This document summarizes staffing levels and quality in California's nursing homes in 2006. It finds that while staffing levels have increased since 1999, when minimum standards were established, nearly a quarter of facilities still did not meet the standards. Facilities with higher staffing levels had fewer deficiencies cited, lower staff turnover, and fewer complaints. The most common complaints related to food and quality of care. While improvements have been made, staffing levels are still below recommended levels needed to provide high quality care across the state.

1. s n a p s h o t
Staffing and Quality in
California’s Nursing Homes
2006

2. ©2006 California HealthCare Foundation 2
Nursing Home
Staffing and Quality
C O N T E N T S
Number of Fulltime Nursing Staff in
Hospitals and Nursing Homes . . . . . .3
Nurse Staffing Hours . . . . . . . . . . . . . .4
Nurse Staffing Levels . . . . . . . . . . . . . .5
Nursing Hours by Ownership Type. . . .6
Facilities that Meet Staffing Goals
by Ownership Type. . . . . . . . . . . . . . .7
by Facility and Ownership Type . . . . .8
Total Deficiencies and Citations
by Staffing Level. . . . . . . . . . . . . . . . .9
Top Ten Deficiencies
in Nursing Facilities . . . . . . . . . . . . .10
Complaints . . . . . . . . . . . . . . . . . . . . .11
Staff Turnover and Satisfaction in
Nursing Facilities, National . . . . . . .12
Freestanding Nursing Home (FNH)
Turnover Rates . . . . . . . . . . . . . . . . .13
Nurse Staff Turnover Rate
by Staffing Level. . . . . . . . . . . . . . . .14
Deficiencies Among Freestanding
Nursing Facilities, by Turnover Rate 15
Turnover and Deficiencies
by Ownership Type. . . . . . . . . . . . . .16
Wages in Freestanding Facilities
by Nursing Turnover Rates. . . . . . . .17
Authors . . . . . . . . . . . . . . . . . . . . . . . .18
Introduction
Staffing levels in California’s nursing homes are a key indicator of the quality of
care. A study from the U.S. Centers for Medicare and Medicaid Services (CMS)
found that homes with low staff levels have an increased probability of causing
serious harm to residents. In 1999, the state passed a law increasing minimum
staffing level from 3.0 to 3.2 hours per resident day.
Since that time the percentage of nursing homes not meeting the new standard
fell from 41 to 24 percent. Among other findings in this snapshot:
• Seventy-nine percent of hospital-based facilities and 21 percent of
free-standing facilities meet the 1999 standards.
• Homes with more staff have higher staff satisfaction rates, significantly
less turnover, and fewer documented deficiencies in care.
• Nearly half of resident complaints center on poor food and more than
38 percent of complaints concern quality of care.
Although there have been improvements in increasing staffing levels for
California’s nursing homes, this snapshot illustrates that levels are still not at the
recommended level for providing high quality care to nursing home residents
across the state.
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3. ©2006 California HealthCare Foundation 3
2003200020032000
131,293
33,860
10,525
86,908
122,990
30,530
10,332
82,128
59,946
42,334
11,286
6,326
63,990
46,024
12,326
5,640
Licensed Nurse
Nursing Assistant
Registered Nurse
Nursing Home Staff
Hospital Staff
Nursing Home
Staffing and Quality
Of the almost 200,000
nursing staff working
in California in 2003,
about a third worked in
nursing facilities and a
majority of those were
nursing assistants.
Number of Fulltime Nursing Staff in
Hospitals and Nursing Homes, 2000 vs. 2003
Source: Division of Nursing, Bureau of the Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services,
Spratley, E., Johnson, A., Sochalski, J., Fritz, M. and Spencer, W. 2000. The Registered Nurse Population March 2000: Findings from the National Sample Survey of
Registered Nurses. Washington, DC.
Office of Statewide Health Planning and Development. 2000 and 2003. Long-Term Care Facility Data. Pivot tables. Sacramento, CA.
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4. ©2006 California HealthCare Foundation 4
2003200220012000
3.60
3.96
4.06 4.00
Nursing Home
Staffing and Quality
Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using Office of Statewide Health Planning and
Development’s long term care and hospital annual financial data for 2000–2003.
