Staffing levels are one of the strongest predictors of nursing home quality. Facilities with more registered nurses (RNs) and certified nursing assistants (CNAs) per resident consistently show better outcomes — fewer falls, fewer infections, and fewer emergency transfers.
Our Staffing pillar combines RN hours per resident per day (weighted 60%) with LPN/aide hours (40%), using CMS-reported data. States at the top of this ranking have nursing homes that provide significantly more hands-on care time per resident.
Staffing is one of five pillars in our Elder Care Index. See how states rank on affordability, quality, access, Medicaid, or view the overall rankings.
Alaska averages 2.15 RN hours per resident per day — more than triple the national average of 0.7. The next closest state (D.C.) is at 1.74. Alaska's tiny nursing home population, high wages, and strict regulatory environment create staffing ratios that most states can't replicate. It's a genuine outlier: a score of 100 that pulls the entire scale.
The bottom of this list tells a consistent geographic story. Texas (0.44 RN hrs), Louisiana (0.32), Oklahoma (0.34), Georgia (0.49), and Missouri (0.46) all cluster in the bottom 10. These states combine low healthcare wages with minimal staffing regulations, creating a structural deficit that shows up in CMS data. For families in these states, asking about specific facility staffing ratios during tours isn't optional — it's essential.
Research consistently shows that RN hours per resident is the strongest predictor of nursing home quality outcomes — fewer falls, fewer infections, fewer emergency hospital transfers. This is why staffing carries 20% weight in our composite, making it the third-heaviest pillar. A state with cheap care but thin staffing (see: affordability rankings) may cost families more in the long run through preventable health complications.
| # | State | Grade | Score | RN Hrs/Resident | Total Nurse Hrs |
|---|---|---|---|---|---|
| 1 | Alaska | F | 100 | 2.15 hrs/day | 7.00 hrs/day |
| 2 | District of Columbia | A | 53 | 1.74 hrs/day | 4.85 hrs/day |
| 3 | Hawaii | F | 49 | 1.63 hrs/day | 4.71 hrs/day |
| 4 | Oregon | D | 41 | 0.68 hrs/day | 4.95 hrs/day |
| 5 | Delaware | F | 37 | 1.03 hrs/day | 4.51 hrs/day |
| 6 | Nevada | C | 34 | 1.06 hrs/day | 4.34 hrs/day |
| 7 | Maine | C | 34 | 1.03 hrs/day | 4.35 hrs/day |
| 8 | North Dakota | A | 34 | 0.93 hrs/day | 4.41 hrs/day |
| 9 | Washington | D | 33 | 0.88 hrs/day | 4.39 hrs/day |
| 10 | Minnesota | A | 32 | 1.06 hrs/day | 4.23 hrs/day |
| 11 | California | B | 32 | 0.65 hrs/day | 4.51 hrs/day |
| 12 | Utah | B | 31 | 1.19 hrs/day | 4.06 hrs/day |
| 13 | Wisconsin | B | 30 | 0.97 hrs/day | 4.20 hrs/day |
| 14 | Vermont | C | 30 | 0.81 hrs/day | 4.31 hrs/day |
| 15 | Nebraska | A | 26 | 0.71 hrs/day | 4.17 hrs/day |
| 16 | Idaho | C | 26 | 0.83 hrs/day | 4.07 hrs/day |
| 17 | Mississippi | D | 26 | 0.63 hrs/day | 4.21 hrs/day |
| 18 | Montana | B | 26 | 0.94 hrs/day | 3.97 hrs/day |
| 19 | Arizona | B | 25 | 0.72 hrs/day | 4.12 hrs/day |
| 20 | Kansas | A | 24 | 0.71 hrs/day | 4.07 hrs/day |
| 21 | Michigan | D | 24 | 0.77 hrs/day | 4.03 hrs/day |
| 22 | Kentucky | A | 24 | 0.77 hrs/day | 4.01 hrs/day |
| 23 | Wyoming | F | 22 | 0.90 hrs/day | 3.84 hrs/day |
| 24 | South Dakota | A | 22 | 0.80 hrs/day | 3.89 hrs/day |
| 25 | Pennsylvania | C | 22 | 0.78 hrs/day | 3.89 hrs/day |
| 26 | Maryland | F | 22 | 0.81 hrs/day | 3.87 hrs/day |
| 27 | New Hampshire | F | 21 | 0.74 hrs/day | 3.88 hrs/day |
| 28 | Florida | F | 20 | 0.73 hrs/day | 3.86 hrs/day |
| 29 | Alabama | B | 20 | 0.64 hrs/day | 3.91 hrs/day |
| 30 | Arkansas | A | 20 | 0.40 hrs/day | 4.07 hrs/day |
| 31 | New Jersey | F | 20 | 0.69 hrs/day | 3.86 hrs/day |
| 32 | Iowa | A | 20 | 0.73 hrs/day | 3.83 hrs/day |
| 33 | Connecticut | F | 20 | 0.70 hrs/day | 3.83 hrs/day |
| 34 | Massachusetts | D | 19 | 0.65 hrs/day | 3.86 hrs/day |
| 35 | South Carolina | D | 19 | 0.63 hrs/day | 3.86 hrs/day |
| 36 | Virginia | D | 19 | 0.69 hrs/day | 3.81 hrs/day |
| 37 | Colorado | C | 19 | 0.83 hrs/day | 3.70 hrs/day |
| 38 | Tennessee | F | 19 | 0.61 hrs/day | 3.85 hrs/day |
| 39 | Rhode Island | D | 18 | 0.77 hrs/day | 3.72 hrs/day |
| 40 | North Carolina | C | 17 | 0.59 hrs/day | 3.78 hrs/day |
| 41 | West Virginia | D | 17 | 0.71 hrs/day | 3.69 hrs/day |
| 42 | Indiana | B | 17 | 0.66 hrs/day | 3.71 hrs/day |
| 43 | Ohio | B | 16 | 0.63 hrs/day | 3.72 hrs/day |
| 44 | New York | B | 16 | 0.70 hrs/day | 3.65 hrs/day |
| 45 | Oklahoma | B | 15 | 0.34 hrs/day | 3.84 hrs/day |
| 46 | Louisiana | B | 14 | 0.32 hrs/day | 3.81 hrs/day |
| 47 | Illinois | C | 13 | 0.73 hrs/day | 3.49 hrs/day |
| 48 | New Mexico | C | 13 | 0.62 hrs/day | 3.56 hrs/day |
| 49 | Georgia | D | 12 | 0.49 hrs/day | 3.57 hrs/day |
| 50 | Missouri | A | 9 | 0.46 hrs/day | 3.47 hrs/day |
| 51 | Texas | C | 8 | 0.44 hrs/day | 3.40 hrs/day |
How we calculate these scores → Our Methodology
CMS reports that the national average is roughly 0.7 RN hours and 3.5 total nurse hours per resident per day. States significantly above these averages, like Alaska and Oregon, provide notably more direct care time.
Staffing differences reflect a combination of state minimum staffing regulations, local labor markets, pay rates, and rural vs. urban facility mix. States with higher wages and stronger regulations tend to have better staffing ratios.
Higher staffing is strongly correlated with better outcomes in research studies, but it's not the only factor. Staff training, retention rates, and management quality also matter significantly.