Invisible staffing churn in nursing homes: CMS turnover metrics miss a growing short-term workforce

Federal policy mandates adequate nursing home (NH) staffing, yet staffing adequacy remains difficult to define and measure. In 2022, the Centers for Medicare & Medicaid Services (CMS) incorporated annual turnover into Five-Star Ratings but adopted a definition excluding staff below a 120-hour-in-90-days threshold, potentially underestimating turnover and weakening validity.

Using Payroll-Based Journal and CareCompare data (2020Q2-2024Q1), we replicated CMS-reported turnover and constructed an inclusive measure counting new hires. We assessed divergence between definitions, associations with ten standardized CMS quality indicators, and changes in facility rankings.

By 2022-2023, 45% of nursing hires were excluded under CMS's definition. As short-term staffing increased, CMS-specification and inclusive turnover diverged (correlation 0.91-0.82). Associations with quality outcomes were modest and similar across definitions. However, facility rankings differed substantially: only 30% of facilities remained in the same turnover decile, with reclassification concentrated among NHs with high short-term attrition, greater contract use, and distinct ownership and payer mix.

CMS turnover metrics miss nearly half of turnover, understating instability and reshaping facility comparisons without improving associations with quality outcomes. As short-term staffing expands, the CMS measure risks becoming less informative about workforce instability, underscoring how metric definitions shape oversight and reporting.