NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
NUR 621: Nursing Leadership and Healthcare Finance
COMPREHENSIVE EXAMINATION
Staffing Model for a 30-Bed Skilled Nursing Facility
Academic Year 2026-2027
75 Questions | Sections I-VI | Multiple Choice (A-D), One Best Answer
Cognitive Levels: 30% Recall | 45% Application | 25% Analysis | Scenario-Based and Direct Calculation Items
Answers and detailed rationales are provided immediately after each question for faculty review and
self-assessment use.
SECTION 1: STAFFING FUNDAMENTALS AND REGULATORY
REQUIREMENTS (Q1-Q15)
Staffing Principles | Federal and State Regulations | Acuity-Based Staffing
Q1. Under the CMS minimum staffing final rule whose phased compliance schedule extends
through the 2026-2027 period, what is the required minimum for TOTAL nursing staff hours per
resident day (HPRD) in a skilled nursing facility, combining RN, LPN/LVN, and nurse aide hours?
A. 2.75 total nurse HPRD
B. 3.00 total nurse HPRD
C. 3.48 total nurse HPRD [CORRECT]
D. 4.10 total nurse HPRD
Correct Answer: C
Rationale: The CMS minimum staffing rule sets the widely benchmarked federal floor at 3.48 total nurse HPRD,
which includes 0.55 RN HPRD and 2.45 nurse aide HPRD. Options A and B reflect older state minimums or
partial targets, while D approximates top five-star benchmarks rather than the federal floor. For a 30-bed SNF, the
nurse executive must build schedules against both this federal benchmark and any stricter state mandate.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 1
,NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
Q2. In addition to the total nursing hours requirement, what minimum RN hours per resident day
(HPRD) does the federal staffing rule require SNFs to provide?
A. 0.25 RN HPRD
B. 0.55 RN HPRD [CORRECT]
C. 0.75 RN HPRD
D. 1.00 RN HPRD
Correct Answer: B
Rationale: The federal rule requires 0.55 RN HPRD, which equals 16.5 RN productive hours per day for a 30-bed
facility at full census (30 x 0.55). Options A and C fall below the requirement, and D is an aspirational target some
high-acuity facilities adopt but is not the federal floor. RN hours are a specific lever because research links RN
presence to fewer hospitalizations and pressure injuries.
Q3. What minimum nurse aide (CNA) hours per resident day (HPRD) does the federal staffing rule
phase in for SNFs during the 2026-2027 compliance window?
A. 1.50 nurse aide HPRD
B. 2.00 nurse aide HPRD
C. 2.75 nurse aide HPRD
D. 2.45 nurse aide HPRD [CORRECT]
Correct Answer: D
Rationale: The federal requirement is 2.45 nurse aide HPRD, the largest single component of the 3.48 total nurse
HPRD floor. At a census of 27, this equals 66.15 aide hours daily, which drives the majority of the SNF labor
budget. Option C exceeds the floor, while A and B fall short and would place the facility at risk for F725
(sufficient staffing) citations.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 2
,NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
Q4. The director of nursing (DON) at a 30-bed SNF proposes eliminating the overnight RN position
and covering the 11 p.m. to 7 a.m. shift entirely with an LPN/LVN to save salary expense. Under the
phased federal staffing requirements for 2026-2027, which response by the nurse executive is most
defensible?
A. LPN/LVNs may cover all shifts as long as total HPRD remains at 3.48 and the budget
balances
B. The proposal is acceptable if state law permits LPN-only night coverage and the
administrator signs the policy
C. Only facilities with ventilator-dependent units are required to maintain RN coverage
overnight
D. An RN must be onsite 24 hours a day, 7 days a week, so the proposal cannot be
implemented as written [CORRECT]
Correct Answer: D
Rationale: The phased federal requirement includes onsite RN coverage 24/7, so an LPN-only night shift cannot
satisfy federal rules even if total HPRD is met. State permission (B) cannot waive a federal requirement, and C
misstates the scope of the rule. The DON should instead explore cost strategies such as internal float pools or
retention investments that protect both compliance and the labor budget.
Q5. During annual budget preparation, the administrator of a 30-bed SNF asks the DON which
document must drive the facility's staffing plan and be updated at least annually and whenever
resident acuity or the physical environment changes. Which response is correct?
A. The Five-Star Quality Rating staffing report downloaded from Care Compare
B. The quarterly Payroll-Based Journal (PBJ) submission summary
C. The facility assessment required under 42 CFR 483.70(f) (F723) [CORRECT]
D. A copy of the nursing schedule from the same quarter of the prior year
Correct Answer: C
Rationale: The facility assessment (F723) must evaluate resident acuity and needs, staff competencies, the
physical environment, and technology, and it is the federally required foundation for staffing and budget decisions.
