Key Findings from 14,751 Facilities
- •5-star facilities have 50% more RN staffing than 1-star facilities (0.77 vs 0.51 hours/resident/day)
- •High turnover kills quality: 1-star facilities average 53% turnover vs 39% for 5-star
- •National average is 0.64 RN hours/resident/day - well below expert recommendations of 0.75-1.0 hours
- •Only 6% of facilities meet the gold standard of 1.0+ RN hours per resident daily
Why Staffing Matters More Than Anything
The building can be brand new. The dining room can look like a hotel. The brochure can promise "5-star care."
But if there aren't enough nurses to answer call lights, help residents eat, or catch a fall before it happens? None of that matters.
Research is clear: staffing levels are the #1 predictor of nursing home quality. Yet most families stare at numbers like "0.64 RN hours per resident per day" and have no idea what that actually means.
We analyzed staffing data from all 14,751 Medicare-certified nursing homes. Here's what adequate staffing looks like—and how to spot the warning signs.
Understanding Staffing Numbers
What "Hours Per Resident Per Day" Means
When you see "0.64 RN hours per resident per day," here's what that actually translates to:
For a 100-bed facility:
- 0.64 hours × 100 residents = 64 total RN hours per day
- 64 hours ÷ 24 hours = 2.67 RN nurses on duty at any given time
- That's approximately 1 RN for every 37 residents
Now picture this: maybe 1-2 of those RNs working nights and weekends. One nurse covering 37 people. This is why those decimal points matter.
RN Hours
National average hours per resident per day
Recommended: 0.75-1.0 hours
Total Nurse Hours
National average (RN + LPN + CNA)
Recommended: 4.1+ hours
Turnover Rate
National average annual turnover
Lower is better: <40% is good
Staffing Levels by Star Rating
The correlation is striking. More nurses equals higher ratings. Every single time.
| Star Rating | RN Hours | Total Hours | Turnover |
|---|---|---|---|
| 1-Star | 0.51 | 3.65 | 53.4% |
| 2-Star | 0.58 | 3.61 | 48.4% |
| 3-Star | 0.73 | 3.89 | 46.4% |
| 4-Star | 0.69 | 3.95 | 43.2% |
| 5-Star | 0.77 | 4.30 | 38.6% |
The Pattern You Can't Ignore
Every star rating increase brings more RN hours and lower turnover. The progression is nearly perfect.
From 1-star to 5-star? That's 50% more RN staffing and 38% less turnover. Not a coincidence.
The Crisis Nobody Talks About: Nurse Turnover
High turnover devastates quality care. When nurses quit constantly, residents lose the familiar faces who know their routines, preferences, and baseline health status.
New staff make more errors. They miss subtle changes in condition. They don't know that Mrs. Johnson always refuses her afternoon meds unless you offer them with apple juice.
High Turnover (60%+)
Average star rating for facilities with 41-60% turnover
When more than half your nursing staff turns over annually, institutional knowledge is lost and care suffers dramatically.
Low Turnover (20-40%)
Average star rating for facilities with 21-40% turnover
Stable staffing means experienced nurses who know residents' needs, preferences, and baseline health status.
Walk Away If Turnover Exceeds 60%
It doesn't matter how nice the building looks. When more than half your staff leaves every year, care suffers. Period.
High turnover means constant training, unfilled shifts, and exhausted nurses who are too overwhelmed to provide good care—let alone notice when something's wrong.
What to Look For When Evaluating Staffing
Green Flags (Good Signs)
- RN hours ≥ 0.75 (only 20% of facilities achieve this)
- Total nurse hours ≥ 4.1 (recommended by experts)
- Turnover < 40% (indicates stable, satisfied staff)
- Staff who know residents by name during your tour
- Residents who seem comfortable with staff (not fearful or hesitant)
🚩 Red Flags (Warning Signs)
- ✗RN hours < 0.5 (bottom 40% of facilities)
- ✗Total hours < 3.6 (inadequate for basic care)
- ✗Turnover > 60% (revolving door of staff)
- ✗Call lights going unanswered for 10+ minutes during your tour
- ✗Staff who seem rushed, stressed, or dismissive of residents
- ✗Many residents in bed mid-day (suggests not enough staff to get them up)
Questions to Ask During Your Tour
The numbers tell part of the story. But you need to ask direct questions to get the full picture:
1. "What is your current nurse-to-resident ratio on each shift?"
They should answer confidently for day, evening, and night shifts. Vague answers are a red flag.
2. "What's your annual nurse turnover rate?"
If they say "I don't know" or won't answer, that's concerning. Good facilities track and work to reduce turnover.
3. "How do you handle staffing when someone calls in sick?"
Look for: on-call staff, cross-trained employees, or agency nurses. Weak answer: "We make do" or "Staff pick up extra residents."
4. "Can I speak with a nurse or CNA who works here?"
Ask staff directly: How long have you worked here? Do you feel supported? Is there enough help? Pay attention to body language—it tells you more than words.
5. "What's your policy on consistent assignment?"
Best practice: same CNAs assigned to same residents daily. This builds relationships and continuity.
Find Facilities with Adequate Staffing
Search by RN hours, total staffing levels, and turnover rates. Find facilities in your area that meet expert recommendations—not just the bare minimum.
Find Well-Staffed Facilities Near You
Now that you know what staffing metrics matter, search for facilities with strong RN hours and low turnover:
Methodology & Data Sources
This guide analyzes staffing data from all 14,751 Medicare-certified nursing homes, current as of October 2024.
Data sources:
- CMS Payroll-Based Journal (PBJ) - actual staffing hours reported by facilities
- CMS Provider Information including overall ratings
- Expert recommendations from CMS, leading researchers, and advocacy groups
Important note: CMS uses 2-week snapshots for ratings, which facilities can game. Our turnover data provides additional context that's harder to manipulate.
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