U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Number 91  February 19, 2016

National Health Statistics Reports

Variation in Residential Care Community Nurse and 

Aide Staffing Levels: United States, 2014 

by Vincent Rome, M.P.H., and Lauren D. Harris-Kojetin, Ph.D.

Abstract

Objectives—This report presents national and state estimates of staffing levels 

in residential care communities for registered nurses, licensed practical or vocational 

nurses, and aides in the United States for 2014.

Methods—Data were drawn from the residential care community component 

of the 2014 wave of the biennial National Study of Long-Term Care Providers, 

conducted by the Centers for Disease Control and Prevention’s National Center 

for Health Statistics. For each staff type, the “staffing level” measure is presented 

as average hours per resident per day, defined as the total number of hours worked 

divided by the total number of residents, which does not necessarily reflect the 

amount of care given to a specific resident. Analyses examined the extent to 

which residential care community nurse and aide staffing levels varied by selected 

organizational characteristics and selected resident composition characteristics of the 

communities. Differences among subgroups were evaluated using two-sided t tests at 

the 0.05 level.

Results—In 2014, the total registered nurse, licensed practical or vocational 

nurse, and aide staffing level among all residential care communities was about 

2 hours and 50 minutes. Registered nurse staffing levels differed for two of the 

three organizational characteristics (size and metropolitan statistical area [MSA]) 

and for only one of the four resident composition characteristics (primarily serving 

residents needing any assistance with activities of daily living). Licensed practical 

or vocational nurse staffing levels differed for all three organizational characteristics 

(size, MSA, and ownership) and for only one of the four resident composition 

characteristics (primarily serving residents diagnosed with Alzheimer’s disease or 

other dementias). In contrast, differences in aide staffing levels were common when 

examining both community organizational and resident composition characteristics. 

Registered nursing, licensed practical and vocational nursing, and aide staffing levels 

varied geographically by state.

Keywords: long-term services and supports • assisted living • home- and 

community-based services • National Study of Long-Term Care Providers 

Introduction

Assisted living and similar 

residential care communities are a critical 

component of the long-term care services 

and supports spectrum for older adults 

and younger adults with disabilities who 

cannot live independently in their home. 

Growth in this sector has been due, in 

part, to shifts in federal and state policy, 

which have incentivized home- and 

community-based long-term care services 

and support settings over institutionalbased settings (1). Residential care 

communities serve residents with 

increasingly complex care needs (2,3). 

Registered nurses, licensed practical 

or vocational nurses, and aides are the 

backbone of care delivery for residents 

living in this setting (4). “Average hours 

per resident per day” is a commonly used 

measure of staffing level in long-term 

care facilities, representing the amount of 

time that staff have available to provide 

care to residents (5). 

Research on staffing in residential 

care communities and other long-term 

care provider settings indicates that nurse 

and aide staffing levels are influenced 

by factors related to the characteristics 

of the facilities and residents (6–9), 

and may have implications for resident 

outcomes and quality of care (10–14). 
Page 2 National Health Statistics Reports  Number 91  February 19, 2016

 

Figure 1. Nurse and aide staffing levels for residential care communities, overall and by selected organizational characteristics and staff 

type: United States, 2014

Most research to date on nurse and 

aide staffing levels in long-term care 

focuses on nursing homes. Less research 

has examined facility and resident 

characteristics associated with nurse and 

aide staffing levels in residential care 

communities (6). Unlike the federally 

regulated nursing home industry, 

residential care community oversight 

occurs at the state level, including the 

delineation of staffing requirements (15). 

This report presents the most current 

national and state estimates of registered 

nurse, licensed practical or vocational 

nurse, and aide staffing levels as average 

hours per resident per day among 

residential care communities.

Methods

Data are from the residential care 

community survey component of the 

2014 wave of the biennial National Study 

of Long-Term Care Providers (NSLTCP). 