PBJ reports and star ratings are monitoring and reporting outputs, not planning documents, and last year's schedule
ignores current acuity. NUR 621 emphasizes that budgets built without a current facility assessment invite both
F725 citations and variance surprises.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 3
, NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
Q6. A nurse manager is asked to explain how CMS verifies the staffing hours a 30-bed SNF reports.
Which statement about Payroll-Based Journal (PBJ) reporting is accurate?
A. Staffing hours are self-reported once a year by the facility administrator on a CMS form
B. Facilities mail audited staffing surveys to their state survey agency each quarter
C. Facilities electronically submit daily staff hours derived from payroll data to CMS every
quarter [CORRECT]
D. Staffing hours are verified only during the annual recertification survey
Correct Answer: C
Rationale: PBJ (42 CFR 483.70(q)) requires quarterly electronic submission of daily staffing hours drawn
directly from payroll and timekeeping systems, categorized by staff credentials and job codes. Self-reporting (A)
is precisely what PBJ replaced to reduce reporting bias, and survey-only verification (D) would not support the
staffing star rating. Accurate PBJ coding of RN, LPN/LVN, and CNA hours protects both the staffing domain
score and survey credibility.
Q7. A 30-bed SNF with an average daily census of 24 wants to convert its director of nursing
(DON) position to a part-time consulting arrangement to reduce salary expense. What is the most
accurate regulatory analysis?
A. Federal rules require a full-time DON in facilities with more than 60 beds, so this plan may
be lawful federally, but state requirements and the facility assessment must be checked before
acting [CORRECT]
B. Federal rules require a full-time DON regardless of facility size, so the plan is prohibited
everywhere
C. Federal rules do not require a DON at all in SNFs under 40 beds
D. The DON may work part-time as long as an LPN supervisor covers the remaining weekly
hours
Correct Answer: A
Rationale: Federal requirements condition the mandatory full-time RN DON on facilities with more than 60 beds,
so a smaller facility may use an alternative arrangement where state law allows and where resident needs are still
met. Option B overstates the federal rule, C is false, and D confuses delegation with the required RN leadership
and supervision structure. The prudent NUR 621 analysis is to verify the state nurse practice and licensure rules
before budgeting the savings.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 4
NUR 621: Nursing Leadership and Healthcare Finance
COMPREHENSIVE EXAMINATION
Staffing Model for a 30-Bed Skilled Nursing Facility
Academic Year 2026-2027
75 Questions | Sections I-VI | Multiple Choice (A-D), One Best Answer
Cognitive Levels: 30% Recall | 45% Application | 25% Analysis | Scenario-Based and Direct Calculation Items
Answers and detailed rationales are provided immediately after each question for faculty review and
self-assessment use.
SECTION 1: STAFFING FUNDAMENTALS AND REGULATORY
REQUIREMENTS (Q1-Q15)
Staffing Principles | Federal and State Regulations | Acuity-Based Staffing
Q1. Under the CMS minimum staffing final rule whose phased compliance schedule extends
through the 2026-2027 period, what is the required minimum for TOTAL nursing staff hours per
resident day (HPRD) in a skilled nursing facility, combining RN, LPN/LVN, and nurse aide hours?
A. 2.75 total nurse HPRD
B. 3.00 total nurse HPRD
C. 3.48 total nurse HPRD [CORRECT]
D. 4.10 total nurse HPRD
Correct Answer: C
Rationale: The CMS minimum staffing rule sets the widely benchmarked federal floor at 3.48 total nurse HPRD,
which includes 0.55 RN HPRD and 2.45 nurse aide HPRD. Options A and B reflect older state minimums or
partial targets, while D approximates top five-star benchmarks rather than the federal floor. For a 30-bed SNF, the
nurse executive must build schedules against both this federal benchmark and any stricter state mandate.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 1
,NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
Q2. In addition to the total nursing hours requirement, what minimum RN hours per resident day
(HPRD) does the federal staffing rule require SNFs to provide?
A. 0.25 RN HPRD
B. 0.55 RN HPRD [CORRECT]
C. 0.75 RN HPRD
D. 1.00 RN HPRD
Correct Answer: B
Rationale: The federal rule requires 0.55 RN HPRD, which equals 16.5 RN productive hours per day for a 30-bed
facility at full census (30 x 0.55). Options A and C fall below the requirement, and D is an aspirational target some
high-acuity facilities adopt but is not the federal floor. RN hours are a specific lever because research links RN
presence to fewer hospitalizations and pressure injuries.
Q3. What minimum nurse aide (CNA) hours per resident day (HPRD) does the federal staffing rule
phase in for SNFs during the 2026-2027 compliance window?
