Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation across Shifts

Abstract

Objectives:

To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NH), assisted living communities (ALC), and their corresponding memory care units (MCU).

Design:

Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021.

Setting and Participants:

NHs (n=678) and ALCs (n=542) that reported staffing by shift in Ohio.

Methods:

Resident-to-staff ratios in Ohio were calculated from staffing data. The proportion of daily nursing staff assigned to each shift were based on staffing data from the Biennial Survey for NHs and ALCs. Outcomes were calculated for aides and licensed nursing staff.

Results:

Ohio’s NHs and ALCs had lower resident-to-staff ratios on the day shift. Lower resident-to-staff ratios mean there were more staff per resident (i.e., better staffed). For both types of staff and all shifts, overall resident-to-staff ratios were lower in NHs than ALCs. However, resident-to-staff ratios for ALC MCUs were on par with NH MCUs. This was consistent with ALC and NH MCUs staffing in a more similar manner. Across all settings, the day shift had the most staff members present, while a number of ALCs had no licensed nurses on duty during the overnight shift.

Conclusions and Implications:

NHs and ALCs have different staffing patterns due to differences in resident needs. However, as ALCs provide for more residents that need nursing home level of care, ALCs may require additional staffing, especially on the overnight shift where some ALCS have no licensed nurses on duty. The evidence here can be used for decision making about future staffing policies, whether facility-wide policies that encompass MCUs or state-wide policies, so that care delivery aligns with care needs.

Brief summary:

Ohio nursing homes and assisted living communities have more aides and licensed nurses on the day shift compared to the overnight shift. Nursing homes also have more staff than assisted living communities for the overall facility, but nursing homes and assisted living communities staff similarly in their memory care units.

Introduction

Many older adults who require long-term services and support may seek care in a nursing home (NH) or an assisted living community (ALC). Both settings provide personal care services,¹ but NHs focus more on medical care and thus have residents with greater needs than those in ALCs.² Additionally, ALCs are regulated at the state level and ALC regulations are less stringent than the federal and state NH regulations.³ Yet, there is growing concern over the rising acuity of residents in ALCs. Studies have suggested that ALC residents have a high prevalence of physical and cognitive impairment that require help with activities of daily living.^4,5 Additionally, many ALCs have dedicated memory care units (MCUs), which specialize in caring for residents with cognitive impairment and may signal to consumers that the community may specialize in caring for residents with Alzheimer’s disease and related dementias. MCUs in ALCs cost more than the general ALC and it is unclear whether MCUs in ALCs provide any additional services or improved quality.^5,6 This has led some to wonder what care is being provided in ALCs.^4,7

A key component of NH and ALC care is direct care nursing staff levels. Direct care staff assess resident medical needs, provide personal care services, and assist with the activities of daily living. In the NH industry, staffing levels have been publicly reported for more than two decades and a number of studies have found an association between staffing levels and resident outcomes.^8,9,10 In recognition of this, in May 2024 the Centers for Medicare and Medicaid Services announced a new federal minimum staffing regulation for NHs.¹¹ However, ALCs are regulated at the state level, and many states do not have regulations that require ALCs to have a minimum number of staff.¹² Additionally, staffing levels for ALCs are not systematically collected or reported. Therefore, there is a lack of information on the staffing patterns of ALCs.

Given these ongoing concerns related to care provided in ALCs, this paper contributes to the literature on NHs and ALCs by examining staffing patterns on three dimensions using Ohio data. First, we compared staffing patterns in NHs to ALCs. While ALCs’ residents have lower needs and thus may require fewer staff, comparing NHs and ALCs provides an important baseline for understanding ALCs’ staffing patterns, especially if ALCs are caring for more residents that would have traditionally sought care in a NH. Second, we compared staffing patterns across shifts to get a better understanding of how NHs and ALCs staff across day, evening, and overnight shifts. And finally, given the increased marketing of dedicated MCUs, we examined staffing patterns in the overall NH or ALC as compared to their MCU. To our knowledge, this the first paper to examine staffing patterns across shifts, for MCUs, and to contrast staffing patterns in NHs and ALCs.