To be eligible for the study, a residential 

care community must: a) be regulated 

by the state to provide room and board 

with at least two meals a day, aroundthe-clock on-site supervision, and help 

with personal care such as bathing and 

dressing or health-related services such 

as medication management; b) have four 

or more licensed, certified, or registered 

beds; c) have at least one resident 

currently living in the community at 

the time of the survey; and d) serve a 

predominantly adult population. The 

survey used a combination of probability 

sampling in some states and censustaking in other states. More details about 

NSLTCP survey design and outcomes are 

published elsewhere (16,17). 

Data analyses were performed 

using both Stata SE 12.1 (18) and SAS 

version 9.3/SAS-callable SUDAAN 

version 11.0.0 statistical package (19). 

Differences among subgroups were 

evaluated using t tests. All statistical 

significance tests were two-sided using 

p < 0.05 as the level of significance. 

Because estimates were rounded, 

individual estimates may not sum to 

totals. Cases with missing data were 

excluded from the analyses on a variableby-variable basis, ranging from 1.7% 

for ownership to 8.6% for communities 

that primarily served participants with a 

diagnosis of Alzheimer’s disease or other 

dementias. When the value of hours per 

resident per day for a given staff type was 

greater than 24, these values were coded 

as 24 (16).

Results

Nurse and aide staffing 

levels, overall and by staff 

type and residential care 

community characteristics

Among all U.S. residential care 

communities, 2014

● Staffing levels were 16 minutes 

(0.27 of 1 hour per resident per day) 

for registered nurses; 12 minutes 

(0.20 of 1 hour) for licensed practical 

or vocational nurses; and 2.37 hours 

(2 hours 22 minutes) for aides 

(Figure 1).
National Health Statistics Reports  Number 91  February 19, 2016 Page 3

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level was 2.84 hours 

(2 hours 50 minutes per resident per 

day).

Number of beds 

● Registered nurse staffing level was 

21 minutes (0.35 of 1 hour per 

resident per day) among residential 

care communities with 4–25 beds, 

compared with 8 minutes (0.13 of 

1 hour) in communities with more 

than 25 beds (Figure 1). 

● Licensed practical or vocational 

nurse staffing level was higher in 

communities with more than 25 

beds (14 minutes or 0.24 of 1 hour), 

compared with communities with 

4–25 beds (10 minutes or 0.17 of 

1 hour).

● Aide staffing level was higher in 

communities with 4–25 beds (2.76 

hours or 2 hours 46 minutes) than in 

communities with more than 25 beds 

(1.71 or 1 hour 43 minutes).

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level was higher in 

communities with 4–25 beds (3.28 

hours or 3 hours 17 minutes) than in 

communities with more than 25 beds 

(2.09 hours or 2 hours 5 minutes).

Geographic locale

● Registered nurse staffing level was 

higher in communities located in 

nonmetropolitan areas (19 minutes or 

0.32 of 1 hour per resident per day), 

when compared with communities 

in metropolitan areas (16 minutes or 

0.26 of 1 hour) (Figure 1). 

● Licensed practical or vocational 

nurse staffing level was higher 

in communities located in 

nonmetropolitan areas (16 minutes 

or 0.27 of 1 hour), compared with 

communities in metropolitan areas 

(11 minutes or 0.18 of 1 hour). 

● Similar aide staffing levels were 

found in nonmetropolitan (2.45 

hours or 2 hours 27 minutes) and 

metropolitan (2.36 hours or 2 hours 

22 minutes) areas. 

● Similar total registered nurse, 

licensed practical or vocational 

nurse, and aide staffing levels were 

found in nonmetropolitan (3.04 

hours or 3 hours 2 minutes) and 

metropolitan (2.80 hours or 2 hours 

48 minutes) areas. 

Ownership status

● Similar registered nurse staffing 

levels were found in nonprofit and 

government-owned communities 

(18 minutes or 0.30 of 1 hour per 

resident per day), compared with 

for-profit communities (16 minutes 

or 0.26 of 1 hour) (Figure 1). 

