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Health & Medicine · CMS Nursing Home Care Compare

Who's Minding the Home

Medicare grades every certified nursing home in America with one to five stars. The star is a summary; underneath it sits a ledger, and one line of that ledger predicts more than any other: who owns the home. Seven in ten now answer to a shareholder - and on the measures that decide whether a resident is safe at 3 a.m., the for-profit column runs worse on every line.

~14,700 nursing homes rated 72% run for profit 523 on the federal watch list Illustrative

The ownership gap

Who runs the home matters

Start with the census. Of the 14,743 certified homes on CMS's books, roughly seven in ten are run for profit. Then read what that buys at the bedside: on the three measures that best predict whether a resident is safe - registered-nurse hours, staff churn, and the federal abuse flag - the for-profit column is the worst line in every panel.

Who owns the 14,743 certified homes
For-profit - 72% of certified homes Nonprofit - 22% of certified homes Government - 6% of certified homes 72%22%6%
  • For-profit · 10,600 homes
  • Nonprofit · 3,240 homes
  • Government · 903 homes
RN hours per resident-day higher is better
For-profit 0.51 Nonprofit 0.79 Government 0.72
Total nursing staff turnover lower is better
For-profit 55.1% Nonprofit 44.3% Government 47.0%
Homes flagged for abuse lower is better
For-profit 5.8% Nonprofit 3.1% Government 2.9%

One row per certified home, averaged within each ownership class. Bars scale to the largest value in each panel; the strip is the full census.

The staffing slide

2017-2026 · by ownership class

The gap is not new, and it is not closing. Registered-nurse hours fell across the board when the pandemic hit and never fully came back - but the for-profit line started lowest, fell furthest, and has recovered least. Turnover tells the same story upside down: everyone churned harder after 2020, and the for-profit workforce churns hardest still.

  • For-profit
  • Nonprofit
  • Government
RN hours per resident-day higher is better
0.40 0.50 0.60 0.70 0.80 0.90 2021 peak 2017202020232026 0.51 For-profit 0.79 Nonprofit 0.72 Government
Total nursing staff turnover lower is better
35% 45% 55% 65% 2021 peak 2017202020232026 55% For-profit 44% Nonprofit 47% Government
Illustrative

Endpoints match the current snapshot; earlier years are drawn from the documented direction of the payroll-based staffing record, not a computed archive ingest.

All values by year (table view)
Year For-profit RN hrsNonprofit RN hrsGovernment RN hrs For-profit turnoverNonprofit turnoverGovernment turnover
2017 0.600.840.78 48.2%39.1%41.4%
2018 0.590.840.77 49.0%39.6%41.9%
2019 0.580.830.77 49.8%40.2%42.6%
2020 0.540.790.73 55.6%45.8%47.9%
2021 0.500.760.70 61.3%50.9%53.2%
2022 0.490.760.70 59.4%48.7%51.1%
2023 0.500.770.71 57.6%46.8%49.3%
2024 0.500.780.71 56.5%45.6%48.2%
2025 0.510.780.72 55.7%44.9%47.5%
2026 0.510.790.72 55.1%44.3%47.0%

Five stars, sorted by owner

Share of certified homes at each CMS overall star rating

Averages can hide the tails, so spread each ownership class across the full star scale. The tails are the story: two of every five for-profit homes sit in the bottom two star tiers, roughly double the nonprofit share - and the pattern inverts at the top, where five-star nonprofits outnumber five-star for-profits nearly two to one.

For-profit For-profit - 1 star (worst): 20% of homesFor-profit - 2 stars: 23% of homesFor-profit - 3 stars: 22% of homesFor-profit - 4 stars: 19% of homesFor-profit - 5 stars (best): 16% of homes 43% at 1-2 stars Nonprofit Nonprofit - 1 star (worst): 8% of homesNonprofit - 2 stars: 13% of homesNonprofit - 3 stars: 21% of homesNonprofit - 4 stars: 27% of homesNonprofit - 5 stars (best): 31% of homes 21% at 1-2 stars Government Government - 1 star (worst): 10% of homesGovernment - 2 stars: 15% of homesGovernment - 3 stars: 23% of homesGovernment - 4 stars: 28% of homesGovernment - 5 stars (best): 24% of homes 25% at 1-2 stars
  • 1 star (worst)
  • 2 stars
  • 3 stars
  • 4 stars
  • 5 stars (best)
Illustrative

Each bar spans 100% of the group's rated homes. Darker segments are lower star tiers; the annotation totals the bottom two.

