By Pradeep Pandey · Co-Founder · 15 min read · Updated
CNA-to-Patient Ratio Laws by State: Hospitals vs Nursing Homes
Almost every guide to CNA ratios is answering a nursing home question. If you run hospital beds, the answer is much shorter. As far as we can tell only one state sets a limit, and the rest set none.
Search for CNA-to-patient ratio laws and you will find long state-by-state tables full of numbers. Nearly all of those numbers come from nursing home regulation. If you are staffing hospital beds, most of them do not apply to your building.
Get that wrong and you pay for it. A manager who staffs to a nursing home number is buying coverage no hospital rule asks for.
Key Takeaways
- Ask one question first. Are you staffing a hospital bed or a nursing home bed? They are governed by separate bodies of law, and the CNA numbers you find online almost all come from the nursing home side.
- For hospitals, Oregon is the only state we can find with a CNA cap written into statute, as of August 2026. It limits a certified nursing assistant to seven patients on a day or evening shift and 11 at night.
- Everywhere else there is no aide number to hit. General hospitals answer to a federal rule asking for “adequate numbers” of staff, and Critical Access Hospitals to a coverage rule about who is on duty. Neither names a figure for aides.
- The one federal CNA number that ever existed, the 2.45 nurse aide hours per resident day that nursing facilities owed, was removed effective February 2, 2026. Congress barred CMS from enforcing it until after September 30, 2034.
- Swing beds at a Critical Access Hospital are not nursing home beds for this purpose. The swing bed rule lists the long term care requirements that carry over, and the nursing services standard is not among them.
- Texas sets no CNA ratio for hospitals at all. Its hospital licensing rule does not mention aides.
Table of Contents
- Do CNA Ratio Laws Apply to Hospitals or Nursing Homes?
- Which States Set a CNA Ratio for Hospitals?
- What Happened to the Federal Nursing Home Staffing Rule?
- Do Swing Beds Count as Nursing Home Beds for Staffing?
- Does Texas Set a CNA Ratio for Hospitals?
- How Do You Staff a Shift When No Ratio Applies?
- How Does SimpleScheduleAI Fit Into Aide Staffing?
- What to Do This Week
- Frequently Asked Questions
Most people get this wrong the same way: they read a nursing facility rule as a hospital requirement.
Do CNA Ratio Laws Apply to Hospitals or Nursing Homes?
Mostly nursing homes. Start with the credential itself. In Texas, nurse aides are certified and tracked by the state’s long term care division, and the training program that leads to the certificate is written for nursing facility work. The letters CNA come from the nursing home world.
The rules follow the same pattern. Nursing homes are regulated on staffing numbers. Hospitals are not. Hospitals get a description instead of a number. Under 42 CFR 482.23(b), a general hospital’s nursing service “must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.” There is no number in that sentence, and no separate aide standard anywhere in the section.
Critical Access Hospitals follow a different federal rulebook again. It says who must be on duty, not how many patients each person can take. Our guide to nurse staffing ratios at a Critical Access Hospital works through it.
So when a state-by-state guide tells you a CNA can cover 10 residents on nights, check the heading above it. That figure is almost certainly a nursing facility rule.
Which States Set a CNA Ratio for Hospitals?
Oregon. As far as we can tell, as of August 2026, it is the only one. ORS 441.768, enacted as part of the 2023 hospital staffing law, is one sentence:
“A hospital may not assign a certified nursing assistant to more than seven patients at a time during a day or evening shift or to more than 11 patients at a time during a night shift.”
Nothing else follows it. No bed-count threshold, and nothing carving out small or rural hospitals.
One detail matters if you operate in Oregon. The state has an exceptions statute, and it lists exceptions to the registered nurse ratios only. It never mentions the CNA section. Oregon also lets a small rural hospital vary from the nurse ratios if its own staffing committee votes for it, under ORS 441.763. No agency sign-off is needed.
The statute does not say whether that flexibility also covers the aide cap. Ask the Oregon Health Authority directly rather than assuming it does.
For the registered nurse side of the state map, including which states use ratios, which use staffing committees, and which do neither, see our guide to nurse-to-patient ratios by state.
We have not attempted a 50-state CNA table here, and that is deliberate. The hospital answer is short. The long tables elsewhere are nursing home law. Print those tables next to hospital guidance and someone will staff to the wrong rule.
What Happened to the Federal Nursing Home Staffing Rule?
It was repealed, and the date matters because a lot of published guidance has not caught up.
CMS issued an interim final rule on December 3, 2025, effective February 2, 2026. It removed the staffing minimums that nursing facilities had to meet. Gone is the requirement for a registered nurse onsite 24 hours a day, seven days a week. Gone too are the minimum hours per resident day that nursing facilities owed: 0.55 for registered nurses, 2.45 for nurse aides, and 3.48 total.
