HHS OIG Data Brief    Augus t 2020    OEI-04-18-00450 
 
Some Nursing Homes Reported Staffing Levels 
Why This Review Is Important 
Nurse staffing is a key contributor to the  in 2018 Raise Concerns; Consumer 
quality of care provided in nursing homes.  
Transparency Could Be Increased 
This review, initiated before the COVID-19 
pandemic emerged, focuses on staffing data 
What OIG Found 
Key Takeaway 
from 2018.  However, the 2020 pandemic 
Nursing homes must have a registered nurse 
Nursing homes reported 
reinforces the importance of adequate 
(RN) on staff at least 8 hours each day and 
staffing for nursing homes, as inadequate  staffing levels often vary on a 
licensed nurse (i.e., RNs and licensed 
staffing can make it more difficult for nursing  day-to-day basis, and 7 percent 
practical/vocational nurses (LPNs/LVNs) on 
homes to respond to infectious disease  fell below required Federal 
staff around-the-clock to meet Federal 
outbreaks like COVID-19.    staffing levels on at least 30 
staffing requirements.  However, 7 percent of 
total days in 2018.  CMSs Star 
Consumers need meaningful information  nursing homes reported at least 30 total days 
Rating System ranks nursing 
about nurse staffing at nursing homes to  in 2018 with staffing below one or more of 
make informed care decisions.  The Centers  these requirements.  Additionally, another  homes on their average staffing 
for Medicare & Medicaid Services (CMS)  7 percent of nursing homes reported  levels each quarter; as a result, 
created the Payroll-Based Journal (PBJ)a  between 16 and 29 days with staffing below  daily staffing variations are not 
system containing self-reported provider  required levels in 2018.  Most of the days (65  transparent to consumers. 
datato collect nursing homes daily staffing  percent) that nursing homes reported staffing 
hours.  CMS requires a minimum number of  below required levels fell on weekends.  This raises concerns that some of these 
daily hours for different types of nurses, but  nursing homes may not have fully met their residents needs in 2018.   
CMS does not use PBJ data to enforce daily 
To further incentivize nursing homes to staff RNs every day, CMS implemented a 
Federal staffing requirements.  CMS uses PBJ 
policy in 2018 to downgrade nursing homes Staffing Star Ratings to 1 Star for 
data to calculate and publicly report Staffing 
having at least 7 total days within a quarter with no reported RN time.  Following 
Star Ratings on Nursing Home Compare.  
CMSs announcement of this policy, 27 percent fewer nursing homes reported at 
Prior public releases of PBJ data indicate that 
least 7 days without any RN time.  At the same time, 7 percent more nursing homes 
some nursing homes report low nurse 
reported days with some RN time, although less than the required 8 hours per day.  
staffing, which could impact residents quality 
These trends suggest overall improvements in staffing levels.  However, the nursing 
of care.  However, CMS does not regularly 
homes reporting days with greater than zero hours but less than the required eight 
publish information on day-to-day nurse 
hours of RN time appear to be falling short of meeting staffing requirements in 
staffing levels.       
ways that this penalty does not address.       
How OIG Did This Review 
Finally, CMSs Star Ratings, based on quarterly averages, do not convey the extent 
We analyzed nursing homes 2018 daily 
to which staffing varies day to day.  Some nursing homes reported staffing levels 
staffing data from the PBJ.  We determined 
varied considerably from day to day, while other nursing homes daily staffing levels 
how frequently nursing homes reported daily 
were more consistent.  Presenting only quarterly staffing averages does not enable 
staffing below federally required levels in 
consumers to identify and consider daily staffing differences when choosing a 
2018 and identified quarterly trends.  We 
nursing home.   
compared nursing homes quarterly Staffing 
Star Ratings to their daily staffing.  To discuss  What OIG Recommends 
residents experiences, we also surveyed 20  We recommend that CMS: (1) enhance efforts to ensure nursing homes meet daily 
Local Long-Term Care Ombudsmen (Local  staffing requirements and (2) explore ways to provide consumers with additional 
LTCOs).  We obtained their perspectives on  information on nursing homes daily staffing levels and variability.  While CMS did 
the ways daily fluctuations in nurse staffing  not explicitly state concurrence with the recommendations, CMS outlined the 
may affect residents in the nursing homes  actions it has taken and plans to take to achieve the recommendations goals.   
that the Local LTCOs monitor.   
Final report found at:  https://oig.hhs.gov/oei/reports/oei-04-18-00450.asp    
BACKGROUND   
The Centers for Medicare & Medicaid Services (CMS) has long identified nurse staffing as a vital 
component of a nursing homes ability to provide quality care.1, 2  For instance, research has found that the 
presence of a registered nurse (RN) improves residents quality of care and outcomes.3  This review, 
initiated before the COVID-19 pandemic emerged, focuses on staffing data from 2018.  However, the 2020 
pandemic reinforces the importance of sufficient staffing for nursing homes, as inadequate staffing can 
make it more difficult for nursing homes to respond to infectious disease outbreaks like COVID-19.4, 5   
Each type of nurse fills important roles at nursing homes.  For example, RNs are responsible for overseeing 
the delivery of residents overall care, while licensed practical and vocational nurses (LPNs/LVNs) care for 
residents under an RNs direction.6  Together, licensed nurse staff (i.e., RNs and LPNs/LVNs) ensure each 
residents care plan is being followed and that their needs are being met.  Nurse Aides (Aides) work under 
the direction of licensed nurse staff and provide most of the day-to-day care for residents (e.g., activities of 
daily living, like eating, bathing, grooming, dressing, transferring, and toileting) 24 hours a day, 7 days a 
week (around the clock).7    
Federal Staffing Requirements 
Federal law requires all nursing homes to provide enough staff to safely care for their residents.8  More 
specifically, unless they are waived, CMS regulations require that nursing homes provide on each day 
(1) 8 consecutive hours of RN services and (2) around-the-clock licensed nurse services.9   
Federal Requirements for Staffing Data 
Nursing homes are required to electronically submit their staffing information to the Payroll-Based Journal 
(PBJ).10  Nursing homes must submit direct-care staffing information based on payroll and other verifiable 
and auditable data in a uniform format as specified by CMS.11  This information must include the category 
of work an employee performs, such as whether the employee is an RN, LPN/LVN, Aide, therapist, or other 
medical personnel.12  
Nursing Home Compare 
CMSs website, Nursing Home Compare, allows consumers to review information about nursing homes 
participating in Medicare and/or Medicaid.  This information includes the quality of care provided, staffing, 
and inspection results.  Nursing Home Compare has a quality rating system that gives each nursing home 
an overall rating between 1 and 5 stars (i.e., the Five-Star Quality Rating System).13  Nursing homes with 5-
star ratings are considered to have above-average quality, and nursing homes with 1-star ratings are 
considered to have below-average quality.14  Each nursing homes overall quality rating is based on star 
ratings of its performance in three areas, one of which is Staffing.15, 16     
Staffing Star Ratings.  In April 2018, CMS began using the PBJ to calculate Staffing Star Ratings for Nursing 
Home Compare.17  The Staffing Star Rating is based on two separate measureseach with its own Star 
Ratingthat are associated with quality of care: (1) the RN measure and (2) the Total Nurse (TN) 
measure.18, 19  The RN and TN staffing measures reported in the Five-Star Quality Rating System do not 
assess compliance with Federal staffing requirements.  Instead, the RN measure reports the quarterly 
average RN staffing hours per resident at each nursing home, adjusted by the residents health needs.20  
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The TN measure reports the quarterly average staffing hours for RNs, LPNs/LVNs, and aides per resident at 
each nursing home, adjusted by the residents health needs.  For additional information on how CMS 
calculates Nursing Home Compares RN, TN, and Overall Staffing Star Ratings, see Appendix A. 
After analyzing PBJ data and identifying that some nursing homes reported many days with no RN time in 
2017, CMS reminded nursing homes of Federal staffing requirements in April 2018.21  As a result, also in 
April 2018, CMS announced that any nursing homes reporting at least 7 total days in a quarter without any 
RN time would have their Staffing Star Rating automatically downgraded to 1 Star.22, 23  The policy change 
impacted Staffing Star Ratings presented on Nursing Home Compare starting in July 2018. 
State Long-Term Care Ombudsman Programs 
In 1972, the Administration on Aging (AoA) began the Long-Term Care Ombudsman Program (LTCOP) as 
a demonstration program.24  Since 1978, the LTCOP has required each State to have a State Long-Term 
Care Ombudsman (State LTCO).25  The program was expanded in 1987 to allow State ombudsmen access 
to nursing homes and residents records and designate local ombudsman programs.26  The State LTCO is 
the contact for all ombudsman activities within the State.  Local Long-Term Care Ombudsmen (Local 
LTCOs) implement the nursing home LTCOP.  Ombudsman programs fulfill many roles within the nursing 
home, such as educating and training facility staff and residents; providing technical support for resident 
and family councils; and conducting a complaint or mediation visit to resolve a complaint.27    
Resident Complaint Process.  To file a complaint, nursing home residents and their family members or 
designated representatives may directly contact their State LTCOP office or their Local LTCO.  When a 
resident registers a complaint, the ombudsman whom the resident contacted acts as a resident advocate 
by assisting and empowering residents or their representatives in resolving complaints.  If the Local LTCO 
encounters difficulty resolving complaints or concerns, the State LTCO may provide assistance.  The State 
LTCO assists the Local LTCO when technical information is needed, or with system-wide problems.28 
METHODOLOGY 
We analyzed staffing data for nursing homes from the PBJ for calendar year 2018.  We also analyzed 
companion datasets from the Minimum Data Set (MDS), which CMS uses to calculate staffing measures on 
Nursing Home Compare.   
We determined how frequently nursing homes reported daily staffing levels below required Federal levels 
for RN and licensed nurse staff using PBJ data.  We also determined how frequently nursing homes 
reported days without any RNs.  However, we make no determination of compliance with Federal RN 
staffing requirements because PBJ data do not include unpaid hours salaried nurses may work.  Therefore, 
actual hours that RNs or licensed nurses worked at nursing homes in 2018 may be higher than the PBJ data 
reflects.  Finally, we determined how frequently nursing homes daily staffing levels did not match their 
quarterly Staffing Star Ratings. We surveyed 20 Local LTCOs regarding how nurse staffing levels at their 
respective nursing homes affected residents quality of care.  See the Detailed Methodology section for 
more information.   
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  RESULTS 
Seven percent of nursing homes (943 of 12,862) reported at least 30 total 
Seven percent of 
days with staffing below 1 or more required levels in 2018 (see Exhibit 1).  
nursing homes 
Additionally, another 7 percent of nursing homes (900 of 12,862) reported 
reported staffing  between 16 and 29 days with staffing below 1 or more required levels in 
2018.  Forty percent of nursing homes (5,127 of 12,862) reported 1 to 15 such 
below required 
days.  Most of the days (65 percent) that these nursing homes reported 
levels for at least 30 
staffing below required levels fell on weekends (see Exhibit 2).  See 
total days in 2018  Appendices B and C for additional information on nursing homes reporting 
staffing below required levels.   
 
