Finding a good nursing home starts with knowing what to look for and where to look. The federal government rates every Medicare- and Medicaid-certified nursing home on a one-to-five-star scale, and that rating system is the single best starting point for narrowing your options. But stars alone don’t tell the full story. The best approach combines public data, in-person visits, conversations with staff and residents, and a careful read of the admission paperwork.
Start With Medicare’s Five-Star Ratings
The CMS Care Compare tool at medicare.gov assigns every certified nursing home an overall rating from one to five stars. That overall score is built from three separate ratings, each measuring something different: health inspections, staffing levels, and quality measures. Understanding what goes into each one helps you read beyond the headline number.
Health inspection ratings are based on state survey results from the past three years, with more recent inspections weighted more heavily. Surveyors look for deficiencies and score each one based on how widespread the problem was (isolated to one resident, a pattern, or facility-wide) and how severe it was (potential for harm, actual harm, or immediate danger). A facility that needs multiple follow-up visits to correct major problems gets additional penalty points. This rating is often the most revealing because it reflects what inspectors actually observed on the ground.
Staffing ratings are calculated from two numbers: registered nurse hours per resident per day and total nursing staff hours per resident per day (registered nurses, licensed practical nurses, and nurse aides combined). Administrative and housekeeping staff don’t count. CMS finalized a minimum staffing rule requiring at least 0.55 hours of direct registered nurse care and 2.45 hours of direct nurse aide care per resident per day. Facilities that fall below these thresholds are a concern. To earn five stars, a facility must meet or exceed higher benchmarks for both measures.
Quality measure ratings track ten specific outcomes, seven for long-stay residents and three for short-stay residents. Long-stay measures include things like how many residents experienced a decline in their ability to perform daily activities, how many developed pressure ulcers, how many were physically restrained, and how many had urinary tract infections or catheter use. Short-stay measures focus on pressure ulcers, pain, and delirium. Declines in mobility and daily functioning are weighted more heavily than other measures. Each facility is ranked against others in its state or nationally, depending on the measure.
What the Stars Don’t Tell You
A five-star facility can still be a poor fit for your family member. The ratings don’t capture things like the warmth of the staff, the culture of the facility, or how well the environment matches a resident’s personality and preferences. They also don’t reflect how a facility handles specific conditions like dementia or Parkinson’s disease. A four-star facility with a dedicated memory care unit and experienced staff may be a far better choice for someone with Alzheimer’s than a five-star facility without that specialty.
Also pay attention to the individual category ratings, not just the overall score. A facility might earn five stars overall while carrying a two-star health inspection rating, propped up by strong staffing and quality measure scores. The health inspection rating deserves extra scrutiny because it’s based on direct observation rather than self-reported data.
Visit at Different Times
Nothing replaces walking through a facility yourself, ideally more than once. Visit on a weekday afternoon when regular staff are working, then drop by on a weekend or evening to see whether staffing and attentiveness hold up. Some facilities look polished during scheduled tours but are short-staffed on nights and weekends.
During your visit, pay attention to a few specific things. Notice whether staff respond quickly and kindly when residents press call lights or call out for help. Lingering unanswered call lights are one of the clearest signs of understaffing. Check whether the facility is free from strong or unpleasant odors. A faint clinical smell is normal, but persistent urine or waste odors suggest cleaning routines are falling behind. If you can visit during a meal, look at whether the food appears appetizing, whether residents are actually eating most of it, and whether staff are patiently helping residents who need assistance.
Watch how staff interact with residents when they don’t know they’re being observed. Are they speaking respectfully? Making eye contact? Calling residents by name? These small moments reveal the facility’s culture more honestly than any brochure.
Ask the Right Questions
Come prepared with specific questions for the administrator or director of nursing. Good ones include:
- Staff turnover rate: High turnover means residents constantly adjust to new caregivers, and institutional knowledge walks out the door. Ask what the annual turnover rate is for nurse aides specifically, since they provide the most hands-on daily care.
- Staffing ratios by shift: Ask how many residents each nurse aide is responsible for on day, evening, and overnight shifts. Lower ratios mean more individual attention.
- Antipsychotic medication use: Off-label antipsychotic use in nursing homes has been a long-standing concern. These medications are sometimes used to sedate residents rather than address underlying behavioral or emotional needs. Ask the facility what percentage of its long-stay residents receive antipsychotics, excluding those with diagnoses like schizophrenia. You can also check this figure on Care Compare.
