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The Long Term Care Community Coalition’s Q1 2026 staffing alert reports that 88% of U.S. nursing homes supplied fewer nursing hours than researchers estimated were necessary for their residents’ clinical needs.

The report was published on August 31, 2026, using staffing data for January through March 2026. Its central conclusion is credible as a description of LTCCC’s analysis, but “understaffed” has a specific meaning here: staffing below a case-mix-adjusted expectation, not necessarily a violation of an enforceable federal numerical minimum.

Main findings

These national figures and LTCCC’s downloadable state and facility information can be accessed through the organization’s Q1 2026 staffing-data page.

How the 24.6% shortage was calculated

The calculation is approximately:

The small difference from the reported 24.6% probably results from calculating with unrounded facility-level figures.

In practical terms:

• Reported
  staffing: 225 nursing minutes per resident per day
• Expected
  staffing: approximately 298 minutes
• Average
  deficit: approximately 73 minutes per resident per day

In a 100-resident facility, that translates into roughly 122 missing nursing labor hours every day, compared with the CASE expectation. That does not mean every individual resident personally lost exactly 73 minutes; HPRD is a facility-wide average.

What “expected staffing” means

LTCCC did not apply one identical staffing target to every nursing home. It used the CASE—Casemix Adjusted Staffing Expectations—methodology.

Case mix refers to the medical and functional complexity of a facility’s residents. For example, a population with extensive mobility limitations, dementia, pressure injuries, feeding assistance, complex medications or post-hospital rehabilitation generally requires more staff time than a comparatively independent population.

The CASE method therefore:

1. Examines the clinical characteristics of each facility’s resident population.

2. Calculates the nursing hours expected for that particular mix of residents.

3. Compares the expected figure with the nursing hours reported by the facility.

LTCCC provides a plain-language explanation of the CASE methodology and links to the peer-reviewed study, “Nursing Home Guide to Adjusting Nurse Staffing for Resident Case-Mix”.

This distinction is important. A home reporting 3.8 HPRD might appear relatively well staffed compared with the national average, yet still fall short if its residents’ clinical conditions call for 5.0 HPRD.

Which employees are included?

“Total nurse staffing” normally combines direct-care hours supplied by:

• Registered
  nurses
• Licensed
  practical or licensed vocational nurses
• Certified
  nursing assistants or nurse aides
• Employed
  and contract/agency personnel in the covered job categories

It does not mean that every counted hour was spent in one-on-one care. HPRD distributes a facility’s reported covered staffing hours across its resident days.

Administrative, therapy, dietary, housekeeping, activities and medical-director hours are separate categories and generally are not part of the total nurse-staffing measure.

Where the information originates

The source is the federal Payroll-Based Journal, or PBJ, staffing system. Medicare- and Medicaid-certified nursing facilities must submit daily staffing information electronically to the Centers for Medicare & Medicaid Services.

CMS explains that PBJ reporting includes employee and agency/contract hours and is based on payroll and other auditable records. The information is used in the federal Nursing Home Five-Star Quality Rating System. The underlying quarterly files are publicly available through the CMS Payroll-Based Journal nursing-staffing dataset and the CMS PBJ information page.

Thus, LTCCC did not conduct a survey asking facilities whether they felt understaffed. It analyzed federally submitted operational data and compared reported hours with calculated resident needs.

Comparison with the previous quarter

LTCCC says that conditions were essentially unchanged from Q4 2025:

The quarter-to-quarter movement is small. The more important finding is persistence: the overwhelming majority of facilities remained below their calculated needs.

State-level results

Only two states reportedly met or exceeded their aggregate expected staffing levels:

• Alaska
• Oregon

The ten states with the largest shortfalls were:

1. Illinois

2. Texas

3. Missouri

4. Georgia

5. New Mexico

6. New York

7. West Virginia

8. Virginia

9. Colorado

10. Wyoming

Illinois had the largest reported gap, providing approximately 39% less nursing care than expected for its residents’ needs.

A statewide average should not be treated as the performance rating for every home in that state. A low-performing state can contain good facilities, while a relatively strong state can still contain severely understaffed homes. Facility-level investigation is essential.

The 4.1-hour and 0.75-RN benchmarks

LTCCC also compares facilities with two benchmarks associated with an influential 2001 CMS-funded staffing study:

• 4.1
  total nursing HPRD
• 0.75
  RN HPRD

The 0.75 RN benchmark equals 45 RN minutes per resident per day. Q1 2026’s reported national RN average of 0.62 equals approximately 37 minutes.

The historical study examined staffing thresholds associated with avoiding delayed or omitted essential care. A scholarly discussion of the study and subsequent evidence is available in “Appropriate Nurse Staffing Levels for U.S. Nursing Homes”. HHS also summarizes the history in its review of state nursing-home staffing ratios.

The 4.1 figure should be understood as a research benchmark, not a guarantee that every facility providing 4.1 hours is adequately staffed. Residents with greater needs may require substantially more.

Federal staffing-rule context

CMS adopted a national rule in 2024 that would have required:

• 3.48
  total nursing HPRD
• At
  least 0.55 RN HPRD
• At
  least 2.45 nurse-aide HPRD
• An
  RN onsite 24 hours a day, seven days a week
• Higher
  staffing whenever the facility assessment showed that residents required
  it

The original rule is described in the CMS 2024 staffing-rule fact sheet.

However, the numerical minimums and 24-hour RN mandate were subsequently struck down in litigation and formally repealed in December 2025. The repeal is documented in the Federal Register.

