NUR 621 — Staffing Model for a 30-Bed Skilled Nursing Facility Comprehensive Examination (2026/2027)
NUR 621 Staffing Model for a 30-Bed Skilled Nursing
Facility
Comprehensive Examination
NUR 621 Healthcare Finance & Budgeting | 2026/2027 Edition
Aligned with the AACN Essentials of Master’s Education, CMS Staffing Standards (Five-Star Quality Rating System,
Payroll-Based Journal), and Skilled Nursing Facility Regulatory Requirements. This 50-question examination is organized
into five sections covering Staffing Model Fundamentals & Regulatory Requirements; Care Delivery Models & Staffing
Approaches; Skill Mix & Workforce Composition; Budgeting & Financial Implications; and Quality Metrics, Monitoring &
Evaluation. Cognitive distribution: 25% recall, 50% application, 25% analysis. Format: 75% scenario-based and 25% direct
knowledge, including 10 calculation-based items. Each question includes the correct answer and a 2–3 sentence rationale
referencing the NUR 621 curriculum and SNF staffing standards.
Section 1: Staffing Model Fundamentals & Regulatory Requirements
Q1. Which CMS staffing measure is reported as case-mix adjusted in the Five-Star Quality Rating System
for skilled nursing facilities?
A. Total nursing hours per resident day only, unadjusted
B. RN hours per resident day, adjusted to reflect resident acuity *[CORRECT]*
C. CNA hours per resident day using raw, unadjusted values
D. LPN hours per resident day including agency and contract staff
Correct Answer: B
Rationale: CMS reports case-mix adjusted RN hours per resident day (HPRD) using a methodology that accounts for resident
acuity (ADL support, clinical complexity), allowing fair comparison across facilities with different resident populations. Total
nursing hours and CNA hours are reported but the RN HPRD is the headline case-mix adjusted measure used in the Five-Star
staffing domain. Per NUR 621, understanding which measures are case-mix adjusted is foundational to interpreting CMS
staffing data and benchmarking a 30-bed SNF's performance.
Q2. Under CMS Payroll-Based Journal (PBJ) reporting requirements, what data must a skilled nursing
facility submit?
A. An annual summary of staffing levels prepared for state surveyors
B. Daily census data and resident demographic information only
C. Quarterly financial reports detailing all staffing expenditures
D. Detailed staffing data including individual employee hours, job categories, and daily hours worked per
resident day, submitted quarterly through the CMS PBJ system *[CORRECT]*
Correct Answer: D
Rationale: PBJ requires facilities to submit granular, payroll-derived data on individual employee hours by job category (RN,
LPN, CNA, etc.), enabling CMS to calculate daily staffing hours per resident day and detect understaffing. The data must come
from auditable payroll systems. Per NUR 621 and CMS regulations, PBJ replaces older self-reported staffing data and is the
basis for Five-Star staffing ratings; options A-C describe incomplete or incorrect reporting obligations.
NUR 621 Healthcare Finance & Budgeting | AACN Essentials | CMS Staffing Standards Page 1
,NUR 621 — Staffing Model for a 30-Bed Skilled Nursing Facility Comprehensive Examination (2026/2027)
Q3. CALCULATION: A 30-bed skilled nursing facility provided 195 total nursing hours (RN + LPN + CNA
combined) on a given day with all 30 beds occupied. What is the Hours Per Resident Day (HPRD)?
A. 5.5 HPRD
B. 6.5 HPRD *[CORRECT]*
C. 7.5 HPRD
D. 8.5 HPRD
Correct Answer: B
Rationale: HPRD = Total nursing hours / resident census = 195 hours / 30 residents = 6.5 HPRD. This is a foundational
calculation in NUR 621 staffing models; HPRD is the standard CMS metric for expressing nursing intensity per resident per
day. Option A (5.5) would result from 165 hours; option C (7.5) from 225 hours; option D (8.5) from 255 hours, all reflecting
arithmetic errors or incorrect divisor use.
Q4. SCENARIO: An administrator at a 30-bed SNF reviews CMS Five-Star staffing data and notices the
facility's weekend RN hours are 30% lower than weekday hours. Under CMS staffing standards, which action
should the administrator prioritize?
