{ "study": { "slug": "nursing-home-staffing-deserts-by-county", "title": "County-Level Nursing-Home RN Staffing Deserts", "url": "https://fonteum.com/research/nursing-home-staffing-deserts-by-county", "methodology_version": "county-staffing-deserts/v1" }, "data_as_of": "2026-06-03", "temporal_coverage": "2025-04-01/2025-06-30", "sources": [ { "name": "CMS Payroll-Based Journal (PBJ) Daily Nurse Staffing", "publisher": "U.S. Centers for Medicare & Medicaid Services", "url": "https://data.cms.gov/quality-of-care/payroll-based-journal-daily-nurse-staffing", "release_date": "2025-06-30", "retrieved_at": "2026-06-03", "license": "U.S. Government Works (17 U.S.C. §105)" } ], "headline": { "published": "2026-06-03", "snapshot_quarter": "2025Q2", "qualifying_counties": 1362, "counties_below_rn_floor": 550, "pct_below_rn_floor": 40.4, "facilities_covered": 12447, "facilities_in_full_quarter": 14537, "pooled_rn_hprd": 0.623, "median_county_rn_hprd": 0.596, "lowest_county_rn_hprd": 0.156, "federal_rn_hprd_standard": 0.55, "federal_total_hprd_standard": 3.48, "min_facilities_per_county": 3, "ranked_deserts_published": 50 }, "sections": [ { "id": "desert_counties", "label": "The 50 lowest-staffed qualifying counties", "columns": [ "county_fips", "county", "state", "state_name", "region", "rank", "facilities", "rn_hprd", "rn_direct_hprd", "total_nurse_hprd", "resident_days", "share_of_federal_standard", "below_standard" ], "rows": [ { "county_fips": "22013", "county": "Bienville", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 1, "facilities": 3, "rn_hprd": 0.156, "rn_direct_hprd": 0.101, "total_nurse_hprd": 3.679, "resident_days": 25853, "share_of_federal_standard": 0.284, "below_standard": true }, { "county_fips": "22101", "county": "St. Mary", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 2, "facilities": 3, "rn_hprd": 0.157, "rn_direct_hprd": 0.038, "total_nurse_hprd": 3.268, "resident_days": 26593, "share_of_federal_standard": 0.285, "below_standard": true }, { "county_fips": "22045", "county": "Iberia", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 3, "facilities": 4, "rn_hprd": 0.176, "rn_direct_hprd": 0.021, "total_nurse_hprd": 3.665, "resident_days": 29229, "share_of_federal_standard": 0.32, "below_standard": true }, { "county_fips": "22055", "county": "Lafayette", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 4, "facilities": 10, "rn_hprd": 0.177, "rn_direct_hprd": 0.04, "total_nurse_hprd": 3.793, "resident_days": 86150, "share_of_federal_standard": 0.322, "below_standard": true }, { "county_fips": "40131", "county": "Rogers", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 5, "facilities": 5, "rn_hprd": 0.192, "rn_direct_hprd": 0.099, "total_nurse_hprd": 3.557, "resident_days": 31463, "share_of_federal_standard": 0.349, "below_standard": true }, { "county_fips": "06031", "county": "Kings", "state": "CA", "state_name": "California", "region": "West", "rank": 6, "facilities": 3, "rn_hprd": 0.195, "rn_direct_hprd": 0.127, "total_nurse_hprd": 4.013, "resident_days": 23209, "share_of_federal_standard": 0.355, "below_standard": true }, { "county_fips": "40051", "county": "Grady", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 7, "facilities": 4, "rn_hprd": 0.197, "rn_direct_hprd": 0.098, "total_nurse_hprd": 3.915, "resident_days": 20767, "share_of_federal_standard": 0.358, "below_standard": true }, { "county_fips": "29159", "county": "Pettis", "state": "MO", "state_name": "Missouri", "region": "Midwest", "rank": 8, "facilities": 5, "rn_hprd": 0.199, "rn_direct_hprd": 0.142, "total_nurse_hprd": 2.043, "resident_days": 47443, "share_of_federal_standard": 0.362, "below_standard": true }, { "county_fips": "40091", "county": "Mcintosh", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 9, "facilities": 3, "rn_hprd": 0.199, "rn_direct_hprd": 0.04, "total_nurse_hprd": 3.603, "resident_days": 16588, "share_of_federal_standard": 0.362, "below_standard": true }, { "county_fips": "40015", "county": "Caddo", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 