Introduction: Nursing homes throughout the U.S. have faced unprecedented challenges in recent years because of staffing shortages, and under-investment, especially since the COVID-19 pandemic. To gain insight into the current state of nursing homes, this study examined nursing home characteristics, quality, and accessibility from a national, regional and state perspective. Methods: This cross-sectional study used secondary data from the Centers for Medicare and Medicaid Services, American Community Survey, Medicare Beneficiary, and the Tennessee Department of Health. Nursing home characteristics and quality were assessed through bivariate and multivariate regression in the U.S. Assessment of HHS Region 4 nursing home characteristics and quality by state cut points were conducted with bivariate analysis. Finally, spatial analysis was conducted to determine nursing home accessibility in Tennessee. Results: In multivariate analyses of all U.S. facilities, non-metropolitan facilities are at 1.27 higher odds of being a 1-star overall rated facility and 0.86 lower odds of being a 5-star facility as compared to metropolitan facilities. When weighted health inspection scores were recategorized by more strict state cut points, 42.45% of HHS Region 4 facilities decreased in health inspection star ratings, while those that were recategorized by more lenient state cut points lead to a 26.64% increase in star ratings. Finally, in the state of Tennessee a mean of 14.9% of county areas are not within 30-minute drive to any nursing home facilities, with 66.4% of county areas being further than a 30-minute drive to a 5-star rated (highest quality) facility. Discussion: Findings from this study show that differences exist in nursing home characteristics that relate to facility quality. Additionally, health inspection 5-star ratings can vary across states, which can make comparison of quality challenging from a consumer perspective. And finally, accessibility to nursing homes can vary throughout a state by metropolitan and non-metropolitan status of the county. An understanding of nursing homes in metropolitan and non-metropolitan communities along with nursing home quality, characteristics of the facility, and characteristics of county populations can enable policymakers to create more equitable policy solutions for nursing homes and the communities they serve.

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