A. Reduce weekday staffing to match weekend levels for cost containment
B. Submit revised PBJ data excluding weekend hours from the calculation
C. Implement a targeted weekend staffing improvement plan to address the documented gap *[CORRECT]*
D. Wait for CMS to issue a deficiency citation before taking any action
Correct Answer: C
Rationale: CMS now publicly reports weekend staffing levels and uses PBJ data to detect weekend understaffing; persistent
gaps can result in lower Five-Star ratings and survey deficiencies. NUR 621 emphasizes proactive continuous monitoring of
staffing data and timely corrective action. Reducing weekday staffing (A) compromises care; excluding weekend hours (B) is
falsification; waiting for citation (D) is reactive and increases legal and regulatory risk.
Q5. Per CMS regulatory requirements, what is the minimum Registered Nurse (RN) coverage requirement
for a skilled nursing facility?
A. 24 hours per day, 7 days per week of RN presence on-site at the facility
B. 8 consecutive hours per day, 7 days per week of RN services *[CORRECT]*
C. RN coverage only during weekday day shifts, with on-call coverage otherwise
D. RN on-call coverage only, with no requirement for on-site presence
Correct Answer: B
Rationale: Under 42 CFR 483.35, SNFs must provide RN services for at least 8 consecutive hours per day, 7 days per week,
and use an RN to assess residents when needed. A 30-bed SNF may also be subject to state staffing ratio laws that exceed this
federal minimum. NUR 621 curriculum emphasizes that compliance with federal/state labor regulations and licensing
requirements is the foundation of any staffing model.
NUR 621 Healthcare Finance & Budgeting | AACN Essentials | CMS Staffing Standards Page 2
, NUR 621 — Staffing Model for a 30-Bed Skilled Nursing Facility Comprehensive Examination (2026/2027)
Q6. CALCULATION: In a 30-day month, a 30-bed SNF recorded a total of 891 resident-days. What is the
Average Daily Census (ADC) for the month?
A. 28.7 residents
B. 29.0 residents
C. 29.7 residents *[CORRECT]*
D. 30.0 residents
Correct Answer: C
Rationale: ADC = Total resident-days / Number of days in the period = = 29.7 residents. ADC is used in NUR 621
staffing calculations to derive staffing needs from actual occupancy rather than licensed bed capacity. Option A (28.7) would
be 861/30; option B (29.0) would be 870/30; option D (30.0) would be 900/30, each reflecting arithmetic errors.
Q7. ANALYSIS: A 30-bed SNF has higher case-mix adjusted RN HPRD than the national average. What does
this most likely indicate?
A. The facility is overstaffed and should reduce RN hours to align with the national average
B. The facility is caring for residents with higher acuity levels requiring more RN time *[CORRECT]*
C. The facility is understaffed relative to its actual care needs
D. The facility has poor RN turnover and is paying excessive overtime
Correct Answer: B
Rationale: Case-mix adjusted RN HPRD reflects RN hours normalized for resident acuity. A higher-than-average case-mix
adjusted value typically indicates that residents have higher clinical complexity (more IV therapy, complex wounds, post-acute
rehab) justifying additional RN time. NUR 621 teaches that staffing must align with patient acuity; reducing RN hours (A)
without acuity analysis could compromise care. The other options confuse cause and effect.
Q8. SCENARIO: During a PBJ audit, CMS identifies that a facility's submitted staffing data differs
significantly from payroll records. What is the most likely consequence under CMS regulations?
A. A written warning with no further enforcement action
B. The facility's Five-Star staffing rating will be downgraded or suppressed, and a deficiency citation may be
issued *[CORRECT]*
C. The facility will be automatically terminated from Medicare participation without appeal
D. The discrepancy will be ignored because PBJ submissions are voluntary
Correct Answer: B
Rationale: CMS treats PBJ data accuracy as a compliance requirement; material discrepancies trigger Five-Star staffing rating
suppression (often displayed as 'No Rating' for the staffing domain) and may result in deficiency citations under F-tag staffing
requirements. NUR 621 emphasizes legal considerations including accurate reporting. Termination from Medicare (C) is a
severe remedy not automatically applied; PBJ submissions are mandatory (D is incorrect). A written warning alone (A)
understates CMS enforcement authority.