10, "facilities": 3, "rn_hprd": 0.2, "rn_direct_hprd": 0.039, "total_nurse_hprd": 3.899, "resident_days": 12371, "share_of_federal_standard": 0.364, "below_standard": true }, { "county_fips": "48361", "county": "Orange", "state": "TX", "state_name": "Texas", "region": "South", "rank": 11, "facilities": 3, "rn_hprd": 0.202, "rn_direct_hprd": 0.127, "total_nurse_hprd": 3.031, "resident_days": 25345, "share_of_federal_standard": 0.367, "below_standard": true }, { "county_fips": "06025", "county": "Imperial", "state": "CA", "state_name": "California", "region": "West", "rank": 12, "facilities": 3, "rn_hprd": 0.207, "rn_direct_hprd": 0.128, "total_nurse_hprd": 3.978, "resident_days": 19479, "share_of_federal_standard": 0.376, "below_standard": true }, { "county_fips": "22061", "county": "Lincoln", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 13, "facilities": 3, "rn_hprd": 0.21, "rn_direct_hprd": 0.082, "total_nurse_hprd": 3.522, "resident_days": 27394, "share_of_federal_standard": 0.382, "below_standard": true }, { "county_fips": "40049", "county": "Garvin", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 14, "facilities": 3, "rn_hprd": 0.217, "rn_direct_hprd": 0.114, "total_nurse_hprd": 3.295, "resident_days": 13408, "share_of_federal_standard": 0.395, "below_standard": true }, { "county_fips": "48405", "county": "San Augustine", "state": "TX", "state_name": "Texas", "region": "South", "rank": 15, "facilities": 3, "rn_hprd": 0.221, "rn_direct_hprd": 0.078, "total_nurse_hprd": 3.53, "resident_days": 12641, "share_of_federal_standard": 0.402, "below_standard": true }, { "county_fips": "22001", "county": "Acadia", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 16, "facilities": 5, "rn_hprd": 0.223, "rn_direct_hprd": 0.111, "total_nurse_hprd": 3.834, "resident_days": 45700, "share_of_federal_standard": 0.405, "below_standard": true }, { "county_fips": "48497", "county": "Wise", "state": "TX", "state_name": "Texas", "region": "South", "rank": 17, "facilities": 4, "rn_hprd": 0.223, "rn_direct_hprd": 0.11, "total_nurse_hprd": 2.954, "resident_days": 29380, "share_of_federal_standard": 0.405, "below_standard": true }, { "county_fips": "22073", "county": "Ouachita", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 18, "facilities": 9, "rn_hprd": 0.228, "rn_direct_hprd": 0.083, "total_nurse_hprd": 3.826, "resident_days": 72725, "share_of_federal_standard": 0.415, "below_standard": true }, { "county_fips": "40089", "county": "Mccurtain", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 19, "facilities": 3, "rn_hprd": 0.229, "rn_direct_hprd": 0.129, "total_nurse_hprd": 2.925, "resident_days": 16034, "share_of_federal_standard": 0.416, "below_standard": true }, { "county_fips": "40147", "county": "Washington", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 20, "facilities": 5, "rn_hprd": 0.229, "rn_direct_hprd": 0.113, "total_nurse_hprd": 3.942, "resident_days": 27374, "share_of_federal_standard": 0.416, "below_standard": true }, { "county_fips": "40135", "county": "Sequoyah", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 21, "facilities": 4, "rn_hprd": 0.23, "rn_direct_hprd": 0.066, "total_nurse_hprd": 4.27, "resident_days": 20260, "share_of_federal_standard": 0.418, "below_standard": true }, { "county_fips": "48265", "county": "Kerr", "state": "TX", "state_name": "Texas", "region": "South", "rank": 22, "facilities": 4, "rn_hprd": 0.231, "rn_direct_hprd": 0.136, "total_nurse_hprd": 3.282, "resident_days": 31578, "share_of_federal_standard": 0.42, "below_standard": true }, { "county_fips": "40031", "county": "Comanche", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 23, "facilities": 4, "rn_hprd": 0.231, "rn_direct_hprd": 0.128, "total_nurse_hprd": 3.815, "resident_days": 32448, "share_of_federal_standard": 0.42, "below_standard": true }, { "county_fips": "34033", "county": "Salem", "state": "NJ", "state_name": "New Jersey", "region": "Northeast", "rank": 24, "facilities": 4, "rn_hprd": 0.232, "rn_direct_hprd": 0.133, "total_nurse_hprd": 