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What 5-Star Facilities Do Differently: Patterns from 2,942 Top-Rated Facilities
2,942 Facilities at the Top
Out of 14,703 Medicare-certified nursing facilities in the United States, 2,942 hold a 5-star CMS rating, exactly 20% of the total. SilverOcean analyzed what distinguishes these facilities from the rest of the field.
Staffing: The Clearest Differentiator
The staffing gap between 5-star and 1-star facilities is not subtle:
| Metric | 1-Star | 5-Star | Difference |
|---|---|---|---|
| Total nursing hours/resident/day | 3.53 | 4.40 | +25% |
| RN hours/resident/day | 0.51 | 0.95 | +86% |
| Staff turnover | 54.5% | 38.6% | -16 pts |
Five-star facilities provide 25% more total nursing hours per resident per day. But the RN gap is even more dramatic: nearly double the registered nurse coverage. And their turnover rate is 16 percentage points lower. They are not just hiring more people. They are keeping the ones they have.
Size: Smaller Tends to Score Better
The distribution of 5-star facilities by size:
| Size | 5-Star Count | % of All 5-Star |
|---|---|---|
| Small (under 50 beds) | 647 | 22.0% |
| Medium (50-99 beds) | 1,272 | 43.2% |
| Large (100-149 beds) | 728 | 24.7% |
| Very Large (150+ beds) | 295 | 10.0% |
The 5-star sweet spot is 50-99 beds, which accounts for 43% of all top-rated facilities. The average 5-star facility has 90 beds, compared to the national average of 107. Very large facilities (150+ beds) are significantly underrepresented among 5-star ratings, making up only 10% of top performers.
Clean Records
Of 2,942 five-star facilities, 2,533 (86%) have zero fines. Only 409 have received any financial penalty. The average fine amount among 5-star facilities that do have fines is $21,924, compared to much higher averages at lower ratings. Operational discipline translates directly to financial outcomes.
Ownership Is Mixed
Unlike some states where nonprofit facilities dominate top ratings, the national 5-star picture is more balanced:
- For-profit corporations: 870 facilities (29.6%)
- Nonprofit corporations: 804 (27.3%)
- For-profit LLCs: 660 (22.4%)
- Various nonprofit, government, and other: remaining 20.7%
Ownership type alone does not determine quality at the national level. Both for-profit and nonprofit models can achieve 5-star outcomes. The differentiators are operational, not structural.
Where the 5 Stars Are
Top 5 states by 5-star facility count: California (280), Ohio (204), Florida (167), Texas (154), Pennsylvania (146). These are also the largest states by total facility count, so the raw numbers are expected. The more interesting metric is 5-star density: what percentage of a state's facilities reach the top rating.
The Data Blueprint
Based on 2,942 facilities at the top of the CMS ratings, the profile of a 5-star facility looks like this:
- Staffing: 4.4+ total nursing hours per resident per day, with 0.95+ RN hours
- Turnover: Below 40% annual nursing staff turnover
- Size: 50-99 beds (the sweet spot)
- Compliance: 86% have zero fines
- Ownership: No single model dominates; execution matters more than structure
These are not aspirational targets. They are the measured characteristics of facilities that are already there. The distance between your current metrics and these benchmarks is the distance between your current rating and 5 stars.
Source: SilverOcean analysis of CMS Provider Data, March 2026. 2,942 five-star facilities out of 14,703 total.
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