Starfile / Guides / Choosing a nursing home

How to choose a nursing home

Choosing a nursing home is usually an urgent decision made under emotional pressure — often during a hospital discharge planning meeting that gives the family a weekend to decide. The research below takes about two hours and will put you ahead of 90% of families in the same situation.

Step 1 — Build a short list

Start geographically. Pull the facilities in the county where the resident's primary family visitor lives, not where the resident lived before. Frequent in-person visits are the single best safeguard against poor care, and they won't happen if the facility is a long drive.

Starfile's state pages list every CMS-certified facility by city; the county page (e.g. Los Angeles County, CA) groups them more usefully. Limit your short list to 5–8 facilities within a 30-minute drive.

Step 2 — Screen by CMS star rating

CMS publishes four ratings for every facility: overall, health inspection, staffing, and quality measures. Each is on a 1–5 scale. The overall rating is a blend, and the components can diverge sharply. A facility can be overall 3-stars while having 1-star staffing; that's not a 3-star facility, that's a staffing crisis with good paperwork.

Cut anything with an overall rating of 1 immediately. These are the bottom ~10% of facilities nationally — you can find them on the Special Focus watchlist and on your state's abuse list. If all the 4+ star options in your area are full and only 1-star beds are available, that itself is a signal: the local market has too much low-quality capacity and you may need to expand the geographic search.

Two-star facilities are worth visiting only if the staffing and health inspection components are at least 3-stars individually and the low overall rating is driven by quality measures (which are partly based on resident acuity mix).

Step 3 — Check for active red flags

Two flags are disqualifying until the family has a direct conversation with the administrator:

• Abuse icon. CMS flags a facility when an inspector has documented abuse, neglect, or exploitation within the past two inspection cycles. The facility may have corrected the issue, but the family has a right to ask exactly what happened.
• Special Focus Facility status.The federal watchlist for the worst facilities in the country. An SFF designation is not a past event — it's an active federal determination that the facility has “more serious problems than most other nursing homes” and is under heightened survey frequency.

Step 4 — Read the citations, not the star rating

Click into each facility's detail page and look at the inspection citations section. Pay attention to:

• Scope & severity letter.Codes J, K, L mean “immediate jeopardy” — the surveyor found a condition likely to cause serious injury, harm, or death. Any recent J/K/L citation is a conversation-stopper.
• F-tag categories. The tag number tells you what went wrong. F689 (accident hazards), F600 (abuse), and F880 (infection control) are the three that most directly predict resident harm. F-tag pages on Starfile list the top-cited facilities nationally for each tag.
• Correction status. Every citation shows whether the facility corrected it and when. Uncorrected or recently-corrected jeopardy-level citations mean the facility may still be in a fragile state.

Step 5 — Staffing ratios, not just the star

The staffing rating hides the most important number: nurse hours per resident per day (HPRD). Research (Harrington et al., multiple peer-reviewed studies) finds residents have materially worse outcomes below these thresholds:

• Total nurse staffing < 4.1 HPRD
• Registered nurse (RN) staffing < 0.75 HPRD

Facility pages on Starfile publish both the reported and the case-mix-adjusted HPRD numbers. CMS's star thresholds are easier than the research thresholds; a 3-star staffing rating can still be well below the clinically meaningful level.

Also check turnover. Total nursing staff turnover above 55% annually signals a churn-driven culture where continuity of care is impossible. Administrator turnover above 1 per year signals ownership instability.

Step 6 — Pull the ownership chain

Every facility discloses every entity with a 5%+ interest on CMS Form 855A. Starfile aggregates these into chain pages and owner pages. If one person or one LLC appears as an owner on 20 other facilities, look at those facilities' ratings. Chains with systematically poor outcomes are a red flag even if the specific facility looks acceptable on its own — the management style usually travels.

Private-equity-backed chains in particular have been the subject of repeated federal research (Gupta et al., 2021; Braun et al., 2022) showing a statistically significant increase in resident mortality and decline in staffing after PE acquisition. This is not a reason to rule out a PE-owned facility — plenty operate well — but it is a reason to read the post-acquisition inspection reports especially carefully.

Step 7 — Visit in person, unannounced

No data source replaces a visit. Two visits, ideally — one announced (scheduled tour during business hours) and one unannounced (nights, weekends). The unannounced visit is the one that matters. What to look and listen for:

• Smell. A persistent urine smell means call bells are being ignored.
• Hallway staffing. Count the CNAs you can see. If it's under 1 per 15 residents on the unit during the day, the staffing rating on paper is probably inflated.
• Residents' grooming and clothing. Not designer labels — clean teeth, combed hair, weather-appropriate clothing.
• Call bell response time. Ask to sit in the family lounge and time it from the nearest room.
• Whether residents are parked in wheelchairs in hallways, unengaged, for long periods.

Step 8 — Ask the administrator the hard questions

Put these questions to the administrator or DON (Director of Nursing), in person:

• “Your most recent CMS citation was for [tag]. What did you change to prevent recurrence?”
• “What is your current agency-nurse percentage?” (Above 25% is a continuity red flag.)
• “What is the facility's RN-to-resident ratio on the night shift?”
• “Who do I contact if I can't reach nursing staff on a weekend?”
• “May I see a copy of the most recent CMS-2567 (Statement of Deficiencies)?” (Federal law requires the facility to make this available on request.)

Step 9 — Call the state ombudsman

Every state has a long-term care ombudsman program— an advocacy office that handles complaints, visits facilities, and keeps its own informal track record. They cannot give you a public “do not go” list, but they will tell you what they know about a specific facility when you ask. Their perspective is closer to the ground than CMS data by a wide margin.

The national ombudsman resource center publishes every state's contact information. Call the ombudsman for each facility still on your short list.

After admission — keep watching

The research is clear: frequent family visits are the single strongest protective factor against abuse and neglect. If the resident is able to communicate, establish a code word or phrase for “something is wrong and I can't say it right now.” Attend every care plan meeting. Check the resident's personal items inventory at each visit. Know your state's APS (Adult Protective Services) number by heart.

Starfile refreshes its data monthly from CMS. Bookmark the facility's page and re-check every month — a new citation or a status change is something you want to know about before the facility tells you.

This guide is research-backed but not legal or medical advice. If you suspect immediate harm, contact Adult Protective Services or 911 — do not wait to complete this checklist.