Registered Nurse Staffing and Its Direct Impact to Nursing Home Cost Calculated (2023 vs 2024)
Several studies revealed that the relationship between staffing and service cost is non- linear. While increasing staffing directly raises costs, it can also improve variables to attain better patient outcomes while decreasing the workforce headcount significantly lessens the quality of care. Weighing which slope to take is continuously becoming a burden.
RN Coverage Definition: "RN coverage" is measured as the average registered nurse hours per resident per day (HPRD). The values below are from CMS Payroll-Based Journal data, which tracks actual staffing hours Higher HPRD means more RN care time per resident.
Cost Data Definition: "Average monthly nursing home cost" refers to the median monthly cost for a semi-private room and a private room in a skilled nursing facility. These cost figures come from Genworth's annual Cost of Care Survey, a widely cited benchmark for long-term care costs (Semi-private rooms house two residents; private rooms house one.) All costs are in USD per month.
Top 3 States by RN Staffing Levels
The top three states with the highest RN coverage in 2023 were Alaska, Hawaii, and Utah. These states continued to lead in 2024. The table below shows their RN staffing and costs:
| State | RN Coverage (HPRD) | Avg. Monthly Cost – Semi-Private Room | Avg. Monthly Cost – Private Room | Year |
|---|---|---|---|---|
| Alaska | 1.75 hours source | $31,512 source | $36,378 source | 2023 |
| Alaska | 1.78 hours source | $30,371 source | $30,371 source | 2024 |
| Hawaii | 1.39 hours source | $12,501 source | ~$14,000 (est.) | 2023 |
| Hawaii | 1.43 hours source | $15,087 source | $16,364 source | 2024 |
| Utah | 1.04 hours source | ~$7,200 source | ~$9,500 (est.) | 2023 |
| Utah | 1.05 hours source | $8,365 source | $10,646 source | 2024 |
Notes: Alaska has by far the highest RN staffing in the nation, with about 1.7–1.8 RN hours per resident-day — roughly 3× the national average source. This correlates with Alaska's extremely high nursing home costs. In 2023, Alaska's median price was over $31k per month for a semi-private room and $36k for a private room source – the highest in the U.S. Hawaii also had well-above-average RN time and high costs (around $12.5k for semi-private in 2023, rising to $15k in 2024). Utah, while not as costly as Alaska or Hawaii, still maintained top-tier RN coverage around 1.0+ HPRD, with nursing home costs slightly below the national median source.
Bottom 3 States by RN Staffing Levels
The bottom three states with the lowest RN coverage were Louisiana, Oklahoma, and Texas. These states ranked at or near the bottom in both 2023 and 2024 for RN HPRD. Their RN staffing levels and costs are shown below:
| State | RN Coverage (HPRD) | Avg. Monthly Cost – Semi-Private Room | Avg. Monthly Cost – Private Room | Year |
|---|---|---|---|---|
| Louisiana | 0.24 hours source | $5,759 source | $6,060 source | 2023 |
| Louisiana | 0.25 hours source | $7,482 source | $7,604 source | 2024 |
| Oklahoma | 0.32 hours source | $5,475 source | $6,083 source | 2023 |
| Oklahoma | 0.33 hours source | $6,448 source | $7,604 source | 2024 |
| Texas | 0.35 hours source | $5,125 source | $7,092 source | 2023 |
| Texas | 0.38 hours source | $5,475 source | $7,087 source | 2024 |
Notes: Louisiana had the lowest RN staffing in the country, at only about 0.24–0.25 hours per resident-day (about 15 minutes) sourcesource. Oklahoma and Texas were only slightly higher, around 0.3–0.4 HPRD. These low-RN states also have some of the least expensive nursing homes. In 2023, Texas's median cost for a semi-private room was about $5,125 per month – the lowest of any state source. (For comparison, the national median was about $8,669 in 2023 source.) Louisiana and Oklahoma were similarly low-cost (~$5.5–$5.8k for semi-private). Even in 2024, a semi-private room in these bottom-RN states averaged only about $5.5k–$7.5k per month, well below the national average sourcesource.
