Washington, District of Columbia — Nearly one in five nursing home residents lives in a rural community, but the number of facilities serving those areas has been shrinking for years, according to a new KFF analysis that puts fresh numbers behind a problem many operators have warned about for decades.
KFF found that the total number of nursing homes nationwide fell from 15,643 in 2015 to 14,742 in 2025. Rural communities saw a steeper drop than urban ones, with the number of rural nursing homes declining by 9% over that period, compared with a 4% decline in urban areas.
The report says about 1.2 million people were living in nursing facilities as of July 2025, and roughly 20% of them were in rural areas. That matters because rural populations tend to be older and more likely to live with disabilities, which can drive heavier demand for long-term care close to home.
Smaller buildings, thinner margins
KFF found that rural nursing homes are generally smaller and more Medicaid-dependent than their urban counterparts. The median rural facility had 88 certified beds, while the median urban facility had 120. In remote rural areas, the typical building was even smaller, with a median of 76 beds.
Those facilities also reported lower occupancy. Remote rural nursing homes had a median occupancy rate of 72%, compared with 79% in other rural areas and 83% in urban markets. Lower census can make it harder to spread labor, compliance and capital costs across enough residents to stay financially stable.
The analysis lands as the sector is already watching what the $50 billion rural health fund was meant to save and whether any of that money will meaningfully reach nursing homes. KFF noted that the 2025 reconciliation law is projected to reduce federal Medicaid spending by $911 billion over 10 years, including an estimated $137 billion in rural areas, while the law’s separate rural health funding is unlikely to fully offset those cuts.
Quality and staffing looked more mixed than expected
Not every finding pointed to a crisis. KFF said rural and urban nursing homes reported fairly similar payer mixes, staffing levels and rates of serious deficiencies. Still, remote rural facilities were more likely to carry four- or five-star overall ratings than other rural homes, yet less likely to post high staffing ratings, a split that suggests quality measures do not always capture the full operating strain in isolated markets.
For operators, the warning is simple: access can erode long before a community loses its last nursing home. When rural facilities shrink, struggle to fill beds or close outright, families may face longer travel times, hospitals may have fewer discharge options, and states may end up with even less flexibility as Medicaid pressure grows.
KFF based the analysis on July 2025 Nursing Home Compare data and county-level rurality definitions from the U.S. Department of Agriculture.
