How to Choose a Nursing Home: A Complete Guide for Families

The Centers for Medicare & Medicaid Services (CMS) maintains the most comprehensive database of nursing home quality in the United States. Every Medicare- and Medicaid-certified nursing home — roughly 15,000 facilities — receives an overall star rating from 1 to 5 stars, updated monthly.

Before you visit a single facility, pull up the nursing home directory on CareFindPeek and filter by your state or city. This gives you an immediate baseline: facilities rated 4 or 5 stars have consistently demonstrated above-average quality across multiple domains. Facilities rated 1 or 2 stars have documented deficiencies that warrant caution.

However, star ratings are a starting point, not the full picture. A 5-star facility may have a recent change in ownership that has not yet affected its scores. A 3-star facility may excel in exactly the area your loved one needs most. The key is to use star ratings to narrow your initial list, then dig deeper.

• Overall rating — a composite of three separate domain ratings
• Health inspection rating — based on the last 3 years of state inspection results, weighted toward recent surveys
• Staffing rating — based on registered nurse hours and total nursing hours per resident per day, adjusted for case mix
• Quality measures rating — based on 15 clinical quality measures like pressure ulcers, falls with injury, and antipsychotic medication use

Each of these domains tells you something different about the facility, and each has limitations we will explore in the next sections.

Health inspections are the backbone of nursing home oversight. State survey agencies conduct unannounced inspections of every certified nursing home at least once every 15 months (the national average is about 12 months). During these multi-day surveys, inspectors review medical records, observe care, interview residents and staff, and check physical conditions.

When you find a facility on CareFindPeek, look at the inspection details carefully. Here is what matters most:

• Number of deficiencies — the national average is about 7-8 deficiencies per inspection. A facility with 15+ deficiencies per survey is significantly below average.
• Scope and severity — CMS categorizes each deficiency on a grid from A (isolated, no harm) to L (widespread, immediate jeopardy). Categories J, K, and L indicate immediate jeopardy to resident health or safety — these are the most serious findings.
• Repeat deficiencies — a deficiency cited on multiple consecutive surveys is far more concerning than a one-time finding. It suggests the facility is unable or unwilling to correct the problem.
• Complaint investigations — in addition to standard surveys, CMS tracks complaint investigations. A high volume of substantiated complaints, especially for abuse, neglect, or exploitation, is a significant red flag.

Keep in mind that zero deficiencies does not necessarily mean perfect care — it may mean a less thorough inspection. The most useful comparison is against other facilities in the same state, since inspection rigor varies by state survey agency.

Data and ratings are essential, but nothing replaces walking through the facility yourself. Plan to visit at least 2-3 facilities on your shortlist, and try to visit each one at least twice — once during the week and once on a weekend or evening, when staffing levels may differ.

When you walk through the door, pay attention to these areas:

The smell test

A well-maintained facility should smell clean and neutral. A persistent urine or fecal odor in common areas indicates either inadequate staffing for incontinence care or poor housekeeping — both are serious quality indicators. A temporary odor near a single room may be normal; a building-wide odor is not.

Resident engagement

Look at the residents in common areas. Are they engaged in activities, interacting with staff, or watching television? A facility where most residents are parked in wheelchairs along a hallway with no engagement is showing you its culture. Ask to see the activity calendar and whether activities are actually happening as scheduled.

Staff demeanor

Watch how staff interact with residents. Do they greet residents by name? Do they knock before entering rooms? Do they explain what they are doing before providing care? These small behaviors reflect the facility's culture far more accurately than any brochure.

Cleanliness and maintenance

Check the bathrooms, dining areas, and resident rooms. Look for working call lights at every bed. Check whether handrails are installed in all hallways and bathrooms. Note whether the building is in good repair or showing signs of deferred maintenance — peeling paint, broken fixtures, and worn flooring often correlate with management that cuts corners.

Food quality

If possible, schedule your visit around a mealtime. The quality, variety, and presentation of food is a direct quality indicator. Ask to see a weekly menu. Ask whether the facility accommodates dietary restrictions and preferences. Poor food is one of the most common complaints in nursing homes, and it directly affects nutrition, hydration, and resident satisfaction.