Method

Data and Sample

Data for this study came from the 2021 Ohio Biennial Survey of Long-Term Care Facilities (See Applebaum et al. for more details on the data).^13,14 The Biennial Survey was conducted every other year, with the survey being developed and collected by Scripps Gerontology Center at Miami University. Per Ohio law (O.R.C. 173.44), all NHs and ALCs were required to complete the survey, which was sent to the administrator of the NH or ALC. The administrator was responsible for providing self-reported responses with the help of other staff, and when possible, the Scripps Gerontology Center validated the responses with other data sources. The Biennial Survey has been ongoing for more than 30 years and in 2021 had a response rate of 83% for NHs and 81% ALCs, which was historically lower due to the COVID-19 pandemic.

The unit of observation was a survey response from a NH or ALC. After assuring each response had all necessary data to calculate staffing patterns, our overall analytic sample consisted of 678 NHs and 542 ALCs. In some of the analyses, we examined subsamples. Details on the data cleaning process, sample selection process, and subsamples are reported in Table 1.

Table 1.

Analytic Sample Selection for Staffing of the Overall NH and ALC

Sample Restriction	Nursing Homes	Assisted Living Communities
Data Restrictions:
Step 1: Total licensed providers in Ohio	N=959	N=791
Step 2: Completed entirety of Biennial Survey	N=796	N=638
Step 3: Reported resident census	N=796	N=617
Step 4: Reported at least one nursing staff member per shift	N=683	N=546
Step 5: Reported at least one aide on all shifts	N=678	N=542
Analytic Samples (Starting from Step 5):
Main Analysis for Aides: At least one aide for all shifts	N=678	N=542
Main Analysis for Licensed Nurses: At least one licensed nurse for all shifts	N=678	N=381
Sensitivity Analysis: At least one licensed nurse and aide for day/evening shifts	N=678	N=506

Notes: All licensed Ohio NHs and ALCs were provided the Biennial Survey, with 83% and 81% completing most sections of the survey. The sample was further restricted to surveys in which the resident census and staffing data was available to calculate a resident-to-staff ratio. The overall analytic sample started with NHs and ALCs which had at least one aide reported for all shifts (Step 5). A total of 164 ALCs did not report having a licensed nurse on duty for the overnight shift and another 39 did not have a licensed nurse on duty for the night shift. Therefore, the ALC sample varied with the analysis performed. The NH sample had the same 678 observations for all analyses.

Staffing Pattern Outcomes

In the Biennial Survey both NHs and ALCs were asked to provide the number of staff members that work on the day, evening, and overnight shifts on a typical day in December 2021. The day, evening, and overnight shifts generally correspond to 7am-3pm, 3pm-11pm, and 11pm-7am, respectively. Additionally, we obtained the number of residents based on location. First, the Biennial Survey provided the number of residents in the MCU for both NHs and ALCs, as well as the number of residents in the overall ALC on December 31, 2021. Next, Payroll-Based Journal data was used to obtain the number of residents in the overall NH.

We constructed two measures of staffing patterns. The first measure was the resident-to-staff ratio. The resident-to-staff ratio was defined as the number of residents divided by the number of staff members. High resident-to-staff ratios indicate that there were more residents that a staff member cared for, and hence theoretically, less time a staff member could devote to each resident. Therefore, higher resident-to-staff ratios are associated with “worse” staffing and lower resident-to-staff ratios are associated with “better” staffing. The second measure was the proportion of staff assigned to each shift. This provides insight into how NHs and ALCs allocated staff resources to resident care over the 24-hour work cycle. The proportion of staff assigned to each shift was calculated by taking the number of workers in each shift and dividing it by the number of workers across all shifts.