Some of the Local LTCOs (11 of 20) reported that daily staffing for licensed 
nurse staff (i.e., RNs and/or LPNs/LVNs) was problematic at the specific 
nursing homes that they monitored.  When RNs or licensed nurse staff are 
not present, residents may be negatively impacted because their care plans 
may not be implemented correctly.  When RNs and licensed nurse staff are 
not present to adequately supervise Aides, residents day-to-day care 
needssuch as bathing, grooming, and toiletingmay not be met, which 
can contribute to a variety of health problems, such as pressure sores, 
urinary tract infections, and falls.   
Exhibit 1.  Seven percent of nursing homes reported at least 30 total 
days with staffing below required levels in 2018 
58 days 
Average number of days this 7 percent 
of nursing homes did not have an RN on 
staff for at least 8 hours  
15 days 
Average number of days this 7 percent 
of nursing homes did not have licensed 
nurse services for at least 24 hours  
 
12,862 nursing homes 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
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  Ombudsman Perspective: Residents Experiences When Nursing Homes 
Report Many Days With Staffing Below Required Levels 
A scarcity of hall nurses (i.e., RNs and/or LPNs) led to poor supervision and 
Aide accountability.  This led to some care issues. 
- Local LTCO in Arkansas 
Systemic concerns from family members and residents were call lights not 
being answered because of lack of Aides and medication errors or 
medications not being given in a timely manner due to lack of LPNs and RNs.   
Wound care or bathing was not being provided because of staff shortage or 
staff calling off often.  Falls or injuries were not reported or documented in the 
residents charts.   
Discharge planning and/or proper discharges were a concern.   
If a resident asked a staff at the facility for water or pain medication, toileting, 
etc., the staff would state "you need to wait because we are short of staff." 
- Local LTCOin Illinois 
My residents go for a week at a time without being showered.  They complain 
of not getting their medications on time, which causes pain and agitation.  
We are already dealing with a population that has behavioral issues; add 
medications not being given in a timely manner, if at all, it's just not a good 
mix. 
- Local LTCO in Texas 
Exhibit 2.  Most of the days when reported nurse staffing fell below 
required staffing levels were on the weekend in 2018 
65% of days 
that nursing 
homes reported 
staffing below 
required levels fell 
on weekends  
  
NOTE: We analyzed the total number of days in 2018 at 12,862 nursing homes when reported RN and 
licensed nurse staffing fell below required levels.  
Source: OIG analysis of 2018 PBJ data, 2019. 
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  Ombudsman Perspective: Residents Experiences When Weekend Staffing Is 
Below Required Levels 
There are not enough RNs on night shifts.  LPNs always seem to staff 
weekends and nights.  There are never enough Aides to help the residents. 
There is not someone "in charge" after hours and/or [on] weekends.  
Residents problems are referred to the next working day. 
- Local LTCO in Texas 
Weekend staffing issues do impact residents in a negative way; there are 
always complaints that the [nursing homes] are short-staffed.   
There are a lot of resident-to-resident altercations and falls [in a facility that 
has a dementia unit and in which residents need additional care]. 
- Local LTCO in California 
Fewer nursing  CMS announced in April 2018 that it would automatically downgrade 
nursing homes Staffing Star Ratings to 1 Star on Nursing Home Compare 
homes reported 
for reporting at least 7 total days with no reported RN time within a quarter.  
days without any 
A lower Staffing Star Rating may discourage consumers from choosing that 
RNs after CMS  nursing home.  The policy change impacted the Staffing Star Ratings in July 
2018. 
announced it 
Following CMSs announcement, fewer nursing homes reported at least 
would begin 
7 days with no RN timethus avoiding the Star rating downgrade (see 
downgrading Star  Exhibit 3).   
Ratings on that 
Exhibit 3.  The number of nursing homes reporting at least 7 total 
basis 
days within a quarter without any RNs decreased 27 percent over 
2018 
27% Decrease 
in the number of nursing 
homes reporting at least 
7 total days in a quarter 
without any RN time by 
the end of 2018 
 
  
NOTE: Of the 12,862 nursing homes in our analysis, 1,135 nursing homes report ed at least 7 total days 
with no RN time within any quarter of 2018. 
 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
 
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  Those nursing homes that did report at least 7 total days with no RN time 
within a quarter most often reported this staffing level for only one quarter 
(see Exhibit 4).  That is, among the 1,135 unique nursing homes that 
reported at least 7 total days with no RN time within any quarter, 61 percent 
(697) did so for only 1 quarter.  A small number of nursing homes continued 
to report at least 7 total days with no RN time within a quarter, despite the 
automatic downgrade to a 1-Star Staffing rating.  In fact, just 71 of 12,862 
nursing homes did so for all 4 quarters of 2018, indicating that followup with 
these specific nursing homes is warranted.   
Exhibit 4.  Of the nursing homes that reported at least 7 total days 
without any RNs, most did so for only one quarter in 2018  
71 nursing homes  
reported at least 7 total 
days with no RN time for 
all 4 quarters in 2018 
 
N = 1,135 nursing homes  
Source: OIG analysis of 2018 PBJ data, 2019. 
As 2018 progressed, 7 percent more nursing homes reported days with 
some RN time, even though the reported time was less than the required 
8 hours per day (see Exhibit 5).  Nursing homes reporting days with some 
RN time, but less than 8 hours, avoid CMSs automatic downgrade to their 
star ratings but may still be falling short of meeting staffing requirements.  
See Appendix D for more information on trends in the number of nursing 
homes reporting days when RN time was below the required Federal levels.  
Exhibit 5.  Seven percent more nursing homes reported days with at 
least some RN time, thus avoiding a Staffing Star downgrade 
7% Increase 
in number of nursing 
homes reporting 
days with some RN 
time but less than 8 
hours of RN services 
by the end of 2018 
 
NOTE: Of the 12,862 nursing homes in our analysis, 4,444 reported days with some RN time, but in 
amounts still below required levels within any quarter of 2018. 
Source: OIG analysis of 2018 PBJ data, 2019. 
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CMSs Star Ratings  Some nursing homes reported staffing levels varied considerably from day 
to day, while others staffing levels were more consistent.  CMS averages 
are based on 
reported daily staffing to calculate nursing homes quarterly RN and TN 
quarterly averages,  Staffing Star Ratings for Nursing Home Compare.  CMS staff explained that 
the rating system is intended to reflect the general level of quality and care 
which do not 
that a facility provides and uses aggregated measures for staffing (and for 
convey the extent 
other quality measures) to do so.  However, presenting only the quarterly 
to which staffing  averages on Nursing Home Compare does not enable consumers to see 
and consider differences in daily staffing levels when choosing a nursing 
varies day to day 
home.  
 
 
How CMS Determines RN and TN Staffing Star Ratings 
on Nursing Home Compare 
To determine each nursing homes RN and TN Staffing Star Ratings, CMS 
establishes thresholds of nurse time per resident for each star rating.  CMS 
then compares each nursing homes average quarterly RN and TN staffing 
levels to these staffing level thresholds.29  Nursing homes with lower 
Staffing Star Ratings report less staff time than nursing homes with higher 
Staffing Star Ratings.  Exhibit 6 below lists the minutes associated with 
1-Star and 5-Star RN and TN staffing thresholds for the fourth quarter (Q4) 
of 2018. 
Exhibit 6.  CMSs Star Rating Thresholds for RN and TN Staffing* 
  1 Star  5 Stars 
Average RN Minutes Per Resident Per Day   < 19 minutes    63 minutes 
Average TN Minutes Per Resident Per Day  < 186 minutes   264 minutes 
*CMS began using these star rating thresholds in Q4 2018 and continued to assign Staffing Star 
Ratings with these thresholds through 2019.  CMS used different thresholds during Q1, Q2, and Q3 
2018.  For more information, see Appendix A. 
Source: CMS.  Nursing Home Compare Technical Users Guide: April 2019. 
 
