Key Findings
- •Hawaii leads with 28.9% five-star facilities (vs 18.9% national average)
- •Louisiana ranks last at 12.1% five-star, with 31.2% one-star facilities
- •Top 10 states average 0.77 RN hours/resident/day vs 0.51 in bottom 10 states
- •Abuse violations 3x more common in worst states (26% vs 8%)
- •Regional patterns exist: Northeast/West generally better than South/Midwest
Why Your State Matters More Than You Think
When choosing a nursing home, most families focus on individual facilities. That's important. But where those facilities are located matters just as much.
A three-star facility in Hawaii is likely better than a three-star facility in Louisiana. Why? State regulations, Medicaid reimbursement rates, inspection rigor, staffing standards, and cost of living all create massive quality differences between states.
We analyzed all 14,751 Medicare-certified nursing homes to show you which states consistently deliver better care—and which ones struggle.
Top 10 States for Nursing Home Quality
These states have the highest percentage of five-star facilities, best staffing levels, and fewest serious deficiencies.
| Rank | State | 5-Star % | Avg RN Hours | Total Facilities |
|---|---|---|---|---|
| 1 | Hawaii | 28.9% | 0.89 | 45 |
| 2 | Rhode Island | 26.4% | 0.82 | 81 |
| 3 | Vermont | 25.7% | 0.81 | 35 |
| 4 | Maine | 24.8% | 0.79 | 105 |
| 5 | Oregon | 24.1% | 0.76 | 134 |
| 6 | New Hampshire | 23.5% | 0.78 | 75 |
| 7 | Washington | 22.9% | 0.75 | 211 |
| 8 | Massachusetts | 22.3% | 0.77 | 369 |
| 9 | Connecticut | 21.8% | 0.74 | 215 |
| 10 | Minnesota | 21.4% | 0.72 | 355 |
What These States Do Right
- Higher staffing requirements: Most have minimum RN hour mandates
- Better Medicaid reimbursement: Facilities can afford quality staff
- Rigorous inspections: States catch problems early
- Strong enforcement: Serious violations result in penalties
- Culture of quality: Regulations create competitive pressure to improve
Bottom 10 States for Nursing Home Quality
These states have the lowest percentage of five-star facilities, poorest staffing, and highest rates of serious deficiencies.
| Rank | State | 5-Star % | 1-Star % | Avg RN Hours |
|---|---|---|---|---|
| 50 | Louisiana | 12.1% | 31.2% | 0.48 |
| 49 | Oklahoma | 13.4% | 28.7% | 0.49 |
| 48 | Tennessee | 14.2% | 27.1% | 0.51 |
| 47 | Alabama | 14.8% | 26.4% | 0.50 |
| 46 | Nevada | 15.1% | 25.8% | 0.52 |
| 45 | Arkansas | 15.6% | 24.9% | 0.53 |
| 44 | New Mexico | 15.9% | 24.2% | 0.54 |
| 43 | Mississippi | 16.2% | 23.6% | 0.55 |
| 42 | Texas | 16.5% | 22.8% | 0.56 |
| 41 | Georgia | 16.8% | 21.9% | 0.57 |
Common Problems in Low-Ranking States
- Low Medicaid reimbursement: Facilities operate on thin margins, can't afford adequate staffing
- Weak staffing requirements: No or minimal state mandates for RN hours
- Lax enforcement: Violations don't result in meaningful penalties
- High poverty rates: Less tax revenue = less funding for oversight and programs
- Rural challenges: Difficulty recruiting qualified healthcare workers
Regional Quality Patterns
Clear regional trends emerge when you look at nursing home quality across the country.
Northeast
Best: Rhode Island, Vermont, Maine, New Hampshire, Massachusetts, Connecticut
Why: High staffing standards, strong union presence, better Medicaid rates, rigorous state oversight
West
Best: Hawaii, Oregon, Washington, Alaska
Why: Progressive regulations, higher cost of living supports better wages, strong patient advocacy
Midwest
Best: Minnesota, Iowa, Wisconsin
Worst: Missouri, Indiana, Ohio
Why: Huge variation—upper Midwest does well, rust belt struggles with funding and recruitment
South
Worst: Louisiana, Oklahoma, Tennessee, Alabama, Arkansas, Mississippi, Texas
Why: Low Medicaid reimbursement, minimal staffing requirements, weaker enforcement, rural staffing challenges
What Drives State Quality Differences?
Three factors explain most of the quality gap between best and worst states.
1. State Staffing Requirements
Federal regulations require only minimal staffing. States that mandate higher levels see dramatically better outcomes.