Sources: State-average RN hours per resident-day are from CMS Payroll-Based Journal staffing data (2023–2024) sourcesource. Cost data are from Genworth's Cost of Care Survey 2023 and 2024 (median monthly costs by state) source source , as reported by official analyses and surveys (SeniorSite, WorldPopulationReview, Genworth). All figures are the latest available for the year indicated.
Staff Ranking for Stars Rating
Through slated evidence that shows a relative relationship between nursing home staffing levels and resident outcomes, the CMS Staffing Study 1 , found a clear association between nurse staffing ratios and the quality of care in nursing homes. There is also a growing body of evidence on the correlation of higher prevalence of staff turnover with poorer quality of care.2
In line with this, the Centers for Medicare & Medicaid Services (CMS), implemented the Nursing Home Compare1, a public reporting site to include a set of quality ratings for each nursing home that participates in Medicare or Medicaid. The grading comes in “star” ratings depending on how each nursing home meets the criteria. The primary goal of this rating system is to make it easier for residents and families to understand how nursing homes are assessed in terms of quality, staffing and overall safety - enabling them to distinguish which nursing homes to consider. 3
Staffing is just one criterion in the star rating system but it has a huge impact because it directly affects the quality of care and the cost for nursing homes service.
Appendix Table 5: Distribution of Nursing Homes, by Staffing Measures Star Rating, Nationally and by State, February 2015
Click column headers to sort. Colors indicate performance levels.
| Staffing Measures Star Rating | ||||||
|---|---|---|---|---|---|---|
| State ▲ | Number of Nursing Homes | ⭐ | ⭐⭐ | ⭐⭐⭐ | ⭐⭐⭐⭐ | ⭐⭐⭐⭐⭐ |
| National Average | 15,505 | 10 % | 14 % | 31 % | 32 % | 12 % |
| Alabama | 226 | 1 % | 8 % | 37 % | 46 % | 8 % |
| Alaska | 18 | n/a | n/a | n/a | n/a | 89 % |
| Arizona | 145 | 1 % | 13 % | 26 % | 43 % | 14 % |
| Arkansas | 227 | 2 % | 7 % | 48 % | 41 % | 2 % |
| California | 1,212 | 2 % | 8 % | 32 % | 40 % | 15 % |
| Colorado | 212 | 1 % | 4 % | 25 % | 44 % | 24 % |
| Connecticut | 229 | 2 % | 3 % | 34 % | 41 % | 20 % |
| Delaware | 46 | 2 % | 2 % | 15 % | 46 % | 35 % |
| District of Columbia | 19 | n/a | n/a | 5 % | 42 % | 47 % |
| Florida | 688 | 2 % | 9 % | 35 % | 43 % | 9 % |
| Georgia | 355 | 32 % | 23 % | 31 % | 10 % | 2 % |
| Hawaii | 46 | 2 % | 4 % | 13 % | 35 % | 28 % |
| Idaho | 78 | n/a | 3 % | 21 % | 47 % | 26 % |
| Illinois | 755 | 12 % | 22 % | 27 % | 21 % | 12 % |
| Indiana | 516 | 6 % | 16 % | 29 % | 35 % | 12 % |
| Iowa | 438 | 3 % | 14 % | 29 % | 38 % | 13 % |
| Kansas | 335 | 3 % | 9 % | 22 % | 40 % | 24 % |
| Kentucky | 281 | 9 % | 14 % | 36 % | 28 % | 11 % |
| Louisiana | 280 | 31 % | 24 % | 31 % | 9 % | 3 % |
| Maine | 103 | 1 % | 3 % | 15 % | 42 % | 40 % |
| Maryland | 227 | 4 % | 8 % | 37 % | 35 % | 14 % |
| Massachusetts | 413 | 1 % | 5 % | 27 % | 49 % | 17 % |
| Michigan | 429 | 3 % | 8 % | 33 % | 38 % | 17 % |
| Minnesota | 376 | 2 % | 6 % | 28 % | 49 % | 13 % |
| Mississippi | 203 | 6 % | 13 % | 32 % | 36 % | 10 % |
| Missouri | 509 | 6 % | 13 % | 36 % | 36 % | 7 % |
| Montana | 82 | n/a | 5 % | 22 % | 48 % | 26 % |
| Nebraska | 214 | 2 % | 7 % | 26 % | 41 % | 22 % |
| Nevada | 52 | 2 % | 13 % | 31 % | 27 % | 19 % |
