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Nursing Home Quality
Nursing Home Quality in United States
United States

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United States Value:


Percentage of certified nursing home beds rated four or five stars over a three-month period

Nursing Home Quality in depth:

Appears In:

Nursing Home Quality by State

Percentage of certified nursing home beds rated four or five stars over a three-month period

Nursing Home Quality Trends

Percentage of certified nursing home beds rated four or five stars over a three-month period

Trend: Nursing Home Quality in United States, 2023 Senior Report

Percentage of certified nursing home beds rated four or five stars over a three-month period

United States

 U.S. HHS, Centers for Medicare & Medicaid Services, Care Compare

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About Nursing Home Quality

US Value: 32.6%

Top State(s): Hawaii: 73.3%

Bottom State(s): Louisiana: 19.7%

Definition: Percentage of certified nursing home beds rated four or five stars over a three-month period

Data Source and Years: U.S. HHS, Centers for Medicare & Medicaid Services, Care Compare, September 2022-November 2022

Suggested Citation: America's Health Rankings analysis of U.S. HHS, Centers for Medicare & Medicaid Services, Care Compare, United Health Foundation,, accessed 2023.

In 2022, there were nearly 1.2 million residents in more than 15,000 nursing homes across the United States. Older adults in nursing homes often have cognitive, mental or functional impairments that make it difficult to complete day-to-day tasks. A landmark study published by the Institute of Medicine in the late 1980s cited the urgent need for better regulatory standards in nursing homes to accommodate a growing older adult population. More recent reports have highlighted recurring problems in the U.S. like low staffing and reports of elder abuse, which contribute to poor health outcomes such as depression among nursing home residents. Quality nursing home practices can help prevent adverse health outcomes and save money.

The Centers for Medicare & Medicaid Services (CMS) added the Five-Star Quality Rating System to Nursing Home Compare in 2008. More stars indicate the nursing home is rated higher in quality. The ratings are a composite score based on health inspections, quality of resident care and overall staffing. The public ratings are intended to encourage nursing homes to achieve higher quality.

Nursing homes with lower ratings include:

  • Nursing homes with more beds (more than 120) compared with nursing homes with less beds (fewer than 60). 
  • Nursing homes unaffiliated with a Continuing Care Retirement Community (CCRC) compared with nursing homes that are part of a CCRC.
  • For-profit nursing homes compared with nonprofit nursing homes. 
  • Nursing homes in states with a higher percentage of low-income older adults.

One study found that nursing homes with three or fewer stars were concentrated in the Southern U.S. Moreover, the quality of nursing home care is lower in areas with a high concentration of racial and ethnic minorities.

The Five-Star Quality Rating System can help individuals and families select the right nursing home for themselves and their loved ones. Information is available from CMS’s new Care Compare tool, which combines its eight distinct provider comparison metrics — including Nursing Home Compare — into a single interface. 

CMS is constantly improving their standards for nursing home quality. In 2019, CMS removed some pain measures to help prevent the overuse of opioids, and announced a new component for reporting elder abuse. In response to the COVID-19 pandemic, CMS set new state survey and reporting requirements focused on preventing the spread of COVID-19. Other regulations and data collection related to Nursing Home Compare and the Five Star Quality Rating System were temporarily modified to adjust to pandemic conditions. 

While overall nursing home quality has been improving, there has been concern regarding the reliability of using self-reported data for nursing home ratings. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act was enacted in 2014 to improve the data reported through Nursing Home Compare, and continues to be updated.

Boccuti, Cristina, Giselle Casillas, and Tricia Neuman. 2015. “Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State.” Issue Brief. KFF.

Gallagher, Lani G. 2011. “The High Cost of Poor Care: The Financial Case for Prevention in American Nursing Homes.” Washington, D.C.: The National Consumer Voice for Quality Long-Term Care.

Harrington, Charlene, Joshua M. Wiener, Leslie Ross, and MaryBeth Musumeci. 2017. “Key Issues in Long-Term Services and Supports Quality.” Issue Brief. KFF.

Institute of Medicine Committee on Nursing Home Regulation. 1986. Improving the Quality of Care in Nursing Homes. Washington, D.C.: National Academies Press.

Shippee, Tetyana P., Weiwen Ng, and John R. Bowblis. 2020. “Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes?” Innovation in Aging 4 (3): 1–9.

Yuan, Yiyang, Kate L. Lapane, Jonggyu Baek, Bill M. Jesdale, and Christine M. Ulbricht. 2019. “Nursing Home Star Ratings and New Onset of Depression in Long-Stay Nursing Home Residents.” Journal of the American Medical Directors Association 20 (10): 1335-1339.e10.

Yuan, Yiyang, Christopher Louis, Howard Cabral, Jeffrey C. Schneider, Colleen M. Ryan, and Lewis E. Kazis. 2018. “Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings.” Journal of the American Medical Directors Association 19 (10): 852-859.e2.

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