Nursing Home Staffing After the Federal Mandate Repeal (CY2025Q4)
Only 28.92% of nursing homes meet the 4.1 HPRD research standard — and 7.4% are critically understaffed below 3.0 HPRD. The Biden-era 3.48 HPRD minimum was rescinded December 3, 2025. CMS Payroll-Based Journal data, 14,362 facilities.
Contents · 8 sections
Executive Summary
- 14,362 U.S. nursing homes analyzed from CMS Payroll-Based Journal (PBJ) daily staffing data, CY2025Q4 (October–December 2025), source-released April 16, 2026.
- Only 4,153 facilities (28.92%) meet the 4.1 total nurse HPRD threshold used in peer-reviewed research (Lynn et al.) as an indicator of adequate staffing. The 4.1 HPRD threshold is NOT a current federal mandate — it is a research benchmark.
- 1,063 facilities (7.4%) are critically understaffed, below 3.0 total nurse HPRD — a level associated in the literature with elevated adverse-event rates.
- The Biden-era Interim Final Rule mandating 3.48 total nurse HPRD was rescinded by the Trump administration on December 3, 2025 (effective February 2, 2026). CMS PBJ data continues to publish per-facility staffing hours; PBJ transparency is now the primary accountability mechanism.
- Oregon leads at 5.073 HPRD mean (125 facilities, 98.4% meet 4.1 threshold). Texas trails at 3.39 HPRD (1,155 facilities, only 9.35% meet 4.1 threshold). The 1.37× state disparity masks compound variation at the facility level.
At a glance — for journalists, researchers, and AI agents
What this dataset covers
- Only 28.92% of nursing homes meet the 4.1 HPRD research standard — and 7.4% are critically understaffed below 3.0 HPRD. The Biden-era 3.48 HPRD minimum was rescinded December 3, 2025. CMS Payroll-Based Journal data, 14,362 facilities.
- Dataset: 14,362 records analyzed.
What this dataset does NOT cover
- Fonteum analysis is not a quality measurement of any individual provider.
- Counts and rankings describe the Fonteum-indexed or source-published dataset, not the entire U.S. market.
Sources
- Fonteum indexed dataset
Snapshot date: 2026
Dataset scope · Snapshot May 25, 2026
Includes: the healthcare-provider records this study covers, each tracing to a dated public-record source named in the citation footer. Does not include: providers outside the source named for this study, or records not present in that source at the snapshot date. Counts describe this Fonteum healthcare-provider dataset — not a representative census of the U.S. healthcare workforce.
Key findings
What this study covers
This study aggregates CMS Payroll-Based Journal (PBJ) daily nurse staffing hours for CY2025Q4 (October–December 2025) — the most recent quarter available as of the data release on April 16, 2026.
What PBJ is: Since 2016, CMS has required all Medicare/Medicaid-certified nursing homes to submit daily payroll data on nurse staffing hours via the Payroll-Based Journal system. This data is the most granular public record of nursing home staffing in the U.S.
What this study is not: This report does not independently audit, inspect, or rate any facility. Fonteum surfaces CMS PBJ submissions — it does not independently audit whether submitted hours are accurate. CMS has noted (~5% of facilities) incomplete submissions in prior periods. Facilities with partial-quarter data availability are flagged in the per-facility data.
Units: HPRD = Hours Per Resident Day. National mean of 3.871 HPRD means nursing homes reported an average of 3.871 total nurse hours for each resident-day during CY2025Q4.
The federal mandate repeal
On December 3, 2025, the Trump administration issued an Interim Final Rule rescinding the Biden-era staffing minimum that had been published in April 2024. The Biden rule had established a 3.48 total nurse HPRD minimum (effective February 2026) along with a 0.55 RN HPRD floor. The IFR voided both.
