How to Choose a Nursing Home: A Data-Driven Approach

Step 1: Understand the Rating System

The Centers for Medicare and Medicaid Services (CMS) rates every Medicare- and Medicaid-certified nursing home on a 1-to-5-star scale. The overall rating combines three component scores:

• Health inspections — The most heavily weighted component. Based on findings from the three most recent annual surveys and any complaint investigations during that period. Covers everything from medication management to infection control to resident rights.
• Staffing — Measures the total nursing hours per resident per day, including RN hours specifically. Based on payroll data submitted by facilities. Higher staffing ratios generally correlate with better resident outcomes.
• Quality measures — Based on clinical outcome data. Includes metrics like the percentage of residents with pressure ulcers, falls with injury, urinary tract infections, and use of physical restraints.

Read our detailed CMS Star Ratings guide for a deeper explanation of how these components interact and where the system has limitations.

Step 2: Filter by Geography and Ratings

Start by browsing facilities in your area on PlainElderCare. Every state and county page shows nursing homes with their CMS ratings, allowing you to quickly identify facilities that meet a minimum quality threshold. As a general rule:

• 4-5 stars — Above average. A good starting point for your short list.
• 3 stars — Average. May still be a good fit depending on specific component scores.
• 1-2 stars — Below average. Deserves careful scrutiny. Check which component is pulling the overall score down.

Do not automatically eliminate a 3-star facility. A facility might score 3 stars overall because of a single mediocre component while excelling in others. Look at the individual health inspection, staffing, and quality scores separately.

Step 3: Dig Into the Details

Once you have a short list of 3-5 facilities, investigate each one more deeply:

• Inspection history — How many deficiencies were cited in the most recent survey? Were any classified as "severe" (causing actual harm or immediate jeopardy)? A pattern of repeat deficiencies is more concerning than a one-time citation.
• Staffing ratios — Look at total nursing hours per resident per day and specifically at RN hours. Research consistently shows that facilities with higher RN staffing have better outcomes. The national average is roughly 4.0-4.5 total nursing hours per resident per day.
• Quality measures — Pay attention to outcome measures like falls with injury, pressure ulcers, and use of antipsychotic medications. Facilities with high antipsychotic use may be chemically restraining residents rather than providing appropriate behavioral interventions.
• Complaint investigations — Check whether the facility has had substantiated complaint investigations, which indicate problems reported by residents, families, or staff outside of routine surveys.

Step 4: Visit In Person

Data provides the foundation, but an in-person visit is irreplaceable. During your visit:

• Observe resident-staff interactions. Are staff members patient and respectful? Do they address residents by name? Is call light response time reasonable?
• Check cleanliness and odor. The facility should be clean and free of persistent unpleasant odors. Some temporary odors are normal; persistent ones may indicate hygiene problems.
• Talk to residents and families. Ask current residents and visiting family members about their experience. They can share insights that no data system captures.
• Ask about activities and engagement. Quality of life depends heavily on social engagement. Ask about activity programs, outdoor access, dining options, and opportunities for personal choice.
• Visit at different times. If possible, visit during meals, in the evening, and on weekends. Staffing and activity levels vary by shift, and a facility that looks great during the daytime tour may be very different at 8 PM.

Step 5: What should you ask on a visit?

Prepare specific questions for the facility administrator or director of nursing:

• What is the staff turnover rate? (High turnover disrupts continuity of care.)
• How do you handle resident complaints?
• What is the ratio of RNs to residents on each shift?
• How do you manage transitions — admission, changes in condition, and end-of-life care?
• Can I see the most recent state inspection report? (They are legally required to make this available.)

Step 6: Understand the Costs

Nursing home costs vary dramatically by state and can range from $5,000 to over $15,000 per month. Browse state cost data on PlainElderCare for current median costs in your area. Read our Paying for Elder Care guide to understand Medicare, Medicaid, and other funding options.

Comparing Cost-Quality Trade-Offs Across Facility Tiers

Selecting a nursing home is rarely about the highest-quality option in absolute terms. Most families face a real-world budget constraint and need to optimize quality per dollar within a shortlist of facilities that have available beds.

Facility Tier	Typical Monthly Cost (semi-private)	Typical CMS Star	Trade-Off
Premium private-pay (urban)	$11,000-$15,000	4-5 stars	High cost, strong staffing ratios
Standard private-pay (suburban)	$8,500-$10,500	3-4 stars	Mid-tier amenities, average inspection record
Medicaid-mix (rural)	$5,500-$7,500	2-3 stars	Lower cost, often understaffed weekends
Special Focus Facility	$5,000-$7,000	1-2 stars	Active CMS enforcement risk; avoid

Worked example: comparing two shortlist facilities

Imagine two facilities at the same suburban price point: Facility A at $9,200 monthly with a 4-star overall rating, and Facility B at $9,700 monthly with a 3-star overall rating. The 5% price difference might look meaningful, but the underlying staffing data often tells a different story. Facility A's PBJ data may show 3.8 RN hours per resident per day; Facility B's may show 2.4 hours per resident per day, a 37% staffing gap that academic research correlates with higher rates of pressure ulcers and antipsychotic use. The $500 monthly premium for Facility B is not just buying brand or amenities — it is often signaling a staffing model with materially higher clinical risk.

The Special Focus Facility flag

CMS designates the worst-performing nursing homes nationally as Special Focus Facilities (SFF) and conducts twice-yearly inspections instead of the standard annual cadence. The list is publicly published on the CMS Care Compare site. Avoid any facility on the SFF list unless emergency placement makes it the only viable option, and even then, plan to transfer within 30 days.

Reading inspection deficiencies in context

State surveyors classify deficiencies on a scope-and-severity grid (A-L) where A is isolated minimal harm and L is widespread immediate jeopardy. A single F-tag at scope-severity D (isolated, no actual harm) is routine; multiple G or higher tags (actual harm) within 12 months are a serious red flag.

Budgeting for spend-down to Medicaid eligibility

Medicaid covers roughly 60% of long-stay nursing home days nationally. Most private-pay residents exhaust assets within 18-30 months at the facility level and transition onto Medicaid coverage. Not every facility accepts Medicaid; some private-pay-only operators will not allow conversion, which can force a mid-stay transfer.

Important Disclaimer

This guide is for informational purposes only. It does not constitute medical, legal, or financial advice. CMS ratings are one important input but cannot capture every dimension of care quality. Always visit facilities in person, consult with healthcare professionals, and make decisions based on the specific needs of your family member.