Congress did this, not a court. Section 71111 of Public Law 119-21 “precludes CMS from implementing, administering, or enforcing the minimum staffing standards” for nursing facilities until after September 30, 2034. CMS then issued the rule above to match.
You will also see this described as a court decision, because a lawsuit against the rule was running at the same time. The law is what settled it.
Nursing facilities still owe three things, and the list is much shorter than it was:
- A registered nurse for at least eight consecutive hours a day, seven days a week
- A full time registered nurse as director of nursing
- Enough nursing staff to meet residents’ needs
That nursing facility figure of 2.45 was the only federal aide number that has ever existed.
Do Swing Beds Count as Nursing Home Beds for Staffing?
No, and this is the question a Critical Access Hospital actually needs answered.
A swing bed is a hospital bed used to deliver long term care, so it is fair to ask whether nursing home staffing rules come with it. The swing bed rule answers that directly. 42 CFR 485.645(d) lists the nursing home requirements a Critical Access Hospital has to meet for those beds, and staffing is not one of them.
| Carries over to your swing beds | Does not carry over |
|---|---|
| Resident rights | Nursing services (§483.35) |
| Admission, transfer and discharge | This is the section that held the hours per resident day figures |
| Abuse and neglect | |
| Social services | |
| Resident assessment and care planning | |
| Specialized rehabilitative services | |
| Dental | |
| Nutrition |
Two things follow, and the second is the one people miss. First, swing bed patients do not bring nursing facility staffing standards into your hospital. Second, that does not leave you free of rules. Your Critical Access Hospital conditions still apply to those patients. That includes the rule under 42 CFR 485.631 requiring a registered nurse, clinical nurse specialist, or licensed practical nurse on duty whenever you have inpatients.
A distinct part skilled nursing facility unit is a different case. That unit is licensed as a skilled nursing facility, and surveyors hold it to the nursing home rules directly. If your hospital has one, treat it as a separate staffing question from your acute beds.
The same split shows up in CMS reporting. Swing beds do not have to file Payroll Based Journal staffing data. A distinct part unit does. Our guide to PBJ reporting and scheduling covers that one.
Does Texas Set a CNA Ratio for Hospitals?
Texas sets no CNA ratio for hospitals. Texas licenses hospitals under 26 Texas Administrative Code §505.41. Its nursing services subsection requires “adequate numbers of RNs, licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients as needed.” It sets no numeric ratio, and it does not mention certified nursing assistants, nurse aides, or unlicensed assistive personnel at all.
What Texas requires instead is a process. Under Health and Safety Code chapter 257 a hospital runs a nurse staffing committee and adopts a written staffing plan. The state tells you how to decide, not what number to hit. Our nurse-to-patient ratios by state guide covers that committee model.
Texas nursing facilities are a separate rulebook, and there the number is about licensed nurses, not aides. A Texas nursing facility must staff one licensed nurse per 20 residents, or 0.4 licensed care hours per resident day. That rule sets no aide number either.
So a Texas Critical Access Hospital has no CNA ratio to meet from any direction. You decide aide staffing on skill and coverage, then write that decision into your staffing plan.
How Do You Staff a Shift When No Ratio Applies?
There is no number. There is still a standard you have to meet. A surveyor will not ask whether you hit a ratio. They will ask how you decided, and whether the record shows you did what you decided.
Your written staffing plan. In a committee state this is the governing document. It should say what coverage each unit needs by shift, aides included, and reflect the patients you actually take.
Skill mix rather than headcount. Aides extend licensed staff. They do not substitute for them. The question on a shift is not how many people are on it. It is whether the right licensed staff are on the floor for the patients you have. Our guide to acuity-based staffing at a small hospital covers how to turn patient need into a staffing decision with no ratio to lean on.
The record. The schedule you actually worked is the evidence. Our guide to staying CMS compliant with nurse scheduling covers what a surveyor asks for.
How Does SimpleScheduleAI Fit Into Aide Staffing?
SimpleScheduleAI is an AI-native nurse scheduling service for Texas Critical Access Hospitals of 25 beds or fewer. We build the software and we run it for you. The AI builds the schedule, our scheduling team checks every draft, and your nurse manager approves it. You can watch a week get built in the interactive simulator, and AI nurse scheduling explains how the drafts are produced.
The honest boundary matters more than usual on this topic. We do not track CNA ratios, hours per resident day, or state staffing law compliance, and no scheduling system should tell you it does. Your nursing leadership decides those, and your staffing plan records them. We are also not right for a hospital that wants to run and configure its own platform.
What the service does is narrower. The rules you set at onboarding are checked on every draft, so the coverage you asked for shows up on every draft. Weekend and holiday distribution is tracked with running counts per person. When someone calls out you get a ranked replacement shortlist with the reasons attached. Every change is logged with a timestamp, which is what matters when a surveyor asks about a shift six weeks ago. See how it works and critical access hospital scheduling for the wider compliance picture.
