New Federal Audit Finds Nursing Home Staffing Reports Often Unsupported, and What It Means for Texas Families

A federal watchdog has concluded that the staffing numbers nursing homes report to the government are often wrong. The Department of Health and Human Services Office of Inspector General released the audit on June 17, 2026, and the findings raise a question every family with a loved one in a nursing home should be asking. If the hours a facility claims its registered nurses worked do not match what actually happened, can anyone trust the staffing levels posted online when choosing a facility? 

This post explains what the audit found, why it matters, and what it does and does not tell us about nursing homes in Texas specifically.

What Did The OIG Audit of Nursing Home Staffing Reports Find?

The OIG reviewed whether registered nurse hours reported in CMS's Payroll-Based Journal for March 2024 were actually supported by payroll records. The answer was no, for a meaningful share of the data. Auditors pulled a random sample of 100 registered nurses from a pool of more than 127,000 nationwide and checked their reported hours against real payroll documentation.

Of the 100 sampled nurses, 45 had hours that nursing homes could not support, totaling a net of 748.5 hours across 44 different facilities. Two more sampled items, covering 336 hours, could not be verified at all because the nursing homes involved had lost the supporting paperwork during a change in ownership. Projecting these results across the full national sampling frame, The OIG estimated that approximately 52,783 registered nurses, or 41.5 percent, had hours reported in the PBJ that were not supported in accordance with Federal requirements, and that approximately 937,823.7 hours, or 4.7 percent of all RN hours reported, fell into that same category. CMS, in its written response, rounded these figures to roughly 53,000 nurses and 938,000 hours and argued that a 95 percent accuracy rate is reasonable given the system's scale.

These point estimates carry real statistical uncertainty, and The OIG's own report discloses it. At a 90 percent confidence level, the share of RNs with unsupported hours could fall anywhere between 32.5 percent and 50.6 percent, and the share of unsupported hours could fall anywhere between 2.1 percent and 8.7 percent. That second range matters more than it looks. It means the true number of unsupported hours nationwide could be as low as roughly 420,000 or as high as roughly 1.75 million, more than a fourfold spread between the low and high end. The rounded figures CMS and The OIG both led with are accurate as point estimates, but anyone citing the 938,000-hour number as a precise national total is overstating what a 100-nurse sample can actually support.

None of this means the sample was too small to be useful. A sample of 100 drawn at random from a much larger group can still produce a reliable estimate, because statisticians can calculate exactly how much uncertainty that sample size produces, and The OIG did exactly that. 

The tradeoff is between sample size and precision, not between sample size and validity. A larger sample would have narrowed the range around the estimate, not made the underlying conclusion more true. The honest way to read these numbers is to treat 938,000 hours as the audit's best single guess, while remembering that the real number could reasonably be anywhere from less than half that figure to nearly double it. 

Either way, the conclusion that a meaningful share of reported staffing hours nationwide could not be supported holds up. What does not hold up is treating the 938,000 figure as an exact count.

Why Does the Payroll-Based Journal Matter for Nursing Home Care?

The Payroll-Based Journal exists because Congress decided that staffing claims needed to be backed by real payroll data, not estimates. Section 6106 of the Affordable Care Act added section 1128I(g) to the Social Security Act, and federal regulations at 42 CFR §483.70(p) require nursing homes to electronically submit complete and accurate direct care staffing information based on payroll and other auditable data.
CMS uses this data for purposes that directly affect families choosing a facility. The numbers feed into the Five-Star Quality Rating System and the public Medicare Compare website. They also tie back to the baseline staffing rule at 42 CFR §483.35, which requires a nursing home to provide the services of a registered nurse for at least eight consecutive hours a day and licensed nursing staff around the clock, unless that requirement has been waived. If the underlying hours are wrong, the star rating built on top of them is wrong too.

What Kinds of Errors Did the Audit Find in Reported Hours?

The errors were not all the same kind of mistake, and that variety is part of why The OIG called the problem systemic rather than isolated. Auditors grouped the unsupported hours into several recurring categories.

1. Reported hours an RN did not actually work, often because of payroll system errors or salaried staff being reported at a flat shift length regardless of actual hours worked.

2. Failure to deduct required meal breaks, the single most common finding across CMS's own audit trend data from 2022 through 2024.

3. Hours an RN worked and was paid for that were never reported at all, including unreported overtime.

4. Hours reported that the RN was never actually paid for.

5. Training hours misclassified as direct resident care, when the nurse was not actually available to provide care.

6. Hours reported on the wrong calendar day for shifts spanning midnight.

7. Hours reported for individuals whose RN licenses were not active, including one nurse whose license had already expired before the audit period began.

8. Hours reported for an agency RN who worked remotely and never set foot in the facility, despite the rule that only onsite hours count.