Nursing homes with a 1-Star RN Staffing Rating report an average of less 
than 19 minutes of RN care per resident per day.  In contrast, nursing homes 
with 5-Star RN Staffing Ratings report over 63 minutes of RN care per 
resident per day.  This means residents at a nursing home with a 5-Star RN 
Staffing Rating may be receiving an average of 44 additional minutes of RN 
care than residents at a nursing home with a 1-Star RN Staffing Rating.  See 
Appendix A for additional information on the specific RN and TN staffing 
thresholds CMS used during 2018. 
 
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  Nursing homes daily staffing levels did not match their Staffing Star Ratings 
for about half of the days in 2018 (see Exhibit 7).  On average, nursing 
homes RN daily staffing levels were below their Staffing Star Ratings slightly 
more often than they were above, but TN daily staffing levels displayed the 
opposite pattern.  See Appendix E for more information on how often 
nursing homes daily staffing levels did not match their RN and TN Staffing 
Star Ratings on Nursing Home Compare.  
Exhibit 7.  Nursing homes daily staffing levels often did not match 
their Staffing Star Ratings   
RN  TN 
 
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings 
were not downgraded to a 1-Star RN or Overall Staffing Star Rating in any quarter of 2018. 
Source: OIG analysis of 2018 PBJ data, 2019. 
Even when they have the same Staffing Star Ratings, nursing homes daily 
staffing levels can vary widely from one another.  For example, on average 
in 2018, nursing homes with 5-Star RN Staffing Ratings reported staffing 
that corresponded to 5-Star staffing levels for 76 percent of days (see 
Exhibit 8).  However, the top 20 percent of these nursing homes reported 
staffing at 5-Star levels almost every day.  In contrast, the bottom 20 
percent of these nursing homes reported staffing below 5-Star levels for a 
little less than half of the days (42 percent), including some days at the 1-
Star level.  Using Nursing Home Compare, consumers have no way to tell 
which nursing homes consistently provide staffing levels that match their 
Staffing Star Ratings and which ones substantially fluctuate from day to day.   
 
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  Exhibit 8.  Nursing homes with 5-Star Staffing Ratings have 
substantially different patterns of daily staffing 
 
Nursing Homes With 5-Star RN Staffing Ratings 
 
This analysis is from a subpopulation of the 11,373 nursing homes whose Staffing Star Ratings 
were not downgraded to a 1-Star RN or Overall Staffing Star Rating in any quarter of 2018.  
Source: OIG analysis of 2018 PBJ data, 2019. 
Nursing homes with RN Staffing Star Ratings below 5 Stars also had wide 
daily variability.  For example, see Exhibit 9 below for information about the 
daily variability among the nursing homes with 4-Star RN Staffing Ratings.  
Additionally, see Appendix F for day-to-day differences in staffing for each 
of the RN and TN Staffing Star Ratings.   
 
 
 
 
 
 
 
 
 
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  Exhibit 9.  Nursing homes with 4-Star Staffing Ratings have 
substantially different patterns of daily staffing 
 
Nursing Homes With 4-Star RN Staffing Ratings
 
The analysis is from a subpopulation of the 11,373 nursing homes whose Staffing Star Ratings 
were not downgraded to a 1-Star RN or Overall Staffing Star Rating in any quarter of 2018. 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
 
 
 
 
 
 
 
 
 
 
   
 
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CONCLUSION AND RECOMMENDATIONS 
CMS has identified nurse staffing as a vital component of a nursing homes ability to provide quality care.  
Nursing staff are responsible for delivering care, ensuring residents care plans are followed, and providing 
most of the day-to-day care for residents.  This review, initiated before the COVID-19 pandemic emerged, 
focuses on staffing data from 2018.  However, the 2020 pandemic reinforces the importance of sufficient 
staffing for nursing homes, as inadequate staffing can make it more difficult for nursing homes to respond 
to infectious disease outbreaks like COVID-19.  Our analysis raises concerns about the reported daily 
staffing levels for some nursing homes and about how well the Staffing Star Ratings on the Nursing Home 
Compare website, which uses quarterly averages only, convey enough information to consumers about 
nursing home staffing. 
Federal requirements state that nursing homes must have an RN on staff for at least 8 consecutive hours 
each day and a licensed nurse on staff around the clock.  However, 7 percent of nursing homes reported 
30 or more total days in 2018 with nurse staffing below required Federal levels.  An additional 7 percent of 
nursing homes reported between 16 and 29 days with nurse staffing below required levels.  Further, 
among all nursing homes, 65 percent of the days with reported staffing below required RN or licensed 
nurse levels occurred on weekends.  This raises concerns that some of these nursing homes may not have 
fully met their residents needs in 2018.     
To incentivize nursing homes to staff RNs every day, CMS announced in April 2018 that it would 
automatically downgrade a nursing homes Staffing Star Rating to 1 Star if it reported having no RN time 
for at least 7 total days within a quarter.  Following CMSs announcement, 27 percent fewer nursing homes 
reported days with no RN time.  At the same time, 7 percent more nursing homes reported days with 
some RN time, although less than the required 8 hours per day.  These trends suggest overall 
improvements in staffing levels.  However, the nursing homes reporting days with greater than zero hours 
but less than the required eight hours of RN time appear to be falling short of meeting staffing 
requirements in ways that this penalty does not address.  
Finally, we found that individual nursing homes reported daily staffing levels did not consistently match 
their Staffing Star Ratings, which are based on quarterly averages.  As CMS staff noted, the current Staffing 
Star Rating is not intended to reflect daily fluctuations in staffing.  However, given that some nursing 
homes have considerable variation in their daily staffing levels, while other nursing homes staffing is more 
consistent from day to day, this additional information could be useful to consumers.  Nursing homes 
reporting day-to-day staffing levels that are substantially different from their current star rating may not be 
providing consistent care.  Providing consumers with information based only on quarterly averages does 
not enable them to identify and consider the extent of these daily staffing differences when choosing a 
nursing home.   
We recommend that CMS: 
 
 
 
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Enhance efforts to ensure nursing homes meet daily staffing requirements  
CMS has taken steps to ensure that more nursing homes meet staffing requirements and should further 
enhance such efforts.  As discussed in our findings, CMSs policy to downgrade Star Ratings for 7 or more 
days per quarter with no RN time resulted in a reduction in nursing homes reporting days with no RN time.  
Further, in 2019, CMS began using PBJ data to identify nursing homes that appeared to be understaffed on 
weekends.  CMS provides lists of these nursing homes to State survey agencies for potential followup.  The 
agency should build upon these efforts and further expand its use of PBJ data to ensure that more nursing 
homes meet staffing requirements on a consistent, day-to-day basis.  For example, CMS could analyze PBJ 
data in ways similar to the Office of Inspector Generals (OIGs) analysis for this report to determine which 
nursing homes appear to be falling short of daily requirements, and then target these nursing homes for 
further oversight.  OIG will provide CMS with the list of the 943 nursing homes that reported staffing levels 
that did not meet CMS requirements on at least 30 days in 2018 so that CMS can review and follow up as 
appropriate.   
Explore ways to provide consumers with additional information on nursing homes daily staffing 
levels and variability  
Information about daily staffing levels and variability could be useful to consumers when making care 
decisions, in addition to the information CMS currently provides on average staffing levels.  Without this 
information, consumers have no way to tell that some nursing homes have considerable variation in their 
daily staffing levels while other nursing homes staffing is more consistent from day to day.  CMS staff has 
raised concerns about whether adding this type of information might create confusion for consumers.  We 
recognize that avoiding consumer confusion is important.  Therefore, we are recommending that CMS 
explore ways to provide this type of information in clear, consumer-friendly ways.  For example, CMS could 
explore ways to show the frequency with which each nursing home reported staffing below required daily 
Federal levels during a given quarter or how nursing homes weekend staffing compares to that of other 
nursing homes with the same Staffing Star Rating. 
 
 
 
 
 
 
 
 
 
 
   
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AGENCY COMMENTS AND OIG RESPONSE 
CMS did not explicitly agree or disagree with our recommendation to enhance efforts to ensure nursing 
homes meet daily staffing requirements.  Instead, CMS stated that it is working to ensure nursing homes 
meet daily staffing requirements.  CMS also stated that it will continue to analyze nursing home staffing 
and enhance its efforts accordingly.  OIG appreciates the efforts CMS has taken to ensure nursing homes 
meet daily staffing requirements.  OIG encourages CMS to continue to build upon these efforts and further 
expand its use of PBJ data to ensure that more nursing homes meet staffing requirements on a consistent, 
day-to-day basis.  We ask that CMS specify in its Final Management Decision how it is enhancing, or plans 
to enhance, these efforts.  
CMS did not explicitly agree or disagree with our recommendation to explore ways to provide consumers 
with additional information on nursing homes daily staffing levels and variability.  Instead, CMS stated that 
it regularly reviews and analyzes how to present information in clear, consumer-friendly ways on its 
websites and in publications.  CMS stated that it will continue to explore ways to provide nursing homes 
daily staffing levels and variability in clear, consumer-friendly ways.  OIG appreciates the efforts CMS has 
taken and encourages CMS to provide consumers with information on nursing homes daily staffing 
variability in addition to the information CMS currently provides on average staffing levels.  Consumers 
may benefit from having more information about daily staffing variability when making care decisions, and 
including this information on Nursing Home Compare may further incentivize nursing homes to provide 
consistent daily staffing for nursing home residents.  We ask that CMS specify in its Final Management 
Decision how it is providing or plans to provide consumers with additional information about staffing 
levels and variability.  
For the full text of CMSs comments, see Appendix G. 
 