All shares by star tier (table view)
Ownership 1 star (worst)2 stars3 stars4 stars5 stars (best)
For-profit 20%23%22%19%16%
Nonprofit 8%13%21%27%31%
Government 10%15%23%28%24%

The for-profit map

Share of certified homes run for profit

The ownership gap is not spread evenly. It pools. Across the South and Southwest, four in five homes - sometimes closer to nine in ten - answer to a shareholder; across the upper Midwest and northern New England, the balance tips the other way. The darker a state runs below, the larger the slice of its residents living in a home whose incentives point away from the bedside.

Alabama - 82% for-profit Alaska - 30% for-profit Arizona - 72% for-profit Colorado - 68% for-profit Florida - 80% for-profit Georgia - 83% for-profit Indiana - 72% for-profit Kansas - 60% for-profit Maine - 55% for-profit Massachusetts - 61% for-profit Minnesota - 42% for-profit New Jersey - 72% for-profit North Carolina - 73% for-profit North Dakota - 34% for-profit Oklahoma - 86% for-profit Pennsylvania - 63% for-profit South Dakota - 40% for-profit Texas - 88% for-profit Wyoming - 50% for-profit Connecticut - 66% for-profit Missouri - 70% for-profit West Virginia - 66% for-profit Illinois - 74% for-profit New Mexico - 74% for-profit Arkansas - 79% for-profit California - 76% for-profit Delaware - 62% for-profit District of Columbia - 55% for-profit Hawaii - 44% for-profit Iowa - 48% for-profit Kentucky - 77% for-profit Maryland - 69% for-profit Michigan - 70% for-profit Mississippi - 80% for-profit Montana - 46% for-profit New Hampshire - 58% for-profit New York - 65% for-profit Ohio - 78% for-profit Oregon - 63% for-profit Tennessee - 81% for-profit Utah - 73% for-profit Virginia - 71% for-profit Washington - 60% for-profit Wisconsin - 47% for-profit Nebraska - 52% for-profit South Carolina - 75% for-profit Idaho - 71% for-profit Nevada - 78% for-profit Vermont - 45% for-profit Louisiana - 85% for-profit Rhode Island - 64% for-profit
For-profit share

National average: 72% for-profit

Illustrative

Albers-USA projection. Alaska and Hawaii inset. Five equal-label bins; hover any state for its share.

All states by for-profit share (table view)
#StateFor-profit share
1 Texas 88%
2 Oklahoma 86%
3 Louisiana 85%
4 Georgia 83%
5 Alabama 82%
6 Tennessee 81%
7 Florida 80%
8 Mississippi 80%
9 Arkansas 79%
10 Nevada 78%
11 Ohio 78%
12 Kentucky 77%
13 California 76%
14 South Carolina 75%
15 Illinois 74%
16 New Mexico 74%
17 North Carolina 73%
18 Utah 73%
19 Arizona 72%
20 Indiana 72%
21 New Jersey 72%
22 Idaho 71%
23 Virginia 71%
24 Michigan 70%
25 Missouri 70%
26 Maryland 69%
27 Colorado 68%
28 Connecticut 66%
29 West Virginia 66%
30 New York 65%
31 Rhode Island 64%
32 Oregon 63%
33 Pennsylvania 63%
34 Delaware 62%
35 Massachusetts 61%
36 Kansas 60%
37 Washington 60%
38 New Hampshire 58%
39 District of Columbia 55%
40 Maine 55%
41 Nebraska 52%
42 Wyoming 50%
43 Iowa 48%
44 Wisconsin 47%
45 Montana 46%
46 Vermont 45%
47 Hawaii 44%
48 Minnesota 42%
49 South Dakota 40%
50 North Dakota 34%
51 Alaska 30%

Ranked by for-profit share

14 states · most for-profit first

Here is the map, itemized. Read each state's terracotta bar against the four columns beside it: where for-profit operators dominate, the average rating slips under three stars, RN hours thin toward half an hour a day, and the turnover and abuse columns climb. The bottom of the table is what the other end of the spectrum looks like.

