{
  "study": {
    "slug": "nursing-home-zero-rn-days",
    "title": "Zero-RN days: how often US nursing homes ran a day with no registered nurse on the floor",
    "standfirst": "In the CMS Payroll-Based Journal's 2025 Q2 snapshot, 5.86% of nursing-home facility-days with residents present recorded zero registered-nurse direct-care hours — 77,542 days across 5,062 facilities. The rate ranged from 27.9% in Louisiana to 0.2% in Rhode Island. Days before the federal staffing floor was rescinded, this is the baseline the country now keeps.",
    "desk": "workforce",
    "article_type": "Original Research",
    "published": "2026-06-04",
    "issue": 52,
    "doi": "10.5072/fonteum/nh-zero-rn-2026",
    "url": "https://fonteum.com/research/nursing-home-zero-rn-days",
    "methodology_version": "pbj-zero-rn/v1"
  },
  "data_as_of": "2025-06-30",
  "datasets": [
    {
      "slug": "pbj-staffing",
      "name": "CMS Payroll-Based Journal",
      "publisher": "CMS — Payroll-Based Journal (PBJ) Daily Nurse Staffing",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "5.86%",
      "finding": "of nursing-home facility-days had zero RN direct-care hours — 77,542 of 1,322,254 days",
      "dataset": "pbj-staffing"
    },
    {
      "number": "34.8%",
      "finding": "of facilities (5,062 of 14,537) had at least one zero-RN day in Q2 2025",
      "dataset": "pbj-staffing"
    },
    {
      "number": "27.9%",
      "finding": "highest state rate (Louisiana) vs 0.2% in Rhode Island — a roughly 120-fold spread",
      "dataset": "pbj-staffing"
    },
    {
      "number": "51",
      "finding": "facilities recorded zero RN direct-care hours on every single day of the quarter — all 91 days",
      "dataset": "pbj-staffing"
    }
  ],
  "faqs": [
    {
      "q": "What is a \"zero-RN day\" in this analysis?",
      "a": "A facility-day on which a Medicare- or Medicaid-certified nursing home reported zero registered-nurse direct-care hours (the CMS Payroll-Based Journal field Hrs_RN) while residents were present that day (midnight census above zero). It counts the RN direct-care job code only; PBJ records RN administrative and director-of-nursing hours separately, and those are excluded from the headline count."
    },
    {
      "q": "How many nursing-home days had no RN on the floor?",
      "a": "In the CMS Payroll-Based Journal 2025 Q2 snapshot, 77,542 of 1,322,254 facility-days with residents present — 5.86% — recorded zero RN direct-care hours. Counted by facility, 5,062 of 14,537 nursing homes (34.8%) had at least one such day during the April–June 2025 quarter."
    },
    {
      "q": "Which states had the most zero-RN days?",
      "a": "Louisiana led, with 27.9% of resident-days recording zero RN direct-care hours, followed by Oklahoma (25.4%) and Arkansas (20.8%). Rhode Island was lowest at 0.2%. The roughly 120-fold spread between the highest and lowest states is far wider than differences in resident need can explain on their own."
    },
    {
      "q": "Were these zero-RN days illegal?",
      "a": "Not in this snapshot. The data covers April–June 2025, before the federal 24-hour, 7-day RN requirement had taken effect and before the staffing rule was rescinded. These are descriptive measures of reported direct-care RN coverage, not findings of regulatory non-compliance. With the federal staffing floor rescinded effective February 2, 2026, no national minimum now sits beneath these figures."
