What state has the highest-rated nursing homes? Here's where they're best (and worst)

A resident wing at a nursing and rehab center. Pictured facility is not the one mentioned in this story.

Researchers say good staffing levels and low turnover are some of the best predictors for good care at a nursing home, but the number of nurses and aides varies greatly between facilities — and between states.

President Joe Biden has called for setting nationwide minimum staffing levels, the details of which should be released this spring for public comment. Thirty-five states have already set their own rules for skilled nursing facilities, with varied results. A recent USA TODAY investigation found that inspectors rarely penalize nursing homes that fall short of staffing benchmarks.

Several tools exist to help consumers understand staffing levels and other factors that research has shown to affect health outcomes.

5 states with the highest-rated nursing homes

Based on the federal government's 5-star rating system for nursing homes from November 2022, Hawaii has the best average score (3.90 across 41 facilities), followed by Alaska (3.80, 20 facilities), Idaho (3.46, 78 facilities), Delaware (3.35, 43 facilities), and Utah (3.34, 96 facilities).

The District of Columbia averaged a rating of 3.41 across its 17 facilities.

5 states with the lowest-rated nursing homes

The states with the worst average federal ratings were Louisiana (2.34, 264 facilities), Mississippi (2.48, 199 facilities), Georgia (2.53, 355 facilities), Texas (2.55, 1,189 facilities) and West Virginia (2.56, 121 facilities).

What is the CMS 5-star rating system?

The Centers for Medicare & Medicaid Services' Five-Star Quality Rating System gives nursing homes and other health care providers a rating of 1 to 5 stars "to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions."

The facility's overall star rating is based on rates for health inspections, staffing and quality measures.

CMS cautions that "no rating system can address all of the important considerations that go into a decision about which nursing home may be best for a particular person."

The agency assigns the grades to all health facilities that accept payments from two federally funded insurance programs: Medicaid and Medicare. That means the vast majority of the country's hospitals, dialysis centers, home health providers and nursing homes are rated.

Recognizing decades of research that link staffing levels to health outcomes, the federal agency recently added more information about caregivers and turnover to the Nursing Home Compare website, which provides details about each nursing home's rating.

States with poor nursing home staffing

A USA TODAY investigation found that thousands of nursing homes each year report having fewer nurses or aides on duty than federal regulators would expect based on the formula used to pay them.

And even fewer are penalized for it.

Some states have more facilities reporting staffing levels that fell short of benchmarks. There also was a wide variation in how many of those nursing homes received citations for insufficient staffing.

In 2021, 97.5% of the 79 facilities in Rhode Island had lower staffing than expected — the nation's highest rate — but only two received citations from government inspectors. It was one of 10 states — along with Utah, Wyoming, South Dakota, Hawaii, Texas, Montana, Illinois, Louisiana and Maine — where more than 9-in-10 nursing homes reported low staffing to federal regulators. Enforcement rates among those 10 varied from 1.67% in Texas to 19.4% in Hawaii.

To see the results of recent inspections and whether facilities were fined, consumers can use ProPublica's Nursing Home Inspect tool. These reports provide more detail than can be found on the federal Nursing Home Compare website.

Search database of nursing home ratings

USA TODAY compiled data filed by more than 15,000 nursing homes and published indicators of how each performed in areas such as total daily nursing hours and mortality.

Nursing home ratings: Search the data for a nursing home near you

The ratings are based on data facilities provided to federal health regulators during a five-month surge of COVID-19 infections and deaths starting October 2020. Our investigation shows the pandemic exacerbated systemic problems long-present in nursing homes. In particular, the virus tested the strength of facilities' training and protocols about infection control.

We found that the pandemic data could be used as a stress test to identify which facilities did better than expected and which did worse at keeping residents safe during a crisis.

Our searchable database also shows staff-level ratings from that same time period that correspond to federal recommendations. Consumers can consider this point-in-time report card alongside other tools to evaluate nursing homes.

Jayme Fraser is a USA TODAY investigative data reporter. Contact Jayme at, @jaymekfraser on Twitter and Facebook, or on Signal and WhatsApp at (541) 362-1393.

Erin Davoran is an audience editor for USA TODAY's investigations team. Contact Erin at or on Twitter @erindavoran.

This article originally appeared on USA TODAY: Nursing home ratings: These states are where they're ranked the best