Does Nursing Home Size Affect Quality?

When families tour nursing homes, larger facilities often make a strong first impression. More amenities, specialized wings, full-time activities directors—it's easy to assume bigger means better. But here's the thing: the data tells a different story.

Our analysis of all 14,751 Medicare-certified nursing homes reveals a clear pattern: facility size inversely correlates with quality. Smaller nursing homes don't just edge out larger ones—they dominate on nearly every quality metric.

This matters more than most families realize. The difference between a 60-bed facility and a 200-bed facility isn't just amenities—it's fundamental to how care is delivered, how staff interact with residents, and ultimately, how safe your loved one will be.

The Size-Quality Relationship: What the Numbers Show

Let's cut through the noise. When we sorted facilities by bed count and compared quality ratings, the pattern was undeniable.

Star Ratings and Bed Count: The Inverse Relationship

Here's where it gets even more interesting. When we looked at average facility size by star rating, the pattern held perfectly:

This isn't random variation. Every star rating drop corresponds with an increase in average facility size. The correlation is remarkably consistent across the entire dataset.

Why Size Impacts Quality: The Mechanisms

So what's driving this pattern? Larger facilities aren't inherently worse—they just face structural challenges that smaller homes avoid.

1. Staff Turnover Increases with Size

Here's a factor that directly impacts resident care: very large facilities have the highest staff turnover at 50.9%. Medium-sized facilities clock in at 45.8%. That 5-percentage-point difference matters when you're talking about continuity of care.

2. Safety Violations Skyrocket in Large Facilities

This is where size becomes a safety issue. Abuse violation rates tell a stark story:

3. RN Staffing Stays Flat (But Shouldn't)

You might expect larger facilities to have more RN hours per resident—economies of scale and all that. But the data shows RN staffing is essentially flat across all size categories (0.62-0.70 hours per resident per day).

What does this mean? Larger facilities don't provide proportionally more nursing supervision despite managing more complex operations. In a 200-bed facility, that 0.68 RN hours per resident means RNs are stretched across far more residents than in a 50-bed facility with the same ratio.

The Ownership Factor: For-Profits Dominate Large Facilities

Here's another piece of the puzzle. When we looked at ownership type by facility size, a clear pattern emerged: very large facilities are overwhelmingly for-profit corporations.

This matters because our separate analysis of nonprofit vs for-profit facilities shows nonprofits earn 5-star ratings twice as often and have 74% fewer abuse violations.

So you've got a double penalty: very large facilities already struggle with quality, and they're disproportionately run by for-profit corporations that statistically perform worse than nonprofits. It's a compounding effect.

What This Means for Your Search

Let's be practical. You can't always choose the smallest facility—sometimes geography, services, or availability narrow your options. Here's how to use this information without limiting your search too much.

State Variations: Where You'll Find Large vs Small Facilities

Average facility size varies dramatically by state. If you have flexibility on location, this matters.

Alaska has dramatically smaller facilities (averaging 41 beds), which likely contributes to its strong quality rankings. Southern states like Alabama and Arizona tend toward larger facilities, which may explain some of their quality challenges.

When Larger Might Make Sense

Look, smaller isn't always better for every family. Here's when a larger facility might actually be the right choice:

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