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Study Finds Nursing Care Varies Tremendously by State

Published April 15, 2014 10:59 AM by Brian Garavaglia

It has been known for some time that nursing home care is not the same in every nursing care facility.  In a recent study published by a nonprofit advocacy group, Families for Better Care, the group's review looked at nursing homes and care found in these facilities found in each state.  The Families for Better Care state that it is the first state-by-state review of nursing home care that has been undertaken.

The data for this undertaking was obtained from three major existing data sources: The Kaiser Health Foundation, Performance measures from the Centers for Medicare and Medicaid Services Nursing Home Care site, and from the Office of State Long-term Care Ombudsman regarding complaint data information. The data obtain compiled information regarding the following areas as they relate to nursing home care:   

  • State's average registered nurse (RN) hours per resident per day
  • State's average certified nurse assistant hours (CNA) hours per resident per day
  • Percentage of facilities with above average registered nurse staffing
  • Percentage of facilities with above average direct care staffing
  • Percentage of facilities with above average health inspections
  • Percentage of facilities with deficiencies for the 2012 calendar year
  • Percentage of facilities with severe deficiencies for the 2012 calendar year
  • Percentage of verified ombudsman complaints for the 2011 federal fiscal year

The abovementioned nursing home data was examined on a state-by-state basis, averaged and then a final letter grade provided to each state based on the quantitative state average. The grades given to the state were letter grades such as A, B, C, D, and F.

The study found that the following states were ranked the highest, or in other words, received an A grade. These states had that highest overall average nursing home care performance:

  • Alaska
  • Rhode Island
  • New Hampshire
  • Hawaii
  • Oregon
  • Maine
  • Utah
  • Idaho
  • South Dakota
  • North Dakota

Conversely, there were a disconcertingly large number of states that had failing marks.  These states had the lowest overall average nursing home care performance ratings. These states were as follows: 

  • Texas
  • Louisiana
  • Indiana
  • Oklahoma
  • Missouri
  • New Mexico
  • New York
  • Michigan
  • Nevada
  • Illinois
  • Iowa

Key Findings From This Study
The study revealed some important findings found among nursing homes and nursing home care throughout the United States. Many of these finding were directly linked to the type of care they provided on a state aggregate level and subsequently the grade that the states received on the basis of the data examined. Here is a brief summary of some of the major findings:

  • States who had greater levels of average nursing home staffing, both professional nursing care staffing and paraprofessional caregivers such as nursing assistants, had higher grades.
  • A very disconcerting finding is that only seven states were found to provide more than one hour of professional nursing care per resident day. Furthermore, it was found that 96 percent of the states offered residents fewer than three hours of direct resident care each day, which entails care not just from nurses, but all staff such as physical therapists, nursing care assistants and activity therapists.
  • Nearly 90 percent of all nursing homes were cited with a deficiency. This statistic has to be viewed cautiously, since it does not say anything about the type or severity of deficiency. However, when looking at the severity of the deficiency as a separate category, Rhode Island nursing care centers scored the lowest with less than four percent of their deficiencies falling into the severe range. Conversely, Michigan performed worst on this statistic, with more than 50 percent of the nursing care facilities receiving a severe deficiency.
  • Resident abuse and neglect in nursing homes was quite common. It was found that one in five nursing homes experienced issues of abuse, neglect or mistreatment in almost one-half of the states.
  • When complaints were submitted and the proper authorities were notified, certain states were found to have higher levels of verified complaint verification. Montana, Connecticut, Wyoming, Washington DC, Missouri, and Massachusetts had extraordinary high complaint verification rates. Conversely, New Hampshire, Nevada, and New Jersey had the fewest. Again, this has to be looked at cautiously as well since those who investigate complaints have a level of subjectivity in their investigative protocol.
  • Health care inspections for nursing homes was found to be low.

The study that has just been discussed is a very large state-by-state study that is the first of its kind in examining nursing home care on a national basis. It provides an important level of information in that it is not just conducting an inter-facility based comparison, but a state-by-state comparison, showing that some states on an aggregate level are doing better than others. However, more needs to be discussed why these states are not doing as well as other states that received superior grades in this area? In particular, why are those states with failing marks not providing enough staffing for the provision of quality care in relation to those states that are given an A grade. This is just but one indicator that needs to be examined in greater depth regarding the disparity found to exist. Nevertheless, the study provides a picture of state-based nursing home care and which states are doing better than others.  However, here again, caution has to exist in interpreting the results. The data was obtained from pre-existing databases, which themselves hold data from surveyors and groups that often obtain data in not exactly the same manner. In other words, although surveys and survey protocol do follow a standard federal basis for surveyors to use, states probably have considerable variability in how they employ and carry out this protocol. This being stated, the study does provide some very interesting, if not attention getting information, that could be used to further nursing home care on a national level.       


Renovating seniors' homes may lead to longer independence. Accessed at:

Families for Better Care. Accessed at:


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About this Blog

    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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