3.506, "resident_days": 41983, "share_of_federal_standard": 0.422, "below_standard": true }, { "county_fips": "22113", "county": "Vermilion", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 25, "facilities": 6, "rn_hprd": 0.232, "rn_direct_hprd": 0.112, "total_nurse_hprd": 3.693, "resident_days": 46858, "share_of_federal_standard": 0.422, "below_standard": true }, { "county_fips": "22105", "county": "Tangipahoa", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 26, "facilities": 6, "rn_hprd": 0.234, "rn_direct_hprd": 0.139, "total_nurse_hprd": 3.959, "resident_days": 56230, "share_of_federal_standard": 0.425, "below_standard": true }, { "county_fips": "22067", "county": "Morehouse", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 27, "facilities": 4, "rn_hprd": 0.235, "rn_direct_hprd": 0.1, "total_nurse_hprd": 3.904, "resident_days": 25218, "share_of_federal_standard": 0.427, "below_standard": true }, { "county_fips": "40079", "county": "Le Flore", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 28, "facilities": 6, "rn_hprd": 0.236, "rn_direct_hprd": 0.093, "total_nurse_hprd": 3.387, "resident_days": 28301, "share_of_federal_standard": 0.429, "below_standard": true }, { "county_fips": "29055", "county": "Crawford", "state": "MO", "state_name": "Missouri", "region": "Midwest", "rank": 29, "facilities": 3, "rn_hprd": 0.237, "rn_direct_hprd": 0.157, "total_nurse_hprd": 2.749, "resident_days": 12764, "share_of_federal_standard": 0.431, "below_standard": true }, { "county_fips": "48245", "county": "Jefferson", "state": "TX", "state_name": "Texas", "region": "South", "rank": 30, "facilities": 13, "rn_hprd": 0.24, "rn_direct_hprd": 0.126, "total_nurse_hprd": 3.409, "resident_days": 89681, "share_of_federal_standard": 0.436, "below_standard": true }, { "county_fips": "22039", "county": "Evangeline", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 31, "facilities": 4, "rn_hprd": 0.241, "rn_direct_hprd": 0.154, "total_nurse_hprd": 3.907, "resident_days": 30852, "share_of_federal_standard": 0.438, "below_standard": true }, { "county_fips": "22033", "county": "E. Baton Rouge", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 32, "facilities": 25, "rn_hprd": 0.243, "rn_direct_hprd": 0.119, "total_nurse_hprd": 3.687, "resident_days": 216008, "share_of_federal_standard": 0.442, "below_standard": true }, { "county_fips": "22071", "county": "Orleans", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 33, "facilities": 11, "rn_hprd": 0.243, "rn_direct_hprd": 0.124, "total_nurse_hprd": 3.83, "resident_days": 106495, "share_of_federal_standard": 0.442, "below_standard": true }, { "county_fips": "22019", "county": "Calcasieu", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 34, "facilities": 10, "rn_hprd": 0.245, "rn_direct_hprd": 0.143, "total_nurse_hprd": 3.81, "resident_days": 79725, "share_of_federal_standard": 0.445, "below_standard": true }, { "county_fips": "48021", "county": "Bastrop", "state": "TX", "state_name": "Texas", "region": "South", "rank": 35, "facilities": 5, "rn_hprd": 0.245, "rn_direct_hprd": 0.123, "total_nurse_hprd": 2.626, "resident_days": 41117, "share_of_federal_standard": 0.445, "below_standard": true }, { "county_fips": "13143", "county": "Haralson", "state": "GA", "state_name": "Georgia", "region": "South", "rank": 36, "facilities": 3, "rn_hprd": 0.245, "rn_direct_hprd": 0.168, "total_nurse_hprd": 3.11, "resident_days": 18487, "share_of_federal_standard": 0.445, "below_standard": true }, { "county_fips": "05033", "county": "Crawford", "state": "AR", "state_name": "Arkansas", "region": "South", "rank": 37, "facilities": 4, "rn_hprd": 0.245, "rn_direct_hprd": 0.088, "total_nurse_hprd": 3.981, "resident_days": 31325, "share_of_federal_standard": 0.445, "below_standard": true }, { "county_fips": "22109", "county": "Terrebonne", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 38, "facilities": 3, "rn_hprd": 0.246, "rn_direct_hprd": 0.149, "total_nurse_hprd": 3.471, "resident_days": 34402, "share_of_federal_standard": 