 
 
 
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DETAILED METHODOLOGY 
We based this study on an analysis of nursing homes staffing data (the PBJ) from calendar year 2018, as 
reported to CMS.  PBJ data contains employee-level, daily payroll records of hours that nursing home staff 
worked, and the data are submitted at the end of each quarter.30  See Exhibit 10 for specific information on 
the start and end dates for each quarter in our review.  
Exhibit 10.  2018 PBJ Data Reporting Periods, Data Submission Due Dates, and Dates PBJ Data 
Were Posted on Nursing Home Compare  
Calendar  Reporting Period  Reporting Period  Reporting Period  Information Posted on 
Quarter  Start Date  End Date  Due Date  Nursing Home Compare 
Q1  January 1  March 31  May 15  Q3 2018 
Q2  April 1  June 30  August 14  Q4 2018 
Q3  July 1  September 30  November 14  Q1 2019 
Q4  October 1  December 31  February 14, 2019  Q2 2019 
Source: OIG analysis of CMS data, 2019. 
We also analyzed companion datasets from the Minimum Data Set (MDS) that CMS uses as it calculates 
staffing measures on Nursing Home Compare.  These datasets include the census information and case-
mix census information of daily residents at each nursing home.  The MDS contains federally mandated 
clinical assessments of the needs of all residents in Medicare-certified and/or Medicaid-certified nursing 
homes.  Residents with similar needs are grouped into 1 of 66 unique Resource Utilization Groups (RUGs).31  
The daily resident census is the daily sum of residents who received MDS assessments at each nursing 
home.32  The case-mix census is the daily sum of residents in each RUG.33   
We also analyzed descriptive information about nursing homes from Certification and Survey Enhanced 
Provider Reporting (CASPER) data.  CASPER data includes descriptive information about nursing homes, 
such as Medicare and Medicaid participation and termination dates; ownership status; chain membership; 
and the number of beds in each home.  
Nursing Homes Included in Our Review 
We included in our review nursing homes that (1) participated in Medicare and/or Medicaid for all four 
quarters of 2018, (2) had a non-zero case-mix census for each day of 2018, (3) did not have their data 
excluded from being publicly reported because of potential unreliability, and (4) submitted all staffing 
information to the PBJ by CMS deadlines for each day of 2018.34, 35, 36  We used this subpopulation of 
nursing homes for our analysis on Federal requirements and trends in RN staffing levels after CMSs policy 
change.  We then limited this population to only those nursing homes whose Staffing Star Ratings were 
not downgraded to 1 Star in any quarter to compare nursing homes daily staffing levels to their quarterly 
RN and TN Staffing Star Ratings.37  See Exhibit 11 for additional information on the number of nursing 
homes in our analysis.  
 
 
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OEI-04-18-00450  Exhibit 11: Number of Nursing Homes Included in Our Review 
Source: OIG analysis of 2018 CASPER, PBJ, and MDS data, 2019. 
Determining Reported Staffing Levels That Fell Below Federal Requirements 
We determined how frequently the 12,862 nursing homes in our review reported daily staffing levels below 
required Federal levels for RN and licensed nurse staff.   
Using CMSs methods from the Nursing Home Compare Technical Users Guide, for every nursing home, 
we identified all RN and licensed nurse hours on each day of 2018.  Then, we summed all RN hours and all 
licensed nurse hours for each nursing home on each day of 2018.38 
We identified days when nursing homes reported less RN hours than Federal requirements stipulate (8 RN 
hours each day).  We determined whether nursing homes reported at least 7.5 hours of RN services every 
day (CMS guidance indicates that an 8-hour RN shift should include a 0.5-hour meal break, and that 
nursing homes should not include the meal break in hours reported to the PBJ).  We categorized days 
when nursing homes staffed at least 7.5 RN hours as meeting this Federal requirement.  Additionally, we 
identified days without any reported hours for RNs.     
We also identified days when nursing homes reported less licensed nurse staff than Federal requirements 
stipulate (around-the-clock licensed nurse staff).  Because staffing data are not timestamped, PBJ data 
cannot indicate whether nursing homes actually provide licensed nurse services around the clock.  
Therefore, we determined whether nursing homes reported at least 22.5 hours of licensed nurse services 
every day (CMS guidance indicates that an 8-hour licensed nurse shift should include a 0.5-hour meal 
break, and that nursing homes should not include the meal break in hours reported to the PBJ).  We 
categorized days when nursing homes staffed at least 22.5 licensed nurse hours as meeting this Federal 
requirement.   
We did not assess the sufficiency of nurse staffing levels to meet residents needs because CMS does not 
use the number of reported staff hours per resident (i.e., hours per resident per day, or HPRD) to define 
the sufficiency of nurse staffing levels.  When State survey agencies inspect nursing homes, they determine 
whether nursing homes have sufficient staff to provide the care and services residents need.39  
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OEI-04-18-00450   
Additionally, we identified the day of the week on which these days fell.  For each day of the week, we 
summed the number of days when nursing homes reported fewer than 8 RN hours and/or fewer than 24 
hours for licensed nurse staff.  We compared these rates for each day of the week. 
Finally, for each nursing home, we determined the number of days that nursing homes reported fewer 
than 8 RN hours and/or fewer than 24 hours of licensed nurse staff.  We identified nursing homes that did 
so for more than 30 total days in 2018, for between 16 and 29 total days in 2018, and for between 1 and 
15 total days in 2018. 
Waivers From Nurse Staffing Requirements.  Nursing homes may request staffing requirement waivers that 
allow them to (1) have an RN on duty for less than 8 consecutive hours every day and/or (2) provide 
licensed nurses for less than around the clock.  Of the 12,862 nursing homes PBJ data we analyzed, 2 had 
RN waivers and 8 had 24-hour waivers.  We did not exclude these nursing homes from our analysis of the 
frequency that nursing homes reported days with staffing below required levels.     
Determining Trends in Registered Nurse Staffing Levels After the Centers for Medicare & 
Medicaid Services Policy Change  
For each quarter in 2018, we determined how frequently the 12,862 nursing homes in our analysis reported 
days without any RNs.  Our analysis focused on identifying the effects on reported staffing levels in the PBJ 
of CMSs announcement that it would automatically downgrade nursing homes Staffing Star Ratings for 
reporting at least 7 days without any RN time.  We identified nursing homes that reported at least 7 total 
days per quarter without any RN time and the number of quarters that these nursing homes did so.  
Finally, to determine whether more nursing homes might shift from reporting days without any RN time to 
reporting days with some RN time (but still less than the required Federal levels), we identified the number 
of nursing homes reporting at least 1 day without any RN hours for each quarter and with more than 0 but 
less than 7.5 RN hours for each quarter.  We reported the percentage change from Q1 2018 to Q4 2018. 
Determining When Nursing Homes Daily Staffing Levels Did Not Match Their Quarterly Staffing 
Star Ratings 
To determine how often nursing homes daily staffing levels did not match their quarterly Staffing Star 
Ratings, we analyzed the 11,373 nursing homes (1) that reported staffing information each day of 2018; 
(2) had RN and TN Staffing Star Ratings; and (3) whose Staffing Star Ratings were not downgraded in any 
quarter in 2018.40  Nursing homes might not have a star rating, for example, because a facility is too new 
to have received two standard surveys from State survey agencies.41  We removed nursing homes with 
downgraded RN and/or Overall Staffing Star Ratings from this analysis because their Staffing Star Ratings 
may not reflect their actual staffing levels.   
For each nursing home, we modified CMSs methods for calculating quarterly star ratings so that we could 
identify a star rating that would correspond to daily staffing levels for each nursing home with an RN or TN 
Staffing Star Rating.  See Appendix A for more information on CMSs methods for calculating quarterly RN 
and TN star ratings.   
We then compared the quarterly Staffing Star Ratings for each nursing home with the measure of its daily 
staffing for each day in 2018.  We determined the number of days that nursing homes daily RN and TN 
staffing levels did not match that which was indicated by their quarterly Staffing Star Ratings.42  Our 
analysis takes into consideration varying Staffing Star Ratings per quarter.     
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OEI-04-18-00450   
Determining When Nursing Homes Daily Staffing Levels Were Substantially Different From Their Quarterly 
Staffing Star Ratings.  To determine the extent to which daily staffing levels at nursing homes with the 
same RN or TN Staffing Star Ratings varied on a daily basis, we compared quarterly staffing patterns at 
nursing homes with the same CMS-assigned quarterly RN or TN Staffing Star Ratings.  For nursing homes 
with ratings of 5 Stars, 4 Stars, 3 Stars, and 2 Stars, we determined the number of days in 2018 that their 
daily RN and TN staffing levels were lower than that indicated by their respective quarterly Staffing Star 
Ratings.  For nursing homes with 1-Star quarterly Staffing Star Ratings, we determined the portion of days 
that daily RN and TN staffing levels corresponded to 1-Star RN and TN levels.  For example, two nursing 
homes could have a 5-Star RN Staffing Rating for Q1 in 2018, but one of them might staff RNs at a level 
corresponding to a 5-Star Rating every day in Q1, while the other nursing home does so only 60 percent of 
the time.  Within each RN and TN Staffing Star Rating, we grouped nursing homes into five groups (i.e., 
quintiles) based on the percentage of days that were either above or below their quarterly Staffing Star 
Rating.   
Analysis of Local Long-Term Care Ombudsman Surveys 
To discuss residents experiences, we surveyed 20 purposively selected Local LTCOs in 2019.  We obtained 
their perspectives on the ways the staffing fluctuations of daily nurses may affect residents in the nursing 
homes the Local LTCOs are responsible for monitoring.  We selected Local LTCOs responsible for 
monitoring nursing homes of assorted sizes, with various reported staffing levels, and that were in different 
parts of the United States.  All 20 Local LTCOs responded to our request.  We reviewed their responses 
and reported staffing issues that pertained to our analysis in the report.  See Exhibit 12 for the locations of 
the Local LTCOs we selected for our survey. 
Exhibit 12.  Locations and Numbers of Local LTCOs Surveyed  
States  Number of Local LTCOs 
Texas  7 
California  3 
Missouri  3 
Illinois  2 
Louisiana  2 
Arkansas  1 
Indiana  1 
Virginia  1 
Total  20 
Source: OIG analysis of 2018 PBJ data, 2019. 
Limitations 
This analysis is based on staffing data that nursing homes submitted to the PBJ.  We did not review the 
adequacy of nursing homes underlying payroll information to support reported staffing levels.   
We also make no determination of compliance with Federal RN staffing requirements because PBJ data do 
not include unpaid hours salaried nurses may work.  Therefore, actual hours that RNs or licensed nurses 
actually worked at nursing homes in 2018 may be higher than our analysis reflects.  Additionally, PBJ data 
are not timestamped; therefore, PBJ data cannot indicate whether nursing homes actually provide licensed 
nurse services around the clock, as required.   
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We did not independently verify Local LTCO responses to our survey.          
We did not assess the consistency of MDS assessment across nursing homes (i.e., whether nursing homes 
assessed residents needs in comparable ways), and we did not assess the adequacy of the values in CMSs 
Staff Time and Resource Intensity Verification (STRIVE) Project to address residents needs.43   
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued by 
the Council of the Inspectors General on Integrity and Efficiency. 
   