NUR 621 Healthcare Finance & Budgeting | AACN Essentials | CMS Staffing Standards Page 3
NUR 621 Staffing Model for a 30-Bed Skilled Nursing
Facility
Comprehensive Examination
NUR 621 Healthcare Finance & Budgeting | 2026/2027 Edition
Aligned with the AACN Essentials of Master’s Education, CMS Staffing Standards (Five-Star Quality Rating System,
Payroll-Based Journal), and Skilled Nursing Facility Regulatory Requirements. This 50-question examination is organized
into five sections covering Staffing Model Fundamentals & Regulatory Requirements; Care Delivery Models & Staffing
Approaches; Skill Mix & Workforce Composition; Budgeting & Financial Implications; and Quality Metrics, Monitoring &
Evaluation. Cognitive distribution: 25% recall, 50% application, 25% analysis. Format: 75% scenario-based and 25% direct
knowledge, including 10 calculation-based items. Each question includes the correct answer and a 2–3 sentence rationale
referencing the NUR 621 curriculum and SNF staffing standards.
Section 1: Staffing Model Fundamentals & Regulatory Requirements
Q1. Which CMS staffing measure is reported as case-mix adjusted in the Five-Star Quality Rating System
for skilled nursing facilities?
A. Total nursing hours per resident day only, unadjusted
B. RN hours per resident day, adjusted to reflect resident acuity *[CORRECT]*
C. CNA hours per resident day using raw, unadjusted values
D. LPN hours per resident day including agency and contract staff
Correct Answer: B
Rationale: CMS reports case-mix adjusted RN hours per resident day (HPRD) using a methodology that accounts for resident
acuity (ADL support, clinical complexity), allowing fair comparison across facilities with different resident populations. Total
nursing hours and CNA hours are reported but the RN HPRD is the headline case-mix adjusted measure used in the Five-Star
staffing domain. Per NUR 621, understanding which measures are case-mix adjusted is foundational to interpreting CMS
staffing data and benchmarking a 30-bed SNF's performance.
Q2. Under CMS Payroll-Based Journal (PBJ) reporting requirements, what data must a skilled nursing
facility submit?
A. An annual summary of staffing levels prepared for state surveyors
B. Daily census data and resident demographic information only
C. Quarterly financial reports detailing all staffing expenditures
D. Detailed staffing data including individual employee hours, job categories, and daily hours worked per
resident day, submitted quarterly through the CMS PBJ system *[CORRECT]*
Correct Answer: D
Rationale: PBJ requires facilities to submit granular, payroll-derived data on individual employee hours by job category (RN,
LPN, CNA, etc.), enabling CMS to calculate daily staffing hours per resident day and detect understaffing. The data must come
from auditable payroll systems. Per NUR 621 and CMS regulations, PBJ replaces older self-reported staffing data and is the
basis for Five-Star staffing ratings; options A-C describe incomplete or incorrect reporting obligations.
NUR 621 Healthcare Finance & Budgeting | AACN Essentials | CMS Staffing Standards Page 1
,NUR 621 — Staffing Model for a 30-Bed Skilled Nursing Facility Comprehensive Examination (2026/2027)
Q3. CALCULATION: A 30-bed skilled nursing facility provided 195 total nursing hours (RN + LPN + CNA
combined) on a given day with all 30 beds occupied. What is the Hours Per Resident Day (HPRD)?
A. 5.5 HPRD
B. 6.5 HPRD *[CORRECT]*
C. 7.5 HPRD
D. 8.5 HPRD
Correct Answer: B
Rationale: HPRD = Total nursing hours / resident census = 195 hours / 30 residents = 6.5 HPRD. This is a foundational
calculation in NUR 621 staffing models; HPRD is the standard CMS metric for expressing nursing intensity per resident per
day. Option A (5.5) would result from 165 hours; option C (7.5) from 225 hours; option D (8.5) from 255 hours, all reflecting
arithmetic errors or incorrect divisor use.
Q4. SCENARIO: An administrator at a 30-bed SNF reviews CMS Five-Star staffing data and notices the
facility's weekend RN hours are 30% lower than weekday hours. Under CMS staffing standards, which action
should the administrator prioritize?