0.447, "below_standard": true }, { "county_fips": "48149", "county": "Fayette", "state": "TX", "state_name": "Texas", "region": "South", "rank": 39, "facilities": 5, "rn_hprd": 0.249, "rn_direct_hprd": 0.169, "total_nurse_hprd": 2.964, "resident_days": 29987, "share_of_federal_standard": 0.453, "below_standard": true }, { "county_fips": "13233", "county": "Polk", "state": "GA", "state_name": "Georgia", "region": "South", "rank": 40, "facilities": 3, "rn_hprd": 0.249, "rn_direct_hprd": 0.134, "total_nurse_hprd": 4.44, "resident_days": 19885, "share_of_federal_standard": 0.453, "below_standard": true }, { "county_fips": "22041", "county": "Franklin", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 41, "facilities": 4, "rn_hprd": 0.249, "rn_direct_hprd": 0.058, "total_nurse_hprd": 3.839, "resident_days": 27352, "share_of_federal_standard": 0.453, "below_standard": true }, { "county_fips": "29113", "county": "Lincoln", "state": "MO", "state_name": "Missouri", "region": "Midwest", "rank": 42, "facilities": 4, "rn_hprd": 0.251, "rn_direct_hprd": 0.166, "total_nurse_hprd": 2.294, "resident_days": 24062, "share_of_federal_standard": 0.456, "below_standard": true }, { "county_fips": "29101", "county": "Johnson", "state": "MO", "state_name": "Missouri", "region": "Midwest", "rank": 43, "facilities": 5, "rn_hprd": 0.252, "rn_direct_hprd": 0.157, "total_nurse_hprd": 2.799, "resident_days": 23943, "share_of_federal_standard": 0.458, "below_standard": true }, { "county_fips": "48241", "county": "Jasper", "state": "TX", "state_name": "Texas", "region": "South", "rank": 44, "facilities": 3, "rn_hprd": 0.252, "rn_direct_hprd": 0.082, "total_nurse_hprd": 3.25, "resident_days": 14835, "share_of_federal_standard": 0.458, "below_standard": true }, { "county_fips": "29175", "county": "Randolph", "state": "MO", "state_name": "Missouri", "region": "Midwest", "rank": 45, "facilities": 3, "rn_hprd": 0.255, "rn_direct_hprd": 0.16, "total_nurse_hprd": 2.183, "resident_days": 28343, "share_of_federal_standard": 0.464, "below_standard": true }, { "county_fips": "13255", "county": "Spalding", "state": "GA", "state_name": "Georgia", "region": "South", "rank": 46, "facilities": 3, "rn_hprd": 0.255, "rn_direct_hprd": 0.15, "total_nurse_hprd": 3.569, "resident_days": 28804, "share_of_federal_standard": 0.464, "below_standard": true }, { "county_fips": "29041", "county": "Chariton", "state": "MO", "state_name": "Missouri", "region": "Midwest", "rank": 47, "facilities": 3, "rn_hprd": 0.256, "rn_direct_hprd": 0.145, "total_nurse_hprd": 2.196, "resident_days": 17315, "share_of_federal_standard": 0.465, "below_standard": true }, { "county_fips": "48099", "county": "Coryell", "state": "TX", "state_name": "Texas", "region": "South", "rank": 48, "facilities": 4, "rn_hprd": 0.259, "rn_direct_hprd": 0.193, "total_nurse_hprd": 3.461, "resident_days": 31055, "share_of_federal_standard": 0.471, "below_standard": true }, { "county_fips": "40101", "county": "Muskogee", "state": "OK", "state_name": "Oklahoma", "region": "South", "rank": 49, "facilities": 10, "rn_hprd": 0.26, "rn_direct_hprd": 0.15, "total_nurse_hprd": 3.809, "resident_days": 57415, "share_of_federal_standard": 0.473, "below_standard": true }, { "county_fips": "22111", "county": "Union", "state": "LA", "state_name": "Louisiana", "region": "South", "rank": 50, "facilities": 3, "rn_hprd": 0.262, "rn_direct_hprd": 0.193, "total_nurse_hprd": 3.639, "resident_days": 22791, "share_of_federal_standard": 0.476, "below_standard": true } ] }, { "id": "by_state", "label": "State rollups", "columns": [ "state", "state_name", "state_fips", "region", "qualifying_counties", "desert_counties", "desert_share", "pooled_rn_hprd", "facilities" ], "rows": [ { "state": "LA", "state_name": "Louisiana", "state_fips": "22", "region": "South", "qualifying_counties": 32, "desert_counties": 32, "desert_share": 1, "pooled_rn_hprd": 0.258, "facilities": 214 }, { "state": "OK", "state_name": "Oklahoma", "state_fips": "40", "region": "South", "qualifying_counties": 37, "desert_counties": 