The OIG also found that CMS itself was not catching repeat problems. At least 4 of the 18 nursing homes that failed to deduct meal breaks correctly had been cited for the identical error in a prior audit, and CMS had no routine process for confirming that earlier findings had actually been fixed.

Does This Audit Identify Any Texas Nursing Homes by Name?

No. This is a national audit, and it is important to be direct about that limitation rather than imply otherwise. The OIG sampled 100 registered nurses from a nationwide pool of more than 127,000 and audited 99 nursing homes spread across the country. Nothing in the published report, the Report Highlights, or the full PDF identifies a state-by-state breakdown, and no Texas facility is named anywhere in the document.

What can fairly be said, and this is an inference rather than a finding stated in the report, is that Texas nursing homes are subject to the exact same federal PBJ requirements as the facilities The OIG did sample. Texas nursing homes are also governed by a state-level staffing and posting rule, 26 TAC §554.1001, which mirrors the federal nurse staffing requirements at 42 CFR §483.35 and requires Texas facilities to post and make available the same categories of daily staffing information the federal PBJ rule is built around. The error categories The OIG documented, particularly the meal-break deductions and the salaried-staff reporting confusion, are tied to how CMS's policy manual is written and applied nationwide, not to any one region. 

However, there is absolutely no reason to assume Texas facilities are immune from the same reporting problems.

What Should Texas Families Know About Nursing Home Staffing Records?

Texas licenses and regulates nursing facilities under Health and Safety Code Chapter 242, and the Health and Human Services Commission's executive commissioner is charged under §242.037 with adopting and enforcing minimum standards for quality of life, quality of care, and residents' rights at every licensed facility. Texas does not operate a separate state version of the PBJ system. Texas facilities report into the same federal system that The OIG audited, which means the staffing hours posted for a Texas nursing home on the Medicare Compare website come from the same data pipeline this audit found to be unreliable for a meaningful share of facilities nationwide.

For a family evaluating whether understaffing contributed to a fall, a pressure injury, or a more serious injury at a Texas nursing home, PBJ data can be one piece of evidence worth examining, alongside payroll records, time clock data, and the facility's own staffing plan. A discrepancy between what a facility reported to CMS and what its own payroll records show is not, by itself, proof of neglect. It is a data point that may be relevant depending on the rest of the facts.

We Can Help

At The Borah Law Firm, PLLC, we represent patients and families across Texas in medical malpractice cases. We only handle these cases, nothing else. If you believe a loved one received substandard nursing home care, we can help you understand whether a case exists and what your options are.

Contact us today for a confidential case review.

Frequently Asked Questions

What is the Payroll-Based Journal?
It is the federal system nursing homes use to electronically submit staffing information to CMS, including the number of hours each direct care staff member was paid to work each day, based on payroll and other auditable data.

Did this audit find problems at any specific Texas nursing home?
No. The audit is national in scope, and no Texas facility is named in the published report. Any connection to Texas facilities described in this post is an inference based on the fact that Texas nursing homes report into the same federal system, not a finding stated by The OIG.

What percentage of nursing home staffing hours did The OIG find were not supported?
The OIG estimated that approximately 4.7 percent of registered nurse hours reported nationwide for March 2024 were not supported in accordance with Federal requirements, affecting an estimated 41.5 percent of the registered nurses in the sampling frame. Both figures come from a 100-nurse sample, and The OIG's published 90 percent confidence interval for the hours estimate runs from 2.1 percent to 8.7 percent, so the true national figure is less precise than the rounded headline number suggests.

Does CMS agree with The OIG's findings?
CMS concurred with two of The OIG's four recommendations, did not take a clear position on a third, and disagreed with the fourth. CMS also argued in its written response that a 95 percent accuracy rate is reasonable for a system of this size.

Can staffing data be used as evidence in a Texas nursing home negligence case?
It can be relevant, depending on the facts of a specific case. An attorney would typically compare PBJ submissions against payroll records, time clock data, and the facility's staffing plan rather than relying on PBJ data alone.

About the Author: J.T. Borah is a Texas medical malpractice attorney and founding attorney of The Borah Law Firm, PLLC, in Austin, Texas. His practice is limited exclusively to medical malpractice cases involving hospitals, nursing homes, and other medical institutions. He has been recognized as a Texas Super Lawyer. He is often asked to lecture at legal seminars on medical malpractice issues and has lectured to attorneys from 18 states.

AI writing tools assisted Mr. Borah in preparing this article. All legal standards, citations, and factual claims were reviewed by Mr. Borah as a licensed Texas attorney.

This article is for general informational purposes only and does not constitute legal advice. Reading this article does not create an attorney-client relationship.