- • Top 10 states average: 0.77 RN hours/resident/day
- • Bottom 10 states average: 0.51 RN hours/resident/day
- • Difference: 51% more RN time in best states
- California: Minimum 3.2 nursing hours/resident/day
- Illinois: RN onsite 8+ hours/day
- Massachusetts: Specific RN/LPN/CNA ratios
- Oregon: Minimum staffing based on resident acuity
Result: Better care, fewer falls, less pressure ulcers, lower mortality rates.
2. Medicaid Reimbursement Rates
Medicaid pays for ~60% of nursing home residents. Low reimbursement = facilities cut costs = worse care.
| Reimbursement Level | Example States | Avg Quality |
|---|---|---|
| High ($200-300/day) | AK, NY, MA, CT | Above average |
| Medium ($150-200/day) | CA, FL, OH | Average |
| Low ($100-150/day) | LA, OK, AL, AR | Below average |
When Medicaid only pays $120/day but quality care costs $180/day, facilities have three choices: lose money, raise private-pay rates to subsidize Medicaid residents, or cut corners. Most choose option 3.
3. Inspection Rigor and Enforcement
Some states aggressively inspect and penalize violations. Others barely enforce minimum standards.
- • More frequent unannounced inspections
- • Higher fines for violations
- • Faster response to complaints
- • Public reporting of all violations
- • License revocation for serious issues
- • Minimum required inspections only
- • Low fines that don't deter
- • Complaint investigations take months
- • Limited public transparency
- • Facilities stay open despite violations
Impact: In strict states, facilities know they'll be caught and penalized. In lax states, shortcuts are business as usual.
The Cost-Quality Trade-Off You Need to Understand
Here's the problem: some of the best quality states are also the most expensive. Some of the worst quality states are the cheapest.
Quality vs. Cost Reality
Hawaii (#1 quality): $12,500/mo | Connecticut (#9): $13,298/mo
Louisiana (#50): $5,985/mo | Oklahoma (#49): $6,205/mo | Texas (#42): $5,639/mo
Minnesota (#10): $8,500/mo | Wisconsin (#15): $8,200/mo | Iowa (#12): $7,800/mo
What This Means for Your Decision:
If cost is no object, choose Hawaii, New England, or Pacific Northwest. If cost matters but quality is critical, look at upper Midwest states (Minnesota, Iowa, Wisconsin)—good quality at moderate prices.
If you're stuck in a low-ranking state, focus on finding the best individual facilities. Even in Louisiana, 12% of facilities are five-star. They exist—you just have to work harder to find them.
How to Use This Information
If You're in a Top 10 State
- Higher baseline quality: Even mid-rated (3-star) facilities may be decent
- More five-star options: Easier to find excellent care
- Still do your research: State averages don't guarantee every facility is good
- Expect higher costs: Quality costs money—budget accordingly
If You're in a Bottom 10 State
- Be extra vigilant: Lower state averages mean more bad facilities
- Don't settle for average: A 3-star facility in Louisiana may be risky
- Focus on the top facilities: Seek out the 12-16% that earn five stars
- Consider relocating: Moving to a neighboring higher-quality state may be worth it
- Visit frequently: Your presence matters even more when oversight is weak
If You Have Geographic Flexibility
The data suggests some states are simply better places to receive nursing home care. If you can choose:
- Prioritize states with staffing mandates (CA, IL, MA, OR)
- Look at upper Midwest for quality + value (MN, WI, IA)
- Avoid the lowest-ranking states unless you've identified specific high-performing facilities
- Research state-level assistance programs (some offer more help than others)
Find Quality Facilities in Your State
State averages tell you the landscape, but individual facility quality is what matters most. Use our search tool to find the best facilities in your specific state and city.
California
Above AvgView top facilities →
Florida
AverageView top facilities →
Texas
Below AvgView top facilities →
New York
Above AvgView top facilities →
Pennsylvania
AverageView top facilities →
Ohio
AverageView top facilities →
Find the Best Facilities in Your State
Search 14,751 facilities, filter by quality ratings, and find the top-performing nursing homes in your area—no matter which state you're in.
Explore Your State's Nursing Homes
See how facilities in your state compare:
Methodology
State rankings are based on analysis of all 14,751 Medicare-certified nursing homes in the United States.
Quality metrics used:
- Percentage of facilities with 5-star overall ratings
- Percentage of facilities with 1-star overall ratings
- Average RN hours per resident per day
- Average total nurse staffing hours per resident per day
- Abuse violation rates
- Serious deficiency citation rates (immediate jeopardy)
Data sources:
- CMS Provider Information dataset (overall ratings, staffing)
- CMS Health Deficiencies dataset (violations, citations)
- CMS Penalties dataset (fines, enforcement actions)
- State Medicaid reimbursement rate reports
Rankings reflect current data as of 2025. Individual facility quality can vary significantly within any state. Always research specific facilities before making decisions.
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