37, "desert_share": 1, "pooled_rn_hprd": 0.318, "facilities": 228 }, { "state": "TX", "state_name": "Texas", "state_fips": "48", "region": "South", "qualifying_counties": 108, "desert_counties": 102, "desert_share": 0.9444444444444444, "pooled_rn_hprd": 0.401, "facilities": 1019 }, { "state": "AR", "state_name": "Arkansas", "state_fips": "05", "region": "South", "qualifying_counties": 26, "desert_counties": 24, "desert_share": 0.9230769230769231, "pooled_rn_hprd": 0.387, "facilities": 148 }, { "state": "MO", "state_name": "Missouri", "state_fips": "29", "region": "Midwest", "qualifying_counties": 59, "desert_counties": 52, "desert_share": 0.8813559322033898, "pooled_rn_hprd": 0.404, "facilities": 402 }, { "state": "GA", "state_name": "Georgia", "state_fips": "13", "region": "South", "qualifying_counties": 42, "desert_counties": 31, "desert_share": 0.7380952380952381, "pooled_rn_hprd": 0.451, "facilities": 218 }, { "state": "NC", "state_name": "North Carolina", "state_fips": "37", "region": "South", "qualifying_counties": 51, "desert_counties": 32, "desert_share": 0.6274509803921569, "pooled_rn_hprd": 0.533, "facilities": 341 }, { "state": "NY", "state_name": "New York", "state_fips": "36", "region": "Northeast", "qualifying_counties": 50, "desert_counties": 29, "desert_share": 0.58, "pooled_rn_hprd": 0.669, "facilities": 577 }, { "state": "SC", "state_name": "South Carolina", "state_fips": "45", "region": "South", "qualifying_counties": 22, "desert_counties": 12, "desert_share": 0.5454545454545454, "pooled_rn_hprd": 0.536, "facilities": 147 }, { "state": "TN", "state_name": "Tennessee", "state_fips": "47", "region": "South", "qualifying_counties": 38, "desert_counties": 20, "desert_share": 0.5263157894736842, "pooled_rn_hprd": 0.584, "facilities": 218 }, { "state": "NJ", "state_name": "New Jersey", "state_fips": "34", "region": "Northeast", "qualifying_counties": 21, "desert_counties": 11, "desert_share": 0.5238095238095238, "pooled_rn_hprd": 0.611, "facilities": 346 }, { "state": "CA", "state_name": "California", "state_fips": "06", "region": "West", "qualifying_counties": 39, "desert_counties": 19, "desert_share": 0.48717948717948717, "pooled_rn_hprd": 0.557, "facilities": 1121 }, { "state": "VA", "state_name": "Virginia", "state_fips": "51", "region": "South", "qualifying_counties": 37, "desert_counties": 18, "desert_share": 0.4864864864864865, "pooled_rn_hprd": 0.566, "facilities": 184 }, { "state": "IL", "state_name": "Illinois", "state_fips": "17", "region": "Midwest", "qualifying_counties": 60, "desert_counties": 28, "desert_share": 0.4666666666666667, "pooled_rn_hprd": 0.674, "facilities": 608 }, { "state": "MA", "state_name": "Massachusetts", "state_fips": "25", "region": "Northeast", "qualifying_counties": 12, "desert_counties": 5, "desert_share": 0.4166666666666667, "pooled_rn_hprd": 0.615, "facilities": 334 }, { "state": "NM", "state_name": "New Mexico", "state_fips": "35", "region": "West", "qualifying_counties": 8, "desert_counties": 3, "desert_share": 0.375, "pooled_rn_hprd": 0.603, "facilities": 45 }, { "state": "OH", "state_name": "Ohio", "state_fips": "39", "region": "Midwest", "qualifying_counties": 78, "desert_counties": 24, "desert_share": 0.3076923076923077, "pooled_rn_hprd": 0.6, "facilities": 900 }, { "state": "OR", "state_name": "Oregon", "state_fips": "41", "region": "West", "qualifying_counties": 14, "desert_counties": 4, "desert_share": 0.2857142857142857, "pooled_rn_hprd": 0.642, "facilities": 111 }, { "state": "MS", "state_name": "Mississippi", "state_fips": "28", "region": "South", "qualifying_counties": 25, "desert_counties": 7, "desert_share": 0.28, "pooled_rn_hprd": 0.567, "facilities": 118 }, { "state": "FL", "state_name": "Florida", "state_fips": "12", "region": "South", "qualifying_counties": 40, "desert_counties": 10, "desert_share": 0.25, "pooled_rn_hprd": 0.726, "facilities": 653 }, { "state": "AL", "state_name": "Alabama", "state_fips": "01", "region": "South", "qualifying_counties": 28, "desert_counties": 6, "desert_share": 