By Michael Mangione, Legal Research EditorChoosing a nursing home is rarely a calm decision. It usually happens after a hospital stay, a fall, or a diagnosis, on a deadline, while a family is frightened and tired. The good news is that you do not have to guess. The federal government publishes detailed quality data on almost every nursing home in the country, and once you know how to read it, you can rule out the worst facilities in an afternoon and walk into a tour asking the right questions.
This guide explains how to choose a safe nursing home the way a careful researcher would. We start with the Medicare star ratings most families have heard of, show you exactly what each star measures and where it can mislead, and then move to the things no rating captures: what a building feels like at 6 p.m., how staff talk to residents, and what the last inspection actually found. Everything here links to a free public source so you can verify it yourself.
The short version
- Start at Medicare's free Care Compare tool, which gives every certified nursing home an overall rating from one to five stars, plus separate ratings for inspections, staffing, and quality.
- The health inspection rating is the backbone of the score and the hardest for a facility to game, so weight it heavily.
- The staffing rating now comes from verified payroll data, which makes it one of the most trustworthy numbers on the page.
- A five-star rating is a starting point, not a guarantee. Quality-measure data is partly self-reported and some facilities under-report serious events.
- Check whether a home is a Special Focus Facility or a candidate, the federal label for the most persistently troubled homes.
- Read the actual inspection report for any home on your shortlist and look for harm-level citations, not just the number of problems.
- Always visit, ideally unannounced, and call your free Long-Term Care Ombudsman before you decide.
01 The rating system
How Medicare's Five-Star ratings work
Every nursing home that takes Medicare or Medicaid is rated from one to five stars on Medicare's Care Compare website. There is one overall rating and three separate ratings behind it: health inspections, staffing, and quality measures. Five stars means much above average and one star means much below average.
The Five-Star Quality Rating System was created by the Centers for Medicare and Medicaid Services, the federal agency known as CMS, to help families compare nursing homes without needing a clinical background. You can find every rating for free at Care Compare, the official government tool at medicare.gov/care-compare. Search a ZIP code and you will see each home's overall star rating along with the three domain ratings that feed into it.
It helps to understand how those pieces combine, because the overall star is not a simple average. CMS starts with the health inspection rating, then adjusts it: a strong staffing rating can add a star and a one-star staffing rating subtracts one, and a top or bottom quality-measure rating can move the score by one more star. The overall rating is held between one and five. Critically, a home with a one-star health inspection rating cannot climb far on staffing and quality alone, which is why inspections matter most.
What each of the three ratings measures
In plain terms, the health inspection rating reflects what state inspectors found on recent visits. The staffing rating reflects how many nursing hours each resident receives and how stable the staff is. The quality measures rating reflects clinical outcomes such as pressure ulcers, falls, and hospital transfers. We walk through each one below, including where it is reliable and where it is not.
Primary source
Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide (CMS)
CMS publishes the full scoring methodology, including how the three domains combine into the overall star and how cut points are set. It is updated as the methodology changes.
Centers for Medicare & Medicaid Services (2026). Five-Star Quality Rating System
Use Care Compare as your first filter, but read all four numbers. Our guide to using Medicare Care Compare to check a facility walks through the tool screen by screen.
02 The backbone of the score
The health inspection rating
The health inspection rating is based on unannounced state surveys plus complaint investigations. Inspectors check care, safety, rights, and cleanliness, and cite problems called deficiencies. More deficiencies, and more serious ones, mean a lower rating. It is the single most important number because it is the hardest to manipulate.
Nursing homes that participate in Medicare or Medicaid receive an unannounced comprehensive health inspection, on average about once a year. A team of trained surveyors spends several days in the building reviewing resident care, medication management, skin care, resident rights, infection control, food service, and the physical environment. They also investigate complaints as they come in.
As of the July 2025 update, CMS calculates the health inspection rating from a facility's two most recent standard surveys, and continues to factor in complaint and infection-control findings over a three-year lookback. Each problem inspectors find is a deficiency, scored by how widespread it is and how badly it could harm residents. The cut points are set state by state, so a home is ranked against others in its own state. Roughly the top ten percent of homes in a state earn five stars on inspections and the bottom twenty percent earn one star.
Why inspections carry the most weight
Of the three domains, inspections are the hardest for a struggling facility to dress up, because they reflect an outside team's direct observation rather than numbers the facility reports about itself. That is why a low inspection rating should weigh heavily even when staffing or quality look acceptable. If you read nothing else, read the inspection history.
Treat the inspection rating as the foundation. A persistent one or two-star inspection record is a serious warning, even if the overall star looks better. Learn how citations are scored in our guide to what a facility's deficiency citations mean.
03 The number that predicts care
The staffing rating and what the law requires
The staffing rating comes from verified payroll data, not self-reports, which makes it one of the most trustworthy numbers on the page. It measures nursing hours per resident each day, registered nurse coverage, and staff turnover. Higher staffing and lower turnover almost always track with better care.
Staffing is widely viewed as the strongest single predictor of nursing home quality. CMS measures it using the Payroll-Based Journal, a system that collects actual payroll and hours data from facilities rather than relying on a one-day snapshot. From that data CMS calculates hours per resident day, often written as HPRD, which is the average amount of hands-on nursing time each resident receives in a day. The staffing rating also reflects registered nurse hours, total nurse staffing, weekend staffing, and turnover among nurses and administrators. To reach five stars, a home must meet or exceed the thresholds for both registered nurse and total nurse staffing.
What federal law actually requires in 2026
This is an area where a lot of online information is out of date, so it is worth being precise. In 2024, CMS finalized a rule that would have set the first nationwide numeric minimums, including a registered nurse on site 24 hours a day and a floor of 3.48 total nursing hours per resident day. That rule never took effect. Federal courts vacated its core provisions in 2025, Congress imposed a moratorium that blocks enforcement until 2034, and CMS formally repealed those provisions in a rule effective February 2, 2026.
So as of 2026 there is no federal numeric staffing minimum and no 24-hour registered nurse mandate. What remains is the longstanding statutory standard: a facility must use a registered nurse for at least eight consecutive hours a day, seven days a week, must employ a full-time registered nurse as director of nursing unless a waiver applies, and must provide licensed nursing services around the clock that are sufficient to meet residents' needs. Some states set their own higher minimums. Importantly, CMS still collects payroll staffing data and still publishes the staffing star rating, so you can and should compare staffing levels across the homes on your list.
Primary source
Repeal of Minimum Staffing Standards for Long-Term Care Facilities
The Federal Register rule confirms that the 2024 numeric staffing minimums and the 24-hour registered nurse requirement were removed, consistent with a statutory moratorium that runs through September 30, 2034.
Federal Register (2025). Medicare and Medicaid Programs; Repeal of Minimum Staffing Standards
Read staffing numbers, not promises
A glossy brochure may describe a home as fully staffed. The payroll-based staffing rating tells you what actually happened on the floor. When the two disagree, believe the data. Chronic understaffing is the root cause of much of the neglect we see, as our guide to understaffing in nursing homes explains.
Favor homes with strong, stable staffing and be cautious about high turnover. For how the law translates into bedside coverage, see what the law requires for nurse-to-resident ratios.