Why nursing home quality ratings vary so much by state

A state's average nursing home rating tells you less than the mechanics behind it. Nursing home quality ratings in the U.S. all come from one federal system: the Five-Star Quality Rating System run by the Centers for Medicare & Medicaid Services. The scores it produces move for reasons that have little to do with what a building looks like on a tour. Staffing levels, Medicaid reimbursement rates, distance from hospitals and nursing schools, and the consistency of state survey agencies all pull regional averages up or down. They cluster in predictable ways.

That clustering is why state-level comparisons can mislead. A facility in a sparsely populated county may struggle to recruit registered nurses no matter how carefully it is run. A nursing home in a state with low Medicaid reimbursement rates has less room to fund the staffing levels that feed two of the three scored components. Ratings in the same state, sometimes in the same city, can differ sharply.

The stakes are practical. Families rarely choose a nursing home at leisure. The decision usually follows a hospital discharge or a sudden decline, and it has to be made within days. A ranked list of state averages does not answer the question in front of them. CMS updates its data on a rolling schedule, so a ranking published this year may not hold next year. What holds steadier are the forces behind the numbers and the method for reading one facility's record.

The five slides ahead start with how the five-star system is built and weighted. From there they turn to nurse staffing, the most reliable predictor of a low score, and the structural disadvantages rural facilities face. The last two explain how Medicaid reimbursement and ownership shape what a home can spend, and how to read a single facility's record instead of a state average.

Illustration: Quartz

The Five-Star Quality Rating System scores nearly every Medicare- and Medicaid-certified nursing home in the country on a scale of one to five, and it builds that overall score from three separately rated components: health inspections, staffing and quality measures. Each component carries its own star rating, and together they produce the summary number shown on Medicare.gov's Care Compare.

Health inspections carry the most weight in that calculation. State survey agencies, working under contract with CMS, conduct unannounced standard surveys at each certified facility on a recurring cycle that averages roughly a year, and they investigate complaints filed between those visits. Inspectors cite deficiencies by scope and severity, covering everything from medication errors to infection control lapses to incomplete care planning. More than one survey cycle feeds the inspection rating, with the most recent findings weighted heaviest, so one clean year does not erase a pattern.

The staffing component comes from payroll records facilities submit through the Payroll-Based Journal system. That shift to verified payroll data, which began driving the staffing rating in 2018, replaced self-reported estimates and made the measure much harder to inflate. The rating counts total nurse staffing hours per resident per day and registered nurse hours separately, since RNs handle clinical assessment work that aides are not licensed to perform. Both figures are adjusted for how sick and dependent a facility's residents are.

Quality measures draw on the resident assessment data facilities must report, known as the Minimum Data Set, along with Medicare claims. They include rates of pressure ulcers, falls with major injury, antipsychotic medication use and unplanned hospital readmissions, reported separately for long-stay and short-stay residents.

The ratings do not refresh once a year. CMS posts new inspection results on a monthly cycle and updates staffing and quality measure data quarterly, which means a facility's star count can move several times within a single year.

Illustration: Quartz

Nurse staffing is the factor most consistently tied to poor nursing home scores, and registered nurse hours per resident per day is the number that predicts trouble earliest. A home that cannot hold steady RN coverage usually slips on the other scored components as well, because thin staffing changes how quickly problems get caught.

The mechanism is direct. RN coverage tends to thin out overnight and on weekends. The work that prevents complications then gets postponed — repositioning residents who cannot move themselves, checking wounds, catching the early signs of a urinary tract infection or pneumonia. Those delays surface weeks later as pressure ulcers, falls with injury and avoidable hospital transfers. Each of those outcomes feeds the quality measures portion of the five-star score. A single understaffed shift rarely registers. A pattern of them does.

Since 2018, CMS has calculated staffing scores from payroll records rather than facility self-reports, which made the measure much harder to overstate. The published figure still carries a quirk worth knowing. A home can post respectable total nursing hours while carrying very little registered nurse time, because certified nurse aides and licensed practical nurses make up the bulk of those hours. Reading the RN line separately from the total gives a clearer view of clinical oversight.

Labor supply explains much of the regional pattern. Homes far from nursing schools, or in markets where hospitals and home health agencies pay more for the same license, draw from a smaller pool and lose candidates to better offers. Many fill the gap with agency staff, who cover the shift but often arrive without knowing a resident's care plan, medication history or behavioral triggers. Continuity suffers even when the headcount looks fine.

CMS finalized a federal minimum staffing rule in 2024 that set floors for total nurse hours and required around-the-clock RN presence. Litigation and later congressional action narrowed the rule and pushed back its implementation. Neither the rule nor the delay changes the size of the available nursing workforce.