We calculated staffing patterns separately for licensed nurses and aides. Licensed nurses include registered nurses and licensed practical nurses. We could not calculate separate staffing patterns for each type of licensed nurse because the ALCs only reported the overall number of licensed nurses. Aides represented nurse aides in NHs and personal care aides in ALCs. We compared nurse aides and personal care aides because both have similar roles of assisting residents with activities of daily living and providing personal care services in their respective settings, though there are training differences between nurse aides and personal care aides.

Memory Care Units

The Biennial Survey asked whether the NH or ALC had a dedicated MCU. If a respondent indicated that they had an MCU, they were asked to provide resident census and staffing information by shift for the MCU. This information was used to calculate staffing pattern outcomes for MCUs. In our analytic sample, approximately 24% of NHs and ALCs reported having an MCU.

Analysis

To compare and contrast staffing patterns, we calculated average resident-to-staff ratios and made three comparisons. First, we compared the overall resident-to-staff ratios for NHs to ALCs. Second, we compared resident-to-staff ratios within the MCU for NHs to ALCs. And third, for NHs and ALCs separately, we compared the overall resident-to-staff ratios with the resident-to-staff ratios in the MCU for a sample of providers with MCUs. When we compared NHs to ALCs, the main analysis was among providers with at least one staff member of each type on all shifts, resulting in different sample sizes for aides and licensed nurses. This was done because many ALCs reported having zero licensed nurses on the overnight shift. As a sensitivity analysis we also calculated the average resident-to-staff ratio for ALCs with at least one licensed nurse and one aide on the day and evening shift. Standard t-tests were utilized to determine whether NHs and ALCs had statistically different resident-to-staff ratios. For the third comparison, which compared the overall staffing to the MCU among providers with a MCU, the sample was restricted to NHs or ALCs with at least one licensed nurse and one aide on all shifts. We utilized pair-wise t-tests to determine whether resident-to-staff ratios were different in MCUs compared to the overall staffing.

We also examined the proportion of nursing staff that was assigned to each shift overall and within the MCU. For the ALC sample, the respondents that reported no licensed nursing staff on the overnight shift were treated as if there were no licensed staff present. All analysis was conducted using SAS 9.4.

Results

Table 2 reports the average resident-to-staff ratios for the overall NH and ALC by shift with Panel A reporting the resident-to-staff ratios for aides and Panel B for licensed nurses. The two main findings were: (1) resident-to-staff ratios were statistically different and lower (i.e., better staffed) in NHs than ALCs and (2) resident-to-staff ratios were lower (i.e., better staffed) during the day shift when compared to the evening and overnight shifts for both staff types and all shifts. During the day shift, the resident-to-staff ratio for aides were 10.4-to-1 in NHs and 14.1-to-1 in ALCs, meaning aides in ALCs cared for 35.6% more residents per aide than aides in a NH. For licensed nurses, the resident-to-staff ratios were 16.0-to-1 in NH and 24.2-to-1 in ALCs, a 63.6% difference. These differences were greater for the overnight shift (65% for aides and 80% for licensed nurses). Notably, the difference for licensed nurses on the overnight shift may be underestimated, as 125 (23%) of ALCs did not report having a licensed nurse on duty on the overnight shift and thus a resident-to-staff ratio could not be calculated. Furthermore, our sensitivity analysis for ALCs, which restricted the sample to ALCs with at least one licensed nurse and one aide on the day and evening shift, found similar results.

Table 2.

Average Resident-to-Staff Ratios by Shift in Nursing Homes and Assisted Living Communities: Overall Facility

Nursing Shift	Nursing Homes	Assisted Living Communities
		At least one staff member on all shifts†	At least one aide and licensed nurse on day and evening shift
Panel A. Aides
Day Shift	10.4	14.1***	14.1
Evening Shift	11.7	16.3***	16.2
Overnight Shift	14.3	23.4***	N/A
N	678	542	506
Panel B. Licensed Nurses
Day Shift	16.0	24.2***	24.2
Evening Shift	20.2	32.3***	32.1
Overnight Shift	23.6	42.5***	N/A
N	678	381	506

Notes. Resident-to-staff ratios report the number of residents per staff member (e.g., 10.4 reflects the number of resident per 1 staff member). Panel A reports the resident-to-staff ratios for aides and Panel B for licensed nurses which includes registered nurses and licensed practical nurses.