Some findings should move a facility from your "maybe" list to your "no" list immediately:

• Immediate jeopardy citations (J, K, or L severity) within the last 2 years — these mean state inspectors found conditions that placed residents in immediate danger of serious harm or death.
• Federal fines exceeding $50,000 in the last 3 years — large fines indicate serious or repeated violations.
• Denial of payment for new admissions — this sanction means CMS has determined the facility's deficiencies are so severe that it cannot safely accept new residents.
• Abuse allegations with substantiated findings — check complaint investigations for confirmed abuse, neglect, or exploitation.
• Consistently below-average staffing — facilities in the bottom quartile for RN hours per resident per day (below 0.5 hours) have significantly higher rates of pressure ulcers, falls, infections, and hospitalizations.
• High staff turnover — CMS now publishes staff turnover rates. Total nursing staff turnover above 60% annually and RN turnover above 50% indicate an unstable caregiving environment.
• Refusal to let you visit freely — any facility that restricts unannounced visits from family members (outside of legitimate infection control periods) is hiding something.

Research consistently shows that staffing levels are the single strongest predictor of nursing home quality. A landmark study in the journal Health Affairs found that facilities with RN staffing below 0.75 hours per resident per day had significantly higher rates of deficiencies, hospitalizations, and mortality.

When evaluating staffing, look at three metrics:

1. Total nursing hours per resident per day (HPRD) — the CMS 5-star threshold for the highest rating is approximately 4.1 HPRD. The national average is about 3.6 HPRD. Below 3.0 is concerning.
2. RN hours per resident per day — registered nurses provide clinical oversight, administer medications, coordinate care plans, and respond to emergencies. The 5-star threshold is approximately 0.75 RN HPRD. Below 0.5 is a red flag.
3. Weekend staffing — CMS now publishes separate weekend staffing data. Many facilities staff significantly lower on weekends. A large weekday-to-weekend gap suggests residents receive inferior care two days out of seven.

CMS collects staffing data through the Payroll-Based Journal (PBJ) system, which requires facilities to submit actual payroll records rather than self-reported estimates. This makes the data more reliable than previous self-reported surveys, though some concerns about accuracy remain.

Use our facility comparison tool to compare staffing levels across facilities in your area.

Come prepared with specific questions. The way staff answer — including what they avoid answering — tells you a lot about the facility:

• What is the ratio of nursing staff to residents on each shift? (Day, evening, and night shifts typically differ significantly.)
• How long has the current administrator been in place? (High administrator turnover often predicts instability.)
• What is the facility's policy on fall prevention? How many falls occurred in the last quarter?
• How does the facility handle a medical emergency at 2 AM? Is there an RN on-site 24/7?
• Can I see the most recent state inspection report? (They are required by law to make this available.)
• What activities are available on weekends?
• How does the facility involve families in care planning? How often are care plan meetings held?
• What is the discharge policy? Under what circumstances would my family member be asked to leave?

Pay attention not just to the answers, but to the willingness of staff to answer. Transparency is itself a quality signal.

After researching data, reading inspection reports, and visiting facilities, you will likely have 2-3 strong candidates. Here is a framework for the final decision:

1. Match care needs to capabilities — does the facility have experience with your loved one's specific conditions (dementia, ventilator care, dialysis, behavioral health)? A high-rated general facility may be a poor fit for specialized needs.
2. Location matters — research shows that residents who receive frequent family visits have better outcomes. Choose a facility close enough that family can visit regularly.
3. Trust your instincts — if something felt wrong during your visit, take that seriously. Families often report that their gut feeling during the first visit was the most accurate predictor of satisfaction.
4. Ask current families — if possible, speak with family members of current residents (in the lobby or parking lot, not in a staged introduction arranged by the facility). Their unfiltered perspective is invaluable.
5. Review the admission contract carefully — look for arbitration clauses, discharge conditions, and billing practices. Consider having an elder law attorney review the contract before signing.

Remember that you can always transfer to another facility if the care is not meeting expectations. The decision is important but not permanent. Monitor care closely in the first 90 days and do not hesitate to escalate concerns to the state ombudsman if needed.