● Licensed practical or vocational 

nurse staffing level was higher in 

nonprofit and government-owned 

communities (20 minutes or 0.34 of 

1 hour), compared with for-profit 

communities (10 minutes or 0.16 of 

1 hour).

● Aide staffing level was higher in 

for-profit communities (2.45 hours or 

2 hours 27 minutes), compared with 

nonprofit and government-owned 

communities (2.17 hours or 2 hours 

10 minutes).

● Similar total registered nurse, 

licensed practical or vocational 

nurse, and aide staffing levels were 

found in nonprofit and governmentowned communities (2.82 hours or 

2 hours 49 minutes), compared with 

for-profit communities (2.88 hours or 

2 hours 53 minutes). 

Nurse and aide staffing 

levels in residential care 

communities, by staff type 

and resident composition

Diagnosis of Alzheimer’s disease 

or other dementias

● Similar registered nurse staffing 

levels were found in communities 

that did not primarily serve 

participants with a diagnosis of 

Alzheimer’s disease or other 

dementias (16 minutes or 0.27 of 

1 hour per resident per day) and 

communities that primarily served 

this population (18 minutes or 0.30 

of 1 hour) (Figure 2).

● Licensed practical or vocational 

nurse staffing level was higher in 

communities that did not primarily 

serve participants with a diagnosis 

of Alzheimer’s disease or other 

dementias (13 minutes or 0.21 of 

1 hour) than in communities that 

primarily served this population 

(10 minutes or 0.16 of 1 hour).

● Aide staffing level was higher in 

residential care communities that 

primarily served residents with a 

diagnosis of Alzheimer’s disease or 

other dementias (3.16 hours or 

3 hours 10 minutes), compared with 

communities that did not primarily 

serve residents with this diagnosis 

(2.30 hours or 2 hours 18 minutes).

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level was 3.62 hours 

(3 hours 37 minutes) in communities 

that primarily served participants 

with a diagnosis of Alzheimer’s 

disease or other dementias, which is 

higher than the total nurse and aide 

staffing level in communities that did 

not primarily serve this population 

(2.79 hours or 2 hours 47 minutes). 

Assistance with any activities of 

daily living 

● Registered nurse staffing level was 

higher in communities that primarily 

served residents needing assistance 

with any of the activities of daily 

living (ADLs) examined (19 minutes 

or 0.31 of 1 hour per resident per 

day), compared with communities 

that did not primarily serve this 

population (14 minutes or 0.24 of 

1 hour) (Figure 2).

● Similar licensed practical or 

vocational nurse staffing levels were 

found in communities that primarily 

served residents needing assistance 

with any of the ADLs (12 minutes 

or 0.20 of 1 hour) and communities 

that did not primarily serve this 

population (13 minutes or 0.21 of 

1 hour). 

● Aide staffing level was higher in 

communities that primarily served 

residents needing assistance with any 

of the ADLs (2.88 hours or 

2 hours 53 minutes), compared with 

communities that did not primarily 

serve this population (1.91 hours or 

1 hour 55 minutes).

● Total registered nurse, licensed 

practical or vocational nurse, and 
Page 4 National Health Statistics Reports  Number 91  February 19, 2016

 

Figure 2. Nurse and aide staffing levels, by residential care communities that primarily serve residents with specific characteristics and 

staff type: United States, 2014

aide staffing level was higher among 

communities that primarily served 

residents needing assistance with any 

of the ADLs (3.39 hours or 

3 hours 23 minutes), compared with 

communities that did not primarily 

serve this population (2.36 hours or 

2 hours 22 minutes).

Assistance with medications

● Similar registered nurse staffing 

levels were found among 

communities that primarily served 

residents needing assistance with 

medications (17 minutes or 0.29 

of 1 hour per resident per day) and 

communities that did not primarily 

serve this population (14 minutes or 

0.24 of 1 hour) (Figure 2).

● Similar licensed practical or 

vocational nurse staffing levels 

were found among communities 

that primarily served residents 

needing assistance with medications 

(12 minutes or 0.20 of 1 hour) and 

communities that did not primarily 

serve this population (13 minutes or 

0.22 of 1 hour).