0.21428571428571427, "pooled_rn_hprd": 0.614, "facilities": 168 }, { "state": "PA", "state_name": "Pennsylvania", "state_fips": "42", "region": "Northeast", "qualifying_counties": 52, "desert_counties": 11, "desert_share": 0.21153846153846154, "pooled_rn_hprd": 0.671, "facilities": 627 }, { "state": "NE", "state_name": "Nebraska", "state_fips": "31", "region": "Midwest", "qualifying_counties": 19, "desert_counties": 3, "desert_share": 0.15789473684210525, "pooled_rn_hprd": 0.733, "facilities": 99 }, { "state": "IA", "state_name": "Iowa", "state_fips": "19", "region": "Midwest", "qualifying_counties": 65, "desert_counties": 10, "desert_share": 0.15384615384615385, "pooled_rn_hprd": 0.721, "facilities": 337 }, { "state": "IN", "state_name": "Indiana", "state_fips": "18", "region": "Midwest", "qualifying_counties": 56, "desert_counties": 8, "desert_share": 0.14285714285714285, "pooled_rn_hprd": 0.609, "facilities": 453 }, { "state": "KY", "state_name": "Kentucky", "state_fips": "21", "region": "South", "qualifying_counties": 22, "desert_counties": 3, "desert_share": 0.13636363636363635, "pooled_rn_hprd": 0.69, "facilities": 144 }, { "state": "KS", "state_name": "Kansas", "state_fips": "20", "region": "Midwest", "qualifying_counties": 30, "desert_counties": 4, "desert_share": 0.13333333333333333, "pooled_rn_hprd": 0.671, "facilities": 209 }, { "state": "AZ", "state_name": "Arizona", "state_fips": "04", "region": "West", "qualifying_counties": 10, "desert_counties": 1, "desert_share": 0.1, "pooled_rn_hprd": 0.663, "facilities": 136 }, { "state": "MI", "state_name": "Michigan", "state_fips": "26", "region": "Midwest", "qualifying_counties": 39, "desert_counties": 3, "desert_share": 0.07692307692307693, "pooled_rn_hprd": 0.662, "facilities": 354 }, { "state": "WV", "state_name": "West Virginia", "state_fips": "54", "region": "South", "qualifying_counties": 13, "desert_counties": 1, "desert_share": 0.07692307692307693, "pooled_rn_hprd": 0.675, "facilities": 63 }, { "state": "CT", "state_name": "Connecticut", "state_fips": "09", "region": "Northeast", "qualifying_counties": 9, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.625, "facilities": 191 }, { "state": "WA", "state_name": "Washington", "state_fips": "53", "region": "West", "qualifying_counties": 18, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.868, "facilities": 173 }, { "state": "MD", "state_name": "Maryland", "state_fips": "24", "region": "South", "qualifying_counties": 19, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.735, "facilities": 211 }, { "state": "WI", "state_name": "Wisconsin", "state_fips": "55", "region": "Midwest", "qualifying_counties": 43, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.931, "facilities": 281 }, { "state": "RI", "state_name": "Rhode Island", "state_fips": "44", "region": "Northeast", "qualifying_counties": 5, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.714, "facilities": 71 }, { "state": "ID", "state_name": "Idaho", "state_fips": "16", "region": "West", "qualifying_counties": 7, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.776, "facilities": 47 }, { "state": "NH", "state_name": "New Hampshire", "state_fips": "33", "region": "Northeast", "qualifying_counties": 10, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.735, "facilities": 74 }, { "state": "MN", "state_name": "Minnesota", "state_fips": "27", "region": "Midwest", "qualifying_counties": 41, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 1.061, "facilities": 263 }, { "state": "VT", "state_name": "Vermont", "state_fips": "50", "region": "Northeast", "qualifying_counties": 8, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.796, "facilities": 29 }, { "state": "NV", "state_name": "Nevada", "state_fips": "32", "region": "West", "qualifying_counties": 3, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.786, "facilities": 54 }, { "state": "SD", "state_name": "South Dakota", "state_fips": "46", "region": "Midwest", "qualifying_counties": 7, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.819, "facilities": 