CMS Care Compare State-by-State Quality Rankings (2026)

Last reviewed May 7, 2026 · By Chad Griffith

The Centers for Medicare and Medicaid Services publishes star ratings and quality measures for the ~14,500 Medicare-certified skilled nursing facilities, ~12,400 home health agencies, and ~6,900 hospices through Care Compare. Star ratings combine multiple quality indicators into a composite measure designed for consumer comparison: Overall Rating, Health Inspection Rating, Staffing Rating, and Quality Measure Rating for SNFs; Quality of Patient Care Rating for HHAs; Hospice Care Index for hospices. Distribution of star ratings varies significantly by state, driven by state survey agency rigor, market characteristics, ownership patterns, and Medicaid policy differences. This analysis surfaces which states rank highest and lowest by quality measure, which states have the most Special Focus Facility designations, and what operational factors explain the variance.

Star Rating Distribution Methodology

CMS calculates star ratings using a forced distribution model designed to ensure meaningful differentiation: approximately the top 10% of facilities nationwide receive 5 stars, 20% receive 4 stars, 40% receive 3 stars, 20% receive 2 stars, and 10% receive 1 star — though actual distribution varies year-to-year. State-level distributions diverge from the national distribution based on operational factors specific to each state's market.

Underlying components for SNF Overall Rating: (1) Health Inspection Rating — derived from the most recent three years of state survey results, weighted by recency and severity; (2) Staffing Rating — derived from CMS Payroll-Based Journal staffing data showing RN, total nurse, and CNA hours per resident day; (3) Quality Measure Rating — derived from clinical and post-acute outcome measures using MDS assessment data. The Overall Rating combines these three, with adjustments for facilities with adverse Special Focus Facility status or recent reportable abuse incidents.

5-Star Distribution by State (Nursing Homes)

States with consistently above-average 5-star nursing home concentrations include New Hampshire, Hawaii, Maine, North Dakota, and Vermont — typically attributed to smaller markets with longer-tenured ownership and stronger nursing labor pools. States with consistently below-average 5-star distributions include Texas, Louisiana, Oklahoma, Mississippi, and Arkansas — typically attributed to higher Medicaid penetration, different ownership patterns, and varying state survey agency citation rates.

Important caveat: 5-star concentration differences do not necessarily indicate care-quality differences. State Survey Agency citation rates vary, and stricter SSAs produce lower star ratings even when underlying care quality is comparable. CMS has periodically adjusted the rating algorithm to mitigate state-level scoring variance, but state-driven differences persist in published ratings.

Methodology note: state-by-state distribution can be reproduced from CMS Care Compare data downloads at provider-data.cms.gov. Distributions shift over time as new survey results enter the rolling three-year window. The state rankings above represent multi-year patterns, not single-year results.

Special Focus Facilities (SFF)

The Special Focus Facility program identifies the most-deficient nursing facilities in each state for enhanced oversight. CMS publishes the SFF candidate list and current SFF list quarterly. SFF designation triggers: more frequent state surveys (typically every 6 months instead of annual); more aggressive enforcement actions; required progress toward sustained improvement within 12-18 months or termination from Medicare.

SFF candidate identification methodology: CMS calculates a Special Focus Facility score based on the facility's three most recent surveys (combining citation count, scope-severity weights, and revisit results). Approximately the bottom 5% of facilities by this score in each state are flagged as SFF candidates. From candidates, CMS designates approximately 88 active SFFs nationwide (based on a fixed budget for enhanced oversight).

States with persistently high SFF candidate counts (relative to facility population) include states with larger nursing home markets, higher Medicaid census, and historical patterns of frequent ownership changes. The SFF list is publicly available at cms.gov and updated quarterly.

Home Health Agency Quality Variance

HHA quality is measured by the CMS Quality of Patient Care Rating combining: timely initiation of care (start of care within 48 hours of physician referral), improvement in walking, improvement in bathing, improvement in transferring, improvement in pain interfering with activity, improvement in dyspnea, improvement in management of oral medications, acute care hospitalization rate (lower is better), and emergency department use without hospitalization (lower is better). Each measure is risk-adjusted to account for patient-mix differences.

State-level variance in HHA quality is typically smaller than SNF variance because HHA care is shorter-duration and less affected by ownership and staffing differences. States with above-average HHA Quality of Patient Care Ratings include Massachusetts, Vermont, New Hampshire, New York, and Washington — generally states with more established HHA market regulation.

Patient Survey Star Rating (HHCAHPS) is a separate measure based on patient satisfaction surveys. Patient Survey ratings often correlate weakly with Quality of Patient Care ratings, suggesting they measure different aspects of HHA performance.

Hospice Care Index by State

The Hospice Care Index (HCI) is a single composite measure introduced in 2022 combining 10 indicators: Continuous Home Care or General Inpatient Care Provided, Gaps in Skilled Nursing Visits, Early Live Discharges, Late Live Discharges, Burdensome Transitions Type 1 (returning home), Burdensome Transitions Type 2 (returning to hospital), Per-Beneficiary Spending, Skilled Nursing Care Minutes per Routine Home Care Day, Skilled Nursing Minutes on Weekends, and Visits in the Last Days of Life. The HCI ranges 0-10 with higher values indicating better performance.

National HCI distribution: most hospices score 6-9 with a smaller tail at the low end. HCI is less subject to state-level survey-agency differences than SNF ratings because most HCI components are derived from claims data rather than survey findings. State variance in HCI is largely driven by hospice market characteristics — for-profit vs nonprofit ownership, hospital-affiliated vs independent, and patient mix.

FileFlo Analysis: What This Means for Operators

For a healthcare facility operator, the state-by-state variance in CMS Care Compare data has practical implications:

• Multi-state operators: the same operational practices can produce different star ratings in different states because state survey agencies cite differently. Operators with facilities in stricter states (e.g., California) typically need higher operational rigor than the national average to achieve target star ratings.
• Acquisitions and ownership changes: facility star ratings can drop after acquisition because the new ownership inherits the prior survey history, but new ownership patterns can also draw heightened SSA scrutiny. Buyers should evaluate the prior 36 months of survey results rather than the current rating alone.
• Special Focus Facility risk: for facilities in the SFF candidate range, the next two surveys are dispositive. Investment in survey readiness — particularly around F-Tag categories cited at the prior survey — directly affects whether the facility moves toward SFF designation or off the candidate list.
• Patient referral implications: hospital-based discharge planners increasingly use Care Compare star ratings to prioritize post-acute referrals. A 3-star vs 4-star difference can produce measurable referral volume differences in markets with sufficient SNF/HHA supply.
• Insurance and bond pricing: Medicare Advantage plans and managed Medicaid plans use star ratings in network adequacy and quality bonus payment calculations. Insurance underwriters reviewing star rating history factor it into general liability and professional liability pricing.

The single highest-impact operational lever for SNFs is consistent F-Tag deficiency reduction — addressing the underlying root causes that drive citations rather than only treating individual deficiencies. The F-Tag Deficiency Response Playbook (available at /healthcare-compliance/f-tag-deficiency-response-playbook) covers the procedural detail of this work.

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