7 states that consistently rank high for nursing home care

Two nursing homes charging similar monthly rates can carry very different quality ratings, and part of that gap traces back to the state line they fall on. The Centers for Medicare & Medicaid Services rates every certified nursing home in the country through its Five-Star Quality Rating System. The score weighs health inspections, staffing levels and clinical quality measures. Those scores roll up into state averages on Medicare's Care Compare site. A consistent set of states has sat near the top of nursing home quality by state for years, while others sit well below the national middle.

What separates a strong state from a weak one usually comes down to a handful of policy levers. The first is money: how much a state pays facilities for Medicaid residents, who account for the largest share of long-stay nursing home residents nationally. The second is staffing law — whether the state requires minimum direct care hours above the federal floor. The third is enforcement: how often state surveyors inspect and how quickly they follow up on cited deficiencies. The fourth is ownership mix — how much of the market belongs to for-profit chains rather than nonprofit, hospital-affiliated or county-run operators. Higher per-resident Medicaid reimbursement tends to keep more nurses and aides on payroll, which feeds directly into the staffing component of the five-star score. Smaller, tightly regulated markets also tend to show a narrower gap between their best and worst homes.

The seven states here have repeatedly appeared near the top of national averages for best-rated nursing homes, and what follows explains the structural reasons behind that performance rather than treating a single year's snapshot as permanent. Ratings move. CMS revises its methodology periodically, payroll-based staffing data is reported quarterly, and a change in ownership can reshape one facility within months.

Read this as a guide to the mechanics of nursing home quality, not a guarantee about any individual building. Even in the strongest states, quality varies sharply from one home to the next, and a high state average can hide a facility with recent citations. Check a home's own Care Compare rating, its most recent inspection report, its staffing hours per resident per day and its registered nurse turnover figure before signing anything.

Illustration: Quartz

Hawaii consistently posts some of the strongest average nursing home ratings in the country, and the simplest explanation is scale. The state certifies only a few dozen nursing facilities in total, a sector small enough for regulators to watch closely and for weak performers to stand out quickly.

Geography reinforces that. The cost and logistics of operating across islands have limited the entry of the large multistate for-profit chains that dominate long-term care across much of the mainland. A substantial share of Hawaii's nursing homes are affiliated with hospital systems or run by nonprofit organizations instead. CMS data has repeatedly shown that nonprofit and government-run facilities, as a group, draw fewer severe health and safety citations than investor-owned chains.

Labor costs cut in the state's favor. Hawaii's cost of living ranks among the highest in the U.S., which pushes wages for registered nurses and certified nurse aides upward. Higher pay supports recruitment and retention of permanent staff rather than heavy reliance on temporary agency workers. That matters for ratings because CMS publishes staff turnover separately from the overall star score, broken out by nursing staff category, and turnover signals whether residents see the same caregivers week to week.

The small market cuts both ways. With so few certified homes statewide, one facility closing, losing certification or collecting a run of serious deficiency citations moves the state average far more than a comparable event would in Texas or Ohio. The average is strong, but it rests on a thin base, and it can shift from one reporting cycle to the next.

Families looking at homes on Oahu, Maui, Kauai or Hawaii Island should treat the statewide reputation as background rather than as a verdict. Pull up each facility's individual Care Compare page, read the most recent inspection report and compare staffing hours per resident per day. Even a market this compact contains lower-rated outliers, and island residency often limits how many alternatives sit within realistic visiting distance.

Illustration: Quartz

Rhode Island licenses a small number of nursing homes inside the smallest land area of any state. That compactness lets its survey workforce cover more of the market per inspector than agencies in sprawling states can manage, and no facility sits much more than an hour's drive from Providence.

The state has also legislated on staffing directly. The Nursing Home Staffing and Quality Care Act, enacted in 2021, set a minimum number of direct care hours per resident per day above the federal baseline, and the General Assembly has returned to its enforcement provisions repeatedly since. Staffing carries weight in the five-star system because CMS does not rely on a facility's own estimate. The agency builds the measure from payroll-based journal data that homes submit each quarter, drawn from payroll records and verified against census counts. Facilities held to a state floor above the federal requirement generally report stronger hours than those working to the federal minimum alone.

Geography shapes clinical access as well. Most Rhode Island nursing homes sit within reach of the Providence hospital cluster, which shortens transfer times and makes it easier to keep working relationships with specialists, wound care teams and infection control consultants. Independent homes in remote corners of larger states rarely have that proximity.