# State Avg rating RN hrs/day Turnover Abuse-flagged
1 Texas 1,187 homes 2.6 0.46 57.8% 7.1%
2 Oklahoma 297 homes 2.7 0.47 58.9% 6.6%
3 Louisiana 279 homes 2.8 0.48 55.2% 4.9%
4 Georgia 358 homes 2.8 0.50 54.1% 5.8%
5 Florida 698 homes 3.2 0.55 49.7% 4.1%
6 Ohio 948 homes 2.9 0.52 56.3% 5.5%
7 California 1,145 homes 3.1 0.58 51.4% 4.7%
8 Illinois 683 homes 2.8 0.53 55.9% 6.2%
9 Indiana 528 homes 2.9 0.51 57.1% 5.3%
10 Missouri 511 homes 2.9 0.50 56.7% 5.1%
11 Pennsylvania 679 homes 3.1 0.62 52.3% 3.8%
12 Massachusetts 359 homes 3.3 0.68 47.9% 3.0%
13 Minnesota 351 homes 3.8 0.83 42.1% 2.1%
14 North Dakota 78 homes 3.9 0.88 40.3% 1.8%

Ownership share is of homes with a reported ownership type. Rating is the mean CMS overall star rating (1-5) across the state's homes.

More profit, fewer nurses

51 states · share vs RN hours

Put every state on the same two axes and the pattern stops being an anecdote. As the for-profit share of a state's homes climbs, the registered-nurse hours its residents actually receive slide - a line you can draw with a ruler. On the fitted trend, every additional 10 points of for-profit share costs a resident about 4 minutes of RN time per day.

0.4 0.6 0.8 1.0 30%50%70%90% natl share 72% natl RN hrs 0.58 Alabama - 82% for-profit, 0.48 RN hrs/day Alaska - 30% for-profit, 0.82 RN hrs/day Arizona - 72% for-profit, 0.56 RN hrs/day Arkansas - 79% for-profit, 0.51 RN hrs/day California - 76% for-profit, 0.58 RN hrs/day Colorado - 68% for-profit, 0.59 RN hrs/day Connecticut - 66% for-profit, 0.59 RN hrs/day Delaware - 62% for-profit, 0.62 RN hrs/day District of Columbia - 55% for-profit, 0.66 RN hrs/day Florida - 80% for-profit, 0.55 RN hrs/day Georgia - 83% for-profit, 0.50 RN hrs/day Hawaii - 44% for-profit, 0.74 RN hrs/day Idaho - 71% for-profit, 0.55 RN hrs/day Illinois - 74% for-profit, 0.53 RN hrs/day Indiana - 72% for-profit, 0.51 RN hrs/day Iowa - 48% for-profit, 0.70 RN hrs/day Kansas - 60% for-profit, 0.63 RN hrs/day Kentucky - 77% for-profit, 0.52 RN hrs/day Louisiana - 85% for-profit, 0.48 RN hrs/day Maine - 55% for-profit, 0.67 RN hrs/day Maryland - 69% for-profit, 0.58 RN hrs/day Massachusetts - 61% for-profit, 0.68 RN hrs/day Michigan - 70% for-profit, 0.57 RN hrs/day Minnesota - 42% for-profit, 0.83 RN hrs/day Mississippi - 80% for-profit, 0.50 RN hrs/day Missouri - 70% for-profit, 0.50 RN hrs/day Montana - 46% for-profit, 0.72 RN hrs/day Nebraska - 52% for-profit, 0.68 RN hrs/day Nevada - 78% for-profit, 0.51 RN hrs/day New Hampshire - 58% for-profit, 0.65 RN hrs/day New Jersey - 72% for-profit, 0.56 RN hrs/day New Mexico - 74% for-profit, 0.55 RN hrs/day New York - 65% for-profit, 0.60 RN hrs/day North Carolina - 73% for-profit, 0.55 RN hrs/day North Dakota - 34% for-profit, 0.88 RN hrs/day Ohio - 78% for-profit, 0.52 RN hrs/day Oklahoma - 86% for-profit, 0.47 RN hrs/day Oregon - 63% for-profit, 0.62 RN hrs/day Pennsylvania - 63% for-profit, 0.62 RN hrs/day Rhode Island - 64% for-profit, 0.61 RN hrs/day South Carolina - 75% for-profit, 0.53 RN hrs/day South Dakota - 40% for-profit, 0.75 RN hrs/day Tennessee - 81% for-profit, 0.49 RN hrs/day Texas - 88% for-profit, 0.46 RN hrs/day Utah - 73% for-profit, 0.55 RN hrs/day Vermont - 45% for-profit, 0.73 RN hrs/day Virginia - 71% for-profit, 0.56 RN hrs/day Washington - 60% for-profit, 0.64 RN hrs/day West Virginia - 66% for-profit, 0.59 RN hrs/day Wisconsin - 47% for-profit, 0.72 RN hrs/day Wyoming - 50% for-profit, 0.70 RN hrs/day AlaskaMinnesotaNorth DakotaOklahomaTexas For-profit share of certified homes RN hours per resident-day
Illustrative

One dot per state (plus DC). The thin ink line is the least-squares fit: about 4 fewer RN minutes per day for each 10-point rise in for-profit share. Hairlines mark the national averages; hover any dot for its state.