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APPENDIX A: STAFFING STAR RATINGS ON 
NURSING HOME COMPARE 
Centers for Medicare & Medicaid Services Calculations of the Registered Nurse and Total Nurse 
Staffing Star Ratings   
For each quarter, CMS awards each nursing home two separate star ratings for staffing: one for RN staffing 
and another for TN staffing.44  These staffing measures depend upon the following data sources submitted 
each quarter through the PBJ System (CMSs system for collecting PBJ data):  
  PBJ data; 
  resident census information derived from MDS assessments (the sum of residents that received 
MDS assessments at each nursing home)45; and  
  case-mix census information derived from MDS assessments (the sum of residents as grouped 
within 66 unique RUGs, Version IV (RUG-IV group)).46  
To determine each nursing homes RN and TN Staffing Star Ratings, CMS takes into account the number 
of RN and TN staff hours reported; the number of residents; and a measure of the severity of residents 
health problems as determined by their RUG classification.47  CMS aggregates nurse staffing hours 
reported through the PBJ and resident census information in the MDS to calculate a ratio of staff hours to 
the number of patients at the nursing home on an average day.  CMS calls this RN or TN hours per 
resident day (HPRD).  CMS determines each nursing homes quarterly RN and TN Staffing Star Ratings by 
using the equation listed below.48   
 
HHHHHHHHHH RRRRRRHHHHRRRRRR 
    HHHHHHHHHH NNCCRRMMHHNNCCNN AAAARRHHCCAARR  =  HHHHHHHHHH AARRAAHHHHRRRRRR
  Hours Reported: HHThHHiHHs HHisHH  tCChCCeHH sRRu-MMmMM MMof reported hours throughout the quarter (from the PBJ) divided by 
the sum of residents throughout the quarter (from the resident census).   
  Hours Case-Mix: This is a daily estimate of the nurse staff time that CMS expects each nursing home to 
provide based on the severity of residents health care needs divided by the number of residents at 
each nursing home.49  CMS calculates this figure first by using the case-mix census to identify the 
number of residents at each nursing home within each RUG on each day of the quarter.  Next, CMS 
multiplies the number of residents in each RUG-IV group by nursing time estimates from the STRIVE 
study.  CMS then sums all nursing hours across all days and RUG-IV groups and divides that by the 
number of residents in the case-mix census.  The daily estimates of RN, LPN, and Aide hours come 
from the STRIVE Project, and are included in Appendix A of CMSs Nursing Home Compare Technical 
Users GuideApril 2019.   
  Hours National Average: This is the average of quarterly RN or TN Case-Mix hours across all nursing 
homes.  CMS calculates this number and updates it every quarter, making it publicly available at 
Data.Medicare.gov.  
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OEI-04-18-00450   
  Hours Adjusted: This is the unit of measure used to calculate Staffing Star Ratings.  It is an estimated 
number of hours that nurses spend with each nursing home resident on each day, adjusted based on 
the needs of residents so that it can be compared across nursing homes.  
Scoring Rules for Centers for Medicare & Medicaid Services Registered Nurse and Total Nurse 
Staffing Star Ratings  
CMS assigns star ratings for both RN and TN staffing.  CMS sets rating thresholds using a percentile-based 
method it developed that takes account of clinical evidence on the relationship between staffing and 
quality.50  Each star rating has a minimum and/or maximum threshold that determines the star assigned to 
each nursing home, depending on that nursing homes Hours Adjusted RN or TN HPRD (as calculated in 
the steps listed above).   
In April 2018, CMS updated the thresholds for RN and TN Staffing Star Ratings using the RUG-IV system.51  
This change impacted the RN and TN Staffing Star Ratings for PBJ data submitted for Q1, Q2, and Q3 of 
2018.  CMS made further adjustments to RN and TN Staffing Star Rating thresholds in April 2019, impacting 
the PBJ data submitted for Q4 2018.  See Exhibits A-1 and A-2 for the HPRD thresholds CMS used to assign 
star ratings for RN and TN staffing during 2018.  
Exhibit A-1.  CMSs National Star Rating Scoring Rules for RN and TN Staffing on Nursing 
Home Compare for Q1, Q2, and Q3 2018 
  1 Star  2 Stars  3 Stars  4 Stars  5 Stars 
RN HPRD  < 0.246  0.2460.382  0.3830.586  0.5870.883   0.884 
< 15  
RN Minutes   1523 minutes  23-35 minutes   35-53 minutes  53 minutes 
minutes  
TN HPRD  < 3.176  3.176  3.551  3.552  4.009  4.010  4.237   4.238 
< 190   254 
TN Minutes  190213 minutes  213 240 minutes  240254 minutes 
minutes  minutes 
Source: CMS.  Nursing Home Compare Technical Users GuideJuly 2018. 
 
Exhibit A-2.  CMSs National Star Rating Scoring Rules for RN and TN Staffing on Nursing 
Home Compare for Q4 2018 
  1 Star  2 Stars  3 Stars  4 Stars  5 Stars 
RN HPRD  < 0.317  0.3170.507  0.5080.730  0.7311.048   1.049 
< 19  
RN Minutes   1930 minutes  30-43 minutes   44-63 minutes   63 minutes 
minutes  
TN HPRD  < 3.108  3.108  3.579  3.580  4.037  4.038  4.407   4.408 
< 186   264 
TN Minutes  186 215 minutes  215  242 minutes  242  264 minutes 
minutes  minutes 
 Source: CMS.  Nursing Home Compare Technical Users GuideApril 2019. 
Centers for Medicare & Medicaid Services Calculations of Overall Staffing Star Ratings 
To calculate nursing homes Overall Staffing Star Ratings, CMS averages the RN and TN Staffing Star 
Ratings.  For instance, if a nursing home has a 3-Star RN Staffing Rating and a 5-Star TN Staffing Rating, 
the overall star rating would average to a 4-Star Overall Staffing Rating.  However, when the average of RN 
and TN Staffing Ratings is between star ratings, the Overall Staffing Rating is weighted toward the RN star 
rating.  For example, if a nursing home earns a 5-Star RN Staffing Rating and a 4-Star TN Staffing Rating, 
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OEI-04-18-00450   
the average would be 4.5.  This is rounded toward the RN Staffing Star Rating value (i.e., 5 Stars); as a 
result, the nursing home would receive a 5-Star Overall Staffing Rating.   
It is important to note that CMS reports only the Overall Staffing Star Rating and the RN Staffing Star 
Rating on Nursing Home Compare.52  The TN Staffing Star Rating is not reported on Nursing Home 
Compare, despite being used in Overall Staffing Star Rating calculations.   
Exceptions to Staffing Star Rating Scoring Rules  
The following are exceptions to the Staffing Star Rating scoring rules described above:  
 
  Nursing homes that fail to submit any staffing data by the required deadline will receive a 1-Star 
rating for the Overall and RN Staffing Star Ratings for the quarter.53  
  CMS assigns 1-Star quarterly Overall and RN Staffing Star Ratings to nursing homes whose PBJ 
data indicate days within a quarter with no RN time, despite having one or more residents in the 
nursing home.54  From Q1 through Q3 2018, CMS applied this scoring rule when nursing homes 
reported 7 or more days with no RN time.55  For Q4 2018, CMS reduced the number of days to 4 or 
more days with no RN time.56, 57    
  Nursing homes will receive a 1-Star rating for Overall staffing and RN staffing for 3 months if they 
either (1) fail to respond to CMS audits of PBJ data; or (2) have audits of PBJ data that identify 
significant discrepancies between the staff hours reported and the staff hours verified.58  The 
3 months begin when the deadline to respond to CMSs audit requests passes or audit 
discrepancies are identified. 
   