Key implications:
- The 3.48 HPRD federal minimum is no longer enforceable (effective February 2, 2026)
- No federal minimum currently applies to total nurse staffing hours
- CMS continues to collect and publish PBJ data — per-facility transparency is now the primary accountability mechanism
- State-level mandates remain in effect where enacted (California, New York, and several others have independent state minimums)
This study's thresholds (not current federal standards):
- 4.1 HPRD — policy-research baseline from Lynn et al. (JAMA 2007 + follow-on literature); used here to assess whether a facility meets the level researchers associate with adequate staffing
- 3.0 HPRD — used here as a critical understaffing flag; not a federal or state regulatory line
- 3.48 HPRD — the former Biden-era minimum (rescinded); referenced for historical comparison only
State-level variation
Top 5 states by mean total nurse HPRD (among states with ≥ 30 facilities, excluding AK/DC due to small sample):
| State | Mean HPRD | Facilities | % Meeting 4.1 |
|---|---|---|---|
| OR | 5.073 | 125 | 98.4% |
| HI | 4.679 | 42 | — |
| CA | 4.524 | 1,059 | 63.2% |
| ND | 4.422 | 69 | — |
| DE | 4.399 | 43 | — |
Bottom 5 states by mean total nurse HPRD:
| State | Mean HPRD | Facilities | % Meeting 4.1 |
|---|---|---|---|
| TX | 3.390 | 1,155 | 9.35% |
| MO | 3.446 | 477 | — |
| IL | 3.485 | 657 | — |
| GA | 3.579 | 349 | — |
| NM | 3.594 | 66 | — |
Texas (1,155 facilities, 9.35% meeting 4.1 threshold) and Illinois (657 facilities) together account for over 1,800 large-state facilities with disproportionately low staffing rates.
Data source
CMS Payroll-Based Journal (PBJ) Daily Nurse Staffing — mandatory daily staffing submission by all Medicare/Medicaid-certified nursing homes. Public domain under 17 U.S.C. § 105.
- Coverage: CY2025Q4 (October 1 – December 31, 2025)
- Source released: April 16, 2026
- Facilities: 14,362 (15 flagged for incomplete rows)
- Source dataset slug: cms-pbj-daily-nurse-staffing-2026-05-08
- Methodology version: pbj-staffing/v1
Limitations
- PBJ data reflects what facilities report to CMS. Fonteum does not independently audit submitted hours for accuracy.
- McKnight's Long-Term Care News (Q4 2024) reported approximately 5% of facilities received penalties for incomplete PBJ submissions in prior periods.
- The 4.1 HPRD and 3.0 HPRD thresholds used here are research benchmarks, not current federal regulatory standards.
- Per-day staffing rows are not materialized in this snapshot — the aggregate reflects the facility-period mean. Per-facility per-day detail requires the source CSV (~226 MB).
- iQIES system migration (July 2025) affected upstream survey data; PBJ submission pipeline is separate and data integrity for CY2025Q4 is not affected.
- State minimums (CA, NY, others) may set different floors; this study uses federal thresholds only.
Limitations
- This study's findings are scoped to the dataset and time window described in the methodology. They do not constitute medical, legal, or financial advice.
- Fonteum does not independently rate, inspect, verify, endorse, or guarantee any provider referenced in this study.
Methodology
Read the full methodology
CMS Payroll-Based Journal (PBJ) daily staffing data aggregated at the facility level for CY2025Q4 (Oct–Dec 2025). Total nurse HPRD = sum of all nurse hours (RN + LPN + CNA) divided by resident-days. Distress thresholds: 4.1 HPRD (Lynn et al. research standard — not a current federal mandate); 3.0 HPRD (critical understaffing flag — not a federal standard). The Biden-era 3.48 HPRD federal minimum was rescinded December 3, 2025 (IFR, effective February 2, 2026). National means are arithmetic averages across all 14,362 facilities. State rankings exclude AK (13 facilities) for top-state analysis due to small-sample sensitivity. Source: CMS PBJ snapshot fetched 2026-05-08, source-released 2026-04-16. Methodology version: pbj-staffing/v1.
CMS Payroll-Based Journal (PBJ) daily staffing data aggregated at the facility level for CY2025Q4 (Oct–Dec 2025). Total nurse HPRD = sum of all nurse hours (RN + LPN + CNA) divided by resident-days. Distress thresholds: 4.1 HPRD (Lynn et al. research standard — not a current federal mandate); 3.0 HPRD (critical understaffing flag — not a federal standard). The Biden-era 3.48 HPRD federal minimum was rescinded December 3, 2025 (IFR, effective February 2, 2026). National means are arithmetic averages across all 14,362 facilities. State rankings exclude AK (13 facilities) for top-state analysis due to small-sample sensitivity. Source: CMS PBJ snapshot fetched 2026-05-08, source-released 2026-04-16. Methodology version: pbj-staffing/v1.