Concentration is the trade-off. With few facilities statewide, the performance of several large homes can move Rhode Island's average in either direction from one rating cycle to the next, so a strong statewide reputation says little about any particular address.

Families evaluating a specific home should pull its survey history on Care Compare and read the scope and severity codes attached to each cited deficiency, which separate a documentation lapse from actual harm to a resident. The date of the most recent standard survey matters too, because an older inspection means the posted health inspection rating describes conditions that may have shifted. Registered nurse hours per resident per day and nurse aide turnover are the other two figures worth checking.

Illustration: Quartz

Delaware's nursing home quality rests on two levers: what the state pays facilities for Medicaid residents, and how often state surveyors walk through the door. Both feed the staffing and health inspection scores that carry most of the weight in a CMS five-star rating.

Medicaid is the dominant payer for long-stay nursing home residents across the country, which makes a state's reimbursement rate the largest single variable in most facility budgets. Homes paid at a higher per-resident rate have room to raise wages, add shifts and keep registered nurse coverage above the federal minimum instead of trimming hours to stay solvent. Payroll-based journal data submitted to CMS makes those choices visible every quarter, and they translate directly into the staffing star rating a family sees on Care Compare.

Oversight is the second lever. Delaware's Division of Health Care Quality licenses and surveys long-term care facilities in a state that runs less than 100 miles from end to end. A survey workforce responsible for a limited number of buildings can complete standard recertification surveys on schedule and still return for complaint investigations and follow-up visits, avoiding the backlogs that accumulate where hundreds of homes are spread across wide territory. Catching problems early keeps minor citations from compounding into the immediate jeopardy findings that sink an inspection score.

Delaware also has a notable concentration of continuing care retirement communities, where a skilled nursing unit shares a campus with independent living and assisted living residences. These multilevel operators draw revenue from residents paying privately at lighter levels of care, which cushions the nursing wing against the thin margins standalone homes work with and supports steadier staffing and building maintenance.

None of that erases the differences between individual buildings. The state's market includes nonprofit and for-profit operators, and CMS data has shown over multiple years that nonprofit and government-run homes accumulate fewer serious health citations on average than investor-owned chains. Families comparing options in Wilmington, Dover or Sussex County should weigh ownership type alongside the overall star rating.

Illustration: Quartz

Wisconsin sets its own nursing home staffing rules through the state licensing code, on top of federal certification requirements. That second layer of regulation shows up in how its facilities perform on the staffing portion of the CMS five-star score. Homes answer to the state Division of Quality Assurance as well as to federal surveyors.

Staffing is the piece of the five-star rating tied most directly to resident outcomes. CMS builds it from Payroll-Based Journal data, which facilities submit each quarter. Those filings tie reported nursing hours to payroll records rather than to an estimate collected during a single survey week. The design rewards homes that hold steady coverage all year instead of adding shifts ahead of an inspection.

Ownership mix matters as well. Wisconsin retains a large number of county-owned nursing homes, many of them in smaller communities, alongside a nonprofit sector tied to religious and fraternal organizations. Government-run and nonprofit homes nationally report lower turnover among certified nursing assistants than investor-owned chains do. CMS posts turnover figures on Care Compare, including a total nursing staff rate and a separate rate for registered nurses.

Wisconsin also runs Family Care, a statewide Medicaid managed long-term care program that helps older adults and people with disabilities receive services at home or in community settings. One result is that residents who do enter a Wisconsin nursing home often arrive with heavier care needs, since the lower-acuity population is served elsewhere. Staffing numbers read differently in that context. A home with a sicker census requires more nursing hours per resident, not the same.

Geography is the practical limit on all of this. In parts of northern and western Wisconsin, a family may find only one facility within an hour's drive, so a strong statewide average translates into little real choice. Travel time also shapes how often relatives can visit, and regular visits remain one of the few informal checks a family keeps on daily care. Distance and star rating both belong in the comparison.

Illustration: Quartz

Vermont runs one of the smallest nursing home sectors in the country, and that limited scale shapes its ratings. Its Department of Disabilities, Aging and Independent Living can track individual facilities more closely than an agency responsible for hundreds of buildings. Surveyors return sooner, and cited deficiencies get follow-up before they harden into patterns.

The department's Division of Licensing and Protection conducts the standard surveys that feed the health inspection portion of the CMS five-star score, and it handles complaint investigations as well. Where the certified facility count is measured in dozens rather than hundreds, a complaint is less likely to sit behind a long queue, and enforcement follow-through is easier to sustain.

