The Short Version
South Carolina, Kentucky, and Alabama post the highest average SunsetWell quality scores in 2026 (67.4, 66.6, and 66.2 out of 100), while Oregon, Washington, and District of Columbia rank lowest. The gap between the top and bottom state is 40.4 points across 14,690 certified nursing homes.
The Full Rankings
Ranked by average SunsetWell score (v2.3), a 0–100 composite of CMS inspection, staffing, and quality-measure data. Citations, immediate-jeopardy (IJ) rates, and fines cover the trailing 3-year survey window. Click any state for its facility directory.
| Rank | State | Facilities | Avg Score | IJ % | Citations / Facility | Total Fines | Fines / Facility | Nurse Hrs / Day |
|---|---|---|---|---|---|---|---|---|
| 1 | South Carolina | 187 | 67.4 | 41.7% | 8.9 | $2.6M | $14,167 | 3.86 |
| 2 | Kentucky | 268 | 66.6 | 20.1% | 6.5 | $5.3M | $19,883 | 3.98 |
| 3 | Alabama | 224 | 66.2 | 12.5% | 2.9 | $3.2M | $14,185 | 3.93 |
| 4 | Florida | 694 | 66.0 | 22.2% | 12.7 | $18.8M | $27,143 | 3.86 |
| 5 | Arkansas | 221 | 65.7 | 20.8% | 14.3 | $1.9M | $8,495 | 4.10 |
| 5 | Georgia | 356 | 65.7 | 15.7% | 11.8 | $5.0M | $14,146 | 3.56 |
| 7 | New Jersey | 348 | 64.7 | 30.2% | 16.0 | $12.2M | $35,053 | 3.88 |
| 8 | Tennessee | 303 | 63.9 | 22.4% | 7.5 | $7.7M | $25,543 | 3.80 |
| 9 | Texas | 1,176 | 63.6 | 62.4% | 23.1 | $58.1M | $49,383 | 3.39 |
| 10 | New York | 596 | 63.4 | 17.1% | 12.1 | $14.2M | $23,763 | 3.66 |
| 11 | Ohio | 921 | 61.7 | 17.5% | 18.2 | $21.1M | $22,867 | 3.72 |
| 12 | Indiana | 507 | 60.9 | 13.8% | 20.7 | $2.6M | $5,226 | 3.69 |
| 13 | Colorado | 210 | 60.2 | 26.2% | 15.7 | $5.4M | $25,606 | 3.66 |
| 14 | New Hampshire | 73 | 59.8 | 15.1% | 11.7 | $539K | $7,386 | 3.98 |
| 15 | North Carolina | 420 | 57.1 | 36.9% | 15.1 | $16.4M | $39,110 | 3.82 |
| 15 | Virginia | 289 | 57.1 | 14.9% | 15.0 | $5.6M | $19,240 | 3.76 |
| 17 | Massachusetts | 341 | 56.5 | 10.0% | 23.3 | $12.5M | $36,641 | 3.87 |
| 18 | Oklahoma | 283 | 56.3 | 35.0% | 16.1 | $5.8M | $20,359 | 3.81 |
| 19 | Utah | 97 | 55.7 | 22.7% | 14.5 | $2.5M | $26,224 | 3.92 |
| 20 | Missouri | 487 | 53.1 | 30.0% | 23.5 | $16.4M | $33,731 | 3.44 |
| 20 | West Virginia | 123 | 53.1 | 39.0% | 28.0 | $3.4M | $27,990 | 3.69 |
| 22 | Arizona | 140 | 52.6 | 5.0% | 13.7 | $1.1M | $7,901 | 4.10 |
| 23 | Idaho | 80 | 52.4 | 10.0% | 18.6 | $1.1M | $13,340 | 4.08 |
| 24 | Louisiana | 266 | 52.2 | 35.0% | 22.8 | $13.4M | $50,330 | 3.82 |
| 25 | Nebraska | 179 | 51.2 | 15.1% | 15.4 | $1.6M | $9,073 | 4.10 |
| 26 | Iowa | 390 | 49.2 | 27.4% | 18.6 | $7.5M | $19,115 | 3.80 |
| 27 | Wyoming | 36 | 49.1 | 13.9% | 15.0 | $835K | $23,189 | 3.81 |
| 28 | Kansas | 297 | 48.4 | 41.4% | 17.6 | $6.5M | $21,822 | 4.06 |
| 29 | Mississippi | 202 | 48.0 | 24.8% | 13.7 | $3.8M | $18,768 | 4.21 |
| 30 | Rhode Island | 73 | 47.6 | 49.3% | 24.7 | $4.4M | $60,342 | 3.70 |
| 31 | South Dakota | 96 | 47.5 | 24.0% | 14.3 | $3.1M | $32,261 | 3.86 |
| 32 | Michigan | 423 | 46.7 | 17.7% | 27.8 | $13.8M | $32,684 | 3.98 |
| 33 | Pennsylvania | 657 | 46.3 | 24.4% | 30.3 | $16.8M | $25,535 | 3.88 |
| 34 | Connecticut | 191 | 46.2 | 24.1% | 23.2 | $3.7M | $19,509 | 3.80 |
| 35 | Illinois | 667 | 45.1 | 36.9% | 31.3 | $64.5M | $96,738 | 3.48 |
| 36 | Delaware | 44 | 44.9 | 52.3% | 30.8 | $2.7M | $60,340 | 4.52 |
| 37 | Nevada | 66 | 44.8 | 9.1% | 30.6 | $865K | $13,108 | 4.30 |
| 38 | North Dakota | 72 | 43.2 | 29.2% | 14.1 | $1.8M | $25,104 | 4.41 |
| 39 | New Mexico | 68 | 42.2 | 36.8% | 40.0 | $2.8M | $41,309 | 3.59 |
| 40 | Maryland | 221 | 40.7 | 23.5% | 27.6 | $5.0M | $22,468 | 3.87 |
| 41 | Hawaii | 42 | 40.0 | 11.9% | 25.2 | $812K | $19,343 | 4.64 |
| 42 | Alaska | 20 | 39.0 | 15.0% | 19.6 | $766K | $38,276 | 6.93 |
| 43 | Maine | 78 | 38.1 | 14.1% | 23.3 | $564K | $7,225 | 4.32 |
| 44 | Minnesota | 338 | 36.9 | 39.3% | 21.6 | $6.3M | $18,528 | 4.18 |
| 45 | California | 1,164 | 36.7 | 17.9% | 38.5 | $30.2M | $25,938 | 4.53 |
| 46 | Wisconsin | 323 | 36.3 | 39.6% | 23.2 | $12.2M | $37,725 | 4.19 |
| 47 | Vermont | 33 | 35.6 | 30.3% | 26.2 | $2.8M | $84,665 | 4.21 |
| 48 | Montana | 61 | 34.8 | 23.0% | 27.7 | $3.3M | $54,890 | 3.95 |
| 49 | Oregon | 128 | 29.3 | 21.9% | 26.1 | $3.5M | $27,363 | 5.06 |
| 50 | Washington | 194 | 28.4 | 20.1% | 42.6 | $10.8M | $55,486 | 4.38 |
| 51 | District of Columbia | 17 | 27.0 | 58.8% | 30.1 | $1.1M | $65,690 | 5.12 |
