reads now requires:

• Sufficient staff. “Sufficient nursing staff with the appropriate competencies and skills sets” to meet residents’ needs, considering “the number, acuity and diagnoses” of residents, in line with the facility assessment. Licensed nurses and other nursing personnel on a 24-hour basis.
• A charge nurse, a licensed nurse designated on each tour of duty.
• An RN “for at least 8 consecutive hours a day, 7 days a week,” unless waived.
• A full-time director of nursing, who is an RN. The DON may serve as charge nurse only in a facility with an average daily occupancy of 60 or fewer residents.
• Nurse aide rules. No one may work as a nurse aide for more than 4 months full time unless they are competent and have completed a state-approved training and competency evaluation program. Check the registry before they start, and seek information from every state registry you believe may have information on them. A performance review of every aide at least once every 12 months.
• Daily posting. At the beginning of each shift, post the facility name, date, resident census, and the total number and actual hours worked by RNs, LPNs/LVNs and CNAs per shift. Keep the postings for at least 18 months, or longer if state law requires.

Two more rules sit behind those. 42 CFR 483.70(p) requires facilities to submit direct care staffing information to CMS “based on payroll and other verifiable and auditable data,” including agency and contract staff, turnover and tenure. That Payroll-Based Journal data is what the public sees. And 42 CFR 483.71 requires a facility assessment reviewed at least annually, which the facility must use to “inform staffing decisions,” consider staffing needs for each unit and each shift, and “develop and maintain a plan to maximize recruitment and retention of direct care staff.”

That last requirement is easy to overlook. A federal regulation now expects a written recruitment and retention plan for direct care staff. See CNA recruitment and caregiver turnover for what goes into one.

Nurse staffing ratios by state: five examples read at source

Many states set their own nursing home staffing rules in statute or licensing regulations, and they differ in form as well as level. These five were read at source on 24 September 2026. They are examples, not a 50-state list.

Details that change how you count

• California excludes people employed for food preparation, housekeeping, laundry or maintenance: they “shall not provide nursing care to residents and shall not be counted” toward ratios. The statute calls its numbers “minimum standards only.”
• Florida measures total hours as a weekly average, Sunday through Saturday, and requires records of compliance to be kept for 5 years. Direct care hours exclude time spent on nursing administration, staff development and staffing coordination.
• Pennsylvania lets you substitute an LPN or RN for a nurse aide, but not an aide for a nurse. A facility with a census of 59 or under may substitute an LPN for the RN overnight only if an RN is on call within a 30-minute drive.
• New Jersey exempts a facility from increased ratios for nine consecutive shifts after an expansion of resident census.

If your state is not listed, start with your state health department’s nursing home licensing regulations, then check the statute. Several of the states above changed their numbers after 2020.

Safe staffing ratios: what the law does and does not define

People search for “safe staffing ratios” expecting one number. There is not one in federal nursing home law. The federal standard is outcome-based: enough staff, with the right skills, to meet each resident’s care plan. That is why the facility assessment matters so much. It is the document where you explain, unit by unit and shift by shift, why your staffing is sufficient for your residents’ acuity.

State minimums are floors, not targets. California says so in its statute, and Florida requires each facility to set staffing based on its facility assessment and residents’ care plans, with the state numbers as the minimum. A building meeting the state HPRD on paper can still be cited federally if residents’ needs are not met. Hospital nurse-to-patient ratio laws are a separate subject; this page covers nursing homes.

Turning a ratio into a hiring number

An illustration, using Pennsylvania’s rules and a 100-resident census. At 3.2 hours per resident per day, the building needs at least 320 hours of direct resident care in each 24-hour period, or 40 eight-hour shifts. The day-shift aide ratio of 1 to 10 alone means at least 10 nurse aides (or licensed nurses substituting for aides) on days. Then add:

• Every day of the week, including weekends, which is where open shifts pile up.
• Paid time off, sick calls, training and orientation days.
• Turnover: every aide who leaves is a vacancy until a replacement is hired, trained and on the registry.

The practical output of any ratio rule is a recruiting target: how many CNAs, LPNs and RNs you need to hire per month to hold the floor. Track it the way you track census. Agency and PRN staff count toward the hours; for the cost comparison, see nurse staffing agency costs.

Step by step: checking your building against the rules

• Find your state’s numbers in statute and licensing regulations: HPRD, shift ratios, who counts and who does not.
• Confirm the federal basics: RN 8 consecutive hours a day, 7 days; full-time RN director of nursing; a charge nurse every shift.
• Update the facility assessment with staffing needs by unit and shift, and the written recruitment and retention plan.
• Reconcile the daily posting with payroll. The posted hours, your state records and your Payroll-Based Journal submission should tell the same story.
• Verify every aide on the registry before their first shift, including other states where they may have worked.
• Set a monthly hiring target from the ratio, your census and your turnover.

Common mistakes

• Still planning for the 3.48 HPRD. The federal minimum was repealed; plan to your state’s numbers and your assessment.
• Assuming repeal means no federal rule. Sufficient staffing, the 8-hour RN requirement and the facility assessment still apply.
• Counting non-nursing staff. California expressly excludes housekeeping, laundry, dietary and maintenance staff; Florida excludes administrative nursing time.
• Meeting the daily average but not the shift. In shift-ratio states, nights and weekends are checked separately.
• A stale posting. Staffing data must be posted at the beginning of each shift and kept for 18 months.
• Treating the recruitment and retention plan as paperwork. It is a federal requirement, and it is the part that actually fills shifts.

What it costs to recruit the staff a ratio requires

In the states above that split the hours by role, most of the required hours are aide hours, so aide recruiting drives compliance. For the wider picture, see the CNA shortage and senior living staffing.

Related: CNA job description, LPN job description, director of nursing job description, CNA interview questions and CNA staffing.

Frequently asked questions

Sources: 42 CFR 483.35, 483.70(p) and 483.71 (eCFR, current to 22 September 2026); Federal Register, CMS final rule of May 10, 2024 and interim final rule of December 3, 2025; California Health and Safety Code 1276.65; New York Public Health Law 2895-b; Florida Statutes 400.23 (2026); New Jersey P.L. 2020, c.112; 28 Pa. Code 211.12; Boostpoint 2026 Social Job Advertising Benchmark. General information, not legal advice. Read at source 24 September 2026.