Choosing a nursing home comes down to matching a facility’s care capabilities, staffing, and culture to your loved one’s specific needs, then verifying those qualities through public data, in-person visits, and careful contract review. The median cost of a private room is $10,646 per month nationally, and a semi-private room runs about $9,277, so the financial stakes of getting this right are enormous. Here’s how to approach the decision systematically.
Clarify the Level of Care Needed
Before comparing facilities, get clear on what kind of care is actually required. Nursing homes (also called skilled nursing facilities) provide round-the-clock medical care from licensed nurses, including wound care, IV management, tube feedings, and therapies like physical, occupational, and speech therapy. They serve people whose health needs go beyond what can safely be managed at home or in an assisted living setting.
Assisted living facilities offer help with meals, housekeeping, medications, and personal care, but they don’t provide the same level of direct medical oversight. Memory care units specialize in dementia and Alzheimer’s, with secured environments and staff trained in cognitive decline. Some nursing homes have dedicated memory care wings, while others don’t. If your loved one has dementia plus significant medical needs like diabetes management or post-surgical recovery, a skilled nursing facility with a memory care program may be the right fit. If their primary challenge is cognitive rather than medical, a standalone memory care community could work better and often costs less.
Use the Five-Star Rating System as a Starting Point
The federal government rates every Medicare- and Medicaid-certified nursing home on a one-to-five-star scale. You can look up any facility on the Care Compare website (medicare.gov/care-compare). Each home receives an overall rating plus separate ratings in three categories: health inspections, staffing, and quality measures. The site also now includes staff turnover rates and weekend staffing levels, both of which matter because high turnover means residents constantly see unfamiliar faces, and weekends are when many facilities run skeleton crews.
A five-star overall rating is a good sign, but don’t stop there. Dig into the individual category scores. A facility might earn high marks on quality measures (things like how many residents develop pressure sores or lose too much weight) but score poorly on health inspections. The inspection rating reflects what state surveyors actually found during unannounced visits, so it carries real weight.
Read the Inspection Reports
Every nursing home undergoes periodic unannounced inspections by state health surveyors, and the resulting deficiency reports are public. You can find them on Care Compare. What you’re looking for isn’t just the number of deficiencies but their severity and scope.
Deficiencies are rated on a four-level severity scale. Level 1 means potential for only minor harm. Level 2 means potential for more than minor harm but no immediate danger. Level 3 means actual harm occurred. Level 4, called “immediate jeopardy,” means the problem caused or was likely to cause serious injury or death and required immediate correction. Any Level 4 finding is a major red flag.
Scope matters too. An “isolated” deficiency affected one or a very small number of residents. A “pattern” means multiple residents or locations within the facility were involved. “Widespread” means the problem was pervasive or reflected a systemic failure affecting a large portion of the facility. A pattern or widespread deficiency at Level 3 or 4 should give you serious pause, even if the facility has since submitted a correction plan. Look at whether the same types of problems recur across multiple inspection cycles, which suggests the fixes aren’t sticking.
Check Staffing Numbers
Staffing is the single biggest predictor of daily care quality. A new federal rule requires nursing homes to provide at least 0.55 hours per resident per day of direct registered nurse care and 2.45 hours per resident per day of direct nurse aide care. Those are minimums, and many experts consider them a floor, not a target.
On Care Compare, you can see each facility’s self-reported staffing levels and compare them to the federal minimum and to other nearby homes. Pay attention to the ratio of registered nurses to total nursing staff. Facilities that rely heavily on temporary or agency staff tend to have less continuity of care. Ask the facility directly how many residents each nurse aide is responsible for on day, evening, and night shifts. A ratio of one aide to eight or fewer residents during the day is generally better; one aide to twelve or more is a warning sign, especially for residents who need help with meals, bathing, or mobility.
Visit in Person, More Than Once
Online data tells you a lot, but nothing replaces walking through a facility yourself. Visit at least twice: once on a scheduled tour and once unannounced, ideally during a mealtime or in the evening when staffing is thinner.