● Aide staffing level was higher in 

communities that primarily served 

residents needing assistance with 

medications (2.61 hours or 

2 hours 37 minutes), compared with 

communities that did not primarily 

serve this population (1.53 hours or 

1 hour 32 minutes).

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level was higher 

among communities that primarily 

served residents needing assistance 

with medications (3.10 hours or 3 

hours 6 minutes), compared with 

communities that did not primarily 

serve this population (1.99 hours or 

1 hour 59 minutes).

Any services paid for by Medicaid 

in the last 30 days

● No statistically significant 

differences were found in registered 

nurse, licensed practical or 

vocational nurse, aide, or total nurse 

and aide staffing levels between 

communities that primarily served 

residents who had some or all of 

their long-term care services paid 

for by Medicaid and communities 

that did not primarily serve residents 

receiving Medicaid (Figure 2).

Nurse and aide staffing 

levels in residential care 

communities, by staff type 

and state

Registered nurses

● Registered nurse staffing level 

ranged from 2 minutes (0.04 of 

1 hour per resident per day) in 
National Health Statistics Reports  Number 91  February 19, 2016 Page 5

 

Figure 3. Registered nurse staffing levels for residential care communities, by state: United States, 2014

Louisiana to 1.03 hours (1 hour 2 

minutes) in South Dakota (Figure 3).

● Registered nurse staffing level 

was significantly higher than the 

national ratio (16 minutes or 0.27 

of 1 hour) in 10 states (Hawaii, 

Iowa, Kansas, Maryland, Minnesota, 

Montana, South Dakota, Vermont, 

West Virginia, and Wyoming), the 

majority of which are clustered in the 

Midwest.

● Registered nurse staffing level was 

significantly lower than the national 

ratio (16 minutes or 0.27 of 1 hour) 

in 13 states (Alabama, Arkansas, 

California, Colorado, Delaware, 

Louisiana, Mississippi, Nevada, 

New York, Pennsylvania, Rhode 

Island, Tennessee, and Virginia), 

which are geographically distributed 

throughout the country. 

Licensed practical or vocational 

nurses

● Licensed practical or vocational 

nurse staffing level ranged from 

1 minute (0.02 of 1 hour per resident 

per day) in Nevada to 1.26 hours (1 

hour 16 minutes) in Iowa (Figure 4). 

● Licensed practical or vocational 

nurse staffing level was significantly 

higher than the national ratio 

(12 minutes or 0.20 of 1 hour) 

in 20 states or areas (Alabama, 

Delaware, District of Columbia, 

Illinois, Indiana, Iowa, Kansas, 

Kentucky, Mississippi, Nebraska, 

New Hampshire, New Jersey, 

North Dakota, Ohio, Oklahoma, 

Pennsylvania, South Dakota, 

Tennessee, Virginia, and West 

Virginia), which are grouped mainly 

in the Midwest and South.

● Licensed practical or vocational 

nurse staffing level was significantly 

lower than the national ratio (12 

minutes or 0.20 of 1 hour) in 11 

states (Alaska, California, Colorado, 

Connecticut, Idaho, Louisiana, 

Maine, New Mexico, Nevada, Rhode 

Island, and Utah), grouped mainly in 

the West and Northeast. 

Aides

● Aide staffing level ranged from 1.18 

hours per resident per day (1 hour 

11 minutes) in Indiana to 3.94 hours 

(3 hours 56 minutes) in Wisconsin 

(Figure 5). 

● Aide staffing level was significantly 

higher than the national ratio (2.37 

hours or 2 hours 22 minutes) in 

7 states (Alaska, Kansas, Minnesota, 

New Mexico, South Dakota, West 

Virginia, and Wisconsin), most of 

which are in the Midwest.

