Choosing a nursing home means evaluating staffing, cleanliness, safety practices, food quality, and how residents are actually treated on a daily basis. No single rating or brochure tells the full story. The best approach combines online research before your visit with careful observation during an in-person walkthrough, ideally more than once and at different times of day.
Start With the Federal Quality Ratings
Every Medicare-certified nursing home receives an overall rating on a one-to-five-star scale from the Centers for Medicare and Medicaid Services (CMS). This overall score is built from three separate ratings: health inspections, staffing levels, and quality measures. You can look these up for free on Medicare’s Care Compare website.
The health inspection rating reflects the results of unannounced state surveys, including any citations for safety violations. CMS now displays citations that are under formal dispute, so you can see the full picture even when a facility is contesting a finding. The staffing rating incorporates not just the number of nurses on duty but also staff turnover rates and weekend staffing levels. High turnover is a warning sign: when staff constantly change, residents lose continuity of care, and errors become more likely. The quality measures rating tracks clinical outcomes like falls, pressure ulcers, and use of antipsychotic medications.
These ratings are a useful starting point, but they have limits. A five-star facility can still have problems that haven’t surfaced in inspections, and a three-star facility might be actively improving. Use the ratings to narrow your list, not to make your final decision.
Staffing Levels and Who’s on the Floor
Staffing is the single strongest predictor of care quality. In 2024, CMS finalized a federal minimum staffing standard requiring nursing homes to provide at least 3.48 hours of total nursing care per resident per day, with at least 0.55 of those hours coming from a registered nurse (RN). That RN minimum translates to roughly 33 minutes of direct RN attention per resident each day. These are floors, not goals. Better facilities exceed them.
When you visit, ask specific questions: How many RNs are on duty during the day shift versus the night shift? Is there always an RN in the building 24 hours a day, or only a licensed practical nurse overnight? What is the ratio of certified nursing assistants (CNAs) to residents? CNAs provide the hands-on daily care like bathing, dressing, and helping residents eat. A ratio of one CNA to eight or fewer residents during the day is generally considered adequate. One CNA responsible for 15 or more residents is a red flag.
Ask about staff turnover directly. Facilities are now required to report this data to CMS, so the information is publicly available, but hearing how the administrator talks about retention tells you something too.
What to Observe During a Walkthrough
Visit unannounced if possible, and visit more than once. A facility that looks polished during a scheduled tour may tell a different story on a random Tuesday afternoon or weekend morning.
Use your senses. Persistent urine or fecal odors suggest that residents are not being changed or toileted regularly, or that the facility is understaffed for cleaning. A faint smell in one hallway is different from a pervasive odor throughout the building. Look at the residents themselves: are they dressed, groomed, and positioned comfortably? Watch for unexplained bruising, bedsores visible on exposed skin, or broken eyeglasses that haven’t been replaced. These are signs of neglect.
Pay attention to call lights. When a resident presses their call button, how long does it stay lit before someone responds? If you see call lights blinking unanswered throughout your visit, staffing is insufficient or staff aren’t prioritizing resident needs. Sit in a common area for 20 minutes and observe. Are staff interacting warmly with residents, or are they rushed and avoidant? Do residents seem engaged, or are they parked in wheelchairs along a hallway with no stimulation?
Check the physical environment for safety basics: handrails in hallways and bathrooms, non-slip flooring, clean and well-maintained equipment, functioning smoke detectors, and clear emergency exit paths. Outdoor spaces where residents can safely spend time are a meaningful quality-of-life feature.
Medication Practices and Antipsychotic Use
Ask the facility about its medication management practices, and pay particular attention to antipsychotic medications. Nationally, about 17% of long-stay nursing home residents receive an antipsychotic. CMS has spent over a decade working to reduce unnecessary use of these drugs because they can act as chemical restraints, sedating residents into compliance rather than addressing the root cause of behavioral symptoms. In older adults with dementia, antipsychotics also carry an increased risk of death.
You can check a facility’s antipsychotic usage rate on Care Compare. A rate significantly above the national average deserves questions. Ask the facility how they handle behavioral symptoms of dementia before turning to medication. Good facilities use person-centered approaches first: redirecting, adjusting the environment, treating underlying pain, or modifying routines.