A. Reduce weekday staffing to match weekend levels for cost containment
B. Submit revised PBJ data excluding weekend hours from the calculation
C. Implement a targeted weekend staffing improvement plan to address the documented gap *[CORRECT]*
D. Wait for CMS to issue a deficiency citation before taking any action
Correct Answer: C
Rationale: CMS now publicly reports weekend staffing levels and uses PBJ data to detect weekend understaffing; persistent
gaps can result in lower Five-Star ratings and survey deficiencies. NUR 621 emphasizes proactive continuous monitoring of
staffing data and timely corrective action. Reducing weekday staffing (A) compromises care; excluding weekend hours (B) is
falsification; waiting for citation (D) is reactive and increases legal and regulatory risk.
Q5. Per CMS regulatory requirements, what is the minimum Registered Nurse (RN) coverage requirement
for a skilled nursing facility?
A. 24 hours per day, 7 days per week of RN presence on-site at the facility
B. 8 consecutive hours per day, 7 days per week of RN services *[CORRECT]*
C. RN coverage only during weekday day shifts, with on-call coverage otherwise
D. RN on-call coverage only, with no requirement for on-site presence
Correct Answer: B
Rationale: Under 42 CFR 483.35, SNFs must provide RN services for at least 8 consecutive hours per day, 7 days per week,
and use an RN to assess residents when needed. A 30-bed SNF may also be subject to state staffing ratio laws that exceed this
federal minimum. NUR 621 curriculum emphasizes that compliance with federal/state labor regulations and licensing
requirements is the foundation of any staffing model.
NUR 621 Healthcare Finance & Budgeting | AACN Essentials | CMS Staffing Standards Page 2
, NUR 621 — Staffing Model for a 30-Bed Skilled Nursing Facility Comprehensive Examination (2026/2027)
Q6. CALCULATION: In a 30-day month, a 30-bed SNF recorded a total of 891 resident-days. What is the
Average Daily Census (ADC) for the month?
A. 28.7 residents
B. 29.0 residents
C. 29.7 residents *[CORRECT]*
D. 30.0 residents
Correct Answer: C
Rationale: ADC = Total resident-days / Number of days in the period = = 29.7 residents. ADC is used in NUR 621
staffing calculations to derive staffing needs from actual occupancy rather than licensed bed capacity. Option A (28.7) would
be 861/30; option B (29.0) would be 870/30; option D (30.0) would be 900/30, each reflecting arithmetic errors.
Q7. ANALYSIS: A 30-bed SNF has higher case-mix adjusted RN HPRD than the national average. What does
this most likely indicate?
A. The facility is overstaffed and should reduce RN hours to align with the national average
B. The facility is caring for residents with higher acuity levels requiring more RN time *[CORRECT]*
C. The facility is understaffed relative to its actual care needs
D. The facility has poor RN turnover and is paying excessive overtime
Correct Answer: B
Rationale: Case-mix adjusted RN HPRD reflects RN hours normalized for resident acuity. A higher-than-average case-mix
adjusted value typically indicates that residents have higher clinical complexity (more IV therapy, complex wounds, post-acute
rehab) justifying additional RN time. NUR 621 teaches that staffing must align with patient acuity; reducing RN hours (A)
without acuity analysis could compromise care. The other options confuse cause and effect.
Q8. SCENARIO: During a PBJ audit, CMS identifies that a facility's submitted staffing data differs
significantly from payroll records. What is the most likely consequence under CMS regulations?
A. A written warning with no further enforcement action
B. The facility's Five-Star staffing rating will be downgraded or suppressed, and a deficiency citation may be
issued *[CORRECT]*
C. The facility will be automatically terminated from Medicare participation without appeal
D. The discrepancy will be ignored because PBJ submissions are voluntary
Correct Answer: B
Rationale: CMS treats PBJ data accuracy as a compliance requirement; material discrepancies trigger Five-Star staffing rating
suppression (often displayed as 'No Rating' for the staffing domain) and may result in deficiency citations under F-tag staffing
requirements. NUR 621 emphasizes legal considerations including accurate reporting. Termination from Medicare (C) is a
severe remedy not automatically applied; PBJ submissions are mandatory (D is incorrect). A written warning alone (A)
understates CMS enforcement authority.
NUR 621 Healthcare Finance & Budgeting | AACN Essentials | CMS Staffing Standards Page 3