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APPENDIX B: NURSING HOMES REPORTING 
STAFFING BELOW REQUIRED LEVELS 
 
Exhibit B-1.  Descriptive Statistics of All Nursing Homes, Nursing Homes Reporting 1 to 29 Days With Staffing Below 
Required Levels, and Nursing Homes With at Least 30 Days With Staffing Below Required Levels  
Nursing Homes   Nursing Homes   Nursing Homes  
All 
With 115   With 1629   With at Least 30  
Nursing 
     Total Days With   Total Days With   Total Days With 
Homes 
Staffing Below  Staffing Below  Staffing Below 
  
Required Levels  Required Levels   Required Levels 
  Total  N = 12,862  N = 5,127  N = 900  N = 943 
Nursing Homes  Mean   7 days   5 days  19 days   58 days  
Reporting Days Without 
Median   1 day  3 days  19 days   45 days  
an RN on Staff for at 
Range  357 days  15 days  29 days  357 days 
Least 8 Hours 
Nursing Homes  Mean   2 days   1 day  3 days   15 days  
Reporting Days Without 
Median   0 days  0 days  0 days   1 day 
Licensed Nursing 
Services for at Least 24  Range  315 days  15 days  29 days  315 days 
Hours 
12,862 nursing homes 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
Exhibit B-2.  Number of Nursing Homes Reporting Staffing Below Required Levels by Type Staffing Below Required 
Levels 
  Number  Percentage 
Nursing Homes Reporting At Least 30 Total Days With Staffing Below Required Levels  943  7% 
Nursing homes with at least 30 total days without an RN on staff for 8 hours   817  6% 
Nursing homes with at least 30 total days without licensed nurse services for at least 24 hours  153  1% 
Nursing homes with at least 30 total days where days without an RN on staff for 8 hours and days without 
74  <1% 
licensed nurse services for at least 24 hours occurred on the same day 
Nursing Homes Reporting Between 1629 Days With Staffing Below Required Levels  900  7% 
Nursing homes with 1629 days without an RN on staff for 8 hours   762  6% 
Nursing homes with 1629 days without licensed nurse services for at least 24 hours  82  1% 
Nursing homes with 1629 days where days without an RN on staff for 8 hours and days without  
10  <1% 
licensed nurse services for at least 24 hours occurred on the same day 
Nursing Homes Reporting Between 115 Days With Staffing Below Required Levels  5,127  40% 
Nursing homes with 115 days without an RN on staff for 8 hours   4,927  38% 
Nursing homes with 115 days without licensed nurse services for at least 24 hours  1,028  8% 
Nursing homes with 115 days where days without an RN on staff for 8 hours and days without  
565  4% 
licensed nurse services for at least 24 hours occurred on the same day 
Nursing Homes Reporting Staffing At or Above Required Levels  5,892  46% 
TOTAL   12,862  100% 
12,862 nursing homes 
Source: OIG analysis of 2018 PBJ data, 2019. 
   
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APPENDIX C: CHARACTERISTICS OF 
NURSING HOMES REPORTING STAFFING 
BELOW REQUIRED LEVELS  
Nursing Homes With At Least 1 Day With  
Nursing Home Characteristics  All Nursing Homes 
Staffing Below Required Levels 
115 Days With   1629 Days With   30+ Days With  
    Staffing Below  Staffing Below  Staffing Below 
Required Levels  Required Levels  Required Levels 
  12,862  5,127  900  943 
   (n)  %  (n)  %  (n)  %  (n)  % 
<50 Beds  1,599  12.43%  747  14.57%  195  21.67%  248  26.30% 
51-100 Beds  4,932  38.35%  2,264  44.16%  400  44.44%  454  48.14% 
Size  101-150 Beds  4,260  33.12%  1,644  32.07%  247  27.44%  195  20.68% 
151-200 Beds  1,388  10.79%  368  7.18%  51  5.67%  38  4.03% 
>200 Beds  683  5.31%  104  2.03%  7  0.78%  8  0.85% 
Urban / Rural  Urban  9,218  71.67%  3,374  65.81%  553  61.44%  559  59.28% 
Status  Rural  3,644  28.33%  1,753  34.19%  347  38.56%  384  40.72% 
Family Group  Family Group  2,713  21.09%  960  18.72%  139  15.44%  139  14.74% 
Status*  No Family Group  10,149  78.91%  4,167  81.28%  761  84.56%  804  85.26% 
For-Profit  9,073  70.54%  3,724  72.64%  687  76.33%  720  76.35% 
Type  Nonprofit  2,990  23.25%  1,104  21.53%  151  16.78%  127  13.47% 
Government  799  6.21%  299  5.83%  62  6.89%  96  10.18% 
Medicare / Medicaid  12,153  94.49%  4,845  94.50%  857  95.22%  866  91.83% 
Medicare / 
Medicare-only  493  3.83%  178  3.47%  23  2.56%  32  3.39% 
Medicaid Status 
Medicaid-only  216  1.68%  104  2.03%  20  2.22%  45  4.77% 
Chain  7,843  60.98%  3,259  63.57%  587  65.22%  546  57.90% 
Chain Status 
Individual  5,019  39.02%  1,868  36.43%  313  34.78%  397  42.10% 
Free-Standing or  Free-Standing  12,408  96.47%  4,964  96.82%  882  98.00%  899  95.33% 
Hospital-Based  Hospital-Based  454  3.53%  163  3.18%  18  2.00%  44  4.67% 
Resident Group  Resident Group  12,422  96.58%  4,974  97.02%  866  96.22%  918  97.35% 
Status*  No Resident Group  440  3.42%  153  2.98%  34  3.78%  25  2.65% 
RN Waiver  2  0.02%  1  0.02%  0  0.00%  1  0.11% 
No RN Waiver  12,860  99.98%  5,126  99.98%  900  100.00%  942  99.89% 
Staffing Waiver  24-Hour Licensed 
Status**  Nurse Waiver  8  0.06%  4  0.08%  0  0.00%  0  0.00% 
No 24-Hour Licensed 
12,854  99.94%  5,123  99.92%  900  100.00%  943  100.00% 
Nurse Waiver 
12,862 nursing homes.  Percentages may not equal to 100.00 percent due to rounding.   
*NOTE: Family groups and/or resident groups meet to discuss issues and concerns about the nursing homes policies and operations and work to ensure 
nursing home residents receive good-quality care.59   
**NOTE: Nursing homes may request waivers from the staffing requirements that allow them to (1) provide less than 24 hours of licensed nursing services 
and/or (2) have an RN on duty for less than 8 consecutive hours every day.60, 61 
Source: OIG analysis of 2018 CASPER and PBJ data, 2019. 
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OEI-04-18-00450  APPENDIX D: FREQUENCY OF NURSING 
HOMES REPORTING REGISTERED NURSE 
STAFFING BELOW REQUIRED LEVELS AFTER 
CENTERS FOR MEDICARE & MEDICAID 
SERVICES POLICY CHANGE  
Exhibit D-1.  Nursing homes reporting some RN timebut still less than 8 hoursincreased by 
7 percent after CMSs announced policy change.  At the same time, nursing homes reporting 
days without any RN time decreased by 15 percent. 
 
 
NOTE: Of the 12,862 nursing homes in our analysis, 4,736 reported days with no RN time within any quarter of 2018.  Additionally, 4,444 of the 
12,683 nursing homes reported days with some RN time, but in amounts still below required levels within any quarter of 2018. 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
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OEI-04-18-00450  APPENDIX E: QUARTERLY AVERAGE 
PERCENTAGE OF DAYS WHEN DAILY NURSE 
STAFFING DID NOT MATCH STAR RATINGS  
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not downgraded 
to a 1-Star RN or Overall Staffing Star Rating in any quarter of 2018. 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not downgraded 
to a 1-Star RN or Overall Staffing Star Rating in any quarter of 2018. 
Source: OIG analysis of 2018 PBJ data, 2019. 
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OEI-04-18-00450  APPENDIX F:  DAY-TO-DAY DIFFERENCES IN 
NURSING HOMES STAFFING LEVELS 
Exhibit F-1.  There are considerable day-to-day differences in staffing levels among nursing 
homes that have the same RN Staffing Star Rating in Nursing Home Compare. 
 
 
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not downgraded to a 1-Star RN or 
Overall Staffing Star Rating in any quarter of 2018. 
NOTE: The groups of nursing homes are ranked based on the percentage of days that staffing levels were either above or below their quarterly 
RN Staffing Star Rating. 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
 
 
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OEI-04-18-00450  Exhibit F-2.  There are considerable day-to-day differences in staffing levels among nursing 
homes that have the same TN Staffing Star Rating in Nursing Home Compare. 
 
 
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not downgraded to a 1-Star RN or 
Overall Staffing Star Rating in any quarter of 2018. 
NOTE: The groups of nursing homes are ranked based on the percentage of days that staffing levels were either above or below their quarterly 
TN Staffing Star Rating. 
Source: OIG analysis of 2018 PBJ data, 2019. 
 