- How care plans are developed: Federal law requires every resident to have an individualized care plan, and residents (or their representatives) have the right to participate in creating it. Ask how often care plans are reviewed and how family input is incorporated.
- Activities and social engagement: Ask to see a monthly activities calendar. Look for variety, not just bingo and TV. Good facilities offer outings, music, exercise, gardening, or other programming tailored to residents’ interests and abilities.
Understand Resident Rights
Every nursing home resident has federally protected rights, and knowing them helps you evaluate whether a facility respects the people living there. Residents have the right to participate in decisions about their own care, to manage their own money (or designate someone they trust), and to access their financial records at any time. If a resident deposits money with the facility, the nursing home must keep those funds completely separate from its own accounts and protect them with a surety bond or similar safeguard.
Residents also have the right to privacy, to voice grievances without retaliation, to receive visitors, and to be free from physical restraints and chemical sedation used for staff convenience rather than medical necessity. A facility that discourages family involvement or makes you feel unwelcome during visits is waving a red flag.
Read the Admission Agreement Carefully
The admission packet is often thick and presented in a rush, but it contains clauses that can significantly affect your family’s legal rights. The most important one to watch for is an arbitration clause. This provision requires you to resolve any future disputes with the facility through private arbitration rather than a court proceeding. Arbitration eliminates the right to a jury trial, limits access to internal documents like staffing logs and incident reports, and keeps proceedings confidential, which shields the facility from public accountability.
These clauses are typically buried in dense legal language and presented as though signing is mandatory. It is not. Federal law prohibits nursing homes from requiring an arbitration agreement as a condition of admission. If a facility tells you otherwise, that itself is a violation. If you’ve already signed one, many agreements include a 30-day opt-out window. Courts have also invalidated arbitration agreements when the signer lacked legal authority, when the resident lacked mental capacity, or when the terms were misleading or one-sided.
Beyond arbitration, look for clauses that require a third party (usually an adult child) to personally guarantee payment. Review what the facility’s policy is on discharge and eviction, including how much notice they’re required to give and under what circumstances they can ask a resident to leave.
Know What Medicare Covers
If your family member is entering a skilled nursing facility for rehabilitation after a hospital stay, Medicare Part A covers up to 100 days per benefit period. The first 20 days are fully covered after the Part A deductible ($1,736 in 2026). Days 21 through 100 require a daily co-insurance payment of $217 in 2026. After day 100, Medicare pays nothing.
This coverage applies only to skilled nursing care, meaning medical treatment or rehabilitation provided by registered nurses or licensed therapists. It does not cover long-term custodial care, which is the day-to-day help with bathing, dressing, eating, and managing chronic conditions that most nursing home residents need. Long-term care is typically paid for through Medicaid (for those who qualify based on income and assets), long-term care insurance, or private funds. Understanding this distinction early prevents painful financial surprises.
Use Your Local Ombudsman
Every state has a Long-Term Care Ombudsman program that investigates complaints related to the health, safety, and rights of nursing home residents. Ombudsmen are advocates for residents, not employees of the facilities. The most frequent complaints they handle involve discharge or eviction disputes, slow responses to requests for help, physical abuse, unattended symptoms, and medication issues.
You can contact your state’s ombudsman program before choosing a facility to ask whether specific nursing homes have a history of complaints. You can also reach out after admission if problems arise. The ombudsman can investigate, mediate disputes, and help you understand your options. Find your local program through the Administration for Community Living at acl.gov.
Compare Several Facilities
Narrow your list to at least three facilities based on Care Compare ratings, location, and whether they accept your family member’s insurance or payment source. Visit each one, bring your questions, and if possible bring the person who will be living there. Their comfort and gut reaction matter. Talk to families of current residents in the lobby or common areas. They’ll often share honest assessments that no website or brochure can provide.
After your visits, compare your notes across all three dimensions: the public data (inspection results, staffing levels, quality measures), what you observed in person (cleanliness, staff attentiveness, resident engagement), and what you learned from conversations (turnover, care planning, family involvement). A facility that performs well across all three is worth serious consideration. One that looks great on paper but felt wrong during your visit deserves a second look, or a second visit at a different time of day, before you commit.