During your visit, pay attention to specific observable details. Are residents’ hair and nails clean and groomed? Are they dressed in their own clothing, and is it clean? These small things reflect whether staff have enough time and attention for basic daily care. Notice whether call lights are answered promptly or left blinking for extended periods. Check whether the facility smells clean. A faint institutional scent is normal; a persistent odor of urine suggests inadequate hygiene routines or understaffing.
Watch how staff interact with residents. Do they address people by name? Do they knock before entering rooms? Is the dining room calm or chaotic? Talk to residents and family members if you can. Ask them what they like and what they’d change. Their answers will tell you more about daily life than any brochure.
Look at the physical environment too. Are hallways clear and well-lit? Are handrails available throughout? Is there outdoor space residents can access? Check whether rooms feel personalized, with family photos or personal items, or sterile and generic. A facility that encourages residents to make their space feel like home is signaling something about its care philosophy.
Understand Resident Rights
Federal law guarantees nursing home residents a specific set of rights, and knowing them helps you evaluate how a facility operates. Your loved one has the right to be fully informed about their medical condition and all medications in a language they understand. They have the right to participate in developing their own care plan, choose their own doctor, and access their medical records promptly. They can refuse experimental treatment and create advance directives like a living will or healthcare proxy.
Privacy protections are also guaranteed: private visits, private phone calls, and privacy in sending and receiving mail and email. The facility must protect residents’ personal property from theft.
Discharge protections are particularly important. A nursing home cannot transfer or discharge a resident unless it’s necessary for the resident’s welfare or the welfare of others, the resident’s health has improved enough that nursing home care is no longer needed, the facility hasn’t been paid, or the facility is closing. Except in emergencies, the home must provide 30 days’ written notice with the reason for discharge, and the resident has the right to appeal the decision to the state.
Read the Admission Contract Carefully
The admission agreement is a legal document, and it deserves close attention before anyone signs. One of the most consequential provisions to watch for is a binding arbitration clause. Signing one means that if something goes wrong, including neglect or abuse, you waive the right to take the case to court and instead go through private arbitration, which tends to favor the facility.
Federal rules prohibit nursing homes from requiring an arbitration agreement as a condition of admission. This must be explicitly stated in the agreement itself. If a facility pressures you to sign one or implies admission depends on it, that’s a violation. Any arbitration agreement must be explained to the resident or their representative in a form and language they understand, and the resident must acknowledge understanding it. The agreement also cannot contain language discouraging anyone from communicating with state surveyors, health department employees, or the state ombudsman.
Beyond arbitration, review what’s included in the base rate versus what costs extra. Some facilities charge separately for laundry, supplies, or certain therapies. Ask for a written breakdown of all potential charges so there are no surprises.
Plan for the Financial Reality
Nursing home care can exceed $127,000 per year depending on location and care needs. Most people pay through some combination of personal savings, long-term care insurance, Medicare, and Medicaid.
Medicare covers skilled nursing 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. Long-term care insurance, if your loved one purchased a policy years ago, can cover a portion of costs, but policies vary widely in what they pay and for how long.
Medicaid is the primary payer for long-term nursing home stays for people who have spent down their assets. Each state sets its own income and asset limits, but a critical rule applies almost everywhere: Medicaid uses a 60-month look-back period when reviewing financial eligibility. That means any assets transferred (given away, placed in certain trusts, or sold below market value) within five years of applying for Medicaid can trigger a penalty period during which Medicaid won’t pay for care. If your family is considering Medicaid as a long-term funding source, start financial planning well in advance with an elder law attorney who knows your state’s rules.
Contact the State Ombudsman
Every state has a Long-Term Care Ombudsman Program, an independent consumer protection service that advocates for nursing home residents. Ombudsmen conduct regular facility visits, investigate complaints, and work to resolve problems between residents and facilities. They can give you information about a specific facility’s complaint history that may not show up in formal inspection reports.
Before making a final decision, call your state or local ombudsman program and ask about the facilities on your short list. They can tell you about patterns of complaints, how responsive a facility has been to resolving issues, and whether there are concerns you should know about. After admission, the ombudsman remains a resource if problems arise. You can find your local program through the Eldercare Locator at eldercare.acl.gov or by calling 1-800-677-1116.