Nursing home quality is measured through federal health inspections conducted by CMS (Centers for Medicare & Medicaid Services). Every nursing home in the country receives regular inspections covering health deficiencies, fire safety, and complaint investigations.
Important context: average health inspection ratings are remarkably similar across states, ranging from roughly 2.7 to 3.1 on a 5-point scale. This means the difference between the "best" and "worst" states is smaller than you might expect. Individual facility quality varies far more than state averages — always check specific facility ratings on Medicare Care Compare.
Quality is one of five pillars in our Elder Care Index. See how states rank on affordability, staffing, access, Medicaid, or view the overall rankings.
Arkansas leads with a 3.13/5 average CMS health inspection rating. Connecticut is last at 2.69/5. That 0.44-point gap is the entire range across all 51 states. In practical terms, the difference between the "best" and "worst" state average is smaller than the difference between a good and mediocre facility within the same city. State-level quality averages are a blunt instrument.
CMS rates every nursing home individually on a 1-5 star scale. Within any state, you'll find 5-star facilities and 1-star facilities. A family in Connecticut (ranked last on state average quality) can still find excellent care — they just need to check Medicare Care Compare for specific facility scores rather than relying on the state number. The table below is useful for broad patterns, not facility selection.
We normalize Quality against the full theoretical 1-5 CMS scale, not the narrow observed range, so all states score between 42 and 53 on this pillar. This honestly reflects reality: quality doesn't vary much at the state level. It carries 25% weight in the composite, but contributes less differentiation than affordability or access, which have much wider spreads. Full details in our methodology.
| # | State | Grade | Score | CMS Inspection | Overall Rating | Facilities |
|---|---|---|---|---|---|---|
| 1 | Arkansas | A | 53 | 3.13/5 | 3.37/5 | 221 |
| 2 | Nevada | C | 50 | 2.98/5 | 3.12/5 | 66 |
| 3 | Kentucky | A | 49 | 2.95/5 | 2.89/5 | 268 |
| 4 | Hawaii | F | 49 | 2.95/5 | 3.56/5 | 42 |
| 5 | Rhode Island | D | 48 | 2.93/5 | 3.12/5 | 73 |
| 6 | North Dakota | A | 48 | 2.92/5 | 3.15/5 | 72 |
| 7 | South Carolina | D | 48 | 2.92/5 | 3.01/5 | 187 |
| 8 | Massachusetts | D | 48 | 2.92/5 | 2.99/5 | 341 |
| 9 | Wyoming | F | 47 | 2.89/5 | 2.97/5 | 36 |
| 10 | District of Columbia | A | 47 | 2.88/5 | 3.53/5 | 17 |
| 11 | North Carolina | C | 47 | 2.88/5 | 2.91/5 | 418 |
| 12 | Iowa | A | 47 | 2.87/5 | 3.08/5 | 390 |
| 13 | Tennessee | F | 46 | 2.86/5 | 2.96/5 | 303 |
| 14 | Montana | B | 46 | 2.85/5 | 3.00/5 | 61 |
| 15 | Vermont | C | 46 | 2.85/5 | 2.85/5 | 34 |
| 16 | Florida | F | 46 | 2.85/5 | 3.21/5 | 694 |
| 17 | Minnesota | A | 46 | 2.84/5 | 3.17/5 | 338 |
| 18 | Oklahoma | B | 46 | 2.84/5 | 2.67/5 | 284 |
| 19 | Nebraska | A | 46 | 2.83/5 | 2.85/5 | 179 |
| 20 | Louisiana | B | 46 | 2.83/5 | 2.43/5 | 266 |
| 21 | Indiana | B | 46 | 2.83/5 | 3.15/5 | 507 |
| 22 | Washington | D | 46 | 2.83/5 | 3.19/5 | 194 |
| 23 | Oregon | D | 46 | 2.83/5 | 3.02/5 | 128 |
| 24 | Maryland | F | 46 | 2.83/5 | 3.11/5 | 221 |
| 25 | Alabama | B | 46 | 2.82/5 | 3.01/5 | 224 |
| 26 | California | B | 46 | 2.82/5 | 3.15/5 | 1,162 |
| 27 | West Virginia | D | 46 | 2.82/5 | 2.83/5 | 123 |
| 28 | Missouri | A | 45 | 2.81/5 | 2.52/5 | 487 |
| 29 | Wisconsin | B | 45 | 2.81/5 | 3.03/5 | 323 |
| 30 | Arizona | B | 45 | 2.81/5 | 3.42/5 | 140 |
| 31 | Ohio | B | 45 | 2.81/5 | 3.18/5 | 922 |
| 32 | Maine | C | 45 | 2.81/5 | 2.99/5 | 78 |
| 33 | Georgia | D | 45 | 2.81/5 | 2.65/5 | 356 |
| 34 | Kansas | A | 45 | 2.80/5 | 2.96/5 | 297 |
| 35 | South Dakota | A | 45 | 2.80/5 | 2.88/5 | 97 |
| 36 | Texas | C | 45 | 2.79/5 | 2.77/5 | 1,177 |
| 37 | Michigan | D | 45 | 2.79/5 | 3.17/5 | 423 |
| 38 | Virginia | D | 45 | 2.79/5 | 3.01/5 | 289 |
| 39 | New Hampshire | F | 45 | 2.79/5 | 2.88/5 | 74 |
| 40 | Utah | B | 44 | 2.78/5 | 3.34/5 | 97 |
| 41 | Mississippi | D | 44 | 2.78/5 | 2.65/5 | 202 |
| 42 | New Jersey | F | 44 | 2.78/5 | 3.30/5 | 348 |
| 43 | Pennsylvania | C | 44 | 2.77/5 | 2.98/5 | 657 |
| 44 | New York | B | 44 | 2.76/5 | 3.03/5 | 596 |
| 45 | Colorado | C | 44 | 2.76/5 | 3.15/5 | 210 |
| 46 | Illinois | C | 44 | 2.75/5 | 2.52/5 | 668 |
| 47 | Connecticut | F | 43 | 2.73/5 | 2.95/5 | 191 |
| 48 | Idaho | C | 43 | 2.72/5 | 3.14/5 | 80 |
| 49 | Alaska | F | 42 | 2.70/5 | 3.45/5 | 20 |
| 50 | Delaware | F | 42 | 2.70/5 | 3.28/5 | 44 |
| 51 | New Mexico | C | 42 | 2.69/5 | 2.76/5 | 68 |
How we calculate these scores → Our Methodology
Arkansas leads with the highest average CMS health inspection rating. However, all states cluster between 2.7 and 3.1 on a 5-point scale, so the differences are relatively small compared to variation between individual facilities.
CMS ratings are based on federal inspections, staffing data, and quality measures. They're the most comprehensive publicly available data, but they reflect facility-level averages aggregated to the state. Always check individual facility scores rather than relying solely on state averages.
Federal inspection standards are applied uniformly nationwide, and most states cluster near the middle of the 1-5 scale. The variation between individual facilities within a state is typically much larger than the variation between state averages.