With fewer than four months remaining until the May 1, 2026 compliance deadline, skilled nursing facilities across the country are scrambling to meet the federal government’s first-ever minimum staffing requirements. The mandate, finalized by CMS in late 2024 after years of advocacy by patient safety groups, establishes minimum hours per resident day (HPRD) for registered nurses and nurse aides in all Medicare- and Medicaid-certified nursing homes.
The Requirements
Under the final rule, facilities must maintain a minimum of 0.55 RN hours per resident day (HPRD) and 2.45 nurse aide HPRD, for a combined minimum of 3.48 total nursing HPRD. Additionally, facilities must have an RN on-site 24 hours per day, seven days per week—eliminating the previous allowance for charge nurses to substitute during certain shifts.
CMS estimates that approximately 75% of nursing homes will need to increase staffing levels to meet the new minimums, with rural facilities and those in states with historically low Medicaid reimbursement rates facing the steepest climb.
Compliance Challenges
The biggest barrier remains workforce availability. Despite a gradual recovery in healthcare employment since the pandemic, the nursing home sector still employs roughly 210,000 fewer workers than it did in February 2020, according to Bureau of Labor Statistics data. Certified nursing assistant (CNA) recruitment has been particularly difficult, with facilities competing against hospitals, home health agencies, and retail and hospitality employers offering comparable wages with fewer physical demands.
Several state healthcare associations have filed formal comments urging CMS to extend the deadline or phase in the requirements more gradually. A coalition of operators from Texas, Louisiana, and Mississippi has argued that strict enforcement could force facility closures in underserved areas where the labor pool simply cannot support the mandated staffing levels.
Enforcement and Penalties
CMS has indicated it will use Payroll-Based Journal (PBJ) data as the primary enforcement mechanism, cross-referencing reported staffing hours with resident census data during each quarterly reporting period. Facilities found to be in persistent non-compliance will face escalating civil monetary penalties, starting at $500 per day and increasing for repeat violations.
Notably, CMS has built in a hardship exemption process for facilities in rural or underserved areas that can demonstrate “good faith efforts” to recruit and retain staff. However, the criteria for qualifying remain vague, and industry groups have called for greater specificity.
Preparing for Compliance
Operators are pursuing multiple strategies to close staffing gaps before the deadline. These include signing bonuses and wage increases for CNAs and RNs, partnerships with local nursing schools for clinical rotations and hire pipelines, expanded use of staffing agencies (despite the premium cost), and investment in retention programs including flexible scheduling and career development pathways.
For facilities that cannot meet the staffing floors by May, the most important step is documenting all recruitment and retention efforts, which will be critical for any hardship exemption application.