How to Choose a Nursing Home: A Practical Evaluation Checklist

The gap between a good nursing home and a poor one can be measured in infection rates, staffing ratios, and federal inspection deficiencies — all of which are public record. This page walks through the structured evaluation framework that informed consumers and social workers use, grounding each step in the regulatory architecture that governs skilled nursing facilities under federal and state law. The goal is a concrete, checklist-level tool that reflects how quality is actually defined and measured in this space.

Definition and Scope

A skilled nursing facility (SNF) is a state-licensed, federally certified care setting that provides 24-hour nursing supervision, rehabilitative therapy, and medical management for residents who cannot be safely cared for at home. The distinction matters because "nursing home" is a colloquial umbrella — one that legally encompasses both SNFs certified under Medicare and Medicaid and facilities that operate purely on private pay without federal certification.

The Centers for Medicare & Medicaid Services (CMS) maintains regulatory authority over the roughly 15,000 Medicare- and Medicaid-certified nursing homes operating in the United States, under requirements codified at 42 CFR Part 483. State health departments layer additional licensure requirements on top of the federal floor. Understanding this dual-authority structure is the first step in any serious evaluation — it tells a family exactly where to look for inspection records, staffing data, and complaint history before setting foot in a lobby.

The scope of this evaluation framework covers long-term residential placement, not short-term post-acute rehabilitation (though the checklist items overlap substantially). For the broader landscape of facility types, Types of Nursing Homes provides the definitional boundaries.

Core Mechanics or Structure

Federal quality oversight runs through two parallel systems: the CMS Five-Star Quality Rating System and the annual survey and certification process conducted by state survey agencies under CMS contract.

The Five-Star system, introduced by CMS in 2008, scores facilities across three domains: health inspections (weighted most heavily), staffing levels, and quality measures. Each domain generates a 1–5 star rating; a composite overall rating is then calculated. Staffing data is drawn from CMS's Payroll-Based Journal (PBJ) system, which requires facilities to submit actual payroll records quarterly rather than self-reported estimates — a change that significantly improved data reliability after 2016.

The annual survey involves unannounced inspections by state surveyors who assess compliance with the 42 CFR Part 483 requirements. Deficiencies are tagged by scope (isolated, pattern, widespread) and severity (potential for harm through actual harm). The most serious deficiencies — "Immediate Jeopardy" citations — indicate a condition that has caused or is likely to cause serious injury, harm, or death. Facilities with Immediate Jeopardy citations are required to submit a plan of correction and may face civil monetary penalties that, under the Nursing Home Reform Act of 1987, can reach $10,000 per day for uncorrected violations.

All of this data is publicly accessible through CMS Care Compare, the federal tool formerly known as Nursing Home Compare. A facility's inspection reports, staffing hours per resident day, and quality measure scores are searchable by ZIP code, facility name, or geographic radius.

Causal Relationships or Drivers

Staffing is the variable most tightly correlated with care quality in the peer-reviewed literature and in CMS's own quality measurement framework. A 2023 proposed CMS rule (CMS-3442-P) proposed a minimum staffing standard of 0.55 registered nurse (RN) hours per resident per day and 2.45 nurse aide hours per resident per day — thresholds that CMS's own analysis found roughly 75% of facilities would not meet at the time of proposal.

The causal pathway is direct: lower RN-to-resident ratios correlate with higher rates of pressure injuries, catheter-associated urinary tract infections, falls, and avoidable hospitalizations. These are not abstract associations — they are the specific quality measures CMS tracks under the Five-Star system and that state surveyors assess during inspections.

Ownership model is a secondary but meaningful driver. Research published in journals including Health Affairs has found that for-profit facilities — which represent the majority of the U.S. nursing home industry — on average spend less on direct care staffing than nonprofit and government-operated facilities. The relationship is not deterministic; high-quality for-profit facilities exist, and low-quality nonprofits exist. But ownership structure shapes the financial incentives that govern staffing decisions. Nursing Home Ownership Models covers this in detail.

The regulatory context for nursing homes explains how federal minimum requirements interact with state-level enforcement variation, which is another causal driver of quality disparity across state lines.

Classification Boundaries

Not all facilities presenting as "nursing homes" occupy the same regulatory category, and the differences have direct bearing on what standards apply.

Medicare-certified SNFs must comply with the full 42 CFR Part 483 conditions of participation, are inspected annually by state survey agencies, and appear on CMS Care Compare with full data transparency.

Medicaid-certified facilities (certified for Medicaid but not Medicare) follow a parallel but distinct certification pathway and are also subject to state survey oversight. Many facilities hold dual certification.

Non-certified private-pay facilities operate under state licensure only. They are not subject to federal certification standards, do not appear on CMS Care Compare, and may have significantly less public oversight data available. Evaluating these facilities requires direct engagement with the state health department's inspection records.

Special Care Units (SCUs), including locked memory care units within a nursing home, are licensed as part of the parent facility but are assessed under additional criteria related to dementia-specific staffing, programming, and environmental design. Dementia Care in Nursing Homes covers the applicable standards.

For families navigating the distinction between nursing home and assisted living placement, Nursing Home vs. Assisted Living maps the care-level and regulatory differences.

Tradeoffs and Tensions

The Five-Star rating is a useful orienting tool, but it is a composite score — and composites obscure variation. A facility can score 5 stars on staffing and 1 star on health inspections and receive a middling overall rating that tells neither story clearly. A family prioritizing infection control, for instance, should weight the health inspection domain directly rather than relying on the composite.