36 }, { "state": "CO", "state_name": "Colorado", "state_fips": "08", "region": "West", "qualifying_counties": 17, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.791, "facilities": 175 }, { "state": "MT", "state_name": "Montana", "state_fips": "30", "region": "West", "qualifying_counties": 5, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.874, "facilities": 23 }, { "state": "DE", "state_name": "Delaware", "state_fips": "10", "region": "South", "qualifying_counties": 3, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.84, "facilities": 43 }, { "state": "ND", "state_name": "North Dakota", "state_fips": "38", "region": "Midwest", "qualifying_counties": 8, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.911, "facilities": 34 }, { "state": "WY", "state_name": "Wyoming", "state_fips": "56", "region": "West", "qualifying_counties": 4, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 0.871, "facilities": 12 }, { "state": "ME", "state_name": "Maine", "state_fips": "23", "region": "Northeast", "qualifying_counties": 9, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 1.035, "facilities": 68 }, { "state": "UT", "state_name": "Utah", "state_fips": "49", "region": "West", "qualifying_counties": 7, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 1.058, "facilities": 81 }, { "state": "HI", "state_name": "Hawaii", "state_fips": "15", "region": "West", "qualifying_counties": 4, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 1.488, "facilities": 41 }, { "state": "DC", "state_name": "District of Columbia", "state_fips": "11", "region": "South", "qualifying_counties": 1, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 1.151, "facilities": 15 }, { "state": "AK", "state_name": "Alaska", "state_fips": "02", "region": "West", "qualifying_counties": 1, "desert_counties": 0, "desert_share": 0, "pooled_rn_hprd": 1.759, "facilities": 3 } ] }, { "id": "by_region", "label": "Census-region rollups", "columns": [ "region", "qualifying_counties", "desert_counties", "desert_share", "pooled_rn_hprd" ], "rows": [ { "region": "South", "qualifying_counties": 544, "desert_counties": 335, "desert_share": 0.616, "pooled_rn_hprd": 0.544 }, { "region": "Northeast", "qualifying_counties": 176, "desert_counties": 56, "desert_share": 0.318, "pooled_rn_hprd": 0.66 }, { "region": "Midwest", "qualifying_counties": 505, "desert_counties": 132, "desert_share": 0.261, "pooled_rn_hprd": 0.664 }, { "region": "West", "qualifying_counties": 137, "desert_counties": 27, "desert_share": 0.197, "pooled_rn_hprd": 0.664 } ] }, { "id": "by_market_size", "label": "Market size (facility-count buckets)", "columns": [ "bucket", "counties", "desert_counties", "desert_share", "pooled_rn_hprd" ], "rows": [ { "bucket": "3 facilities (smallest markets)", "counties": 371, "desert_counties": 173, "desert_share": 0.466, "pooled_rn_hprd": 0.584 }, { "bucket": "4–5 facilities", "counties": 394, "desert_counties": 175, "desert_share": 0.444, "pooled_rn_hprd": 0.58 }, { "bucket": "6–9 facilities", "counties": 284, "desert_counties": 99, "desert_share": 0.349, "pooled_rn_hprd": 0.626 }, { "bucket": "10+ facilities (largest markets)", "counties": 313, "desert_counties": 103, "desert_share": 0.329, "pooled_rn_hprd": 0.634 } ] } ], "limitations": [ "Single quarter. This snapshot covers 2025Q2 only; staffing varies seasonally and with local labor conditions, so a county's rank can move across quarters.", "Self-reported payroll. PBJ is payroll-derived and auditable, but it is still submitted by facilities. CMS audits a sample; this study does not independently re-audit hours.", "Census denominator. RN-HPRD uses MDS census as the resident count. Days with suppressed or missing census are excluded from that facility's contribution.", "Urbanicity is a proxy. The rural/urban view uses facility count as a stand-in for market size, not a Census rural-urban-commuting-area classification.", "County boundaries follow the PBJ file; independent cities and parish/borough equivalents are counted as their own counties. Puerto Rico municipios are present in the source but rarely meet the facility threshold.", "CMS now reports Connecticut under its nine 2022 Census planning regions. Every CT planning region reports RN-HPRD above the federal floor; all nine appear at full fidelity in the ranked dataset.", "No quality claim. Low RN-HPRD is a staffing-input measure, not an outcome judgment about any specific facility. Fonteum does not rate or rank individual homes." ], "reproducible_sql": "-- county-staffing-deserts.sql — canonical aggregation for the\n-- /research/nursing-home-staffing-deserts-by-county study.