Key Findings

Hawaii has claimed the top spot as America's best nursing home state, according to Families for Better Care's 2019 Nursing Home Report Card.

The Aloha State grabbed the highest ranking by scoring above average grades in nearly every performance measure. Although this marks the first time Hawaii sits atop the list, the state is not unfamiliar with peak nursing home performance — ranking among the Top 10 nursing home states in all previous report cards.

But while Hawaii mounted its rankings takeover, Texas continued its stranglehold on last place. The Lone Star State ranked as the nation's worst nursing home state for the third consecutive report card. Failing scores in staffing levels, inspection ratings, and ombudsman complaints anchored the state once again to the bottom.  


State nursing home rankings changed dramatically since the last report card with 47 of 51 states shifting position. Highlights included:

  • Three of the previous best nursing home states slid out of our last report card’s top ten, including Vermont, which plunged from #3 to #31 overall. The remaining states were New Hampshire (down from #2 to #11) and Florida (falling seven spots from #6 to #13).
  • States that climbed into the top ten were Alaska (3), Idaho (6), District of Columbia (8), and New Jersey (10). This year marks the first time the District of Columbia and New Jersey entered the top ten nursing home states. 
  • Five states with the biggest gains in overall ranking were New York (↑20), Mississippi (↑17), Nevada (↑14), Alaska (↑13), and Connecticut (↑11).
  • Vermont (↓27), Massachusetts (↓24), Arkansas (↓17), North Carolina (↓15), Pennsylvania (↓14), Oregon (↓13), and California (↓10) suffered double-digit losses in state nursing home rankings.
  • Four state’s rankings did not change since the last reporting period, Texas (51), Tennessee (38), Maryland (33), and Nebraska (21).
  • Eight of the 10 top ranked nursing home state increased in overall ranking since the last report card.
  • Texas, Illinois, New Mexico, Michigan, Oklahoma, Louisiana, and Indiana consistently linger at, or near, the bottom in state nursing home care, scoring failing grades in every nursing home report card.


Only 28% of nursing homes scored an above average inspection, a 14% decrease since the last report card. In fact, this report card marks the first time that no state achieved a majority percentage of above average nursing home inspections, indicating a significant step back in overall nursing home quality.


The majority of nursing homes (54 percent) failed to staff at above average levels. On average, residents received 2 hours and 33 minutes of direct care daily—unchanged from the previous report card. 


For the third consecutive report, nearly 90% of all nursing homes were cited a deficiency for violating federal or state laws.


Despite a marginal decrease in percentage of facilities with severe deficiencies, 20 percent of nursing homes abused, neglected, or mistreated residents in almost half of all states for the second consecutive year.


States where ombudsmen verified the highest percentage (>90%) of identified complaints included: Kentucky (94.75%), Massachusetts (93.19%), Texas (93.07%), Tennessee (91.16%), Mississippi (90.91%), and Michigan (90.73%). 

In contrast, Florida (40.42%), South Carolina (40.93%), Missouri (44.43%), New Jersey (45.07%), Rhode Island (48.08%), and Idaho (49.26%) had the fewest (<50%) verified complaints.


With more than 480,000 elderly nursing home residents living in facilities with below average staffing scores, it’s beyond time for a nursing home transformation.

Grossly inadequate staffing levels continue to vex state nursing home quality. States with below average staffing ratings are, once again, the sediment of this year’s Nursing Home Report Card. 

But those states that scored above average grades, overall, excelled in professional and frontline caregiving standards. States like Hawaii, Alaska, and have become the beacons of light leading the nation toward better nursing home care. They’ve solved the looming nursing home quality quagmire that’s befallen our nation. 

And their solution is simple.

More staffing. 

Outstanding nursing home quality thrives on higher staffing levels. And while providers would agree, they would also argue that more money is necessary to hire more staff to provide better care. The nursing home industry remains heavily dependent on Medicare and Medicaid reimbursements to maintain financial solvency in an ever-expanding health care market. 

Families for Better Care believes that now is the time for federal and state leaders to finally give the nursing home operators what they really need to provide better care for our loved ones—and that’s more reimbursement funding. 

By and large, those states that excel in nursing home quality do so because of higher staffing levels. On the flip side, those states that are chronically bad have abysmally low staffing, with as much as 25 minutes less per resident care daily. In order for nursing homes to provide better care, they need more staff. Period. So it’s time to give nursing homes what they need to properly care for our loved ones, with a caveat. Any new funding appropriated for nursing homes should be accompanied by the strictest nursing home staffing requirements. 

Families for Better Care would happily stand shoulder-to-shoulder with our friends in the industry for more reimbursement if, and that’s a huge IF, they agree to newly legislated minimum staffing standards for any new funding allocation.

We desire to see all states perform at the highest nursing home standard, with more money and statutorily mandated staffing requirements, they will be able to


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