Food and Nutrition Quality
Federal regulations require every nursing home to employ or contract with a qualified dietitian who reviews menus for nutritional adequacy. Menus must be prepared in advance, meet established nutritional guidelines, and reflect the religious, cultural, and ethnic needs of the resident population. Residents also have the right to alternative meal choices if they don’t want what’s initially served.
During your visit, try to be there during a mealtime. Watch whether residents are eating in a dining room with social interaction or alone in their rooms. Look at the food itself: is it visually appealing, served at the right temperature, and varied? Ask to see the posted menu and compare it to what’s actually being served. If your loved one requires a therapeutic diet for diabetes, heart disease, or swallowing difficulties, ask how those diets are managed and how often the dietitian reassesses each resident’s nutritional needs.
Hydration matters too. Dehydration is a common and preventable problem in nursing homes. Look for whether water and drinks are within easy reach of residents throughout the day, and whether staff are actively offering fluids.
Activities and Social Engagement
A nursing home is not just a medical facility. It’s where someone lives. Ask for the activity calendar and evaluate whether it offers genuine variety: exercise programs, music, art, religious services, outings, and small-group activities. Then observe whether activities are actually happening as scheduled and how many residents are participating.
For residents with cognitive impairment, look for whether the facility has a dedicated memory care program or unit with activities designed for different levels of ability. Meaningful engagement reduces agitation, depression, and the perceived need for sedating medications.
Resident Rights and How Complaints Are Handled
Federal law guarantees nursing home residents a set of rights, including the right to privacy, dignity, freedom from abuse and restraints, participation in their own care planning, and the ability to voice grievances without retaliation. Ask the facility how they handle complaints. Is there a resident council? How are family concerns addressed, and how quickly?
Every state has a Long-Term Care Ombudsman program, established under the Older Americans Act, that investigates complaints, advocates for residents, and works to resolve problems related to health, safety, and rights. Before choosing a facility, contact your state’s ombudsman program and ask about the complaint history for the facilities you’re considering. Ombudsman staff can also share insights that don’t appear in formal inspection reports. You can find your state’s program through the Administration for Community Living website.
Understanding the Cost and Payment Structure
Medicare covers skilled nursing facility care only after a qualifying hospital stay of at least three days, and only for up to 100 days. It’s designed for short-term rehabilitation, not long-term residence. After day 100, or if you don’t meet the qualifying criteria, Medicare pays nothing for nursing home care.
Medicaid covers nursing facility care beyond that 100-day limit, but eligibility depends on income and assets. For most programs, the individual asset limit is $9,950 (or $14,910 for a couple). Many families need to plan well in advance to navigate Medicaid eligibility, and the rules around asset transfers and spend-down periods are complex enough to warrant consulting an elder law attorney.
When evaluating a facility, ask whether it accepts Medicaid and whether Medicaid residents receive the same level of care and room options as private-pay residents. Some facilities accept Medicaid but place those residents in less desirable rooms or units. Ask directly. Also clarify what is and isn’t included in the base rate: are there extra charges for laundry, phone service, beauty care, or specialized supplies?
Questions to Ask the Staff Directly
- What is your RN-to-resident ratio on each shift? Night and weekend ratios matter as much as daytime ones.
- How do you handle medical emergencies? Find out whether there’s a protocol for transferring residents to a hospital and how families are notified.
- What’s your approach to fall prevention? Falls with injury are one of the most tracked quality indicators in nursing homes. A good facility has individualized fall risk assessments and prevention plans.
- Can I see a recent inspection report? Facilities are required to make their most recent state survey results available. If they hesitate, that tells you something.
- How are families involved in care planning? Look for facilities that hold regular care conferences and genuinely welcome family input.
- What happens if my loved one’s needs increase? Some facilities can accommodate a progression from needing moderate help to requiring full skilled nursing care. Others may discharge residents whose needs exceed their capacity.
The best nursing home for your family depends on your loved one’s specific medical needs, personality, and preferences. But the fundamentals of quality, adequate staffing, a clean and safe environment, respectful treatment, good food, and transparent communication, are non-negotiable everywhere. Visit multiple facilities, compare what you see to the data available online, and trust your instincts when something feels off.