Nursing Home Staffing Levels: CMS Benchmarks, PBJ Measurement, and County Rankings
Nursing home staffing levels measure nurse hours per resident per day (HPRD). CMS tracks them via the mandatory Payroll-Based Journal (PBJ) and proposed a minimum of 0.55 registered nurse hours per resident day in 2024 — a benchmark now rescinded but still widely cited for county-level comparison across 14,537 facilities.
What “nursing home staffing level” means
A staffing level is a ratio: total nurse hours worked in a period divided by the total resident-days in that period. A facility with 100 residents where nurses collectively work 55 RN hours per day has an RN-HPRD of 0.55. The metric is additive — RN, LPN, and CNA hours can be summed into a total-nurse figure — but regulators and researchers track each category separately because RNs, LPNs, and CNAs perform distinct clinical functions.
CMS Five-Star ratings show a “staffing” score that reflects both the HPRD values and whether an RN is present in the building at least eight hours a day. Facilities that rely heavily on contract (agency) nurses can earn high HPRD scores while still failing the on-site continuity measure — two separate signals with different implications for resident care.
Nurse staffing categories tracked by CMS
| Staff type | Abbr. | 2024 CMS benchmark | Primary role |
|---|---|---|---|
| Registered Nurse | RN | 0.55 hrs/resident-day | Skilled care, assessments, care plans, medication management |
| Licensed Practical Nurse | LPN | No separate federal floor | Routine nursing, medication administration under RN supervision |
| Certified Nurse Aide | CNA | No separate federal floor | Activities of daily living — bathing, dressing, feeding, mobility |
| Total Nurse Staff | All | 3.48 hrs/resident-day | Combined RN + LPN + CNA hours across all shifts |
Source: CMS 42 CFR §483.35 (final rule April 2024, rescinded February 2026). Benchmarks are cited for comparison — not as in-force federal minimums as of 2026.
How CMS measures staffing: the Payroll-Based Journal (PBJ)
The CMS Payroll-Based Journal (PBJ) Daily Nurse Staffing is a mandatory CMS reporting system that replaced quarterly census snapshots with daily payroll records. Every Medicare- and Medicaid-certified nursing home must file actual hours worked by each employee — by job code, shift, and date — every quarter.
PBJ data became mandatory on July 1, 2016, under §6106 of the Affordable Care Act. Before PBJ, facilities self-reported their staffing levels using census snapshots that were easy to inflate; payroll records are tied to IRS-traceable wage payments, making systematic inflation substantially harder.
CMS releases the PBJ public-use file quarterly. Fonteum’s county-level staffing study draws from the 2025Q2 file, covering 14,537 facilities across qualifying counties in all 50 states.
County-level staffing data from Fonteum
Fonteum’s County-Level Nursing-Home RN Staffing Deserts study ranks every county in the US by census-weighted RN-HPRD, flags counties below the 0.55 benchmark, and publishes the underlying SQL so anyone can reproduce or audit the figures. As of the 2025Q2 PBJ release, 40% of qualifying counties fell below the floor.
View county staffing rankingsStaffing and the CMS Five-Star rating
CMS Nursing Home Compare assigns a dedicated Staffing star (1–5) based on two measures: (1) total-nurse HPRD compared to a case-mix-adjusted expected level, and (2) whether an RN was on-site at least eight hours every day in the quarter. A facility can have ample contract-agency hours and still receive a lower staffing star if it failed the on-site RN measure.
Research published in Health Affairs and the New England Journal of Medicine consistently finds higher RN-HPRD associated with lower 30-day readmission rates, fewer survey deficiencies, and lower rates of pressure ulcers and falls. CMS cites this evidence as the basis for the 2024 rulemaking.
Frequently asked questions
- What is a nursing home staffing level?
- A nursing home staffing level is the number of nurse hours provided per resident per day (HPRD). CMS measures it separately for registered nurses (RN-HPRD), licensed practical nurses (LPN-HPRD), and certified nurse aides (CNA-HPRD), then reports a total-nurse HPRD combining all three categories.
- What staffing level did CMS require for nursing homes?
- A 2024 CMS final rule (42 CFR §483.35) proposed a minimum of 0.55 RN hours per resident day and 3.48 total nurse hours per resident day. The rule was rescinded in early 2026, but 0.55 RN-HPRD remains the most widely cited federal benchmark for comparison.
- How does CMS measure nursing home staffing?
- CMS requires nursing homes to submit daily payroll data through the Payroll-Based Journal (PBJ) system. Facilities report actual hours worked by staff category and job code every calendar quarter. CMS uses this data to compute HPRD figures, which appear on Nursing Home Compare and in federal Five-Star ratings.
- What is a staffing desert?
- A staffing desert is a county where the census-weighted average RN-HPRD across reporting facilities falls below the 0.55 federal benchmark. Fonteum's county-level analysis found that 40% of counties with three or more reporting nursing homes fell below that floor as of 2025 Q2.
- Where can I find staffing data for a specific nursing home?
- CMS Nursing Home Compare (medicare.gov/care-compare) publishes facility-level staffing ratings. Fonteum publishes county-level staffing rankings built from the same PBJ source, aggregated to show geographic access gaps rather than individual facility performance.
- Does a higher staffing level mean better care?
- Research consistently links higher RN-HPRD to lower adverse-event rates, fewer deficiencies, and lower rehospitalization. The CMS Five-Star staffing rating reflects both reported HPRD and whether a facility has an RN on-site daily — two distinct dimensions of staffing adequacy.
- What is the PBJ and why does it matter?
- The Payroll-Based Journal is a CMS system where nursing homes submit actual payroll records for every employee, every day. Unlike self-reported census snapshots (which preceded PBJ), payroll data is harder to inflate — it ties staffing to verifiable payroll records. PBJ became mandatory in July 2016 under ACA §6106.
Related resources
- County-Level Nursing-Home RN Staffing Deserts (research study)
- Nursing Home Medicare Payment Denials (DPNA): What They Are and How Often They Happen
- Nursing Homes Banned from New Medicare Admissions (research study)
- Nursing Home Compare — CMS data hub
- Hospital-Acquired Conditions: CMS Definition & Penalty Data