An audit found 42% of nursing homes' RN staffing hours unsupported
Summary
A federal audit of the system CMS uses to calculate nursing home star ratings and monitor nurse-staffing compliance found that nearly half of the registered-nurse hours it sampled couldn't be verified against payroll records. Extrapolated nationwide, that's an estimated 53,000 nurses -- 42% of those in the audit's scope -- whose reported March 2024 hours weren't properly supported. CMS's own auditor has flagged similar problems every year since 2022, but its main guidance to nursing homes on avoiding these errors is more than seven years old.
A database that drives ratings and monitoring
Nursing homes participating in Medicare or Medicaid are legally required to report detailed staffing data⧉ to 's Payroll-Based Journal, based on payroll and other verifiable records. uses that data for three things: calculating each nursing home's star rating on its public Care Compare website, studying how staffing levels affect care quality, and identifying homes that fall short of the federal requirement for at least 8 consecutive hours of daily RN coverage. The audit covered 127,100 registered nurses whose hours -- roughly 20 million of them -- were reported by 14,535 nursing homes for March 2024.
View data as table
| Hours supported | 53 |
|---|---|
| Hours not supported | 45 |
| Hours could not be verified at all | 2 |
Why the hours didn't hold up
Auditors pulled a sample of 100 RN staffing records -- about 17,700 hours across 99 nursing homes -- and checked them against payroll and other supporting documentation. Fifty-three checked out. Forty-five didn't, totaling a net 748.5 unsupported hours⧉ across 44 different nursing homes -- as little as 60 hours underreported in one case, as much as 192.5 hours overreported in another. Two more records couldn't be verified at all because the nursing homes never produced documentation. The errors ranged from reporting hours nurses never worked, to failing to deduct meal breaks, to reporting hours for nurses without an active RN license or who never worked onsite.
View data as table
| Total RNs in audit scope | 127,100 |
|---|---|
| RNs with an estimated unsupported hour, nationwide | 53,000 |
This isn't new, and CMS knows it
This wasn't a one-time finding. CMS's own PBJ auditor⧉ identified some kind of reporting problem in 39% to 55% of the nursing homes it audited every year from 2022 through 2024 -- with failing to deduct meal breaks the single most common issue in all three years. Yet 's main public guidance addressing common errors is a memo from April 2018, over seven years old. also found doesn't consistently ensure nursing homes fix problems flagged in prior audits, or fully understand the reporting rules in the first place.
CMS agreed to some fixes. Not all of them.
Of 's four recommendations, agreed to two: weighing this audit's findings in choosing homes for future PBJ audits, and notifying nursing homes about updated reporting guidance (which it says it did in July 2025). asked to consider a third recommendation -- verifying that flagged homes actually fix their errors -- already implemented; OIG disagreed⧉, noting follow-up audits reach only a small share of homes with findings. flatly rejected the fourth recommendation, to regularly share audit-finding trends with nursing homes, saying it already communicates through memos and its Medicare Learning Network. 's reply: the only relevant memo is from 2018, and it couldn't find any Medicare Learning Network material on PBJ trends at all.
The takeaway
- Families use this data to choose a nursing home. 's star ratings, built partly on PBJ staffing data, are a public tool for comparing nursing homes -- and says the errors it found 'may be indicative of systemic issues across the nursing home industry' that put those ratings' accuracy at risk.
- The errors are mostly mechanical, not exotic. Unpaid meal breaks left in the count, hours logged for shifts that didn't happen, hours for nurses without active licenses -- these are the kind of payroll-process errors a modest oversight fix could catch.
- has known about the pattern for years and hasn't closed the gap. Its own auditor has flagged similar issues every year since 2022, but rejected the one recommendation aimed squarely at telling nursing homes what those recurring problems are.
This audit sampled RN hours only, not the full range of direct care staff (licensed practical nurses, nurse aides, therapists) also reported to the PBJ, so its findings should not be generalized beyond RNs. 'Unsupported' means the nursing home could not produce documentation matching federal requirements at the time of the audit -- the report does not allege fraud or intentional misreporting anywhere, and its own examples (unremoved meal breaks, hours logged on the wrong calendar day, misunderstood rules for salaried staff) point to process and systems errors. The report also does not say whether errors skewed toward over- or under-reporting hours overall -- individual examples went both ways. The 42%/938,000-hour figures are statistical estimates extrapolated from a 100-item sample, not a full census of every nursing home's records. Note also that the federal RN-coverage rule this piece references is the pre-existing 8-consecutive-hours-daily requirement, not 's more stringent 2024 minimum-staffing rule -- that separate rule was vacated by two federal courts and formally rescinded by effective February 2, 2026, before this audit was issued.
Sources(1) ▾
- HHS Office of Inspector General (OIG), CMS's Processes Were Not Effective in Ensuring the Accuracy of Staffing Information Reported in the Payroll-Based Journal (Report A-09-24-02005) (2026-06-17) — A statistical-sample audit of registered nurse staffing hours nursing homes reported to 's Payroll-Based Journal (PBJ) for March 2024, including 's formal written response and the 's reply. Fetched directly and converted with pdftotext -layout. oig.hhs.gov · original document
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Every quarter, nursing homes report the hours their registered nurses worked to a federal database called the Payroll-Based Journal. uses that data to calculate the public star ratings families use to pick a nursing home, and to monitor compliance with the federal rule requiring RN coverage at least 8 consecutive hours a day. A Health and Human Services Inspector General audit⧉ found nearly half of the RN hour records it checked against payroll documentation didn't hold up.