Fewer than one in five nursing homes earned top honors in the latest U.S. News Best Nursing Homes 2026 rankings. Of the more than 15,000 long-term and skilled rehabilitation facilities in the United States, the latest analysis finds that 12,000 fell short of providing the highest-quality care due to staffing shortages or other issues. The analysis further confirms decades of research showing that adequate staffing positively affects patient outcomes.
Location also impacts the quality of care received, according to the report. California, Pennsylvania and New York had a greater proportion of high-quality skilled rehabilitation and long-term care facilities than did Louisiana, Montana, or West Virginia. Meanwhile, vast swaths of rural America face what amount to nursing home deserts.
These latest rankings come as H.R.1, also known as the One Big Beautiful Bill Act, pauses federal nursing home staffing mandates, delaying implementation by a decade. The Trump administration is seeking to permanently overturn these regulations. This would require minimum nurse-to-resident ratios.
Journalists can use state and metro rankings to see how facilities in their communities fare, ask about staffing ratios and outcomes, including hospitalizations or patient complications and cross-check this information with CMS data. They can use ProPublica’s Nursing Home Database to check for any recent inspection violations. Reporters can also speak with families, who must often choose a facility when in a crisis mode and with little tangible information, according to Ben Harder, U.S. News’s chief of health analysis.
Why this matters
In 2024, nursing homes in the U.S. cared for approximately 1.2 million older adults and people under 65 with significant disabilities or health issues requiring 24/7 care. Approximately 1in 8 people 85 and older reside in a long-term nursing facility. Nearly half have dementia.
U.S. News’ analysis found that the best nursing homes provide 20% more total staffing per resident per day compared to the national average. Top rehab facilities offer 80% more physical therapy per resident. This extra care translates directly into better outcomes: 15% fewer hospitalizations for long-term residents and 33% fewer emergency room visits for rehab patients.
“They’re [family caregivers] handed a mimeographed list by a hospital discharge planner and told to figure it out themselves — often while mom is still recovering from a broken hip or dad is being transferred after a stroke. You’re supposed to make one of the most crucial healthcare decisions imaginable, usually within 24 to 48 hours, with almost no real information,” he said in an interview.
More precise and nuanced data
U.S. News overhauled its methodology this year to specifically capture staffing in far greater detail. “We know the evidence strongly, just time after time, underscores how important staffing is,” Harder said.
The methodology includes 17 distinct quality measures for both short-term rehabilitation and long-term care ratings, nearly double last year’s count. There are 11 different staffing dimensions for long-term care alone — from weekday versus weekend coverage to the ratio of registered nurses to aides, physical therapy hours per resident, and staff turnover rates.
The analysis also tracks the “all-in” rate of antipsychotic use by analyzingdata obtained through a Freedom of Information Act request, rather than relying on the Centers for Medicare & Medicaid Services’ version, which excludes residents with certain diagnoses. That matters because “the proportion of long-term care residents who have those diagnoses is kind of implausible,” Harder said.
The expanded staffing measures capture nuances that matter enormously but often go unnoticed. For example, the ratings can parse whether two skilled nursing facilities have the same total staffing, but one has more during the week and has a gap on the weekends, according to Harder. The same is true for facilities that pad their numbers with nursing assistants instead of registered nurses, or those with high staff turnover, a red flag for poor working conditions that inevitably affect resident care.
“Did this patient end up in the emergency room, or in the hospital or fall and have a major injury? You can’t fudge those things,” Harder said.
The analysis also distinguishes between those needing skilled nursing, or short-term rehabilitation versus those who require long-term services and supports. “Family and patient considerations are different for those segments,” Harder said. “The reimbursement is different, so access may be different as well.”
It’s also important to know whether some facilities may be gaming the system to hide what critics call chemical restraint — drugging residents into docility because it’s cheaper than hiring adequate staff. Not every resident requires an anti-psychotic, but it’s easier and cheaper to medicate them than hire enough people, Harder said. According to a 2022 report by the HHS Inspector General’s office, between 2011 and 2019, some 80% of long-term care residents were prescribed a psychotropic drug. Some research finds these drugs may actually worsen certain behaviors.
Use caution when citing CMS data
Harder isn’t shy about critiquing the federal government’s five-star rating system, which relies too heavily on state surveys that can be years out of date and vary wildly in precision from state to state. “Some states are woefully behind in surveying, so CMS is using pretty outdated information as sort of the foundation of its rating system,” he said.
Ownership changes complicate things further. Private equity firms buy facilities, staffing drops, outcomes worsen — but the data showing the decline may not surface for years. “We can see when staffing drops and outcomes get worse following a sale,” Harder said.
CMS awards five-star ratings to about one-fifth of all nursing facilities, compared with U.S. News’ recognition of fewer than 2,000 facilities as high-performing. There are facilities with five CMS stars that U.S. News rates as mediocre when you examine staffing-heavy, outcome-driven measures, Harder said.
“I would evangelize for a more journalistic critique of quality,” Harder said, “particularly with some government data disappearing or of questionable prominence. “Skepticism has never been more warranted than it is now.”
Geography and access to quality care
Where you live increasingly determines whether you’ll find quality care — or any care at all. “These are kitchen table issues for local communities,” Harder said, pointing to a coastal Maine facility that closed, briefly reopened thanks to a local philanthropist’s million-dollar donation, then faced an uncertain future again. “There really wasn’t another nursing facility, nowhere else you could move if you were no longer able to live at home.”
That scenario is even worse in rural parts of the U.S., and in states where Medicaid reimbursement rates make it nearly impossible for facilities to stay afloat, much less maintain quality standards. And H.R.1’s proposed Medicaid cuts could accelerate closures, particularly in areas already struggling. “If private equity firms see profits shrink, they may look to divest or close,” Harder said. Even nonprofit, church-run facilities may not survive on thinner margins.
If someone needing care must move because they can’t get needed post-acute care near home, that complicates the transition back to where they were living before,Harder said. And when families can’t visit regularly because they’d have to drive a hundred miles, they can’t keep tabs on care, which leads to worse outcomes.
Low pay and long hours has hisotircally been a problem for facilities seeking qualified staff. “You can work at Target for the same money as a certified nursing assistant job and it’s a less demanding job,” Harder said. In many regions, staffing shortages threaten even high-performing facilities. Some operators are creating certificate programs with community colleges to train aides or therapy assistants, but they’re still worried that many of those people are going to leave the community, leaving older adults and those who care for them, scrambling.
Resources
- CMS Nursing home compare.
- Long Term Care Community Coalition Nursing Home Ratings.
- Most nursing homes don’t have enough staff to meet the federal government’s new rules, NPR/KFF Health News (April, 2024).
- Ownership Matters: Not-for-Profit Chain Nursing Homes Have Higher Utilization of Agency Nursing Staff, The Journal of Healthcare Organization, Provision and Financing (October 2024).
- Nursing Home Basics: The Benefits of Age-Friendly Care for Residents and Staff, Institute for Healthcare Improvement.
