We will conduct a cross-sectional analysis of the Provider Information File from the Centers for Medicare & Medicaid Services using the July 2023 data set. Total nursing staff turnover and, separately, registered nursing staff turnover will be obtained from this file. Nursing homes will be linked to the county in which they are located based on facility address. Nursing homes will be defined as rural or urban based on non-metropolitan/metropolitan status of the county. We will compare turnover rates across nursing homes based on rurality, staff workload, ratio across different types of nursing personnel, and quality score. Using descriptive statistics and bivariate analyses, we will:

• Examine whether turnover is greater in rural or in urban counties.
• Test whether nursing homes with the lowest quartiles for nurse to resident hours have higher nursing turnover rates.
• Examine whether that relationship is the same in rural and urban counties.
• Compare the ratio of registered nurse time to other nursing staff time.
• Examine the racial composition of the county and patients and the association with nursing staff turnover.