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. By 2022-2023, 45% of nursing hires were excluded under CMS’s definition of turnover and therefore left unreported and not included in nursing home turnover statistics.
A study entitled Invisible staffing churn in nursing homes: CMS turnover metrics miss a growing short-term workforce published on April 18, 2026 in HealthAffairs Scholar stated:
CMS’s use of a minimum-hours threshold reflects a purposeful effort to focus turnover measurement on retention of core staff and to exclude workers who contribute only intermittently to facility staffing. This approach may have been more appropriate in earlier labor market contexts, when short-tenure and contract staffing were less prevalent. However, current staffing patterns include a large and growing share of workers with short employment durations. As a result, hours-based inclusion rules now exclude a substantial portion of the workforce that contributes to day-to-day care delivery.
Short-term staff contribute meaningfully to workforce instability. Early attrition is particularly consequential in direct-care roles, where continuity is central to quality and frequent cycling of staff can disrupt resident routines, strain remaining workers, and complicate care coordination. By restricting turnover measurement to longer-tenure staff, the CMS specification excludes a large and growing segment of employment that increasingly characterizes the contemporary NH workforce.
[T]he principal consequence of the 120-hour rule is comparative distortion. Facility placement within the turnover distribution differed markedly by definition, with only about 30% of NHs occupying the same turnover decile under both measures. Reclassification was systematic rather than random. These shifts reflected consistent differences in staffing practices and broader facility and market characteristics, indicating that the CMS definition systematically reshapes how workforce stability is characterized across NHs.
[T]hese findings suggest that the CMS turnover measure risks losing relevance as an indicator of workforce instability in a staffing environment increasingly defined by short-term employment. As turnover metrics assume a larger role in public reporting and regulatory oversight, definitions that overlook short-term staffing dynamics risk obscuring critical information needed to assess staffing conditions and compare facility performance.
Short-term staffing now represents a large and growing share of the NH workforce. Yet the CMS turnover metric excludes staff who work fewer than 120 hours in their first 90 days, increasingly omitting meaningful workforce instability from public reporting and systematically understating volatility in facility staffing. This exclusion does not improve associations with resident outcomes, but it substantially reshapes how facilities are classified, often making homes with high levels of short-term or contract staffing appear more stable than they are in practice.
As turnover metrics play an expanding role in Five-Star ratings, consumer decision-making, and regulatory oversight, measurement choices matter. Definitions that narrow turnover to longer-tenure staff risk becoming progressively less informative in a labor market characterized by short term and flexible staffing employment. Refining turnover measurement to better reflect contemporary workforce dynamics is feasible using existing PBJ data and would improve transparency, enhance comparability across facilities, and better align public reporting with the staffing conditions experienced by residents.
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