^†ALCs do not have licensed nurses on all shifts. Therefore, the aide sample includes all ALCs in which at least one aide was reported on all shifts and a sample were at least one aide was reported on the day and evening shifts. The licensed nurse sample includes all ALCs in which at least one licensed nurse was reported on all shifts and a sample were at least one licensed nurse was reported on the day and evening shifts. Statistical tests (t-test for difference in two groups) compared whether the resident-to-staff ratios for NHs were different from ALCs. These tests used the following significance levels:

^***<0.01;

^**< 0.05; and

^*< 0.10

Table 3 reports the average resident-to-staff ratios within MCUs. Similar to the overall NH or ALC, resident-to-staff ratios were lower (i.e., better staffed) during the day when compared to evening and overnight shifts. However, the resident-to-staff ratios in ALC MCUs were lower and statistically significant for aides on the day and evening shift when compared to NH MCUs. Yet, resident-to-staff ratios for aides on the overnight shift and for licensed staff were not significantly different between ALC and NH MCUs. These results were consistent with staffing levels being similar or even slightly better in ALC MCUs compared to NH MCUs.

Table 3.

Average Resident-to-Staff Ratios by Shift in Nursing Homes and Assisted Living Communities: Memory Care Units

Nursing Shift	Nursing Homes	Assisted Living Communities
		At least one staff member on all shifts†	At least one aide and licensed nurse evening shift
Panel A. Aides
Day Shift	9.0	8.0**	8.0
Evening Shift	9.8	8.6**	8.7
Overnight Shift	11.9	11.8	N/A
N	164	129	129
Panel B. Licensed Nurses
Day Shift	17.2	15.7	15.4
Evening Shift	18.2	18.2	17.6
Overnight Shift	19.2	19.2	N/A
N	164	115	129

Notes. Resident-to-staff ratios report the number of residents per staff member (e.g., 10.4 reflects the number of resident per 1 staff member). Panel A reports the resident-to-staff ratios for aides and Panel B for licensed nurses which includes registered nurses and licensed practical nurses.

^†ALCs do not have licensed nurses on all shifts. Therefore, the aide sample includes all ALCs in which at least one aide was reported on all shifts and a sample were at least one aide was reported on the day and evening shifts. The licensed nurse sample includes all ALCs in which at least one licensed nurse was reported on all shifts and a sample were at least one licensed nurse was reported on the day and evening shifts. Statistical tests (t-test for difference in two groups) compared whether the resident-to-staff ratios for NHs were different from ALCs. These tests used the following significance levels:

^***<0.01;

^**< 0.05; and

^*< 0.10.

The results that assess whether MCUs were staffed differently from the overall facility are reported in Table 4 among a sample of NHs and ALCs that had a MCU. Of note, MCUs had lower (i.e. better staffed) resident-to-staff ratios compared to overall staffing in both NHs and ALCs. For NHs, depending on the shift, resident-to-staff ratios imply each aide on a MCU was caring for 13% to 16% fewer residents than the overall facility. Licensed nurses in NH MCUs cared for 0 to 20% fewer residents compared to the overall facility. Among ALCs, each aide in MCUs cared for 36 to 40% fewer residents while each licensed nurse cared for 36 to 60% fewer residents when compared to the overall facility.

Table 4.

