Best and Worst States for Nursing Home Quality (2026 CMS Data)

It is 1:15 AM on a Wednesday. You sit at the kitchen table with cold coffee, a stack of hospital discharge forms, and four different browser tabs open to Medicare's Care Compare website. Your mother is 82. Three days ago, she tripped over a doorstep in her hallway and fractured her pelvis. The hospital discharge planner just told you she needs four to six weeks of skilled rehabilitation care before she can safely step back inside her house.

You are handed a sheet listing twelve nursing facilities within driving distance. Some have glowing five-star badges. Others carry grim one-star ratings. A few sit right in the middle at three stars, leaving you wondering if average care is safe enough for an aging parent who needs help getting to the bathroom in the middle of the night.

What most families learn during a midnight crisis is that facility quality depends heavily on state geography. A nursing home operating five miles south of a state border can offer a completely different level of care than one five miles north. That difference stems from state Medicaid formulas, regional staffing shortages, and how state health inspectors enforce federal rules.

To help families make sense of these geographic disparities, ElderVoice analyzed the latest 2026 Centers for Medicare & Medicaid Services (CMS) Care Compare dataset, tracking 14,695 nursing homes across all 50 states. The numbers reveal a deep divide in senior care across the country.

State lines create massive divides in nursing home performance

Across the United States, 20.7% of the 14,695 nursing homes tracked in the 2026 CMS dataset hold a 5-star overall rating. On the opposite end, 19.6% hold a 1-star rating. That means roughly one out of five facilities operates at the peak of federal standards, while another one out of five operates at the lowest score assigned by Medicare.

When you group these numbers by state, the gap becomes impossible to overlook. In top-performing states, over a third of all nursing facilities earn 5 stars. In lower-performing states, barely one in ten hits that benchmark.

Here is how top-ranking and bottom-ranking states compare in ElderVoice's analysis of 2026 CMS Care Compare data:

Hawaii leads the country, with 35.7% of its 42 facilities receiving a 5-star overall rating. North Dakota ranks second at 33.3%, with Arizona (27.9%), Arkansas (27.6%), and Washington (26.9%) filling out the top five states for high-performing nursing homes.

At the bottom sits Louisiana, where only 10.2% of its 266 facilities reach 5 stars, bringing the state's average overall rating down to 2.50 stars. Missouri follows closely at 11.1% (average 2.45 stars), followed by Vermont at 12.1%, Texas at 13.3%, and Oklahoma at 13.4%.

If you are searching for facilities near your home, you can search specific locations in ElderVoice's nursing home directory to check inspection histories, staffing ratios, and star breakdowns.

Why star ratings swing so wildly from one state to another

Why does Hawaii have three times the proportion of 5-star nursing homes compared to Louisiana or Missouri? The contrast comes down to state Medicaid funding, regional labor markets, and how local health departments conduct inspections.

Medicaid funds daily care for roughly six out of ten nursing home residents in America. While CMS sets federal rules, Medicaid is administered jointly by federal and state governments. Each state determines its own daily reimbursement rate per resident bed. In states where Medicaid daily rates fall below the actual cost of providing care, nursing homes operate on razor-thin budgets. That financial squeeze makes it hard to pay competitive wages for certified nursing assistants (CNAs) and registered nurses (RNs), leading to chronic understaffing and high turnover.

When a facility loses experienced aides, resident care suffers immediately. On a short-staffed evening shift, a single CNA might be responsible for sixteen residents instead of eight. Call bells ring unanswered for twenty or thirty minutes. Basic care—helping someone sit up, guiding them to the toilet, or offering a glass of water—gets delayed or skipped entirely.

For an older parent recovering from a fall, sitting in bed for hours waiting for help creates a fear of moving. This loss of walking confidence—often called post-fall syndrome—can stall physical therapy and delay recovery. If your parent is rebuilding strength after a bad spill, our guide on overcoming post-fall syndrome breaks down practical steps to help them regain mobility safely.

Labor dynamics also vary by region. Rural states and regions with declining populations struggle to hire licensed nurses, while urban hubs near nursing programs have larger applicant pools. In addition, state health departments inspect nursing homes differently. Even though CMS sets national guidelines, physical inspections are conducted by state health inspectors. Some state enforcement agencies issue citations for minor administrative mistakes, while others reserve citations for severe safety threats.

How CMS calculates facility stars behind the scenes

To make sense of a nursing home's profile, you need to understand how CMS builds its overall score. CMS evaluates facilities across three distinct categories: health inspections, staffing levels, and clinical quality measures.

Health inspection ratings carry the greatest weight in the overall calculation. This rating comes from unannounced state inspection surveys performed over the previous three years. State inspectors evaluate food safety, medication delivery accuracy, infection control measures, building upkeep, and resident rights. Because these scores are relative to other facilities within the same state, a 3-star health inspection rating in Texas measures a facility against Texas peers, not facilities in Hawaii or North Dakota.

Staffing ratings evaluate the daily care hours provided to each resident by registered nurses, licensed practical nurses, and certified nursing assistants. CMS pulls these numbers directly from electronic payroll records through the Payroll-Based Journal (PBJ) system. Facilities earn higher staffing scores when they maintain consistent RN coverage on nights and weekends, as direct RN presence strongly links to lower emergency room visits and fewer hospital readmissions.

