If you could only look at one metric when evaluating a nursing home, it should be staffing. Research consistently shows that nurse staffing levels — both the total hours and the registered nurse hours specifically — predict resident outcomes better than almost any other measurable factor.
Here's how to read the staffing data and what numbers actually matter.
The Three Key Staffing Numbers
CMS reports three staffing metrics per facility:
1. Total Nurse Staffing Hours Per Resident Per Day
This is the combined hours of all nursing staff — registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) — divided by the average daily resident census.
Benchmarks:
- Below 3.0 hours: Very low. Residents are likely not receiving adequate hands-on care.
- 3.0–3.5 hours: Below average. Watch for other warning signs.
- 3.5–4.1 hours: Average range for US nursing homes.
- 4.1+ hours: Above average. CMS research supports this as the minimum for good care outcomes.
A 2023 Biden administration proposed rule would have required a minimum of 3.48 total hours — including at least 0.55 RN hours. Even if the specific rule doesn't take effect, these numbers represent a reasonable minimum threshold.
2. RN Hours Per Resident Per Day
This is specifically registered nurse hours — the clinicians responsible for assessments, care planning, medication management, and supervising other staff.
RN hours matter separately from total nursing hours because RNs have clinical training that CNAs and LPNs lack. Having a high total staffing number but very low RN hours often means the facility is meeting its totals primarily with CNAs — less costly, but less clinically capable.
Benchmarks:
- Below 0.3 hours: Very low. Residents may not receive adequate clinical oversight.
- 0.3–0.5 hours: Below average.
- 0.5–0.8 hours: Average range.
- 0.8+ hours: Above average. Strong clinical oversight.
3. RN Turnover Rate
This is the percentage of full-time equivalent RNs who left the facility in the past year. High turnover destabilizes care — new nurses don't know residents, don't know the facility's workflows, and make more errors.
Benchmarks:
- Below 20%: Low turnover. Sign of a stable work environment.
- 20–40%: Moderate, typical for the industry.
- 40–60%: High. Worth investigating why.
- Above 60%: Very high. A significant warning sign.
Why the Numbers Are Now More Reliable
Before 2016, CMS relied on facilities to self-report their staffing numbers. Unsurprisingly, this led to widespread over-reporting — facilities had every incentive to claim higher staffing than they actually had.
In 2016, CMS implemented the Payroll-Based Journal (PBJ) system, which requires facilities to submit actual payroll data every quarter. Now the staffing numbers on NursingHomeUSA are derived from real payroll records, not self-reported claims.
The Daily Staffing Problem
One limitation of averages is that they hide variation by shift. A facility might average 3.8 hours per resident per day across all shifts, but Sunday nights might have only one CNA for 40 residents.
CMS does not publish shift-level staffing data publicly, but you can ask facilities for their staffing schedules during a visit. Specifically ask: "What is your minimum staffing level for the overnight shift on weekends?" The answer is often revealing.
How to Use This Data When Choosing a Facility
Filter out any facility below 3.5 total nursing hours per resident per day as your starting threshold.
Separately check the RN hours. A 4.0-hour total that's mostly CNAs is less valuable than a 3.8-hour total with strong RN coverage.
Look at the RN turnover rate. A facility with great staffing hours but 70% RN turnover is unstable. High turnover often precedes rating declines.
Compare against the state average. NursingHomeUSA shows each facility's data alongside state averages, so you can see whether a facility is above or below average for its state.
The Understaffed Nursing Home Problem in America
The United States has a systemic nursing home staffing problem. Studies estimate that the average nursing home is understaffed relative to what research shows produces good outcomes. This is driven by low Medicaid reimbursement rates (Medicaid covers the majority of nursing home days nationally), thin operating margins, and a longstanding workforce shortage.
The COVID-19 pandemic made this dramatically worse — nursing homes lost significant portions of their nursing workforce, and many facilities have not fully recovered.
This context matters when you're evaluating data: a facility that was 5-star pre-pandemic may be operating with significantly fewer staff today. Always look at the most recent data.
The Bottom Line
Staffing hours are the single most important number you can look at in CMS data. A beautiful facility with attentive marketing and a terrible staffing ratio is still a dangerous choice. An ordinary-looking facility with excellent staffing and low turnover is likely providing genuinely good care.
Check the numbers before you visit, and ask facility staff directly about staffing during your tour.