A. 1.50 nurse aide HPRD
B. 2.00 nurse aide HPRD
C. 2.75 nurse aide HPRD
D. 2.45 nurse aide HPRD [CORRECT]
Correct Answer: D
Rationale: The federal requirement is 2.45 nurse aide HPRD, the largest single component of the 3.48 total nurse
HPRD floor. At a census of 27, this equals 66.15 aide hours daily, which drives the majority of the SNF labor
budget. Option C exceeds the floor, while A and B fall short and would place the facility at risk for F725
(sufficient staffing) citations.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 2
,NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
Q4. The director of nursing (DON) at a 30-bed SNF proposes eliminating the overnight RN position
and covering the 11 p.m. to 7 a.m. shift entirely with an LPN/LVN to save salary expense. Under the
phased federal staffing requirements for 2026-2027, which response by the nurse executive is most
defensible?
A. LPN/LVNs may cover all shifts as long as total HPRD remains at 3.48 and the budget
balances
B. The proposal is acceptable if state law permits LPN-only night coverage and the
administrator signs the policy
C. Only facilities with ventilator-dependent units are required to maintain RN coverage
overnight
D. An RN must be onsite 24 hours a day, 7 days a week, so the proposal cannot be
implemented as written [CORRECT]
Correct Answer: D
Rationale: The phased federal requirement includes onsite RN coverage 24/7, so an LPN-only night shift cannot
satisfy federal rules even if total HPRD is met. State permission (B) cannot waive a federal requirement, and C
misstates the scope of the rule. The DON should instead explore cost strategies such as internal float pools or
retention investments that protect both compliance and the labor budget.
Q5. During annual budget preparation, the administrator of a 30-bed SNF asks the DON which
document must drive the facility's staffing plan and be updated at least annually and whenever
resident acuity or the physical environment changes. Which response is correct?
A. The Five-Star Quality Rating staffing report downloaded from Care Compare
B. The quarterly Payroll-Based Journal (PBJ) submission summary
C. The facility assessment required under 42 CFR 483.70(f) (F723) [CORRECT]
D. A copy of the nursing schedule from the same quarter of the prior year
Correct Answer: C
Rationale: The facility assessment (F723) must evaluate resident acuity and needs, staff competencies, the
physical environment, and technology, and it is the federally required foundation for staffing and budget decisions.
PBJ reports and star ratings are monitoring and reporting outputs, not planning documents, and last year's schedule
ignores current acuity. NUR 621 emphasizes that budgets built without a current facility assessment invite both
F725 citations and variance surprises.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 3
, NUR 621 - Nursing Leadership and Healthcare Finance Total: 75 Questions | One Best Answer
Q6. A nurse manager is asked to explain how CMS verifies the staffing hours a 30-bed SNF reports.
Which statement about Payroll-Based Journal (PBJ) reporting is accurate?
A. Staffing hours are self-reported once a year by the facility administrator on a CMS form
B. Facilities mail audited staffing surveys to their state survey agency each quarter
C. Facilities electronically submit daily staff hours derived from payroll data to CMS every
quarter [CORRECT]
D. Staffing hours are verified only during the annual recertification survey
Correct Answer: C
Rationale: PBJ (42 CFR 483.70(q)) requires quarterly electronic submission of daily staffing hours drawn
directly from payroll and timekeeping systems, categorized by staff credentials and job codes. Self-reporting (A)
is precisely what PBJ replaced to reduce reporting bias, and survey-only verification (D) would not support the
staffing star rating. Accurate PBJ coding of RN, LPN/LVN, and CNA hours protects both the staffing domain
score and survey credibility.
Q7. A 30-bed SNF with an average daily census of 24 wants to convert its director of nursing
(DON) position to a part-time consulting arrangement to reduce salary expense. What is the most
accurate regulatory analysis?
A. Federal rules require a full-time DON in facilities with more than 60 beds, so this plan may
be lawful federally, but state requirements and the facility assessment must be checked before
acting [CORRECT]
B. Federal rules require a full-time DON regardless of facility size, so the plan is prohibited
everywhere
C. Federal rules do not require a DON at all in SNFs under 40 beds
D. The DON may work part-time as long as an LPN supervisor covers the remaining weekly
hours
Correct Answer: A
Rationale: Federal requirements condition the mandatory full-time RN DON on facilities with more than 60 beds,
so a smaller facility may use an alternative arrangement where state law allows and where resident needs are still
met. Option B overstates the federal rule, C is false, and D confuses delegation with the required RN leadership
and supervision structure. The prudent NUR 621 analysis is to verify the state nurse practice and licensure rules
before budgeting the savings.
Staffing Model Examination - 30-Bed Skilled Nursing Facility 4