\n--\n-- Source table: public.pbj_daily_nurse_staffing\n-- CMS Payroll-Based Journal (PBJ) Daily Nurse Staffing public-use file.\n-- Grain: one row per facility (CCN) per calendar day.\n-- Snapshot: 2025Q2 (2025-04-01 .. 2025-06-30), 1,322,867 rows, 14,537 facilities.\n--\n-- Output: one JSON array (column `data`) of qualifying-county rows, ranked\n-- ascending by total RN hours-per-resident-day. Written verbatim to\n-- public/research/data/county-staffing-deserts-2025q2.json\n--\n-- Methodology:\n-- * Total RN hours = Direct-Care RN (job code 7, hrs_rn)\n-- + RN Administrative (job code 6, hrs_rnadmin)\n-- + RN Director of Nursing (job code 5, hrs_rndon).\n-- * Resident-days = Σ mds_census.\n-- * County RN-HPRD = Σ RN hours / Σ resident-days (census-weighted).\n-- * Minimum-facility threshold: ≥ 3 distinct reporting CCNs per county\n-- (damps small-county noise).\n-- * 5-digit FIPS = state FIPS (from the USPS→FIPS map) + 3-digit county_fips.\n--\n-- Re-run cadence: regenerate when a newer PBJ quarter is loaded into\n-- pbj_daily_nurse_staffing; bump SNAPSHOT_QUARTER + the committed JSON filename\n-- in src/lib/research/county-staffing-deserts.ts to match.\n\nWITH sfips(st, fp) AS (\n VALUES\n ('AL','01'),('AK','02'),('AZ','04'),('AR','05'),('CA','06'),('CO','08'),('CT','09'),\n ('DE','10'),('DC','11'),('FL','12'),('GA','13'),('HI','15'),('ID','16'),('IL','17'),\n ('IN','18'),('IA','19'),('KS','20'),('KY','21'),('LA','22'),('ME','23'),('MD','24'),\n ('MA','25'),('MI','26'),('MN','27'),('MS','28'),('MO','29'),('MT','30'),('NE','31'),\n ('NV','32'),('NH','33'),('NJ','34'),('NM','35'),('NY','36'),('NC','37'),('ND','38'),\n ('OH','39'),('OK','40'),('OR','41'),('PA','42'),('RI','44'),('SC','45'),('SD','46'),\n ('TN','47'),('TX','48'),('UT','49'),('VT','50'),('VA','51'),('WA','53'),('WV','54'),\n ('WI','55'),('WY','56'),('PR','72')\n),\nfac AS (\n SELECT state, county_name, county_fips, provnum,\n SUM(COALESCE(hrs_rn,0) + COALESCE(hrs_rnadmin,0) + COALESCE(hrs_rndon,0)) AS rn_t,\n SUM(COALESCE(hrs_rn,0)) AS rn_d,\n SUM(COALESCE(hrs_rn,0) + COALESCE(hrs_rnadmin,0) + COALESCE(hrs_rndon,0)\n + COALESCE(hrs_lpn,0) + COALESCE(hrs_lpnadmin,0)\n + COALESCE(hrs_cna,0) + COALESCE(hrs_medaide,0)) AS tot,\n SUM(COALESCE(mds_census,0)) AS rd\n FROM public.pbj_daily_nurse_staffing\n WHERE county_fips IS NOT NULL AND county_fips <> '' AND state IS NOT NULL\n GROUP BY state, county_name, county_fips, provnum\n),\ncounty AS (\n SELECT f.state, f.county_name, f.county_fips,\n COUNT(DISTINCT f.provnum) AS fac,\n SUM(f.rn_t) AS rn_t, SUM(f.rn_d) AS rn_d, SUM(f.tot) AS tot, SUM(f.rd) AS rd,\n s.fp\n FROM fac f\n LEFT JOIN sfips s ON s.st = f.state\n GROUP BY f.state, f.county_name, f.county_fips, s.fp\n)\nSELECT json_agg(row_to_json(o) ORDER BY o.rn_hprd ASC) AS data\nFROM (\n SELECT\n (fp || county_fips) AS fips,\n state AS st,\n county_name AS county,\n fac,\n ROUND((rn_t / NULLIF(rd,0))::numeric, 3) AS rn_hprd,\n ROUND((rn_d / NULLIF(rd,0))::numeric, 3) AS rn_direct_hprd,\n ROUND((tot / NULLIF(rd,0))::numeric, 3) AS total_nurse_hprd,\n rd AS resident_days\n FROM county\n WHERE rd > 0 AND fac >= 3 AND fp IS NOT NULL\n) o;\n", "license": "U.S. Government Works (17 U.S.C. §105)", "generated_by": "Fonteum — https://fonteum.com", "notes": "Aggregate, source-traced figures frozen to the as-of date above. Re-derive by running the published query against the named source file; no per-person records are included." }