By Linnea Stonebraker, RN

Nurses working in U.S. long-term care (LTC) facilities have faced rapid policy changes over the past two years. In April 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the nation’s first minimum staffing standards for nursing homes. The rule set a total minimum of 3.48 nursing hours per resident day (HPRD), including at least 0.55 RN HPRD and 2.45 nurse aide HPRD, with the remaining 0.48 HPRD met by any nursing personnel mix. It also required an RN to be on-site 24/7. Compliance was to be phased in over several years, with longer timelines for rural facilities. In 2025, however, litigation produced conflicting outcomes, and reports now indicate CMS is preparing to repeal the rule, leaving frontline staff and nurse leaders in a holding pattern (Centers for Medicare & Medicaid Services [CMS], 2024; Kaiser Family Foundation [KFF], 2024; Reuters, 2025a, 2025b; McKnight’s Long-Term Care News, 2025a).

What changed in 2025
Early in 2025, a federal judge in Iowa declined to issue a preliminary injunction that would have paused the rule, noting that most requirements would not take effect until 2026–2027 (Reuters, 2025a). But in April, a Texas federal court vacated the rule, concluding that CMS exceeded its statutory authority by imposing nationwide staffing levels and a 24/7 RN mandate (Reuters, 2025b). By September 2025, industry trade reporting indicated CMS had drafted an interim final rule to repeal the staffing standards, and subsequent coverage suggested HHS sought to end related appeals—signals that the agency may step back from the 2024 framework (McKnight’s Long-Term Care News, 2025a, 2025b). While these developments may change again, the immediate effect is uncertainty for operational planning.

What the (now-contested) rule required
For nurse leaders who already invested in implementation plans, it helps to remember what the CMS framework emphasized. First, the national floor of 3.48 HPRD was intended as a minimum, not a ceiling. Second, the 24/7 RN requirement and explicit RN and nurse aide minimums would have standardized role mix across facilities. Third, CMS required facility-specific staffing assessments that linked staffing to resident acuity and quality outcomes. The timelines were staggered: non-rural facilities were to meet the 24/7 RN standard roughly two years after publication and the HPRD minimums at about three years; rural facilities were afforded longer windows (CMS, 2024; Washington State Hospital Association, 2024). Even if repeal proceeds, these benchmarks remain useful in quality discussions.

Implications for nurse leaders and bedside nurses now

1. Monitor state actions. Federal uncertainty does not preclude states from adopting or enforcing their own staffing standards. Clinical leaders should track state health department guidance and payer expectations, which may incorporate elements of the CMS framework regardless of federal status.

2. Keep the facility assessment current. One durable aspect of the 2024 rule is the emphasis on written, data-driven staffing assessments. Maintaining a living acuity assessment—along with contingency plans for surges, admissions, and high-risk residents—supports both survey readiness and patient safety.

3. Use the HPRD model for planning. The 3.48/0.55/2.45 structure can serve as a planning anchor for shift assignments, skill-mix modeling, and budget requests. Document any justified variance and the resident-safety rationale.

4. Link staffing to outcomes. Pair staffing levels with outcome metrics (falls, pressure injuries, unplanned hospital transfers, complaint trends) and share this dashboard with leadership. Even absent an enforceable mandate, outcome-linked staffing strengthens advocacy for safe coverage.

5. Educate the team on role mix. The “flex” 0.48 HPRD acknowledges that facilities can meet part of the total with RNs, LPNs/LVNs, or nurse aides. Cross-training, clearly defined scopes, and deliberate delegation can preserve safety while addressing shortages.

6. Communicate timelines and risk. If repeal moves forward, communicate clearly to staff: the goal remains safe, acuity-responsive staffing. Setting internal targets and transparent timelines can reduce anxiety and maintain morale during policy swings.

Workforce reality check
Even before the 2024 rule, many facilities struggled to recruit enough RNs and nurse aides. KFF’s 2024 analyses estimated that fewer than half of facilities would meet all three minimums under full implementation, and many markets would require significant hiring to reach the RN and nurse aide thresholds (KFF, 2024, 2024b). These constraints do not negate the importance of safe staffing; rather, they highlight the need for evidence-based staffing, sustained recruitment, stronger retention strategies, and academic-practice partnerships to expand pipelines.

Bottom line for 2025
As of October 2025, the federal staffing rule for nursing homes faces legal headwinds and a potential regulatory rollback. Yet its core ideas—24/7 RN presence, explicit RN and nurse aide HPRD floors, and robust facility assessments—continue to influence payer expectations, surveyor questions, and professional standards. For nurse leaders and bedside nurses, the pragmatic approach is to remain agile: follow litigation and CMS updates, sustain acuity-based staffing assessments, and use the 2024 benchmarks as reference points in quality and safety conversations. Regardless of federal flux, residents benefit most when staffing decisions are transparent, data-driven, and tied to measurable outcomes.