How to Choose a Nursing Home: A Step-by-Step Process

Most families start with the wrong question. They ask "which nursing home is best?" when the useful question is "which homes can actually take my parent, at the level of care they need, paid for by the money we have, close enough that someone can get there on a Tuesday night?" That narrows the field fast. Then you do the real work: reading inspection records, comparing staffing numbers, and finding out what happens when the money runs out.

This is a sequence. Follow it in order and you will not waste a week touring homes that were never going to work. Skip a step and you will likely fall in love with a building that cannot admit your parent, or can admit them but not keep them once Medicaid becomes the payer.

Step one: shortlist by location before anything else

Distance is not a soft factor. It is the single strongest predictor of whether your parent gets visitors, and visitors are how problems get caught. A home forty minutes away in good traffic becomes ninety minutes in the snow, and the Tuesday night visit quietly stops happening. Staff notice which residents have no one checking in.

Draw a radius you can honestly commit to. If you work and have kids, that radius is smaller than you think. For most families, twenty to thirty minutes from either your home or the home of whichever relative will do the most visiting is the realistic zone. A sibling who lives ten minutes away and will actually go twice a week is worth more than a marginally better inspection record an hour out.

Be honest about the trade. In some markets, the closest homes are the weakest ones, and you will have to choose between proximity and quality. That is a real choice with no universally right answer. What you should not do is pretend the distance does not matter and then discover in month three that nobody is visiting.

Say, for the sake of illustration, a family is choosing between a home eight minutes from the daughter who will visit most and a home with a cleaner inspection record thirty-five minutes away. The daughter works full time. Realistically she will visit the near home several times a week and the far one maybe once a fortnight. Over a year, that difference in eyes on the resident probably outweighs a modest gap in citation history. That is not a rule, it is the kind of arithmetic worth doing out loud before you tour.

Start your list at our search of all Medicare-certified nursing homes, filter to your radius, and take the whole set forward to step two rather than pre-judging by star rating.

Step two: filter by who pays, and Medicaid is the trap

This step eliminates more homes than any other, and it is the one families most often skip. A nursing home can be Medicare-certified and still not be certified to accept Medicaid for long-term care. Those are two different certifications.

Here is why it matters. Medicare pays for a short skilled stay after a hospital discharge, typically a limited number of days, and it is not a long-term funding source. Once a resident needs custodial long-term care, the payer is usually Medicaid, private funds, or long-term care insurance. If your parent has modest savings and you expect Medicaid to fund the stay within a year or two, you need a home that is Medicaid-certified now, not one that says "we'll deal with that later."

Our database covers 14,696 Medicare-certified nursing homes, and 14,156 of them are certified to accept Medicaid. So the great majority do. That is exactly why families get complacent. The homes that are not Medicaid-certified tend to be clustered in certain markets and certain price points, and if you fall for one of them without checking, you can end up moving your parent a second time, mid-decline, which is its own harm.

The three payer questions to ask before you tour

• Is this facility Medicaid-certified for long-term care, not just Medicare-certified for skilled nursing?
• Does the facility have a Medicaid bed available now, or is there a waitlist, and does the waitlist operate by date or by care need?
• If my parent enters as a private-pay resident, what is the facility's written policy on converting to Medicaid when the money runs out?

That third question is the one that separates honest operators from the ones that will hand you a discharge notice. Some facilities are certified for Medicaid but maintain only a small number of Medicaid beds, and a private-pay resident who spends down may find those beds full. Ask for the policy in writing. If they will not put it in writing, treat that as your answer.

Medicaid rules vary enormously by state, including how spend-down works and what counts as an available bed. Our Medicaid by state pages lay out the state-level picture, and our guide to who pays for nursing home care walks through the transition from private pay to Medicaid. Read both before you tour. You will ask better questions.

Step three: read the inspection record for G or above

Every Medicare-certified home gets inspected, and every citation is graded on a scope and severity scale. The letter grades matter. Citations at scope and severity G or above mean the deficiency caused actual harm to a resident, or placed residents in immediate jeopardy of serious harm or death. Below G, you are generally looking at potential for harm or isolated problems.

Our database holds 419,479 health inspection citations across the facilities we cover. Of those, 22,914 were scored at G or above. That is a small share of the total, which is what makes a G-or-above citation on a specific home worth your attention. It is not paperwork. It is a finding that something harmed a real resident.

What you are looking for is not one bad citation from five years ago. You are looking for a pattern: the same problem cited repeatedly across inspection cycles, or a cluster of G-or-above findings in the last two or three years, or a recent G-or-above finding that the home has not yet had a chance to correct. A single old citation with a clean record since is a different animal from three citations for the same thing in three consecutive surveys.

How to read a citation in five minutes

1. Find the citation's scope and severity letter. Anything G or above goes to the top of your list.
2. Note the date. A finding from the most recent survey is more relevant than one from three years ago, especially if ownership or management has changed since.
3. Read the actual deficiency text, not just the category. "Falls" covers a lot of ground, from a single unwitnessed fall to a pattern of not answering call lights for residents who cannot walk.
4. Check what the facility submitted as its plan of correction, and whether the next survey found the same problem again.