Quality measures track clinical outcomes across more than a dozen specific indicators. These include the percentage of short-stay residents who successfully return home, pressure injury (bedsore) rates, fall frequencies, and the off-label use of antipsychotic medications for residents without a primary psychiatric diagnosis.

Because clinical quality measures rely partly on self-reported assessment data sent by facility staff, a nursing home can show a 5-star quality measure score while holding a 1-star health inspection rating due to unresolved safety citations. Families should always evaluate all three categories separately rather than relying on the top-line average.

Red flags that state star ratings miss during in-person tours

A star score on a website cannot tell you what a nursing home feels like on a Thursday afternoon. A facility showing four stars might have changed ownership two months ago, resulting in widespread staff resignations that have not yet appeared in annual inspection data.

When you walk through a facility, watch for practical cues that data tables miss:

• Staff interactions and eye contact: Watch how aides speak to residents in hallways. Are they addressing people by name, or walking quickly past open doors while looking down at clipboards?
• Call light response times: Pick a chair in a central corridor and sit quietly for fifteen minutes during your tour. Listen to how many call alarms sound and time how long it takes a staff member to enter the room.
• Odors and environmental noise: A clean facility smells like clean laundry or mild soap, not overwhelming floral cover-up sprays. Continuous background alarms and yelling signal an overworked, stressed floor staff.
• Resident appearance and positioning: Check whether residents are dressed in clean personal clothes, seated comfortably, and offered fluids. Are water cups kept within easy reach on bedside trays?
• Physical therapy activity: Walk past the rehabilitation gym. Are residents actively working with therapists, or sitting unattended in wheelchairs against the wall?
• Staff turnover on the unit: Ask the charge nurse directly how long most aides on that floor have worked at the facility. Frequent turnover disrupts daily routines and care consistency.

Be cautious of fancy physical features. Some operating companies spend heavily on renovated lobbies, waterfall displays, and upscale dining furniture while keeping nurse staffing at minimum levels on resident floors. If you want to spot common sales tactics used during facility tours, consult our overview of senior living facility warning signs to protect your family during your search.

Step-by-step guide: selecting care when your state ranks near the bottom

If your family lives in Louisiana, Missouri, Vermont, Texas, or Oklahoma, finding reliable care requires additional homework. Low state averages do not mean good facilities do not exist—they simply mean the difference between a high-performing home and a struggling one is much wider.

Here is a practical approach to finding safe care, even in low-ranking markets:

1. Read raw health survey details (Form CMS-2567): Do not stop at the star summary. Access the actual survey logs on CMS Care Compare or ElderVoice's nursing home directory. Look specifically for Scope and Severity codes rated "G" or higher, which indicate actual harm to residents, or codes "J", "K", or "L", which represent immediate jeopardy to resident safety.
2. Call your local Long-Term Care Ombudsman: Ombudsmen are independent advocates who track resident grievances and visit facilities regularly. While they cannot officially rank facilities for you, you can ask focused questions like: "Which facilities in this county generate the fewest complaints regarding weekend staffing levels?"
3. Review memory care and temporary relief options: If your parent has Alzheimer's disease or cognitive impairment, confirm whether the facility provides a dedicated, secured memory care wing rather than general skilled nursing. If you need temporary home support while waiting for a room opening, review our breakdown of Medicare GUIDE dementia respite care benefits to access funded care at home.
4. Conduct unannounced visits during shift changes: Schedule your official tour during regular business hours, but drop back by on a Sunday afternoon or at 6:45 PM during evening shift handoff. Staffing numbers and hallway noise levels during off-peak hours give you a realistic picture of everyday operations.
5. Evaluate medical monitoring and cognitive baseline reviews: Inquire how the facility tracks cognitive shifts and sudden changes in medical status. Care teams that perform regular, structured evaluations—similar to Medicare cognitive assessments at home—are far better prepared to detect urinary tract infections, delirium, or cognitive decline before minor issues turn into hospital visits.

What can caregivers do when moving a parent is not an option?

Relocating an aging parent across state boundaries to reach a better nursing home market is often unworkable. Medicaid coverage does not transfer directly between states without new applications, long-distance moves cause emotional stress for frail seniors, and local family members need to be close enough to visit.

When moving states is off the table, maintaining an active, visible presence inside the facility is your best tool for ensuring good care. Facilities where family members visit regularly and ask informed questions consistently deliver higher attentiveness.

For families living in another town or state who cannot visit every week, establishing a reliable daily check-in routine keeps you connected. Automated check-in services like ElderVoice deliver daily, friendly phone calls directly to your parent's standard telephone or landline—requiring zero internet or technical setup. These structured calls offer conversation, confirm daily wellness, and provide family caregivers with real-time updates and peace of mind when they cannot be in the room.

Finally, participate actively in every quarterly care plan conference. Federal regulations mandate that nursing homes hold care plan meetings for every resident every 90 days, or whenever a major change in health occurs. Attend these meetings—in person or via video link—with specific questions ready. Ask about weight stability, pressure ulcer prevention, physical therapy goals, and medication reviews. If your parent is taking multiple maintenance drugs, ensure discontinued prescriptions are properly phased out and disposed of; review our guide on senior medication disposal guidelines to understand proper drug safety practices.

A state star rating provides a starting point, but your steady oversight is what protects your parent's safety, health, and comfort every day.