Want the underlying records? Download the raw facility-level data or read how SunsetWell scores are calculated.
What the Data Shows
Illinois leads the nation in federal fines
Nursing homes in Illinois were fined $64.5M over the trailing three years — $96,738 per facility, also the highest per-facility figure in the country. The national average is $30,557 per facility.
A 3.5-hour-per-day staffing gap between states
Residents in Alaska receive an average of 6.93 nurse hours per day versus 3.39 in Texas. 100% of Alaska facilities meet the 3.5-hour benchmark, compared with 27% in Texas.
Immediate-jeopardy rates vary sharply by state
In Texas, 62.4% of facilities received at least one immediate-jeopardy citation — the most serious finding an inspector can issue — in the past three years, against 5.0% in Arizona and a national rate of 27.2%.
Washington inspectors cite the most deficiencies
The average Washington nursing home accumulated 42.6 health citations over three years — roughly 2.0x the national average of 21.3. High counts can reflect stricter state survey agencies as well as worse facilities.
Composite scores and enforcement records can diverge
South Carolina ranks #1 on average score yet sits at #47 of 51 on immediate-jeopardy rate (41.7% of its facilities). Composite scores weight staffing and quality measures alongside inspections, so check both columns — and individual facilities — before drawing conclusions about any one state.
The national picture
This analysis covers 14,690 certified nursing homes with 1,568,353 certified beds. Texas operates the most facilities (1,176). Federal fines across all states total $448.9M for the trailing three-year window.
Methodology
What each column means
- Facilities — Medicare/Medicaid-certified nursing homes listed in the CMS Provider Data Catalog, May 2026 release, grouped by the state where the facility is located. Territories and regions with fewer than 5 facilities are excluded.
- Avg Score — the mean SunsetWell score (v2.3) of a state's facilities. SunsetWell scores are a 0–100 composite of CMS health inspections, nurse staffing, and clinical quality measures; see the full scoring methodology. States are ranked on this column.
- IJ % — the share of facilities with at least one immediate-jeopardy citation in the trailing 3-year survey window. Immediate jeopardy means an inspector found a situation likely to cause serious injury, harm, or death.
- Citations / Facility — mean health-inspection deficiencies per facility over the same 3-year window.
- Total Fines and Fines / Facility — federal civil monetary penalties imposed over the trailing 3 years, summed by state and divided by facility count.
- Nurse Hrs / Day — average total nurse staffing hours (RN + LPN + aide) per resident per day, from CMS payroll-based journal data, averaged over facilities that report staffing.
Caveats
- All figures are per facility, not per capita. States differ enormously in facility size and in how much long-term care is delivered outside nursing homes, so these are facility-quality comparisons, not measures of how well a state serves its older residents overall.
- Citation and fine counts partly reflect how aggressively each state's survey agency inspects, not only how facilities perform. A strict state can look worse than a lenient one with identical care.
- Small jurisdictions (for example, District of Columbia with 17 facilities and Alaska with 20) have volatile averages — a single facility can move the state's numbers.
- State averages hide wide variation within states. Every state has excellent and poor facilities; use the facility search to compare specific homes.
Source & reuse
All underlying data comes from the CMS Provider Data Catalog (May 2026 release). SunsetWell scores were calculated on June 10, 2026 (version v2.3); the aggregation script is deterministic, so every figure on this page can be reproduced from the public CMS files.
Journalists and researchers: this table and dataset are free to reuse under CC BY 4.0 — just credit “SunsetWell” with a link to sunsetwell.com/reports/nursing-home-quality-by-state. For facility-level extracts or questions about the numbers, see the data downloads page.
Looking for care in your state?
State averages are a starting point, not an answer. Every state page lists its top-scoring facilities, typical costs, and Medicaid guidance — or jump straight to the facilities near you.