Nursing Home Staffing Ratios: What the Data Shows

How CMS Measures and Reports Nursing Home Staffing

The Centers for Medicare and Medicaid Services (CMS) collects and publishes staffing data for approximately 15,000 Medicare- and Medicaid-certified nursing facilities across the United States. The primary metrics used to standardize comparisons across facilities of different sizes are expressed as hours per resident day (HPRD), meaning the total number of nursing hours worked divided by the total number of resident days in a given reporting period.

CMS tracks several distinct staffing categories:

• Registered Nurse (RN) hours per resident day: Federal law requires at least one RN on duty for eight consecutive hours per day, seven days a week. The national average RN HPRD hovers near 0.7 hours, though this figure varies considerably by facility type and ownership model.
• Total nurse staffing hours per resident day: This figure combines RN, Licensed Practical Nurse (LPN), and Certified Nursing Assistant (CNA) hours. The national average across all facility types is approximately 3.8 to 4.0 HPRD.
• CNA hours per resident day: CNAs provide the majority of direct care. The national average is roughly 2.3 to 2.5 HPRD.
• Administrator hours: CMS also collects data on director of nursing and administrator time, which informs oversight quality metrics rather than direct care calculations.

CMS assigns a staffing rating of one to five stars within its Five-Star Quality Rating System. The staffing domain accounts for roughly 22 percent of the overall star rating weight. Facilities are evaluated both on their reported staffing levels and on whether an RN was present on all seven days of the week during the reporting period.

The Federal Minimum Staffing Rule and Implementation Timeline

In April 2024, CMS finalized a landmark federal rule establishing minimum staffing requirements for long-term care facilities that receive Medicare or Medicaid funding. This rule marked the first time the federal government set explicit numerical floors for nursing home staffing, moving beyond the longstanding requirement of simply having an RN on duty eight hours per day.

The finalized requirements include:

• A minimum of 0.55 RN hours per resident day.
• A minimum of 2.45 CNA hours per resident day.
• A total minimum of 3.48 total nurse staffing hours per resident day.
• An RN on site 24 hours a day, seven days a week.

The implementation timeline is phased to account for workforce availability challenges. Facilities in rural or underserved areas, or those that can document good-faith recruitment efforts, may qualify for hardship exemptions. The baseline total staffing floor of 3.48 HPRD is scheduled to be fully enforced within two years of the rule's effective date for most facilities, while the 24/7 RN requirement takes effect within three years. The CNA and RN individual minimums have a five-year compliance window for facilities facing documented workforce shortages.

Industry groups representing nursing home operators have contested aspects of the rule in federal court, arguing that workforce supply in many rural markets makes compliance structurally impossible. As of mid-2025, litigation remains ongoing, and facilities should monitor CMS guidance for any regulatory updates.

Locating Staffing Data for a Specific Facility on CMS Care Compare

CMS Care Compare, accessible at medicare.gov/care-compare, is the primary public portal for facility-level staffing data. Users can search by facility name, city, or ZIP code. Each nursing home profile includes a staffing section that displays the following data points:

• RN hours per resident day, shown as both a raw figure and a comparison to state and national averages.
• Total nurse staffing hours per resident day.
• CNA hours per resident day.
• Whether an RN was on duty seven days a week during the most recent reporting period.
• The facility's staffing star rating on a one-to-five scale.

CMS updates staffing data quarterly based on Payroll-Based Journal (PBJ) submissions. The data displayed typically reflects a rolling 12-month average rather than a single quarter, which reduces the distortion caused by temporary staffing spikes. Families researching a facility should note the "data period" date listed on the profile to understand how current the figures are.

What Research Shows About Staffing Levels and Resident Outcomes

Decades of peer-reviewed research have documented associations between nursing home staffing levels and measurable resident outcomes. The relationship is not perfectly linear, and facility culture, case mix, and physical environment also influence outcomes, but staffing consistently emerges as a significant variable.

• Pressure ulcers: Studies published in journals including The Gerontologist and Health Services Research have found that facilities with higher RN HPRD have lower rates of pressure ulcer development. One widely cited analysis found that each additional 0.1 RN hours per resident day was associated with a statistically significant reduction in pressure ulcer prevalence.
• Falls and fall-related injuries: Higher CNA staffing is associated with lower fall rates, likely because more direct-care staff allows for more frequent mobility assistance and observation. Some studies report a 10 to 15 percent lower fall rate in facilities in the top staffing quartile compared to the bottom quartile.
• Hospitalizations: A 2019 analysis in JAMA Internal Medicine found that nursing homes in the lowest staffing quintile had significantly higher rates of potentially avoidable hospitalizations compared to better-staffed facilities. These hospitalizations carry both health risks for residents and substantial cost implications, often exceeding $15,000 per acute episode.
• Infection rates and COVID-19 mortality: During the COVID-19 pandemic, multiple studies identified low RN staffing as one of the strongest predictors of facility-level COVID-19 mortality, independent of facility size and geographic COVID burden.

Payroll-Based Journal Data Versus Self-Reported Staffing

Before 2016, nursing homes submitted staffing data to CMS through self-reported surveys conducted roughly every 12 to 15 months. Research comparing self-reported figures to independent payroll audits found systematic overreporting. A 2010 study estimated that self-reported staffing was inflated by roughly 10 to 25 percent at many facilities, with spikes in staffing immediately before and during inspection periods.

CMS addressed this with the Payroll-Based Journal system, which became mandatory for all Medicare- and Medicaid-certified facilities in 2016. Under PBJ, facilities submit actual payroll records electronically every quarter. Because PBJ data is derived from payroll systems, it is harder to manipulate than survey responses, and it captures day-level variation rather than a single snapshot.

However, PBJ data is not fully audit-proof. CMS has identified cases of facilities submitting payroll records that include agency and contract staff hours inconsistently, and data entry errors remain a documented issue. In 2023, the HHS Office of Inspector General issued a report noting that a portion of PBJ submissions contained anomalies warranting closer review. Families and researchers should treat PBJ data as a materially more reliable indicator than pre-2016 self-reported figures, while recognizing it still carries some margin of error.

Questions Families Should Consider When Evaluating a Facility's Staffing

When reviewing staffing data for a specific facility, the following inquiries can help clarify what published figures mean in practice:

• What is the facility's staffing level relative to state and national averages? Care Compare displays these comparisons directly. A facility reporting 2.0 RN HPRD is well above average; one reporting 0.4 RN HPRD is well below.
• Is an RN present 24 hours a day, seven days a week? Care Compare flags whether this standard was met in the most recent reporting