Geographic access creates a tension that data alone cannot resolve. In rural areas, the nearest 5-star facility may be 90 minutes from a resident's family. Research consistently shows that regular family visitation is associated with better care outcomes — meaning that a 3-star facility close to family may, in practice, produce better lived experience than a distant 5-star placement. The National Consumer Voice for Quality Long-Term Care has published extensively on this tension.

Cost is a third variable that doesn't appear on any star rating. The national median annual cost of a private room in a nursing home exceeded $100,000 in 2022 (Genworth Cost of Care Survey, 2022). Medicaid eligibility, benefit scope, and bed availability vary significantly by state, creating access disparities that are invisible in quality ratings. Medicaid and Nursing Home Care covers the financial eligibility structure.

Common Misconceptions

Misconception: A high star rating means no serious deficiencies. Five-star facilities can and do receive deficiency citations. The star rating reflects relative performance within a population of facilities and is recalculated periodically. A facility that earned 5 stars in one survey cycle may have received citations in a subsequent unannounced inspection not yet reflected in the composite.

Misconception: State inspection reports are difficult to obtain. They are public documents. CMS Care Compare publishes inspection reports directly. State health department websites typically provide the same records, often with more historical depth. Long-term care ombudsman programs — established under the Older Americans Act — can assist in interpreting inspection data. The Nursing Home Ombudsman Program explains how to access this resource.

Misconception: Staffing ratios on file reflect day-to-day reality. PBJ data captures quarterly averages, not shift-by-shift variation. Weekend and night-shift staffing can differ substantially from weekday staffing, and averages can mask chronic understaffing on specific shifts. A direct conversation with charge nurses during a facility visit — particularly on a weekend — is more informative than the aggregate figure.

Misconception: Nonprofit status guarantees superior care. Ownership model is a predictor at the population level, not a guarantee at the facility level. Individual nonprofit facilities may perform poorly; individual for-profit facilities may perform well. The ownership variable is one input among many, not a dispositive factor.

Evaluation Checklist

The following items reflect the framework used by hospital discharge planners, elder law practitioners, and long-term care ombudsmen. Each item maps to a publicly verifiable data source or direct observation criterion.

Before the Visit — Data Review
- [ ] Search facility on CMS Care Compare and record the star rating for each of the three domains separately (not only the composite)
- [ ] Review the most recent health inspection report; note the count, scope, and severity of deficiencies — specifically any Immediate Jeopardy or Actual Harm citations within the past 36 months
- [ ] Check the staffing domain: record RN hours per resident per day and total nurse staffing hours per resident per day; compare against the proposed CMS minimums (0.55 RN hours, 2.45 aide hours per CMS-3442-P)
- [ ] Verify Medicare and/or Medicaid certification status
- [ ] Identify whether any Special Focus Facility (SFF) or Special Focus Facility Candidate designation has been applied — these designations indicate chronic poor performance under CMS oversight
- [ ] Contact the state long-term care ombudsman to request complaint history for the facility (Eldercare Locator, 1-800-677-1116)

During the Visit — Direct Observation
- [ ] Visit at least twice: once on a weekday during business hours, once on a weekend or evening
- [ ] Observe the dining room during a meal: note call-light response times, staff-to-resident interaction, and whether residents appear alert and appropriately positioned
- [ ] Ask to speak with the Director of Nursing and the Social Services Director separately; note whether responses to questions about staffing, turnover, and complaint handling are specific or deflective
- [ ] Request the facility's current Certified Nursing Assistant (CNA) turnover rate; the national median hovers near 50% annually, and rates significantly above that signal instability
- [ ] Examine hallways and resident rooms for odor, cleanliness, and call-light accessibility
- [ ] Ask whether the facility has a Resident and Family Council and when it last met

Regulatory and Administrative Verification
- [ ] Confirm the facility's current state licensure status with the state health department
- [ ] Request a copy of the most recent written care plan process explanation (required under 42 CFR §483.21); ask how families are notified of care plan meetings
- [ ] Ask about the facility's hospitalization rate; CMS tracks this as a quality measure and facilities should be able to provide it
- [ ] Review the admissions agreement before signing; verify it does not require arbitration waivers as a condition of admission (prohibited for federally certified facilities under CMS regulations)
- [ ] Confirm the facility's policy on resident rights, including the right to receive visitors and to file grievances without retaliation

The nursing homes resource index provides additional reference tools organized by care category and regulatory domain.

Reference Comparison Matrix

Evaluation Domain Data Source Where to Find It What to Flag
Health Inspection Star Rating CMS Care Compare medicare.gov/care-compare 1–2 stars; any Immediate Jeopardy citation in past 36 months
Staffing Star Rating CMS Payroll-Based Journal (PBJ) CMS Care Compare — Staffing tab RN hours <0.55/resident/day; total nurse <3.48/resident/day
Quality Measures Star Rating CMS administrative claims + MDS CMS Care Compare — Quality tab 1–2 stars; high rates of pressure injuries or falls
Deficiency Count and Severity State Survey Agency / CMS CMS Care Compare — Inspections tab Scope "widespread" + severity "actual harm" or higher
Complaint History Long-Term Care Ombudsman Eldercare Locator Repeated complaint categories; unresolved findings
Special Focus Facility Status CMS Special Focus Facility Program CMS Care Compare / CMS website Any SFF or SFF Candidate designation
Ownership Model CMS provider data CMS Care Compare — About tab Cross-reference with staffing and inspection data
State Licensure Status State Health Department State agency licensure lookup Any provisional, conditional, or suspended status

References