Nursing Home Ratings in Texas: A Data Analysis of Quality, Safety, and Staffing

When the Numbers Tell a Story Your Family Needs to Hear

If you're searching for a nursing home for a parent or loved one in Texas, you're facing one of the most consequential decisions a family can make — and you're making it in a state where the odds are stacked against finding well-staffed care.

Texas is home to 1,160 nursing homes caring for more than 87,000 residents on any given day. That makes it the second-largest nursing home market in the country. But size doesn't translate to quality. The data tells a troubling story: Texas ranks among the bottom five states nationally for nursing home staffing levels, and nearly 7 out of 10 facilities fall below the staffing levels that federal researchers once deemed the minimum acceptable standard.

This isn't about a few bad actors. It's a systemic pattern. When you look at the numbers across every facility in the state — from El Paso to Beaumont, from the Dallas suburbs to the Rio Grande Valley — the staffing gaps are wide, persistent, and directly connected to the quality of care residents receive.

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The Texas Nursing Home Landscape

The Scale

Texas operates one of the largest networks of nursing care facilities in the nation. With 1,160 facilities serving approximately 87,467 residents daily, the state's nursing home infrastructure is a critical component of its healthcare system. These facilities range from small rural homes with a dozen beds to large urban complexes housing hundreds of residents. Oversight of these facilities relies in part on standardized data — including daily staffing reports, health inspections, and quality measures — submitted to the Centers for Medicare and Medicaid Services.

The Challenge

The data reveals a stark reality: Texas nursing homes are significantly understaffed compared to the rest of the country. The state's average total nurse staffing level is 3.40 hours per resident per day (HPRD) — well below the national average of 3.90 HPRD. That half-hour difference may sound small, but multiply it across 87,000 residents and it represents tens of thousands of missing care hours every single day.

The staffing shortfall is especially acute for registered nurses. Texas facilities average just 0.44 RN hours per resident per day, compared to 0.68 nationally. Only 6.6% of Texas nursing homes meet the research-recommended RN staffing level of 0.75 HPRD — meaning more than 93% of facilities lack sufficient registered nurse coverage.

For families, this creates a difficult landscape. Quality varies enormously from facility to facility, and the difference between a well-staffed home and an understaffed one can be the difference between attentive daily care and residents waiting extended periods for basic needs to be met.

What Families Want to Know

Which nursing homes in Texas provide the best and worst care according to the data? And what should families know about staffing patterns, inspection results, and quality measures when evaluating their options?

What the Data Reveals

Our analysis breaks down every measurable dimension of nursing home quality in Texas — from staffing hours and weekend coverage gaps to inspection deficiency histories and grade distributions — using data that every facility is required to report to the federal government. You can explore the national trends to see how Texas compares over time.

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Texas by the Numbers: Key Data Insights

Overall Staffing: Below the National Standard

Texas's average total nurse staffing of 3.40 HPRD places it among the five lowest-performing states in the country. The national average is 3.90 HPRD — meaning the typical Texas nursing home provides roughly 13% less nursing care per resident than the national norm. See how every state stacks up on our rankings page.

The median is even more revealing at 3.28 HPRD. Because averages can be pulled up by a few high-performing facilities, the median tells us what a "typical" Texas facility looks like — and it's below the 3.48 HPRD benchmark.

CMS Benchmark Compliance: Only 3 in 10

Just 29.8% of Texas nursing homes meet the CMS staffing benchmark of 3.48 total nurse HPRD. Compare that to the national rate of 65.8%. Texas is less than half as likely to have a facility meeting this basic threshold compared to the national picture.

For the higher research-recommended level of 4.10 HPRD, only 9.6% of Texas facilities qualify. Nationally, that figure is more than double.

RN Staffing: A Critical Gap

Registered nurse coverage in Texas is among the weakest in the nation:

• Average RN HPRD: 0.44 (national: 0.68)
• Only 6.6% of facilities meet the 0.75 RN HPRD research recommendation
• This means for every 100 residents, many Texas facilities have the equivalent of just one RN covering an entire shift

RN staffing matters more than any other single metric because registered nurses are the clinical decision-makers — they assess residents, manage medications, respond to emergencies, and supervise other staff. When RN coverage is thin, problems go unnoticed longer.

Texas falls below the national average on every staffing category except LPN hours. The RN gap is especially stark — Texas provides barely half the national average of registered nurse care.

Grade Distribution: The Weight Falls to the Bottom

When we assign letter grades based on staffing levels, Texas's distribution is bottom-heavy:

The 220 F-rated facilities — nearly 1 in 5 — are providing less than 2.5 hours of total nursing care per resident per day. That's less than the time most people spend watching television in an evening.

Weekend Staffing: The Saturday Drop-Off

Texas facilities reduce staffing by an average of 16.0% on weekends compared to weekdays. While this is slightly better than some states, it still means that residents receiving care on a Saturday or Sunday are getting meaningfully less attention than they would on a Tuesday.

For families visiting on weekends — which is when most family visits happen — the facility you see may actually be operating at higher staffing than the weekend norm. The daily view in our data shows the real pattern.

Agency Staff: Low but Not Reassuring

Texas nursing homes use contract/agency staff for only 2.1% of total hours — one of the lowest rates in the country. Normally low agency usage would be a positive sign (it suggests a stable, permanent workforce). But in Texas's case, the low agency usage combined with low overall staffing suggests that many facilities are simply operating short-staffed rather than filling gaps with temporary workers.

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Closing the Information Gap

The Problem Families Face

Families searching for nursing home care in Texas have historically faced an overwhelming process. CMS's Care Compare website provides star ratings, but those ratings blend multiple factors in ways that can obscure staffing problems. A facility can achieve a moderate overall rating while having dangerously low RN coverage. Inspection reports are available but run dozens of pages in dense regulatory language. Comparing two facilities requires navigating multiple government databases and interpreting metrics that even healthcare professionals find confusing.