| New Hampshire | 76 | 1 % | 8 % | 22 % | 39 % | 25 % |
| New Jersey | 361 | 5 % | 14 % | 35 % | 34 % | 12 % |
| New Mexico | 70 | 4 % | 19 % | 30 % | 20 % | 11 % |
| New York | 625 | 20 % | 18 % | 31 % | 24 % | 6 % |
| North Carolina | 416 | 15 % | 21 % | 28 % | 25 % | 7 % |
| North Dakota | 80 | n/a | 1 % | 13 % | 56 % | 30 % |
| Ohio | 941 | 16 % | 20 % | 35 % | 23 % | 6 % |
| Oklahoma | 305 | 15 % | 19 % | 37 % | 22 % | 5 % |
| Oregon | 135 | n/a | 4 % | 16 % | 56 % | 24 % |
| Pennsylvania | 696 | 13 % | 24 % | 30 % | 22 % | 9 % |
| Rhode Island | 84 | 2 % | 10 % | 31 % | 43 % | 14 % |
| South Carolina | 188 | 6 % | 8 % | 37 % | 32 % | 14 % |
| South Dakota | 109 | 1 % | 13 % | 33 % | 33 % | 18 % |
| Tennessee | 317 | 17 % | 14 % | 42 % | 21 % | 5 % |
| Texas | 1,193 | 35 % | 22 % | 25 % | 12 % | 3 % |
| Utah | 99 | 1 % | 13 % | 31 % | 30 % | 20 % |
| Vermont | 37 | n/a | 3 % | 19 % | 59 % | 19 % |
| Virginia | 286 | 13 % | 18 % | 33 % | 20 % | 14 % |
| Washington | 221 | n/a | 5 % | 27 % | 48 % | 19 % |
| West Virginia | 126 | 18 % | 19 % | 33 % | 18 % | 8 % |
| Wisconsin | 388 | 2 % | 10 % | 25 % | 45 % | 17 % |
| Wyoming | 38 | n/a | 13 % | 21 % | 34 % | 29 % |
Color Legend:
Notes: Tallied by Kaiser Family Foundation analysis of Nursing Home Compare data, the table showed star ratings per nursing homes in each state based on the Staffing measures. Correlated, Alaska which landed on the top of the tier when it comes to RN staffing received 89% of 5 stars rating. Ranking second in the RN coverage is Hawaii garnering 35% and 28% of 4 and 5 stars, below 20% for 1-3 stars respectively. Utah on the other hand ranked third in staffing and gained a fair 31% of 3 stars, 30% of 4 stars and only 13% of 2 stars and 1% for 1 star rating.
Notes: On the contrary, Louisiana which earned the first place in the lowest staffing unfortunately garnered a concerning 31% of 1 star rating. Oklahoma which ranked second gained 15% and 19% in 1-2 stars bracket respectively. In third place, Texas posted a 35% mark in 1 star rating.
Given these data, availability of more staff for more focused assistance has significant implications on the satisfaction level received by patients/residents in nursing homes. But to lengthen the duration of care per resident per day, an increase in the number of RNs on duty may be required hence, raising the cost allotted for manpower expenses. In profit based nursing homes, this might not be a favorable option and this most of the time, becomes the root cause of staff shortage and high staff turnover.
NOTE: Analysis is based on the overall composite star rating score for nursing homes. Analysis includes only nursing homes certified by either Medicare or Medicaid and excludes nursing homes with unavailable star ratings.
SOURCE: Kaiser Family Foundation analysis of Nursing Home Compare data, February 2015
Resources:
1 Kramer AM, Fish R. “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care.” Chapter
2 in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report. Abt Associates, Inc., Winter 2001. 2 Zheng Q, Williams CS, Shulman ET, White AJ. Association between staff turnover and nursing home quality - evidence from payroll-based journal data. Journal of the American Geriatrics Society. May 2022. doi:10.1111/jgs.17843
3 https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf
4 https://files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-quality-star-ratings-nationally-and-by-state