    },
    {
      "q": "Does a zero-RN day mean no nurse at all was present?",
      "a": "No. A licensed practical nurse or certified nursing assistant may have been on duty, and on most zero-RN-direct-care days an RN performing administrative or director-of-nursing work may have been in the building. A stricter measure — zero RN hours across all three RN job codes — covered 0.56% of facility-days. The headline metric specifically tracks RN direct-care hours, the category tied to bedside assessment."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 04). Zero-RN days: how often US nursing homes ran a day with no registered nurse on the floor. Fonteum Research, Issue 52. https://doi.org/10.5072/fonteum/nh-zero-rn-2026",
    "url": "https://fonteum.com/research/nursing-home-zero-rn-days"
  },
  "reproducible_sql": "-- Zero-RN days in US nursing homes (CMS PBJ, CY2025 Q2).\n-- Snapshot: pbj_daily_nurse_staffing, snapshot_quarter = '2025Q2'\n--           (the immutable CMS Payroll-Based Journal quarter covering\n--            2025-04-01 .. 2025-06-30, downloaded from data.cms.gov).\n--\n-- Definitions (locked):\n--   facility-day  := one nursing home on one calendar day.\n--   included      := mds_census > 0  (residents present that day).\n--   zero-RN day   := Hrs_RN = 0      (RN direct-care job code; this column\n--                    EXCLUDES RN administrative and RN director-of-nursing\n--                    hours, which PBJ records separately as Hrs_RNadmin and\n--                    Hrs_RNDON).\n--\n-- Re-running these queries against the 2025Q2 snapshot reproduces every headline\n-- figure in the study, exactly. Each query is annotated with its expected result.\n\n-- ── (1) Headline figures ─────────────────────────────────────────────────────\nwith day_rn as (\n  select\n    provnum,\n    state,\n    work_date,\n    mds_census,\n    coalesce(hrs_rn, 0) as rn_direct_hours\n  from public.pbj_daily_nurse_staffing\n  where snapshot_quarter = '2025Q2'\n    and mds_census > 0\n)\nselect\n  count(*)                                                          as facility_days,        -- 1,322,254\n  count(*) filter (where rn_direct_hours = 0)                       as zero_rn_days,          -- 77,542\n  round(100.0 * count(*) filter (where rn_direct_hours = 0)\n        / count(*), 2)                                              as pct_zero_rn_days,      -- 5.86\n  count(distinct provnum)                                           as facilities,            -- 14,537\n  count(distinct provnum) filter (where rn_direct_hours = 0)        as facilities_any_zero,   -- 5,062\n  round(100.0 * count(distinct provnum) filter (where rn_direct_hours = 0)\n        / count(distinct provnum), 1)                               as pct_facilities_any,    -- 34.8\n  round(avg(mds_census), 0)                                         as avg_daily_census       -- 85\nfrom day_rn;\n\n-- ── (2) State-level rates ────────────────────────────────────────────────────\n-- Two columns: share of resident-days with zero RN direct-care hours, and share\n-- of facilities with at least one such day. Among states with >= 20 reporting\n-- facilities. Louisiana highest (27.9% of days, 79.8% of facilities); Rhode\n-- Island lowest (0.2% / 7.0%) — a ~120x spread on the day rate.\nwith day_rn as (\n  select provnum, state, coalesce(hrs_rn, 0) as rn_direct_hours\n  from public.pbj_daily_nurse_staffing\n  where snapshot_quarter = '2025Q2' and mds_census > 0\n)\nselect\n  state,\n  round(100.0 * count(*) filter (where rn_direct_hours = 0)\n        / count(*), 1)                                              as pct_days_zero_rn,\n  round(100.0 * count(distinct provnum) filter (where rn_direct_hours = 0)\n        / count(distinct provnum), 1)                               as pct_facilities_zero_rn\nfrom day_rn\ngroup by state\nhaving count(distinct provnum) >= 20\norder by pct_days_zero_rn desc;\n--  LA 27.9 / 79.8 · OK 25.4 / 80.3 · AR 20.8 / 78.7 · TX 14.2 / 62.2\n--  MO 11.8 / 62.2 · GA  8.7 / 51.4 · KS  8.0 / 52.2 · OR  7.5 / 55.6\n--  ... (lowest) FL 0.9 / 11.5 · CO 0.9 / 10.7 · MD 0.8 / 12.3\n--               NH 0.7 / 18.9 · RI 0.2 / 7.0\n\n-- ── (3) Per-facility distribution of zero-RN days across the 91-day quarter ───\nwith per_fac as (\n  select\n    provnum,\n    count(*)                                            as resident_days,\n    count(*) filter (where coalesce(hrs_rn, 0) = 0)     