Nurse Staffing Hours, 2000–2003
Average Hours per Resident Day
Higher levels of nurse
staffing are related
to better quality of
care. Since legislation
was passed for a
minimum of 3.2 hours
per resident day in
California in 1999,
average nurse staffing
hours for residents in
nursing homes have
increased.
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5. ©2006 California HealthCare Foundation 5
41%
56%
3%
24%
71%
5%
Nursing Home
Staffing and Quality
Nurse Staffing Levels, 2001 vs. 2003
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations using the Office of Statewide Health Planning and
Development’s long-term care annual financial data for 2001 and 2003; Center for Medicare and Medicaid Services: Appropriateness of Minimum Nurse Staffing Ratios
in Nursing Homes, Report to Congress, 2001.
Between 2001 and
2003, the number of
homes that failed to
meet state-mandated
staffing standards fell
58 percent. Still, nearly
one in four homes did
not meet the standard
in 2003.
■ Recommended
(4.1+ hours)
■ State Mandated
(3.2+ hours)
■ Below State Mandated
(< 3.2 hours)
Hours per Resident Day
2001 2003
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6. ©2006 California HealthCare Foundation 6
For ProfitNonprofit
6.47
1.68
1.39
3.40
3.49
.40
.70
2.39
Registered Nurse (RN)
Licensed Nurse (LVN)
Nursing Assistant
Nursing Home
Staffing and Quality
Nursing Hours by Ownership Type,
2003
In 2003, 11 percent
of nursing hours in
for profits were
provided by RNs while
26 percent of nursing
hours were by RNs
in nonprofit facilities.
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care and hospital financial data for 2000–2003, and California Department of Health, Licensing and Certification Program,
Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
Total Hours of Care per Resident Day
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7. ©2006 California HealthCare Foundation 7
Nonprofit
TOTAL
For Profit
2000 2001 2002 2003
Nonprofit 81% 90% 90% 93%
TOTAL 43% 60% 71% 76%
For Profit 36% 53% 68% 73%
Nursing Home
Staffing and Quality
Most (93 percent)
nonprofit nursing
homes meet the
minimum state staffing
standard (3.2 hours per
resident day); staffing
levels have increased
over this four-year
period.
Sources: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
Facilities that Meet Staffing Goals
by Ownership Type, 2000–2003
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8. ©2006 California HealthCare Foundation 8
Hospital-based
79%
Freestanding
21%
Nonprofit
62%
For Profit
38%
Nursing Home
Staffing and Quality
Studies have shown
that a staffing goal
between 4.1 and 4.5
hours per resident
day, depending on the
needs of the residents
in a facility, provides
the most appropriate
level of care. Most
nursing homes that
meet this staffing goal
are hospital-based or
nonprofits.
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000-2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
Facilities that Meet Staffing Goals
by Facility and Ownership Type
Facility Type Ownership Type
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9. ©2006 California HealthCare Foundation 9
Meets…
Minimum Standard
3.2 hours per resident day
Recommended Goal
4.1 to 4.5 hours per resident day
2000 2001 2002 2003
13.39 14.83 14.81 14.29
8.57 9.62 9.53 9.13
Nursing Home
Staffing and Quality
Total Deficiencies and Citations
by Staffing Level, 2000–2003
Nursing homes that
met the recommended
goal (4.1 to 4.5 hours
per resident day) had
more than one-third
fewer deficiencies than
those that met the
state minimum staffing
standard (3.2 hours per
resident day).
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
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10. ©2006 California HealthCare Foundation 10
Housekeeping
Pharmacy Procedures
Infection Control
Hazards
Incomplete Care Plan
Unnecessary Drugs
Dignity Not Respected
Incomplete Records
Quality Care
Food 46.2%
38.7%
33.7%
30.2%
28.9%
28.8%
28.8%
28.2%
25.4%
24.1%
Nursing Home
Staffing and Quality
Almost half of surveyed
nursing facilities
reported food-related
deficiencies; more
than a third reported
deficiencies that were
quality of care-related.
Source: CMS OSCAR Survey Data, updated December 2005. Prepared by CAHF IRC January 2006.