Comparison of Average Resident-to-Staff Ratios in Memory Care Units to the Overall NH and ALC

	Nursing Homes		Assisted Living Communities
Nursing Shift	Overall Facility	Memory Care Unit†	Overall Facility	Memory Care Unit†
Panel A. Aides
Day Shift	10.4	9.0***	12.4	7.9***
Evening Shift	11.6	9.8***	13.7	8.5***
Overnight Shift	14.0	11.9***	21.3	11.9***
N	164	164	111	111
Panel B. Licensed Nurses
Day Shift	16.5	17.2	24.9	15.8***
Evening Shift	20.5	18.2***	33.8	18.2**
Overnight Shift	24.1	19.2***	48.6	19.2***
N	164	164	111	111

Notes. Resident-to-staff ratios report the number of residents per staff member (e.g., 10.4 reflects the number of resident per 1 staff member) for the overall facility and the memory care unit among NHs and ALCs with memory care units. Panel A reports the resident-to-staff ratios for aides and Panel B for licensed nurses which includes registered nurses and licensed practical nurses. ALCs do not have licensed nurses on all shifts. Therefore, we examined a sample of ALCs in which at least one aide and licensed nurse staff member is reported on all shifts in the overall facility and MCU.

^†Statistical tests (pairwise t-test) compared the resident-to-staff ratios in the memory care unit versus the overall facility, separately for NHs and ALCs. The test used the following significance levels:

^***<0.01;

^**< 0.05; and

^*< 0.10.

For more detail on staffing by shift, Table 5 reports the proportion of staff assigned to each shift. Given that residents were awake and more active, it is not surprising that most staff time was assigned to the day shift. In NHs, 38.1% of aides and 41.0% of licensed nurses were assigned to the day shift. In ALCs, 39.8% of direct care workers and 45.6% of licensed nurse staff were assigned to the day shift. The overnight shift had the lowest proportion of staff time assigned to it for both settings. Furthermore, both NHs and ALCs tended to assign a slightly higher proportion of staff to the overnight shift in the MCU relative to overall staffing, though NHs assign a greater proportion of staff to the overnight shift than ALCs.

Table 5.

Proportion of Direct Care Nursing Staff on Each Shift

	Nursing Homes		Assisted Living Communities
Nursing Shift	Overall	Memory Care Unit	Overall	Memory Care Unit
Panel A. Aides
Day Shift	38.1%	36.8%	39.8%	38.4%
Evening Shift	34.1%	34.2%	34.8%	35.3%
Overnight Shift	27.8%	29.0%	25.3%	26.2%
N	678	164	506	129
Panel B. Licensed Nurses
Day Shift	41.0%	35.6%	45.6%	39.0%
Evening Shift	31.6%	32.9%	34.9%	34.2%
Overnight Shift	27.4%	31.5%	19.4%	26.8%
N	678	164	506	129

Notes. The proportion of nursing staff assigned to each shift is calculated for all NHs and ALCs. Panel A reports the resident-to-staff ratios for aides and Panel B for licensed nurses which includes registered nurses and licensed practical nurses. Some ALCs do not report having any staff on the overnight shift for licensed nurses. These ALCs are treated as if they have zero licensed nurses on the overnight shift. The proportions may not add up to 100% due to rounding.

Discussion

Using a unique dataset from Ohio, this study examined staffing patterns in NHs and ALCs by shift, as well as within MCUs. Resident-to-staff ratios were found to be lower (i.e. better staffed) among aides and licensed nurses in NHs than for the overall ALCs. A lower resident-to-staff ratio means that each staff member needs to care for fewer residents, and hence is associated with more staff per resident. These results were expected as NHs and ALCs were required to staff to meet resident needs, and on average, prior research shows that the needs of ALC residents as measured by acuity were less than NH residents.²

Both settings were also found to have higher (i.e., worse staffing) resident-to-staff ratios on the evening and overnight shifts when compared to the day shift. Compared to the day shift for the overall facility, each aide on the overnight shift in a NH had to care for 3.9 more residents compared to 9.3 more residents in ALCs; while among each licensed nurse, these differences were 7.6 residents in NHs and 18.3 residents in ALCs. More importantly, the difference for licensed nurses in ALCs is likely underestimated as 23% of ALCs in our analytic sample did not report having a licensed nurse present on the overnight shift. This pattern aligns staffing levels with periods when support for activities of daily living were likely to occur, as residents were more likely to be awake during the day and part of the evening shift. However, having fewer staff on the overnight shift, when accounting for resident needs, could put resident’s safety at risk. If a resident had an emergency during the overnight shift, the higher resident load in ALCs may make it difficult to address an emergency and still provide care to other residents.

