The purpose of this study was to profile rural end-stage renal disease (ESRD) facilities, focusing specifically on those at greatest risk for closure based on low-volume designation and/or negative Medicare profit margins. Specifically, we examined the characteristics of these facilities, the quality of care they provide, and the distance patients in rural areas would have to travel if these facilities were to close. We found a higher prevalence of facilities designated as low-volume and facilities with negative profit margins in rural areas. Rural facilities, especially those with low-volume designation and/or negative profit margins, are likely to become more vulnerable. Our study also found that rural ESRD facilities (particularly those at risk for closure) offered fewer services (i.e., fewer dialysis stations, fewer late shifts). Despite functioning at a lower scale, these facilities performed similarly to or, in some cases, better than their urban counterparts in terms of quality. A significantly higher proportion of patients in rural facilities achieved clinical targets, including hemoglobin (Hgb) management, AV fistula, Kt/V ≥1.5, and Urea Reduction Ratio (URR) ≥65%. We found low uptake of home hemodialysis among the population studied. Further, the rates were lower among rural facilities and even more so in rural low-volume facilities. Our study found that rural patients will be adversely affected by potential closures of at-risk rural facilities, although travel distances will vary by the type of facility a patient chooses as an alternative venue for care. Should their at-risk facility close, rural patients would have to travel an average of >100 miles to seek care from a facility that is not at risk. It is imperative that CMS recognize and address the potential impacts of bundled payments on facilities in rural areas running on low volumes and/or negative Medicare profit margins. The possible closure and consolidation of such facilities will increase the travel distances faced by rural patients and will likely lead to lower compliance rates and, ultimately, higher mortality.