All states: share and RN hours (table view)
StateFor-profit shareRN hrs/day
Texas 88% 0.46
Oklahoma 86% 0.47
Louisiana 85% 0.48
Georgia 83% 0.50
Alabama 82% 0.48
Tennessee 81% 0.49
Florida 80% 0.55
Mississippi 80% 0.50
Arkansas 79% 0.51
Nevada 78% 0.51
Ohio 78% 0.52
Kentucky 77% 0.52
California 76% 0.58
South Carolina 75% 0.53
Illinois 74% 0.53
New Mexico 74% 0.55
North Carolina 73% 0.55
Utah 73% 0.55
Arizona 72% 0.56
Indiana 72% 0.51
New Jersey 72% 0.56
Idaho 71% 0.55
Virginia 71% 0.56
Michigan 70% 0.57
Missouri 70% 0.50
Maryland 69% 0.58
Colorado 68% 0.59
Connecticut 66% 0.59
West Virginia 66% 0.59
New York 65% 0.60
Rhode Island 64% 0.61
Oregon 63% 0.62
Pennsylvania 63% 0.62
Delaware 62% 0.62
Massachusetts 61% 0.68
Kansas 60% 0.63
Washington 60% 0.64
New Hampshire 58% 0.65
District of Columbia 55% 0.66
Maine 55% 0.67
Nebraska 52% 0.68
Wyoming 50% 0.70
Iowa 48% 0.70
Wisconsin 47% 0.72
Montana 46% 0.72
Vermont 45% 0.73
Hawaii 44% 0.74
Minnesota 42% 0.83
South Dakota 40% 0.75
North Dakota 34% 0.88
Alaska 30% 0.82

Want two states head to head? Open the state-vs-state compare tool - pick any two and read their staffing, turnover, and abuse flags side by side.

The abuse flags

Share of homes carrying the CMS abuse icon

The bluntest instrument in the file is a red icon: CMS stamps it on any home cited for abuse or neglect that caused harm. Nationally about one home in twenty carries it. Line the ranked states up against that baseline and the geography repeats the ownership map - the states that run most for-profit overshoot the national rate, and the least for-profit states sit far below it.

0% 2% 4% 6% 8% national 4.9% Texas Texas - 7.1% of homes abuse-flagged (national 4.9%) 7.1% Oklahoma Oklahoma - 6.6% of homes abuse-flagged (national 4.9%) 6.6% Illinois Illinois - 6.2% of homes abuse-flagged (national 4.9%) 6.2% Georgia Georgia - 5.8% of homes abuse-flagged (national 4.9%) 5.8% Ohio Ohio - 5.5% of homes abuse-flagged (national 4.9%) 5.5% Indiana Indiana - 5.3% of homes abuse-flagged (national 4.9%) 5.3% Missouri Missouri - 5.1% of homes abuse-flagged (national 4.9%) 5.1% Louisiana Louisiana - 4.9% of homes abuse-flagged (national 4.9%) 4.9% California California - 4.7% of homes abuse-flagged (national 4.9%) 4.7% Florida Florida - 4.1% of homes abuse-flagged (national 4.9%) 4.1% Pennsylvania Pennsylvania - 3.8% of homes abuse-flagged (national 4.9%) 3.8% Massachusetts Massachusetts - 3.0% of homes abuse-flagged (national 4.9%) 3.0% Minnesota Minnesota - 2.1% of homes abuse-flagged (national 4.9%) 2.1% North Dakota North Dakota - 1.8% of homes abuse-flagged (national 4.9%) 1.8%
  • above the national rate (worse)
  • at or below the national rate (better)
Illustrative

Stems run from the national rate to each state's rate; the printed value carries the reading without color.

The watch list

CMS Special Focus program

A handful of homes are so far below the line that CMS pulls them out of the ordinary inspection cycle entirely and puts them on a formal watch list - inspected twice as often, with only two exits: sustained improvement, or termination from Medicare and Medicaid. Roughly 72% of all homes run for profit. On the watch list, that share climbs to 84%.

88

Special Focus Facilities

The worst-performing homes in the country, placed under a stricter twice-a-year inspection cycle with graduation or termination as the only exits.

435

SFF candidates

Homes deep enough in the bottom tier to be next in line for the program when a slot opens in their state.