What Transparent Data Makes Possible

With clear, graded staffing analysis, the picture changes:

• A family can immediately see that a facility receiving a D grade has staffing levels that place it in the bottom tier of care
• Weekend staffing comparisons reveal whether Saturday care is substantially different from Wednesday care
• RN-specific HPRD shows whether there's adequate clinical oversight — not just aides providing basic care
• Trend data over four quarters shows whether a facility is improving or declining — the direction matters as much as the current position
• Benchmark comparisons against county, state, and national averages put each facility in context

Use the facility comparison tool to evaluate any two Texas nursing homes side by side across every metric.

Our Commitment

This analysis exists to close the gap between raw federal data and the decisions families need to make. Every metric — from the letter grade to the weekend drop-off percentage — is computed directly from data that facilities are legally required to report to CMS. No facility pays to be listed. No rating is influenced by advertising. The data speaks for itself.

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How Nursing Home Ratings Are Calculated

Understanding how ratings work helps families interpret them correctly.

Our Staffing Grades (A+ through F)

Our letter grades are based on Hours Per Resident Day (HPRD) — the total nursing staff hours divided by the daily resident count. This normalizes for facility size: a 200-bed facility with 400 nurse hours and a 20-bed facility with 40 nurse hours both have 2.0 HPRD.

The grade thresholds are anchored to two evidence-based benchmarks:

• 3.48 HPRD: The level CMS established through rulemaking as an appropriate staffing standard (the rule was subsequently repealed, but the research supporting this threshold remains valid)
• 4.10 HPRD: The level recommended by the landmark 2001 CMS-commissioned STRIVE study as the minimum to avoid quality problems

Grades A+ and A correspond to facilities meeting or exceeding the research recommendation. Grade B meets the CMS benchmark. Grades C through F fall below these standards in progressively concerning ways. Learn more in our guide to understanding HPRD and staffing grades.

CMS Five-Star Ratings

CMS assigns separate star ratings (1 to 5) for overall quality, staffing, quality measures, and health inspections. These are valuable but limited — they update on different schedules, weight factors differently, and can mask specific weaknesses. Our staffing grades complement the CMS stars by providing a more granular view of one critical dimension: how many nursing hours each resident actually receives.

What Goes Into the Data

Every nursing home in the US must submit daily staffing data to CMS. This includes hours worked by every employee, broken down by role (RN, LPN, CNA) and employment type (permanent vs. contract). Combined with daily resident census counts, this data allows precise calculation of staffing ratios at every facility, every day.

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Key Takeaways for Families in Texas

• Check the RN staffing level first. With only 6.6% of Texas facilities meeting the RN recommendation, this is the metric most likely to separate good facilities from struggling ones. A facility with strong RN coverage has clinical oversight that catches problems early.

• Look at the overall grade, but dig into the details. A C-grade facility with improving trends may be a better choice than a B-grade facility that's declining. Direction matters.

• Ask about weekends. The average 16% staffing drop on weekends is a statewide pattern, but individual facilities vary widely. Some maintain near-weekday levels; others cut much deeper. The daily staffing data reveals which is which.

• Don't assume expensive means well-staffed. Facility pricing and staffing levels don't always correlate. Some of the highest-staffed facilities in Texas are in smaller communities, while some large urban facilities with higher costs operate at the D or F level.

• Compare against peers, not just the state average. Texas's state average is low, so a facility that looks decent compared to other Texas homes may still fall well below national norms. Check the national comparison, not just the state one.

• Check the inspection history. Staffing data tells you about resources; inspection data tells you about outcomes. A facility with thin staffing and repeated deficiency citations is showing you two different signals pointing the same direction.

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Frequently Asked Questions

How are nursing homes rated in Texas?

Nursing homes in Texas receive CMS Five-Star ratings based on health inspections, staffing levels, and quality measures. Our analysis adds a letter grade (A+ through F) based specifically on staffing hours per resident per day, calculated from data that every facility must report to the federal government quarterly. Explore the full Texas state page for details.

What is considered a good nursing home rating?

A facility with an A or A+ grade provides 4.1 or more total nurse hours per resident per day — the level research has shown is associated with fewer falls, infections, and other adverse outcomes. In Texas, only about 4% of facilities reach this level. A B grade (3.48+ HPRD) represents a solid minimum standard.

How many nursing homes are in Texas?

Texas has 1,160 Medicare and Medicaid certified nursing homes serving approximately 87,467 residents daily, making it the second-largest nursing home market in the United States.

What factors affect nursing home ratings in Texas?

Key factors include total nurse staffing hours, RN coverage specifically, weekend staffing consistency, reliance on temporary agency staff, staff turnover rates, health inspection deficiency history, and clinical quality measures such as fall rates and infection rates.

How can families compare nursing homes in Texas?

Our comparison tool lets you select any two Texas nursing homes and view them side by side across every metric — staffing grades, HPRD levels, weekend drop-off, agency staff reliance, CMS star ratings, and inspection history. You can also view county-level comparisons to see how facilities in your area stack up.

Why is Texas ranked so low for nursing home staffing?

Texas has the highest percentage of D and F rated facilities (61.3%) of any large state. Contributing factors include the state's high proportion of for-profit facilities, relatively low Medicaid reimbursement rates, and workforce challenges in a large, geographically diverse state. The low use of agency staff (2.1%) combined with low overall staffing suggests that many facilities are operating chronically short-staffed rather than temporarily understaffed. Track how this evolves on our trends page.