● Aide staffing level was significantly 

lower than the national ratio (2.37 
Page 6 National Health Statistics Reports  Number 91  February 19, 2016

 

Figure 4. Licensed practical or vocational nurse staffing levels for residential care communities, by state: United States, 2014

hours or 2 hours 22 minutes) in 

21 states (Arkansas, Connecticut, 

Delaware, Illinois, Indiana, 

Kentucky, Louisiana, Massachusetts, 

Mississippi, Missouri, Nevada, New 

Jersey, New York, North Dakota, 

Ohio, Oregon, Pennsylvania, Rhode 

Island, Tennessee, Virginia, and 

Wyoming), grouped primarily in the 

Northeast, Midwest, and South.

Total nurse and aide staff 

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level ranged from 1.66 

hours per resident per day (1 hour 40 

minutes) in New York to 4.9 hours (4 

hours 54 minutes) in Iowa (Figure 6). 

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level was significantly 

higher than the national ratio (2.84 

hours or 2 hours 50 minutes) in 

8 states (Alaska, Kansas, Iowa, 

Minnesota, New Mexico, South 

Dakota, West Virginia, and 

Wisconsin), most of which are in the 

Midwest.

● Total registered nurse, licensed 

practical or vocational nurse, and 

aide staffing level was significantly 

lower than the national ratio (2.84 

hours or 2 hours 50 minutes) in 

17 states (Arkansas, California, 

Colorado, Connecticut, Delaware, 

Illinois, Indiana, Louisiana, 

Massachusetts, New Jersey, Nevada, 

New York, Pennsylvania, Rhode 

Island, Tennessee, Virginia, and 

Wyoming), which are geographically 

distributed throughout the country.

Summary

In 2014, the total registered 

nurse, licensed practical or vocational 

nurse, and aide staffing level among 

all residential care communities was 

about 2 hours and 50 minutes. In terms 

of the organizational characteristics 

of the communities, registered nurse 

staffing levels were higher in smaller 

communities and communities located 

in nonmetropolitan areas. Licensed 

practical or vocational nurse staffing 

levels were higher in larger communities, 

communities located in nonmetropolitan 

areas, and communities under nonprofit 

or government ownership. Aide 

staffing levels were higher in smaller 

communities and those under for-profit 

ownership. In terms of the resident 

composition of the communities, 

registered nurse staffing levels were 

higher in communities that primarily 

served residents needing assistance with 

any of the ADLs examined. Licensed 

practical or vocational nurse staffing 

levels were higher among communities 

WA
National Health Statistics Reports  Number 91  February 19, 2016 Page 7

 

Figure 5. Aide staffing levels for residential care communities, by state: United States, 2014

that did not primarily serve residents 

with a diagnosis of Alzheimer’s disease 

or other dementias. Aide staffing 

levels were higher in communities 

that primarily served residents with 

Alzheimer’s disease or other dementias, 

residents needing assistance with any 

of the ADLs examined, and residents 

needing assistance with medications. This 

report found no statistically significant 

differences in staffing levels by the 

percentage of residents in the community 

that had some or all of their long-term 

care services paid for by Medicaid.

Registered nurse staffing 

levels differed for two of the three 

organizational characteristics (size and 

metropolitan statistical area [MSA]) but 

only one of the four resident composition 

characteristics (primarily serving 

residents needing any assistance with 

ADLs). Licensed practical or vocational 

nurse staffing levels differed for all 

three organizational characteristics 

(size, MSA, and ownership) but only 

one of the four resident composition 

characteristics (primarily serving 

residents with Alzheimer’s disease or 

other dementias). In contrast, differences 

in aide staff hours per resident per day 

were common when examining both 

community organizational and resident 

composition characteristics. Aide staffing 

levels differed for two of the three 

organizational characteristics (size and 

ownership) and three of the four resident 

composition characteristics (primarily 

serving residents with Alzheimer’s 

disease or other dementias, needing 

any assistance with ADLs, and needing 

assistance with medications). 

In 2014, state estimates of 

nursing staff levels in residential care 

communities were available for the 

first time. For each of the three nursing 

staff types examined (registered nurse, 

licensed practical or vocational nurse, 

and aide), the average nursing staff hours 

per resident per day in Kansas, South 

Dakota, and West Virginia were above 

the national rate, while the ratios in 

Louisiana and Nevada were below the 

national rate.