Our Take
The published guides are not wrong. They are answering a different question. They are nursing home references, written for nursing home operators, and they show up when a hospital manager types the same words into Google. If you run hospital beds the useful version is short. One state caps CNA assignments. Your swing beds are not nursing home beds. Everywhere else you staff to a plan, not a number. That is less satisfying than a table of figures, and it is what actually applies to your building.
What to Do This Week
- Write down which kind of bed you are asking about. Hospital, swing bed, or distinct part skilled nursing unit. The answer changes with each, and mixing them is the whole problem.
- Check your staffing plan for aide coverage by shift. If the plan names licensed coverage but is silent on aides, that silence is what a surveyor will find.
- If you operate in Oregon, ask the Oregon Health Authority about the aide cap directly. The exceptions statute is written against the nurse ratios, so do not assume a variance you have not confirmed.
- Date-check any ratio guide you are relying on. Anything still quoting 2.45 nurse aide hours per resident day for nursing facilities predates February 2026.
Staffing to a plan, not a ratio
We build and check the schedule your nurse manager approves, with the coverage rules you set checked on every draft and every change logged. Onboarding takes 3 to 5 business days and your first schedule lands inside two weeks.
See how it works →Frequently Asked Questions
Is there a federal CNA-to-patient ratio?
Not now. The only federal aide number that has ever existed was 2.45 nurse aide hours per resident day for nursing facilities, and it was removed effective February 2, 2026. Congress barred CMS from enforcing the minimum staffing standards until after September 30, 2034. For hospitals there has never been a federal aide ratio.
Which states have CNA ratios for hospitals?
Oregon is the only one we can find, as of August 2026. Its statute caps a certified nursing assistant at seven patients on a day or evening shift and 11 at night. Other states that appear in CNA ratio guides are setting nursing facility rules, not hospital rules.
Do CNA ratios apply to critical access hospital swing beds?
No. The swing bed rule lists which long term care requirements a Critical Access Hospital must meet, and the nursing services standard that carried the staffing figures is not on that list. Your Critical Access Hospital conditions still apply to those patients, including the on-duty requirement. A distinct part skilled nursing unit is a different answer: it is certified as a skilled nursing facility and surveyed against the long term care requirements in its own right.
Does Texas set a CNA ratio?
No, in either setting. Texas hospital licensing sets no numeric ratio and does not mention aides. Texas nursing facility rules set a licensed nurse figure with no aide number attached.
If there is no ratio, what will a surveyor look at?
Your written staffing plan and the schedule you actually worked. The question is whether you defined the coverage your patients need and whether the record shows you delivered it.
Sources
[1] Oregon hospital CNA staffing cap. ORS 441.768, enacted 2023 c.507 §8. oregon.public.law. Verified 2026-08-20.
[2] Oregon nurse staffing exceptions, written against the registered nurse ratios in ORS 441.765. ORS 441.766. oregon.public.law. Verified 2026-08-20.
[3] Repeal of the long term care minimum staffing standards: interim final rule published December 3, 2025, effective February 2, 2026; section 71111 of Public Law 119-21 precludes enforcement until after September 30, 2034; removes the 0.55 RN, 2.45 nurse aide, and 3.48 total hours per resident day requirements and the 24/7 RN onsite requirement. Federal Register via govinfo. Verified 2026-08-20.
[4] Hospital nursing service standard, “adequate numbers,” no ratio. 42 CFR 482.23(b).
[5] Critical Access Hospital swing bed requirements, listing the Part 483 provisions that apply. 42 CFR 485.645(d). Verified 2026-08-20.
[6] Critical Access Hospital staffing and on-duty requirement. 42 CFR 485.631.
[7] Texas hospital licensing, nursing services. 26 Texas Administrative Code §505.41(o), transferred from 25 TAC §133.41 effective January 31, 2025 (transfer notice published in the January 10, 2025 Texas Register). Cornell LII. Verified 2026-08-20.
[8] Texas nursing facility staffing, licensed nurse requirement. 26 Texas Administrative Code §554.1002. Cornell LII.
[9] Texas nurse aide certification and the Nurse Aide Registry are administered by Texas HHS under long term care credentialing. The agency’s pages on this sit behind an access control that blocks some visitors, so no direct link is given here; search “Texas HHS Nurse Aide Registry” if you need the current page.
Scope note: This page covers hospital-applicable rules and the federal long term care position. It does not reproduce state-by-state nursing facility CNA figures, because those bind nursing homes rather than hospital units. Staffing law changes; confirm anything decision-critical with your state agency before relying on it.
Pradeep Pandey is the co-founder of SimpleScheduleAI, an AI-native nurse scheduling service for Critical Access Hospitals in Texas. He serves as Deputy General Manager of Operations at Apollo Hospitals and holds an MBA from IIM Trichy (Operations and Marketing). LinkedIn →
