Data

Nursing home credential and training citations by state

Maryland cites 77% of its buildings on these tags. Alabama cites 10%. The variation is far too large to be explained by how well the buildings are run, and what it actually tells you is where your state's surveyors are looking.

August 24, 2026 6 min read

Two nursing homes, one in Maryland and one in Alabama, running identical processes with identical files, do not face the same odds. Maryland has cited 77.4% of its certified buildings on a staff credential or training F-tag. Alabama has cited 10.3%.

That is a seven-fold difference, and no reasonable reading of it says Alabama's nursing homes keep seven times better records. What it says is that survey emphasis varies enormously by state, and that a compliance program calibrated to the national picture is calibrated to nowhere in particular.

The national picture

Across the 24 F-tags that turn on staff credentials or staff training:

11,028 citations written between 2017 and mid-2026.
5,559 facilities cited, out of 14,690 Medicare and Medicaid certified nursing homes nationally. That is 37.8%.
Those facilities hold roughly 593,688 certified beds.
276 citations, about 2.5%, were written at actual harm or worse.
6,344 of the citations are credential tags; 4,684 are training tags.

Every state

Sorted by the share of the state's certified nursing homes that have been cited at least once.

State	Certified facilities	Facilities cited	Share cited	Citations in last 24 months	Beds at cited facilities
Maryland	221	171	77.4%	286	21,888
Vermont	33	25	75.8%	36	2,085
New Mexico	68	45	66.2%	66	4,824
Delaware	44	29	65.9%	38	3,228
Maine	78	50	64.1%	68	3,334
Connecticut	191	121	63.4%	107	13,901
California	1,165	717	61.5%	775	73,267
Kansas	296	182	61.5%	179	10,928
Rhode Island	72	43	59.7%	56	5,173
Washington	193	115	59.6%	137	11,093
District of Columbia	17	10	58.8%	24	1,941
Hawaii	43	25	58.1%	14	2,571
Missouri	487	281	57.7%	280	28,853
Idaho	80	45	56.2%	46	3,328
Nevada	66	36	54.5%	67	4,064
Oregon	128	69	53.9%	51	5,862
Montana	61	32	52.5%	49	2,624
West Virginia	123	62	50.4%	34	5,625
Alaska	20	10	50.0%	14	486
Pennsylvania	656	314	47.9%	691	40,402
Louisiana	265	126	47.5%	122	15,530
Utah	97	45	46.4%	33	4,121
Colorado	210	97	46.2%	51	9,324
Virginia	289	128	44.3%	129	15,658
Nebraska	180	77	42.8%	84	5,994
Massachusetts	341	131	38.4%	113	16,099
Arizona	140	52	37.1%	43	5,815
New Jersey	348	128	36.8%	90	19,550
Oklahoma	283	103	36.4%	46	9,627
Wisconsin	323	113	35.0%	187	9,499
Michigan	422	146	34.6%	138	14,579
Texas	1,177	405	34.4%	427	46,606
Illinois	666	222	33.3%	224	26,617
Wyoming	36	12	33.3%	11	1,064
Minnesota	338	109	32.2%	131	7,737
Iowa	387	124	32.0%	91	7,896
New York	593	188	31.7%	130	32,645
New Hampshire	73	22	30.1%	14	2,081
Ohio	922	268	29.1%	174	23,988
Arkansas	221	61	27.6%	37	6,701
Florida	694	151	21.8%	83	18,325
Indiana	507	109	21.5%	96	10,153
North Carolina	419	90	21.5%	55	10,296
South Dakota	96	20	20.8%	19	1,348
Georgia	356	72	20.2%	32	8,642
North Dakota	72	14	19.4%	9	541
Tennessee	303	52	17.2%	36	6,309
South Carolina	187	25	13.4%	14	2,743
Kentucky	267	33	12.4%	17	3,396
Mississippi	202	23	11.4%	14	2,223
Alabama	224	23	10.3%	4	2,835

Reading it properly

A high rate is not a quality signal. Maryland, Connecticut, California and Kansas all sit above 60%. These are not four states with uniquely bad nursing homes; they are four states whose survey agencies look hard at credential files. If you operate in one of them, assume the file will be opened.

A low rate is not safety. Alabama at 10.3%, Mississippi at 11.4%, Kentucky at 12.4%. A building in one of those states has the same underlying exposure and simply has not been asked about it as often. That is a different thing from being compliant, and it changes the day the survey emphasis changes.

Volume and rate are different questions. California has 717 cited facilities, more than any other state, and a 61.5% rate. Texas has 405 cited facilities and a 34.4% rate. If you run a multi-state portfolio, California is where the largest absolute number of your buildings will be cited; Maryland is where any individual building is most likely to be.

The recent column is the one to act on. Citations in the last 24 months tell you where the current pressure is, not the historical average. Pennsylvania has 691 citations in the last 24 months against 314 facilities ever cited, which is repeat findings, not new buildings. Repeat findings on a credential tag are the ones that escalate.

What varies, and what does not

The interesting thing about the state spread is what it does not explain.

The failure modes are the same everywhere. A license that lapsed on a date nobody watched. Twelve in-service hours where eleven have a sign-in sheet. An infection preventionist with the role and without the completed training. Those do not become different problems at a state line.

What changes across the line is only the probability that somebody opens the drawer. Which means the operational question a director of nursing should ask is not "what is my state's rate," it is the same question everywhere: on the day a credential expires, who finds out, and how?

If the answer is a person rather than a mechanism, the state figures above are just a table of how long you are likely to get away with it.

Questions people ask about this

Which state cites nursing homes most often on credential and training tags?

Among states with at least 100 certified facilities, Maryland is the highest at 77.4%, with 171 of its 221 certified nursing homes cited on at least one credential or training F-tag since 2017. Connecticut follows at 63.4%, then California and Kansas at 61.5% each.

Which state cites them least often?

Among states with at least 100 certified facilities, Alabama is the lowest at 10.3%, followed by Mississippi at 11.4%, Kentucky at 12.4% and South Carolina at 13.4%. A low rate is not evidence that buildings in those states keep better records; it usually reflects survey emphasis.

How many nursing homes nationally have been cited on these tags?

5,559 of 14,690 certified facilities, which is 37.8%. Those facilities hold roughly 593,688 certified beds between them.

What time period does this cover?

Surveys from 2017 through mid-2026, using CMS nursing home deficiency data. Facility counts are current certified providers, so a facility that closed during the period is not counted in the denominator.