This brief profile of residential care 

community nursing staff provides useful 

information to policy makers, providers, 

researchers, and consumer advocates as 

they plan to meet the needs of an aging 

population.

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Page 8 National Health Statistics Reports  Number 91  February 19, 2016

 

Figure 6. Total nurse and aide staffing levels for residential care communities, by state: United States, 2014

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Page 10 National Health Statistics Reports  Number 91  February 19, 2016

Technical Notes

Definition of terms

Aide—Refers to certified nursing 

assistants, nursing assistants, home 

health aides, home care aides, personal 

care aides, personal care assistants, and 

medication technicians or medication 

aides.

Assistance with activities of daily 

living (ADLs)—Refers to needing any 

help or supervision from another person 

with any of six limitations in ADLs 

(transferring in or out of a bed, eating, 

dressing, bathing or showering, toileting, 

and locomotion or walking) that reflect 

a resident’s capacity for self-care; also 

includes the use of special equipment. 

Communities that primarily serve 

residents with specific characteristics 

(resident composition)—Based on a 

prevalence of 80% or more within the 

community. The methodology used to 

determine the cutoff for communities that 

primarily served specific populations of 

residents was derived from a recent study 

by Anderson, Park, Monteleone, and 

Dabelko-Schoeny on adult day services 

centers (20).

Community bed size—Based on 

the number of licensed, registered, or 

certified residential care beds (both 

occupied and unoccupied) in a residential 

care community: 4–25 beds and more 

than 25 beds.

Metropolitan statistical area 

(MSA)—Contains an urban core 

of 50,000 or more population. A 

nonmetropolitan area contains an urban 

cluster of fewer than 50,000 residents. 

Ownership type—Categorization 

of residential care communities into 

two ownership types: 1) private, forprofit and 2) nonprofit. The private, 

for-profit category includes publicly 

traded communities and limited liability 

communities. Nonprofit includes private 

nonprofit, as well as federal, state, county, 

and local government ownership. 

Residential care communities—

Includes assisted living communities and 

other residential care communities (e.g., 

personal care homes, adult care homes, 

board care homes, and adult foster care) 

that meet the study eligibility criteria 

specified in “Methods.”

Residential care bed—Refers 

to licensed, registered, or certified 

residential care beds. 

Staffing level—The average number 

of staffing hours per resident per day, 

which is the ratio of the average number 

of hours providing care for a resident 

per day for a given nursing staff type, or 

for all nursing staff types combined. The 

number of full-time equivalents (FTEs) 

for a given staff type for a community 

was converted into hours by multiplying 

each FTE (or fraction of FTE) for the 

staff type at the community by 35 hours, 

then dividing the total number of hours 

for the staff type by the number of current 

residents in the community, and dividing 

that estimate by 7 days to arrive at hours 

per resident day. Nursing staff hours per 

resident per day does not necessarily 

reflect the amount of care given to a 

specific resident. Estimates include 

employee and contract staff hours. 
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Acknowledgment

The authors are grateful for the technical support and assistance from Eunice Park-Lee, formerly with CDC’s National Center for Health 

Statistics, Division of Health Care Statistics. 

Suggested citation

Rome V, Harris-Kojetin LD. Variation in 

residential care community nurse and aide 

staffing levels: United States, 2014. National 

health statistics reports; no 91. Hyattsville, 

MD: National Center for Health Statistics. 

2016.

Copyright information

All material appearing in this report is in the 

public domain and may be reproduced or 

copied without permission; citation as to 

source, however, is appreciated.

National Center for Health Statistics

Charles J. Rothwell, M.S, M.B.A., Director

Nathaniel Schenker, Ph.D., Deputy Director

Jennifer H. Madans, Ph.D., Associate Director 

for Science

Division of Health Care Statistics

Clarice Brown, M.D., M.S., Director

Alexander Strashny, Ph.D., Associate Director 

for Science