Our guide to reading an inspection report goes through this in more detail, including how to find the plan of correction. If you only do one piece of homework before touring, do this one.

Step four: compare staffing hours and turnover

Staffing is the number that most directly affects your parent's day. Not the brochure. Not the activities calendar. How many nursing hours each resident actually receives, and how often the staff turning over.

The national average for total nurse staffing is 3.86 hours per resident per day. Registered nurse staffing averages 0.69 hours per resident per day. Weekend nurse staffing averages 3.42 hours, which is lower than the weekday figure and reflects the reality that many homes run thinner on Saturdays and Sundays. National average nursing staff turnover is 46%, meaning nearly half the nursing staff leaves in a given year.

Those are averages. A home well below them on total hours is running thin. A home well below on RN hours specifically may be relying on licensed practical nurses and aides where a registered nurse's assessment would be better. A home with turnover well above 46% is constantly training new people, and new people make more mistakes, miss more subtle changes in a resident's condition, and do not know your parent's baseline.

Compare the same numbers across your shortlist, not against the national average alone. If three of your five candidate homes run 3.4 total hours and one runs 4.1, the outlier is worth a closer look, including whether that staffing is spread evenly across all shifts or concentrated on weekdays when surveyors tend to visit.

Our guide to what the staffing numbers mean explains how to read these figures and where to find them. The short version: a home can look well staffed on paper and still leave residents waiting, if the hours are scheduled in a way that does not match when care is actually needed.

Step five: check ownership and the rest of the chain

Who owns the building tells you something about how decisions get made. A standalone non-profit with a local board answers to a different set of pressures than a facility owned by a large chain answering to a regional operator answering to an investment entity. Neither structure is automatically better for residents, but the structure predicts how the home behaves when money gets tight.

Of the homes we cover, 10,882 are for-profit and 2,869 are non-profit. 10,119 belong to a named chain. Our ownership tracker holds 248,794 ownership records from the CMS ownership file. That file matters because it names the entities behind the facility, including ones that do not appear on the front door.

The practical move is to look at the chain's other homes. If a facility belongs to a chain whose other locations in your state carry repeated G-or-above citations, or high turnover, or a cluster of abuse icons, that is a signal about the operator's standards, not just about this one building. Operators tend to run their facilities to a common playbook, for better and worse.

Our ownership tracker lets you pull up the other facilities under the same owner, and our guide to who owns nursing homes explains how to trace ownership through layered corporate structures to whoever actually controls the decisions.

Red flags in the ownership record itself

• Recent change of ownership with no corresponding improvement in inspection results yet. New owners inherit old survey history for a while, so the record lags reality.
• A chain with facilities in the Special Focus Facility programme, which currently covers or is considering 526 facilities nationally.
• An owner whose other homes have been cited for the same problem this home is cited for. That is a pattern, not an accident.

Step six: visit twice, and one visit should be unannounced

A scheduled tour shows you the building at its best. The administrator knows you are coming. The unit is tidy. The staff are smiling. That tour has value, but it is not the visit that tells you the most.

Go back a second time without telling anyone, on an evening or a weekend. That is when staffing is thinnest and when the truth about how the place runs shows up. Walk the halls. Sit in a common area for twenty minutes and just watch. How long does a call light stay on? Are residents parked in front of a television with no one interacting with them? Does anyone acknowledge you, or do you wander unescorted the entire time?

What you are looking for is the gap between the scheduled tour and the unannounced one. Some difference is normal. A large difference, where the evening home looks nothing like the daytime home, is your answer about how the place is actually staffed.

Our guide to red flags on a tour lists what to look for in both visits, including the smells, the sounds, and the specific things to check in a resident's room. Bring it with you.

What to look at on the unannounced visit

• Call light response time. Stand where you can see a lit call light and time how long it takes someone to answer.
• Staff-to-resident interaction. Are staff talking to residents, or only to each other?
• Residents' appearance and positioning. Are people clean, dry, and sitting comfortably, or slumped and unattended?
• The unit's general state at that hour. Evening and weekend is when maintenance and housekeeping are thin, but basic cleanliness should hold.
• Whether anyone asks who you are. A home that lets a stranger walk the halls unescorted for twenty minutes has a security gap, which is also a resident-safety gap.

Step seven: ask what happens when the money runs out

This is the question families avoid because it forces them to confront the financial reality. Ask it anyway, and ask it early, before you are emotionally invested in a particular home.

The honest version of the question is: "If my parent pays privately for a year and then needs to convert to Medicaid, what happens? Do they stay in this room? Do they move to a different unit? Is there a written policy?"

A facility that is genuinely Medicaid-certified and committed to long-term residents will have a clear answer. A facility that is Medicaid-certified on paper but runs mostly private-pay beds may tell you, in careful language, that the situation would be "reviewed at the time." That is not an answer. It is a placeholder for a discharge notice.

