Staffing Ratios: Trends and Tips For Assisted Living Facilities

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. While staffing remains an ongoing challenge across the healthcare industry, it is even more so in post-acute care facilities given these demographic shifts.

Meeting this increasing structural demand means that establishing and maintaining the right assisted living staffing levels will become vital for your facility. Let’s look at why it’s so critical to have safe staffing ratios and how you can get in front of this coming trend.

Current Challenges With Assisted Living Staffing Levels

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. One study analyzed the consequences of unsafe nurse-to-patient ratios by looking at inspection data in a single state over a nearly two-year period. It examined 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 the Right Staffing Ratios for ALFs?

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. State requirements for assisted living facilities vary, but Florida offers one example of a state which sets minimal staffing requirements. According to Florida ALF staffing requirements, the minimum staff hours per week vary by number of residents, as follows:

  • Up to 5 residents: 168 staff hours per week
  • Between 6 and 15 residents: 212 staff hours per week
  • Between 16 and 25 residents: 253 staff hours per week
  • Between 26 and 35 residents: 294 staff hours per week

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 state requirements for assisted living facilities, administrators must still maintain staff counts that provide enough qualified staff for the proper supervision of residents. This includes arranging for services that meet residents’ scheduled and unscheduled service needs, contracts, and required resident care standards. Administrators are also required to ensure that adequate staff are awake during hours needed to meet any 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 the proper staffing ratios for their assisted living facilities will see results that reverberate through quality of care, revenues, reduced burnout, and easier hiring, retention, and improvement.

Improved Care

Insufficient staffing can have significant adverse impacts on residents in nursing homes and assisted living facilities are no different. A healthy nurse-resident ratio 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
  • Reductions in improper and overuse of antipsychotics
  • Lower mortality rates

Healthier Revenues

Having a low nurse-patient ratio can also result in a non-optimal patient census which can lead to unrealized revenue for a facility. When a facility is suffering from sub-optimal occupancy rates because of short staffing issues, it’s subjecting itself to ongoing cash flow problems.

These problems are more difficult to address when you don’t have flexible staffing options. With an agile staffing strategy in place you can align facility goals with safe staffing ratios by allowing leadership to access qualified nursing professionals when they need them.

Reduced Burnout in Nursing Professionals

Not surprisingly, the heavier workload associated with nurse-to-patient ratio problems can hit your staff the hardest. One study of nurses working in residential home care facilities found that role overload created specific types of burnout amongst nurses including depersonalization, emotional exhaustion, and a decrease in feelings of personal accomplishment.

Ensuring adequate staffing levels is one way to combat these burnout issues and prevent nursing staff from jumping ship, or even jumping careers. The right staffing ratio is also a highly attractive factor to highlight when recruiting candidates.

Tips for Improving Assisted Living Staffing Levels

As you step forward to optimize your nurse-resident ratios, we suggest keeping a few of the following best practices in mind.

1. Familiarize Yourself With State Requirements

Several states, including California, Florida, Pennsylvania, and Georgia, have requirements for ALF minimum staffing ratios. A total of 38 states and the District of Columbia do not. In either case, these are just baseline requirements. Look to professional associations and other advocacy organizations for guidance in going beyond the minimum nurse patient ratios by state and instead establishing an optimal ratio for your facility.

2. 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).

3. Cover “Off” Hours

Make sure you’ve established appropriate staff-to-resident ratios for weekends, nights, and evenings. You should always have one direct care worker and one staff worker (for example, security) present at all times, but this may need to be higher based on your facility and the needs of your residents.

4. 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 during their work day.

5. Obtain Continual Feedback

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. Use this data to fill gaps and build out your staffing strategy to ensure the best nurse staffing ratios and patient outcomes.

Need Help With Your Staffing Ratios?

Inadequate staffing in nursing takes its toll on all stakeholders. If you need help getting to your optimal staffing level, IntelyCare has a number of flexible and cost-efficient staffing options. Find out more today.


Megan is a business writer with over 15 years of 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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