 
 
 
 
Some Nursing Homes Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased  27
OEI-04-18-00450   
Exhibit F-3.  Average Number of Nursing Homes by RN Staffing Star Rating on Nursing Home Compare 
and Number of Days Staffing Levels Corresponded to 1-Star RN Levels in 2018 
  1-Star Nursing  2-Star Nursing  3-Star Nursing  4-Star Nursing  5-Star Nursing 
Homes  Homes  Homes  Homes  Homes 
0 Days  0  7  233  1,239  2,034 
16 Days  0  50  858  1,329  433 
7+ Days  789  1,789  2,034  542  36 
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not downgraded to a 1-Star RN or 
Overall Staffing Star Rating in any quarter of 2018. 
Source: OIG analysis of 2018 Nursing Home Compare and PBJ data, 2019. 
 
Exhibit F-4.  Average Number of Nursing Homes by TN Staffing Star Rating on Nursing Home Compare 
and Number of Days Staffing Levels Corresponded to 1-Star TN Levels in 2018 
  1-Star Nursing  2-Star Nursing  3-Star Nursing  4-Star Nursing  5-Star Nursing 
Homes  Homes  Homes  Homes  Homes 
0 Days  0  8  500  709  2,191 
16 Days  0  42  992  502  444 
7+ Days  1,757  2,503  1,569  117  39 
This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not downgraded to a 1-Star RN or 
Overall Staffing Star Rating in any quarter of 2018. 
Source: OIG analysis of 2018 Nursing Home Compare and PBJ data, 2019. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
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APPENDIX G: AGENCY COMMENTS 
 
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OEI-04-18-00450   
 
 
 
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OEI-04-18-00450   
   
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OEI-04-18-00450   
ACKNOWLEDGMENTS 
Victoria Coxon served as the lead analyst for this study.  Others in the Office 
of Evaluation and Inspections who conducted the study include Lucio Verani 
and Brianna Weldon.  Office of Evaluation and Inspections staff who 
provided support include Althea Hosein, Joe Chiarenzelli, and Christine 
Moritz.  
We would also like to acknowledge the contributions of other Office of 
Inspector General (OIG) staff, including Eddie Baker, Mandy Brooks, and 
Berivan Demir-Neubert.   
This report was prepared under the direction of Dwayne Grant, Regional 
Inspector General for Evaluation and Inspections in the Atlanta regional 
office; Evan Godfrey, Deputy Regional Inspector General; and Jaime Stewart, 
Assistant Regional Inspector General. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov. 
Some Nursing Homes Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased  32 
OEI-04-18-00450   
ENDNOTES 
 
1 Kramer, A.M., and Fish, R., The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care, 
in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report, Abt Associates, Inc., 
Winter 2001.  This study, also known as the CMS Staffing Study, found a clear association between nurse staffing and 
nursing home quality of care.  CMS, Nursing Home Compare Technical Users GuideApril 2019, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 14, 2019. 
2 Additionally, we use the term nursing homes to refer to both Medicare Skilled Nursing Facilities and Medicaid 
nursing facilities. 
3 CMS, QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019. 
4 Mathews, Anna Wilde, and Kamp, Jon, Coronavirus Hits Nursing Homes Hard, as Staff Combat Infections, 
Shortages, Wall Street Journal, https://www.wsj.com/articles/coronavirus-hits-nursing-homes-hard-as-staff-combat-
infections-shortages-11585250841?ns=prod/accounts-wsj.  Accessed on April 7, 2020. 
5 Kenan, Joanne;  Roubein, Rachel, and Luthi, Susannah, How Public Health Failed Nursing Homes, Politico, 
https://www.politico.com/news/2020/04/06/public-health-failed-nursing-homes-167372.  Accessed on April 7, 2020.  
6 CMS, About Nursing Home Compare, 
https://www.medicare.gov/NursingHomeCompare/About/nhcinformation.html.  Accessed on October 1, 2019.   
7 Ibid. 
8 42 CFR 483.35.  Nursing homes must also have sufficient hours of nurse services to meet residents needs to attain 
or maintain practical physical, mental, and psychological well-being for each resident.  We did not assess the 
sufficiency of nurse staffing levels to meet residents needs because CMS does not use the number of reported staff 
hours per resident (i.e., Hours Per Resident per Day or HPRD) to define the sufficiency of nurse staffing levels.  When 
State survey agencies inspect nursing homes, they determine whether nursing homes have sufficient staff to provide 
the care and services residents need.  CMS, State Operations ManualAppendix PP, 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.  
Accessed on February 26, 2020.   
9 42 CFR  483.35(a)(1)(i) and  483.35(b).  Out of the 12,862 nursing homes we analyzed, 2 had RN waivers and 8 had 
24-hour waivers. 
10 Section 6106 of the Patient Protection and Affordable Care Act instructed the Department of Health and Human 
Services (HHS) to require nursing homes to electronically submit this data as codified in 42 USC 1320a-7j(g) and 
implemented in 42 CFR 483.70(q).  The Improving Medicare Post-Acute Care Transformation Act of 2014 provided 
funding for the creation of the PBJ.  
11 Direct care staff are those individuals who, through interpersonal contact with residents or resident care 
management, provide care and services to allow residents to attain or maintain the highest practicable physical, 
mental, and psychosocial well-being.  Direct care staff does not include individuals whose primary duty is maintaining 
the physical environment of the long-term care facility (for example, housekeeping).  CMS, Electronic Staffing Data 
Submission Payroll-Based Journal: Long-Term Facility Policy Manual Version 2.5, 
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V25-11-19-2018.pdf.  Accessed on July 16, 
2019. 
12 Ibid.  PBJ staffing data include both full-time and part-time nursing home employees and individuals under an 
agency or individual contract. 
13 CMS, About Nursing Home Compare, 
https://www.medicare.gov/NursingHomeCompare/About/nhcinformation.html.  Accessed on October 17, 2019.  CMS, 
Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-Enrollment-
and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on February 27, 2020.   
 
Some Nursing Homes Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased  33 
OEI-04-18-00450   
 
14 CMS Newsroom, CMS Improving Nursing Home Compare in April 2019, https://www.cms.gov/newsroom/press-
releases/cms-improving-nursing-home-compare-april-2019.  Accessed on September 13, 2019. 
15 The other two areas that contribute to each nursing homes Overall 5-Star Rating are:  
  Health Inspections: Ratings for the overall health inspection area, including the number, extent, and severity 
of deficiencies identified during the three most recent on-site state annual health inspections. 
  Quality Measures: Ratings for the overall quality measure area are based on nursing homes performance on 
12 quality measures based on residents MDS assessments and 5 measures based on residents Medicare 
claims data.   
CMS, Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on February 27, 2020.   
16 The Staffing Rating considers differences in the levels of residents' care needs in each nursing home.  For example, 
a nursing home with residents who have more health problems would be expected to have more nursing staff than a 
nursing home where the residents need less health care.  CMS, About Nursing Home Compare, 
https://www.medicare.gov/NursingHomeCompare/About/nhcinformation.html.  Accessed on October 1, 2019.   
17 CMS, QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019. 
18 Kramer, A.M., and Fish, R., The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care, 
in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report, Abt Associates, Inc., 
Winter 2001; Abt Associates,  Nursing Home Compare Five-Star Quality Rating System: Year Three Report, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/Downloads/FSQRS-Report.pdf.  Accessed on September 13, 2019. 
19 CMS, Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on September 26, 
2019. 
20 The RN and TN staffing hours per resident do not necessarily show the number of nursing staff present at any 
given time or reflect the amount of care given to any one resident.  CMS, QSO-18-17-NH Memorandum, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019. 
21 CMS, QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on September 6, 2019. 
22 Ibid.  Any nursing homes with an automatically downgraded Staffing Star Rating would also have their overall 
(composite) rating reduced by one star. 
23 Additionally, in April 2019, CMS changed its automatic downgrade policy criterion from 7 days without any RN time 
to 4 days without any RN time.  CMS, WSO-19-08-NH Memorandum, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO19-08-NH.pdf.  Accessed on October 2, 
2019.  
24 Administration for Community, Administration on Aging, https://acl.gov/about-acl/administration-aging.  
Accessed on April 30, 2020.  In 2012, the creation of the Administration for Community Living (ACL) consolidated the 
efforts of AoA, the Administration on Intellectual and Developmental Disabilities, and the HHS Office on Disability.  
AoA continues to administer the LTCOP.  ACL, About ACL, Mission & Strategic Plan, https://acl.gov/about-acl.  
Accessed on April 30, 2020.    
25 Pub. L. 95-478: Comprehensive Older Americans Act Amendments (October 18, 1978). 
26 Pub. L. 100-175: Older Americans Act Amendments of 1987 (November 29, 1987). 
27 45 CFR Part 1324, Subpart A. 
28 Administration for Community Living, Long-Term Care Ombudsman FAQ, https://acl.gov/programs/long-term-
care-ombudsman/long-term-care-ombudsman-faq.  Accessed on February 3, 2020. 
29 CMS converts the reported nurse staffing hours into measures that indicate an average RN and TN hours per 
resident day (HPRD) throughout each quarter.  CMS adjusts the staffing levels for differences in the acuity of 
residents at each nursing home.  Each nursing homes RN and TN Staffing Star Ratings are assigned based on how its 
RN and TN staffing levels compare to the distribution of RN and TN staffing levels for nursing homes in the Nation.  
 