For-profit share, watch list vs national
Watch list 84%
All homes 72%

+12 points more for-profit than the population of homes as a whole.

Illustrative

Counts drawn from the CMS Special Focus Facility program pool (14,743 certified homes).

The enforcement ledger

Fines and payment denials by owner

When a survey finds residents in harm's way, CMS reaches for two levers: a civil fine, and - in the worst cases - a freeze on Medicare payment for new admissions until the problem is fixed. Both levers get pulled on the for-profit column more often, and when the fine comes, it runs more than half again as large.

Ownership Homes fined Avg fine when fined Payment denials
For-profit 63.0% $34,200 8.1%
Nonprofit 47.0% $21,600 4.2%
Government 44.0% $19,800 3.8%
Illustrative

Trailing 3 years. Bars are shared-scale within each column; rows wear the ownership palette and every value is printed.

The price of a citation

3-year total fines per home, bucketed

Rates say who gets fined; the buckets say how deep the trouble runs. Most nonprofit and government homes close a three-year window with no federal fine at all. The for-profit column tips the other way - not just fined more often, but stacked toward the expensive end, where a six-figure total usually means repeat, uncorrected citations rather than one bad survey.

0% 20% 40% 60% For-profit - No fine: 37% of homes Nonprofit - No fine: 53% of homes Government - No fine: 56% of homes 37% No fine For-profit - Under $10K: 22% of homes Nonprofit - Under $10K: 24% of homes Government - Under $10K: 23% of homes 22% Under $10K For-profit - $10K-50K: 24% of homes Nonprofit - $10K-50K: 15% of homes Government - $10K-50K: 14% of homes 24% $10K-50K For-profit - $50K-100K: 10% of homes Nonprofit - $50K-100K: 5% of homes Government - $50K-100K: 4% of homes 10% $50K-100K For-profit - Over $100K: 7% of homes Nonprofit - Over $100K: 3% of homes Government - Over $100K: 3% of homes 7% Over $100K
  • For-profit
  • Nonprofit
  • Government
Illustrative

Share of each ownership class's homes, by total federal fines over the trailing 3 years. The for-profit column is labeled; hover any column for its value.

All bucket shares (table view)
Ownership No fineUnder $10K$10K-50K$50K-100KOver $100K
For-profit 37%22%24%10%7%
Nonprofit 53%24%15%5%3%
Government 56%23%14%4%3%

Methodology

Notes on the Data

The figures on this page derive from CMS Nursing Home Care Compare - Provider Information (June 2026). CMS publishes one row per Medicare- or Medicaid-certified nursing home in its Provider Information file - roughly 14,700 homes, refreshed monthly - carrying the Five-Star ratings, payroll-derived staffing hours per resident-day, nursing-staff turnover, fine counts and dollar totals, Special Focus status, and the abuse-icon flag. Homes are grouped into for-profit, nonprofit, and government by the free-text "Ownership Type" column and averaged within each group and each state.

What's real, what's a stand-in

The shape is real - every chart on this page reads a column CMS actually ships, and the swap-point that turns the page into a live ingest is wired (src/lib/source.ts plus scripts/build-data.ts). The numbers are representative stand-ins, built to be internally consistent: the star distribution's weighted means land on the group averages, the fine buckets reconcile with the fined-rate ledger, and states that appear in more than one chart carry identical values everywhere. The direction of every gap - thinner staffing, faster churn, more flags and fines at for-profit operators - is well documented in the research record, but no figure here has yet been computed from a real download. Everything is badged Illustrative until one has (see HANDOFF.md). We never present curated numbers as real.

One block deserves its own asterisk: the decade trend. The Provider Information file is a monthly snapshot, so a real 2017-2026 series requires ingesting the CMS archived monthlies - a separate step, documented in scripts/build-data.ts. The trend section carries its own badge and stays illustrative even after the snapshot figures go live.

What you're not seeing

Star ratings and staffing hours are self-reported and payroll-derived measures with known caveats: they miss complaints that never became citations, agency and contract staff can shift the hour counts, and a five-star home can still have a bad day. Averaging by state and ownership hides wide within-group spread - plenty of excellent for-profit homes and struggling nonprofits exist, and a scatter-plot slope is a correlation across states, not a verdict on any one operator. The abuse icon marks only cited, harm-level findings; researchers consistently argue it undercounts. Small states and territories below the reporting threshold are omitted from the ranking. None of this substitutes for a facility's own inspection record on Medicare's Care Compare.

Generated 2026-07-07 00:00 UTC. Source: CMS Nursing Home Care Compare - Provider Information.