Assisted Living Staffing Ratios Need an Update to Keep Up With One Exploding Demographic

assisted living staffing ratios

As the number of Americans over the age of 65 increases and life expectancies lengthen, assisted living facility (ALF) administrators will be some of the most heavily impacted. This means that establishing and maintaining optimal assisted living staffing ratios will become increasingly important. Let’s look at why they’re so critical and how you can get in front of this coming trend. 

Assisted Living Staffing Ratios Today

While optimal staffing levels are foundational to improved outcomes and positive patient and provider experiences, ALFs have no federally mandated staffing levels. At the same time, unlike nursing homes, they also have no federal regulations to monitor quality. States do create regulations, but insights into care outcomes are sparse. 

The result has been a seeming and unfortunate correlation between nursing staff availability and deficiencies in ALF care. A 2019 study analyzed inspection data for one state from 2015 to 2017, examining associations between severe deficiencies or threat to resident health and facility characteristics, including nursing staff availability. 

The study found that six percent of ALFs reported at least one or more severe deficiencies. In large and extra-large facilities, a lack of part-time or no nursing staff availability was correlated with more than double the risk of severe deficiencies (compared to ALFs that had 24-hour availability). The study authors stress the importance of nursing staff availability in reducing deficiencies. 

What are Proper ALF Staffing Levels?

While optimal staffing levels can be highly individualized for a facility and difficult to determine, there are some guidelines that will help you set your own benchmarks. Requirements vary by state, but this example from Florida, a state that does have minimal requirements, is a potential example. 

Florida minimum staff hours per week vary by number of residents. For example:

  • If a facility has up to five residents, they must maintain 168 staff hours per week
  • Between six and 15 residents requires 212 hours
  • At 16 to 25, the requirement is 253 hours
  • And a range of 26 to 35 residents requires 294 hours 

For every 20 residents that a facility has over the age of 95, 42 hours have to be added each week, translating to about one full-time employee for every 20 residents. 

But beyond these minimum requirements, administrators are tasked with maintaining staff counts that provide enough qualified staff to provide proper supervision of residents—this includes arranging for services that meet residents’ scheduled and unscheduled service needs, contracts, and required resident care standards. This responsibility also includes ensuring that adequate staff are awake during hours needed to meet scheduled and unscheduled needs. 

In Florida, if a licensing agency determines resident needs aren’t being met or service plans aren’t being followed because of insufficient staff, facilities are then responsible for providing additional or appropriately qualified staff. 

Benefits of Proper Staffing Levels

Administrators who establish and achieve proper staffing levels will see results that reverberate through quality of care, revenues, reduced burnout, and easier hiring, retention, and improvement. 

Improved care

Insufficient staffing ratios can have significant negative impacts on residents in nursing homes and assisted living staffing ratios are no different. Healthy staffing ratios can improve the quality of care and quality of life of your residents. In nursing homes, these results have translated to fewer pressure ulcers, lower restraint use, decreased infections, improved activities of daily living independence, decreased weight loss, a reduction in improper and overuse of antipsychotics, and lower mortality rates. 

Healthier revenues

A non-optimal patient census can translate to unrealized revenue for a facility. When a facility is suffering from sub-optimal occupancy rates because of short staffing issues, it is subjecting itself to ongoing cash flow problems. These are problems that are more difficult to address in the absence of the flexible staffing options that support an agile staffing strategy—one that aligns with facility goals and allows leadership to access qualified nursing professionals when they need them. 

Reduced burnout in nursing professionals

Nurses working in residential home care for the elderly can experience depersonalisation, emotional exhaustion, and a decrease in personal accomplishment. This 2018 study found an association between role overload and burnout in residential home care workers. 

As a solution, adequate staffing levels can be used to combat burnout issues. Addressing burnout can also be a highly attractive factor for recruitment candidates. 

Tips for Improving Assisted Living Staffing Levels

As you step forward to optimize your staffing levels, we suggest keeping a few of the following practices in mind.

Familiarize yourself with state requirements

Several states, including California, Florida, Pennsylvania, and Georgia, have requirements for ALF minimum staffing ratios. 38 states and the District of Columbia do not. In either case, these are minimum requirements. Look to professional associations and other advocacy organizations for guidance in going beyond the minimum and establishing your optimal assisted living staffing ratios.

Communicate with your community

ALFs should be open with the public and the state about daily care staffing levels based on payroll and other auditable records. These can be presented on a public website which should be done in a timely manner with frequent updates (e.g. quarterly).

Cover “off” hours

Make sure you’ve established appropriate staff-to-resident ratios for weekends, nights, and evenings. At a minimum, one direct care worker and one staff worker (for example, security) should be present at all times. 

Create additional ratios

Establish a ratio for additional staffing based on the residents in your facility. You might find it helpful to consider establishing a staffing strategy that makes use of nursing float pool professionals to maintain flexibility. Also, set a standard for the number of residents that a direct care worker should attend to doing their work day. 

As you evaluate and update your approach to assisted living staffing, consider conducting periodic resident assessments to improve the availability of outcomes data used to evaluate and monitor quality. As you fill gaps and build out a new strategy, make sure your new approach steps away from the status quo and leverages new, flexible options built to fit the needs of tomorrow’s adult living facility leaders, residents, and workers. 


Megan is a business writer with over 15 years’ experience in healthcare enterprise technology. She holds an MBA and B.S. in Healthcare Administration. She now keeps an ongoing eye on the latest developments and successes in healthcare admin technology and the people who use it to build a better world for providers, patients, and their care communities.


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