Get it in writing if you can. At minimum, get the name of the person who told you and the date. If the facility will not commit, assume the worst case and factor that into your decision. Moving a parent out of a nursing home they have settled into, because the money ran out and the bed was not there, is a harm you can often avoid by asking this question at the start.

The CMS star rating is graded on a curve and it lags

The five-star rating you see on the CMS Care Compare site is useful, but it is not the straightforward quality score most families assume it is. Two things about it catch people out.

First, the rating is graded on a curve within each state. A three-star home in one state is not the same as a three-star home in another, because the comparison set is different. A home's stars tell you where it sits relative to its in-state peers, not where it sits nationally.

Second, the health inspection component of the rating leans on up to three years of survey history. That means the rating reflects the home as it was over the last three years, not as it is today. If a facility changed ownership or management six months ago, the stars may still reflect the previous operator's record. The same works in reverse: a home that has recently declined may still carry stars earned under better management.

So use the star rating as a starting filter, not a final answer. Cross-check it against the most recent survey, against current staffing numbers, and against who owns the building now. Our explanation of how our grade is calculated covers how we handle these lag issues and what we weight, and our data sources page shows exactly which CMS files feed the numbers.

Questions to ask on every tour

Bring these. Write them down. Ask the same questions at every home so you can compare answers, and note who gives you a straight answer and who deflects.

• What is the current total nurse staffing hours per resident per day, and how does it break down by shift?
• What is the nursing turnover rate here, and how long has the director of nursing been in the role?
• Who owns this facility, and how many other homes does that owner operate?
• What was the most recent survey result, and what deficiencies were cited?
• Is there a current or recent citation at scope and severity G or above, and what was the plan of correction?
• Is this facility Medicaid-certified for long-term care, and how many Medicaid beds are currently available?
• What is the written policy if a private-pay resident needs to convert to Medicaid?
• How are care plans updated, and how often does the family get to participate?
• What is the process for raising a concern, and who is the resident's assigned point of contact?
• What happens on weekends and at night when staffing is thinner?

If you are comparing several homes, our side-by-side comparison tool will put the inspection, staffing, and ownership data next to each other so you can see the differences without holding it all in your head.

The mistake families most often make

The most common mistake is choosing a home based on the scheduled tour alone. The building is clean, the staff are warm, the administrator says all the right things, and the family signs. Then, three months later, they discover that the evening shift is one aide short, that the same fall-prevention deficiency has been cited three surveys running, and that the home's Medicaid beds are full when the money runs out.

What that mistake costs is a second move. Moving a parent with dementia or a recent fracture out of a home they have started to settle into is disorienting and, in some cases, dangerous. Falls and hospitalizations spike around transitions. The family also loses the time and emotional energy of starting the search over, often under worse conditions because now there is a deadline.

Every piece of that outcome was visible before the first tour. The staffing numbers were published. The citations were published. The ownership record was published. The Medicaid certification status was published. The only thing missing was the hour it would have taken to look.

Do the homework before you fall in love with a building. It is the cheapest hour you will spend in this entire process.

Where ElderGrade fits in

We grade 14,651 of the 14,696 Medicare-certified nursing homes in the country. The remaining homes are left ungraded because CMS has not published enough data for us to grade them responsibly, and we would rather show you a gap than a number we cannot stand behind.

Our database holds 419,479 health inspection citations, 248,794 ownership records, and the full federal enforcement picture, including 1,428 facilities currently carrying a CMS abuse icon and 526 in or being considered for the Special Focus Facility programme. CMS has imposed $456,985,787 in federal fines across the facilities we cover.

Start with the best-graded homes in your area if you are early in the search, or go straight to the watchlist of flagged homes to make sure nothing on your shortlist is on it. Both lists draw on the same underlying data, and both are updated as CMS publishes new surveys.

If your parent's needs might be met at home for longer, our home health agency directory and hospice provider directory cover the other end of the care spectrum. And if you are still working out what any of this will cost, our cost pages and the guide to residents' rights will help you understand what you are entitled to ask for once your parent is admitted.

The bottom line

Choose in this order: location first, payer second, then the inspection record, then staffing and turnover, then ownership, then two visits with one unannounced, then the money-runs-out conversation. If a home fails at any step before the visits, cross it off and move on, because the homes that fail early steps will not be rescued by a nice building. The star rating is a filter, not a verdict, and it is graded against in-state peers on up to three years of history, so treat it as the beginning of your research rather than the end of it. The families who end up satisfied are almost always the ones who did the reading before they did the touring.

Where these figures come from

Every number in this article that describes American nursing homes comes from the CMS Provider Data Catalog, the same public federal files behind Medicare's Care Compare. You can see exactly which datasets we use, and how current they are, on our data sources page. Nothing here is medical, legal or financial advice, rules differ by state and change over time, so verify anything that affects a decision with the facility, your state survey agency, your Long-Term Care Ombudsman, or a qualified professional.