Consequently, the alert’s findings should not be read as proving that 88% of homes violated the now-repealed numerical rule. Its conclusion is that 88% fell below the CASE clinical-needs expectation.

Federal regulations still require facilities to maintain sufficient staff with appropriate competencies to meet residents’ assessed needs. State-specific numerical requirements may also apply.

Why the average of 3.75 HPRD does not contradict the 88% finding

At first glance, the national average of 3.75 HPRD seems higher than the former federal minimum of 3.48. Nevertheless, 88% can still be below expected staffing because:

• LTCCC
  used a 4.97 average case-mix expectation, not the former 3.48
  floor.
• The
  CASE target changes with each facility’s resident population.
• A
  national average can conceal extremely low staffing on particular days or
  shifts.
• Total
  hours do not show whether the facility had the right mix of RNs, LPNs and
  aides.
• A
  quarterly average can conceal weekends or individual days with dangerously
  low coverage.

These are different comparisons: minimum regulatory floor, historical research benchmark and resident-needs expectation should not be treated as interchangeable.

Medical-director finding requires caution

The assertion that 4,753 facilities reported zero medical-director time is troubling, but it does not by itself prove that every one of those homes operated for the entire quarter without a medical director.

Possible explanations include:

• An
  actual lack of medical-director service
• Failure
  to report the hours correctly
• Misclassification
  of the physician’s work
• Hours
  provided through arrangements not properly reflected in PBJ
• Data-quality
  or submission problems

It is therefore best understood as a serious reporting and oversight warning, rather than conclusive proof that 4,753 facilities had no physician serving in that capacity.

Important data-quality limitation

PBJ is more reliable than older self-reported annual staffing forms because it is based on payroll and auditable records. It is not error-free.

A June 2026 HHS Office of Inspector General audit found unsupported RN hours in its sample and estimated that approximately 5% of the RN hours in the March 2024 audit sampling frame were unsupported. The OIG warned that stakeholders might not be receiving completely accurate staffing information. Read the HHS-OIG staffing-data audit and recommendations.

That finding does not invalidate the Q1 2026 analysis. If anything, overstated hours could mean that some staffing conditions are worse than the published figures suggest. Nevertheless, the OIG’s audit examined an earlier period and should not automatically be projected onto every Q1 2026 facility.

What understaffing can look like in daily life

Insufficient staffing can contribute to:

• Delayed
  responses to call lights
• Residents
  remaining in wet or soiled clothing
• Missed
  bathing, oral care or repositioning
• Inadequate
  feeding and hydration assistance
• Falls
  or unsupervised wandering
• Medication
  delays or errors
• Pressure
  injuries
• Avoidable
  emergency-room visits
• Limited
  activities and social interaction
• Staff
  burnout and turnover
• Inadequate
  monitoring of changing medical conditions

Research generally finds stronger and more consistent benefits from higher RN staffing than from total staffing alone. One systematic review concluded that higher RN staffing and a stronger licensed-nurse skill mix may be associated with better resident outcomes, although findings for total staffing were more mixed; see the Journal of the American Medical Directors Association review.

Staffing is crucial, but it is not the only quality factor. Training, supervision, staff retention, infection control, management, physician availability and enforcement history also matter.

How families should investigate a particular facility

Start with the government’s Medicare Care Compare nursing-home search. Examine:

• Total
  nursing hours
• RN
  hours
• Weekend
  staffing
• Staff
  turnover
• Staffing
  star rating
• Health-inspection
  rating
• Recent
  deficiencies and penalties
• Abuse
  citations
• Special
  Focus Facility designation
• Ownership
  changes

Then compare those records with LTCCC’s Q1 2026 facility-level staffing information.

Questions to ask a facility include:

1. How many residents is each aide responsible for on days, evenings, nights and weekends?

2. How many RNs are physically present on each shift?

3. How often does the facility use agency staff?

4. What were the last quarter’s RN, aide and total HPRD figures?

5. What is the annual turnover rate?

6. Who is the medical director, and how often is that physician onsite?

7. How does management replace employees who call out?

8. How long do residents ordinarily wait for toileting or call-light assistance?

9. Has the facility reduced admissions when it cannot staff safely?

10. May the family council review staffing schedules and raise concerns with management?

Complaints and immediate concerns

Suspected neglect, abuse or unsafe staffing can be reported to the state agency responsible for inspecting nursing homes. CMS maintains a current directory of State Survey Agency complaint contacts.

The federal complaint process covers alleged abuse, neglect, exploitation, mistreatment, unexplained injuries and misappropriation of resident property; see the CMS State Operations Manual complaint procedures.

For an immediate threat to life or safety, contact emergency services first.

Overall assessment

The alert’s strongest and most defensible conclusion is that understaffing remains widespread when staffing is measured against the clinical complexity of residents—not merely against a single nationwide floor.

The central figures come from a serious analysis of federal payroll-based data and a peer-reviewed case-mix method. However:

• LTCCC
  is an advocacy organization, not a regulatory agency.
• “Below
  expected staffing” is an analytical classification, not automatically a
  legal violation.
• Quarterly
  averages can obscure dangerously low days and shifts.
• PBJ
  data are useful but subject to reporting and verification problems.
• State
  averages should never replace investigation of an individual home.

Even with those qualifications, the size and persistence of the gap—88% of facilities, about 1.15 million residents and an average deficit of 73 nursing minutes per resident per day—indicate a substantial national long-term-care problem.