Another contribution of this study is understanding the trends in the staffing of MCUs. As the number of older Americans with cognitive impairment increases, many families are turning to MCUs in NHs and ALCs for care. In NHs and ALCs, MCUs have resident-to-staff ratios that were lower (i.e. better staffed) than the overall facility, meaning there were more staff present in the MCUs. Interestingly, comparing the resident-to-staff ratios of NH MCUs and ALC MCUs found that ALCs tended to staff their MCUs on par with NHs. While we did not have data on the acuity of residents, this finding has two potential interpretations: (1) ALCs and NHs had similar staffing levels in their MCUs because the acuity of their residents was similar; or (2) if ALCs had similar or lower acuity residents in their MCUs, ALCs were staffing better than NHs on an acuity adjusted basis. Regardless, we found that ALC MCUs were providing additional nursing staff per resident relative to the overall ALC, with the average ALC MCU having staffing levels on par with NH MCUs. This is consistent with memory care in ALCs providing additional services, potentially justifying their higher prices.⁴

While this study provides insight into staffing patterns in NHs and ALCs, additional work is needed to further our understanding of staffing and to address the limitations of this study. First, while NHs and ALCs must have “sufficient staff” to meet the needs of their residents and NHs must also meet federal staffing standards (CMS, 2024),^11,15,16 an understanding of what suffices as “sufficient” requires an assessment of resident needs and preferences. We did not have information on resident needs or acuity, thus our results do not determine whether the reported staff levels are optimal. Second, the staffing levels were self-reported. While we cannot verify if the staffing levels by shift were accurate, the information collected was only presented in aggregate format and there is little incentive to not be truthful. Where possible, we and past research had verified NH staffing levels with the other publicly available data and found the overall responses to be consistent with daily staffing levels.¹³ Third, the staffing pattern outcomes were based on the number of staffing in December and resident census was based on the last day of the year. This construction can lead to some measurement error, but we believe any measurement error is random and hence would not impact our general conclusions. Furthermore, the Payroll-Based Journal data suggested that staffing levels tend to be lower in NHs in December. This seasonality around the holidays could cause us to overestimate the resident-to-staff ratios, but seasonality should have impacted both NHs and ALCs. Therefore, we do not believe seasonality would change our general conclusions. Fourth, we compared nurse aides in NHs to personal care aides in ALCs. There are training differences between these two types of staff and we did not assess how the competency of aides in both settings vary and whether this variation in training impacts resident outcomes. And finally, our analysis was restricted to Ohio which does not have a minimum staffing requirement for ALCs, MCU specific staffing requirements, or a staffing standard by shift at the time the data was collected. Because states may implement different regulations, our results may not be representative of states with different regulations.

Conclusions and Implications

NHs and ALCs serve a wide range of residents with physical, cognitive, and behavioral health problems. The nursing teams, whether nurse aides, personal care aides, or licensed nurses, are integral to the care received by residents. While some states have explicit minimum staffing standards and other criteria, Ohio and most states only require ALCs to have “sufficient staff” to meet care needs. As ALCs care for a greater share of older Americans that need long-term services and support, greater understanding of who is cared for in ALCs and what services they are receiving (or not receiving) is warranted. The results of this study point to the real-world staffing assignments by shift and our comparison of ALCs to NHs, an industry for which we have better information, provides insights into how to better care for and regulate ALCs in the future. As policymakers consider regulating ALCs and NHs, these results provide evidence that can be used to make more informed decisions, including whether they encompass organization-wide or MCU-specific policies that better align care delivery with resident needs.