Ownership mix matters here too. Vermont's long-term care market includes a substantial share of nonprofit and hospital-affiliated homes, in line with a health system that leans nonprofit across hospitals and home health as well. In CMS data nationally, nonprofit and government-run facilities have tended to draw fewer severe health and safety citations than investor-owned chains. A state whose market tilts that way starts from a better baseline.

The constraint is labor. Vermont is rural and its overall workforce is small. Recruiting registered nurses, licensed practical nurses and certified nursing assistants is difficult across much of the state, particularly in the Northeast Kingdom and other areas far from Burlington. Thin local labor pools push some homes toward agency staffing, which breaks continuity of care even when total hours look adequate on paper.

Vermont facilities have worked within CMS's National Partnership to Improve Dementia Care in Nursing Homes. That federal initiative targets antipsychotic prescribing for residents who lack a diagnosis supporting it. The prescribing rate is one of the long-stay quality measures built into the five-star system, and lower rates generally point to more deliberate dementia care.

For families, the practical effect is a short list of options with close supervision behind it. Choice is limited, but the homes that exist are watched carefully.

Illustration: Quartz

South Dakota undercuts the assumption that rural states with small tax bases and thin labor markets must post weak nursing home scores. Its facilities have held up well on CMS measures, and the explanation has less to do with spending than with who owns the homes.

A large share of South Dakota's nursing facilities are county-owned, church-affiliated or otherwise nonprofit rather than run by national investor-owned chains. Ownership type is among the more durable predictors of performance in federal data, and facilities without a return obligation to outside investors tend to put more of their revenue into direct care hours. In a town of a few thousand people, the nursing home is often the largest employer and answers to a local board instead of a corporate office in another state.

The state's Department of Health licenses and surveys those facilities. The total number of certified homes is small enough that one poor performer moves the statewide average in a way it never would in California, Texas or Ohio. That works in both directions — a strong average in South Dakota rests on far fewer facilities than the same average in a populous state, so it carries less statistical weight.

Staffing is the pressure point. Recruiting registered nurses and certified nursing assistants to towns hours from Sioux Falls or Rapid City is hard, and some homes have leaned on contract and agency workers to cover shifts. CMS publishes the share of nursing hours supplied by contract staff alongside total staffing hours and turnover rates, so that reliance shows up on Care Compare rather than staying buried in a facility's scheduling records.

Ownership stability matters as well. Homes operating under the same county or community control for decades avoid the abrupt management changes that often follow a sale, and CMS now publishes change-of-ownership data that makes those transactions easier to trace. Families comparing South Dakota facilities should read the contract staffing percentage and the ownership history together, since the two often explain a rating better than the star count alone.

Illustration: Quartz

Utah's nursing home sector benefits from a comparatively young building stock and a population that is still growing, two conditions that support steady occupancy and fewer of the aging-infrastructure problems that surface during health inspections. Utah also has the lowest median age of any state, which shapes both its labor pool and the pace at which long-term care capacity has been added.

The physical building counts for more in a star rating than families tend to expect. The health inspection portion of the CMS Five-Star Quality Rating System incorporates life safety code surveys, which test compliance with the National Fire Protection Association standards CMS applies to certified facilities. A home built or substantially renovated in recent decades was designed around current sprinkler, smoke compartment and accessibility requirements, so it tends to collect fewer citations tied to the structure rather than to care practices.

Ownership stability is the second factor. CMS publishes ownership records for every certified nursing home, including changes of ownership, through Care Compare and its downloadable provider data files. When a facility changes hands repeatedly, administrators, directors of nursing and payroll systems often turn over alongside the owner, and that churn surfaces in the payroll-based staffing figures CMS collects each quarter. Markets where operators hold on to buildings for long stretches give staffing patterns time to settle.

Population growth gives Utah operators a steadier revenue base than counterparts in states losing rural residents, where partially filled buildings squeeze both staffing budgets and maintenance schedules.

State surveyors work on the federal cycle, which requires a standard recertification survey of every certified nursing home no more than 15 months after the previous one, with a statewide average of 12 months. Holding to that schedule means problems get documented and corrected before they escalate into the immediate jeopardy findings that sink a rating.

Anyone comparing Utah homes should open the ownership section on Care Compare, check when the building last drew a life safety citation, and read the most recent survey narrative instead of stopping at the overall star count.