as zero_days\n  from public.pbj_daily_nurse_staffing\n  where snapshot_quarter = '2025Q2' and mds_census > 0\n  group by provnum\n)\nselect\n  count(*) filter (where zero_days = 0)                  as fac_none,        -- 9,475 (65.2%)\n  count(*) filter (where zero_days between 1 and 6)      as fac_1_6,         -- 2,650 (18.2%)\n  count(*) filter (where zero_days between 7 and 29)     as fac_7_29,        -- 1,497 (10.3%)\n  count(*) filter (where zero_days between 30 and 90)    as fac_30_90,       --   864 (5.9%)\n  count(*) filter (where zero_days >= 91)                as fac_every_day,   --    51 (0.4%)\n  -- Among facilities with ANY zero-RN day: mean count, and how many ran a\n  -- zero-RN day on at least half of their resident-days.\n  round(avg(zero_days) filter (where zero_days > 0), 1)  as avg_zero_days_among_any, -- 15.3\n  count(*) filter (where zero_days > 0\n                   and zero_days >= 0.5 * resident_days) as fac_half_or_more         -- 536\nfrom per_fac;\n\n-- ── (4) Direct care vs the whole RN department ───────────────────────────────\n-- The headline isolates the RN DIRECT-CARE column. Widening to require zero RN\n-- hours across ALL three RN job codes (direct care + administrative + director\n-- of nursing) collapses the count: most zero-direct-care days still had an RN\n-- in the building, booked to administration or department management.\nwith day_rn as (\n  select\n    provnum,\n    coalesce(hrs_rn, 0) + coalesce(hrs_rnadmin, 0)\n      + coalesce(hrs_rndon, 0)                          as rn_all_codes_hours\n  from public.pbj_daily_nurse_staffing\n  where snapshot_quarter = '2025Q2' and mds_census > 0\n)\nselect\n  count(*) filter (where rn_all_codes_hours = 0)                    as all_rn_zero_days,      -- 7,399\n  round(100.0 * count(*) filter (where rn_all_codes_hours = 0)\n        / count(*), 2)                                              as pct_all_rn_zero,       -- 0.56\n  count(distinct provnum) filter (where rn_all_codes_hours = 0)     as facilities_all_rn_zero -- 1,373\nfrom day_rn;\n\n-- ── (5) Weekday vs weekend zero-RN-direct-care rate ──────────────────────────\n-- Counterintuitive: weekdays are WORSE than weekends for zero RN DIRECT-CARE\n-- days, because the on-site RN is more often coded to administrative / DON\n-- duties Monday–Friday. A bookkeeping pattern, not a clinical one.\nwith day_rn as (\n  select\n    extract(isodow from work_date) in (6, 7)            as is_weekend,\n    coalesce(hrs_rn, 0)                                 as rn_direct_hours\n  from public.pbj_daily_nurse_staffing\n  where snapshot_quarter = '2025Q2' and mds_census > 0\n)\nselect\n  is_weekend,\n  round(100.0 * count(*) filter (where rn_direct_hours = 0)\n        / count(*), 2)                                              as pct_zero_rn_days\nfrom day_rn\ngroup by is_weekend\norder by is_weekend;\n--  is_weekend = false (weekday) -> 6.51\n--  is_weekend = true  (weekend) -> 4.26\n\n-- ── (6) Nurse staffing hours per resident-day (national) ──────────────────────\n-- Hours-per-resident-day = sum(hours) / sum(census), the standard PBJ HPRD.\nselect\n  round(sum(coalesce(hrs_rn, 0)) / sum(mds_census), 2)              as rn_direct_hprd,  -- 0.43\n  round(sum(coalesce(hrs_rn, 0) + coalesce(hrs_rnadmin, 0)\n        + coalesce(hrs_rndon, 0)) / sum(mds_census), 2)             as rn_all_hprd,     -- 0.62\n  round(sum(coalesce(hrs_rn, 0) + coalesce(hrs_rnadmin, 0)\n        + coalesce(hrs_rndon, 0) + coalesce(hrs_lpn, 0)\n        + coalesce(hrs_lpnadmin, 0) + coalesce(hrs_cna, 0)\n        + coalesce(hrs_natrn, 0) + coalesce(hrs_medaide, 0))\n        / sum(mds_census), 2)                                       as total_nurse_hprd -- 3.70\nfrom public.pbj_daily_nurse_staffing\nwhere snapshot_quarter = '2025Q2' and mds_census > 0;\n\n-- ── (7) Contract / agency share of RN hours ──────────────────────────────────\n-- PBJ splits each job code into employee vs contract columns. Agency reliance is\n-- a recognized marker of staffing instability; it does not, on its own, drive\n-- the zero-RN-day count.\nselect\n  round(100.0 * sum(coalesce(hrs_rn_ctr, 0))\n        / nullif(sum(coalesce(hrs_rn_emp, 0)\n                     + coalesce(hrs_rn_ctr, 0)), 0), 1)             as pct_rn_hours_contract -- 7.3\nfrom public.pbj_daily_nurse_staffing\nwhere snapshot_quarter = '2025Q2' and mds_census > 0;",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}