Illustration: Quartz

Geography itself depresses nursing home ratings in rural areas, independent of how well a facility is managed. Distance from hospitals, specialists and nursing schools shrinks both the clinical backup a home can call on and the pool of credentialed staff it can hire from, and that shows up in the staffing and quality measure components of the federal score.

Recruitment is the sharpest constraint. Registered nurses and licensed practical nurses weighing offers can often choose urban or suburban employers paying more, with more predictable schedules and clearer paths to advancement. A long-term care home an hour from the nearest metro area competes for the same licensed workers and frequently loses, leaving a small core staff absorbing overtime or agency nurses rotating through to fill gaps.

Admissions work differently in these markets. A rural facility is sometimes the only long-term care option within a wide radius, which limits how selective it can be about whom it accepts. That can mean caring for medically complex residents without an on-site specialist or the equipment an urban home would have, since transferring someone to a hospital for every complication is impractical when the hospital is 50 miles away.

Closures compound the pressure. When a rural hospital or a neighboring nursing home shuts down, residents and caseloads shift to whatever facilities stay open. A home that absorbs them without adding nurses will see its hours-per-resident figures fall and its quality measures soften, with no change in management or practice.

State funding decisions sit on top of all this. Most of the long-term care bill in these homes is paid by Medicaid, and each state sets its own reimbursement rate. A rural facility in a low-reimbursement state has less revenue per resident than a comparable home elsewhere, which narrows what it can do on wages, hiring, equipment and the building repairs inspectors notice.

Illustration: Quartz

Medicaid is the largest single payer for nursing home care in the U.S. The rate a state sets therefore acts as a ceiling on what most facilities within its borders can spend on staff, equipment and building upkeep. A home funded mainly by Medicaid cannot raise prices the way an ordinary business does when costs rise.

Rate-setting methods vary by state. Some use cost-based formulas that tie payment to a facility's documented expenses. Others pay a flat daily rate, or a case-mix-adjusted rate that rises with the medical complexity of its residents. What matters is the gap between the payment and the real cost of delivering care. When a state rebases its formula infrequently, labor and supply costs can outrun it for years. Medicare and private-pay rates typically run higher, so a facility's payer mix determines how much pressure the Medicaid rate applies.

Squeezed facilities tend to cut in predictable places. Nurse hours get trimmed on the shifts administrators judge least risky. Maintenance is deferred. Activities, dietary staffing and other services that carry no licensing requirement shrink first. Those choices surface later in the five-star score — a sanitation or maintenance citation on a health inspection, or a staffing component that slips as hours per resident day fall.

Ownership adds a second variable on top of payment rates. A National Bureau of Economic Research working paper on private equity acquisitions of nursing homes linked those deals to worse resident outcomes and shifts in frontline staffing, a pattern that held apart from local reimbursement levels. Ownership type is not a verdict on any single home, and well-run for-profit facilities are common, but it is a factual input worth having.

CMS publishes nursing home ownership data, and each facility's Care Compare listing shows whether it is for-profit, nonprofit or government-operated and whether it belongs to a chain. State health department licensing records carry similar detail, often including recent ownership changes that federal data has not yet absorbed.

Illustration: Quartz

An individual facility's Care Compare record is a far better guide than any state average, because ratings vary more within a state than between states. Two homes in the same ZIP code can hold one star and five stars, so the search starts at the facility level.

Pull apart the three component scores instead of stopping at the overall star count. A home can post a respectable overall rating while carrying a weak staffing score, especially after a clean health inspection. Medicare.gov lists the components separately, and the gaps between them often say more than the headline number.

Within the staffing section, look at registered nurse hours per resident per day rather than total nurse staffing hours. Total hours include certified nursing assistants, who provide most hands-on care but do not carry an RN's clinical assessment duties. A facility can hit an acceptable total while running thin on RN coverage overnight and on weekends.

Read the inspection report itself, not just the stars attached to it. CMS classifies each deficiency by scope and severity, which separates a paperwork lapse from a violation that harmed a resident. Check the survey date too — a rating resting on an inspection from two years ago may not describe current staffing or management.

Check whether the home appears on CMS's Special Focus Facility list or the published candidate list. That designation marks a documented pattern of serious problems that routine oversight has not resolved, rather than one bad survey cycle.

Then ask questions the data cannot answer. Staff turnover rates, which CMS publishes on Care Compare, are a start, and administrators can be asked directly about typical nurse-to-resident ratios on night and weekend shifts. Families of current residents fill in what averages flatten. Ratings describe past performance built on federal inspection and payroll records — not a guarantee of future care.