Top Ten Deficiencies
in Nursing Facilities, 2005
Percent Reporting
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11. ©2006 California HealthCare Foundation 11
Met Recommended Goal
(4.1+ hours)
Met Minimum Standard
(3.2+ hours)
1.6
2.8
2.1
1.0
Quality of CareTotal
Number of Complaints
Nursing Home
Staffing and Quality
Complaints
Total and Quality of Care, 2003
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
The number of total
complaints and quality
of care complaints
is higher at nursing
homes that meet the
minimum state staffing
requirement (3.2 hours
per resident day) than
those that meet the
recommended goal
(4.1 to 4.5 hours per
resident day).
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12. ©2006 California HealthCare Foundation 12
…High Number of Satisfied Staff
…Fair Number of Satisfied Staff
…Very Few Satisfied Staff
8%
79%
18%
66%
36%
58%
Staff Satisfaction
Turnover Rate
Nursing Home
Staffing and Quality
Staff Turnover and Satisfaction
in Nursing Facilities, National, 2003
Nursing facilities with
higher percentages
of satisfied staff have
lower turnover rates.
Share of Very Satisfied Staff in a Facility with…
Source: Tellis-Nayak, V., Customer Satisfaction in Long Term Care: A Guide to Assessing Quality, AHCA, 2003.
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13. ©2006 California HealthCare Foundation 13
2003200220012000
80% 80%
70%
65%
Nursing Home
Staffing and Quality
Freestanding Nursing Home (FNH)
Turnover Rates, 2000–2003
Turnover rates for
nursing staff in
freestanding nursing
homes decreased
by 19 percent from
2000 to 2003.
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using Office of Statewide Health Planning and
Development’s long term care financial data for 2000–2003. Employee [percent] turnover rates for health care and social services, NOBSCOT
www.nobscot.com/survey/us_voluntary_turnover_0103.cfm.
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14. ©2006 California HealthCare Foundation 14
Met Recommended Goal
(4.1+ hours)
Below Recommended Goal
(< 4.1 hours)
66%
55%
Nursing Home
Staffing and Quality
The turnover rate for
nursing homes that
met the recommended
nurse staffing goal
of 4.1 to 4.5 hours
per resident day was
significantly lower than
for nursing homes that
did not meet the goal.
Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
Nurse Staff Turnover Rate
by Staffing Level, 2003
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15. ©2006 California HealthCare Foundation 15
Low Turnover
(< 47%)
Medium Turnover
(47% to 71%)
High Turnover
(72%+)
16.0
14.5
13.2
Nursing Home
Staffing and Quality
In 2003, nursing homes
with the highest
turnover rates received
a higher number of
deficiencies than those
nursing homes with
average or low turnover
rates.
Deficiencies Among Freestanding
Nursing Facilities, by Turnover Rate, 2003
Average Number of Deficiencies
Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
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16. ©2006 California HealthCare Foundation 16
Average Number of DeficienciesNurse Turnover Rate
55%
66%
15.2
9.7
NonprofitFor Profit
Nursing Home
Staffing and Quality
Turnover and Deficiencies
by Ownership Type, 2003
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
Nonprofit nursing
facilities have lower
turnover rates and
fewer deficiencies than
for-profit facilities.
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17. ©2006 California HealthCare Foundation 17
Low Turnover
(< 47%)
High Turnover
(72%+)
$10.17
Licensed Nurse (LVN)Nursing Assistant
$22.52
$10.76
$23.21
Nursing Home
Staffing and Quality
Wages in Freestanding Facilities
by Nursing Turnover Rates, 2003
Wages for nursing
assistants and
licensed nurses were
significantly lower in
nursing homes with
high turnover rates
than in nursing homes
with low turnover rates.
Low wages is one of
the primary reasons
for high turnover rates
among nursing staff.
Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health
Planning and Development’s long term care financial data for 2000–2003, and California Department of Health, Licensing and Certification Program, Automated
Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.
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18. ©2006 California HealthCare Foundation 18
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Nursing Home
Staffing and Quality
Authors
Charlene Harrington, Ph.D., Janis O’Meara, M.P.A., and Taewoon Kang, Ph.D.
Department of Social and Behavioral Sciences, School of Nursing, UCSF
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