Some Nursing Homes Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased  34 
OEI-04-18-00450   
 
CMS, Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on October 18, 2019; 
CMS, QSO-18-17-NH Memorandum, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on October 25, 2019. 
30 CMS, PBJ Public Use Files Data DocumentationPayroll-Based Journal Public Use Files: Technical Specifications
April 2019, https://data.cms.gov/Special-Programs-Initiatives-Long-Term-Care-Facili/PBJ-Public-Use-Files-Data-
Documentation/ygny-gzks.  Accessed on November 22, 2019.   
31 Residents needs are clinically assessed with MDS assessments that measure several aspects of residents needs (i.e., 
acuity), such as mental and physical functioning; pain; medical diagnoses and health conditions; and medication use.  
Residents with similar needs are grouped into 1 of 66 unique Resource Utilization Groups (RUGs), creating a mix of 
residents needs (case-mix) specific to each nursing home.  CMS, Long-Term Care Facility Resident Assessment 
Instrument 3.0 Users Manual, Version 1.17.1, October 2019, https://downloads.cms.gov/files/mds-3.0-rai-manual-
v1.17.1_october_2019.pdf.  Accessed on February 20, 2020. 
32 Only residents with MDS assessments that (1) occurred in the year prior to the quarter when the census will be 
calculated and (2) were not discharged or deceased are included in the daily resident census.  CMS, Nursing Home 
Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 4, 2019. 
33 Ibid.  Residents at each nursing home included in CMSs case-mix census are those who (1) have received MDS 
assessments in the year prior to the quarter when the case-mix census will be calculated; (2) have been assigned to a 
RUG based on their health needs; and (3) were not discharged or deceased. 
34 CMS includes all nursing homes PBJ data in the PBJ Public Use File (PUF) if the nursing homes were participating in 
Medicare and/or Medicaid on the last day of the quarter.  CMS excludes nursing homes from being included in the 
PBJ PUF for several reasons which indicate that the nursing homes PBJ data may be unreliable.  These are (1) if 
average TN staffing within a quarter is less than 1.5 HPRD; (2) if average TN staffing within a quarter for both nurses 
and residents is greater than 12 HPRD; and (3) average Aide staffing within the quarter is greater than 5.25 HPRD.  
CMS, Payroll-Based Journal Public Use Files: Technical SpecificationsApril 2019.      
35 Nursing homes may be excluded from the PBJ PUF for multiple quarters within a year for other reasons, including 
that the nursing home did not submit information on time, did not submit MDS Census data, or may be too new to 
submit staffing data, among others.  CMS, Nursing Home Compare Technical Users GuideApril 2019, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 6, 2019.    
36 Nursing homes may be excluded from the PBJ PUF for multiple quarters within a year for other reasons, including 
that the nursing home did not submit information on time, did not submit MDS Census data, or may be too new to 
submit staffing data, among others.  CMS, Nursing Home Compare Technical Users GuideApril 2019, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 6, 2019.  We also 
removed two nursing homes that shared a unique identifier but submitted separate staffing information because 
including the staffing data for both nursing homes would have counted  
37 We used the Provider Information files available on Data.Medicare.gov to determine which nursing homes were not 
downgraded to a 1-Star RN or TN Staffing Rating in any quarter during our review period.  The Provider Information 
files we used populated the information on Nursing Home Compare from July, October, and January 2018, and April 
2019.    
38 RN hours include hours from RNs, the RN director of nursing, and RNs with administrative duties.  Licensed nurse 
hours include hours from LPNs/LVNs, LPNs/LVNs with administrative duties, and any type of RN hours listed in the 
prior sentence.  CMS, Nursing Home Compare Technical Users Guide, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on October 30, 2019.  
The full list of PBJ job codes is available in CMSs Electronic Staffing Data Submission Payroll-Based Journal Long-Term 
Care Facility Policy Manual.  This manual is accessible at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/NursingHomeQualityInits/Downloads/PBJ-Policy-Manual-Final-V24.pdf. 
 
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39 CMS, State Operations Manual  Appendix PP, 430, https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.  Accessed on February 26, 2020. 
40 This analysis includes only the subpopulation of 11,373 nursing homes whose Staffing Star Ratings were not 
downgraded to a 1-Star RN or Overall Staffing Star Rating in any quarter of 2018.                                                                                                                                       
41 CMS, Nursing Home Compare Technical Users GuideJuly 2018, 21.   
42 This analysis reflected CMSs changes to the Staffing Star Rating thresholds for Q4 2018.  In addition, Nursing 
Home Compare does not post TN Staffing Star Ratings; therefore, we assigned each nursing home a quarterly TN 
Staffing Star Rating.  To do so, we first, obtained the quarterly Adjusted TN HPRD for each nursing home for each 
quarter of 2018 from the Provider Information files available on www.data.cms.gov.  We then assigned TN Staffing 
Star Ratings to each nursing home for each quarter using CMSs Staffing Star Ratings thresholds, as appropriate.  
43 CMS funded a national staff time measurement study on nursing homes (i.e., the STRIVE Project) to update the 
RUG-III case-mix weights, which support the Medicare Skilled Nursing Facility Prospective Payment System.  The 
STRIVE Projects primary objective was to use resident characteristics to explain the daily cost of care.  A large part of 
daily care costs is nursing staff time.  Residents with similar needs may require similar resources (i.e., amounts of 
nurse staff time); therefore, residents with similar needs were placed into RUGs.  CMS counts the number of residents 
in each RUG to determine the daily case-mix census (i.e., RUG census).  CMS, Staff Time and Resource Intensity 
Verification Project  Phase I Report, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/SNFPPS/TimeStudy.html.  Accessed on November 13, 2019. 
44 These star ratings are based on CMSs calculation of each nursing homes quarterly average RN and TN Adjusted 
HPRD. 
45 The daily sum of residents at each nursing home is determined by the number of residents with MDS assessments.  
CMS refers to this sum of residents as the MDS Census.  CMS, Nursing Home Compare Technical Users GuideApril 
2019, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 4, 2019. 
46 Nursing home residents are placed into RUGs using the RUG-IV classification system.  Based on residents resource 
needs, the RUG-IV classification is divided into eight major categories: rehabilitation plus extensive; rehabilitation; 
extensive services; special care high; special care low; clinically complex; behavioral symptoms and cognitive 
performance; and reduced physical functioning.  Residents needs are further differentiated between and within the 
eight major categories.  The RUG-IV system replaced the RUG, Version III (RUG-III) system for Medicare starting on 
October 1, 2010.  CMS, Nursing Home Compare Technical Users GuideApril 2019, 
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 13, 2019. 
47 A nursing home with residents who have more severe health problems would be expected to have more nursing 
staff than a nursing home with residents who have less severe health problems.  CMS About Nursing Home 
Compare, https://www.medicare.gov/NursingHomeCompare/About/nhcinformation.html.  Accessed on November 
13, 2019.   
48 The Nursing Home Compare Technical Users Guide is available at https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.   
49 CMSs Nursing Home Compare Technical Users GuideApril 2019 contains detailed instructions for calculating the 
quarterly RN and TN Case-Mix HPRD.   
50 CMS, Nursing Home Compare Technical Users GuideApril 2019, 10. 
51 Prior to this April 2018 change, CMS used the RUG-III risk adjustment methodology to determine nursing homes 
Staffing Star Ratings.  CMS, Memorandum  QSO-18-17-NH, https://www.cms.gov/Medicare/Provider-Enrollment-
and-Certification/SurveyCertificationGenInfo/Downloads/QSO18-17-NH.pdf.  Accessed on November 22, 2019. 
52 CMS, Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on November 22, 
2019. 
53 CMS, Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on December 6, 2019. 
 
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OEI-04-18-00450   
 
54 CMS, Nursing home Compare Technical Users GuideJuly 2018, 12; CMS, Nursing Home Compare Technical Users 
GuideApril 2019, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on December 6, 2019. 
55 CMS, Nursing Home Compare Technical Users GuideJuly 2018, 12. 
56 CMS, QSO Memorandum QSO19-08-NH, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/QSO19-08-NH.pdf.  Accessed on December 6, 2019. 
57 CMS, Nursing Home Compare Technical Users GuideApril 2019, https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf.  Accessed on December 6, 2019. 
58 Ibid. 
59 CMS, Your Rights and Protections as a Nursing Home Resident, 
https://downloads.cms.gov/medicare/Your_Resident_Rights_and_Protections_section.pdf.  Accessed on November 24, 
2019.   
60 42 CFR 483.35(e)-(f).  
61 States may grant Medicaid-certified nursing home waivers from all nursing services requirements, and the HHS 
Secretary may grant waivers from the daily 8-consecutive-hour RN requirement to (1) nursing homes participating 
only in Medicare; and (2) nursing homes participating in both Medicare and Medicaid.  The HHS Secretary delegates 
authority to grant waivers, and this authority differs by facility certification type.  For example, the State has authority 
to grant waivers for nursing homes that are only Medicaid-certified, and CMS has authority if the facility participates 
in both Medicare and Medicaid.  CMS, State Operations Manual  Appendix PP, 444.  To be eligible for staffing 
waivers, the facility must (1) be located in a rural area with a shortage of skilled nurses, (2) have one full-time RN on 
duty for 40 hours per week, and (3) demonstrate an inability to recruit appropriate personnel.  Additionally, the 
agency granting the waiver must notify the State Long Term Care Ombudsman (State LTCO) and the States 
protection and advocacy system for individuals with mental disorders.  Nursing homes that have been granted 
waivers must notify residents. 
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