How to Choose a Nursing Home: What Black Families Should Check

You are usually choosing a nursing home in a hurry, from a hospital discharge planner's list, for someone you love. The federal government publishes more about these buildings than about almost anything else in American health care, and almost none of it reaches the families deciding. Start with the star rating, understand what each part of it actually counts, and then check the two things the rating handles worst.

Medicare's Care Compare gives each certified nursing home an overall rating from one to five stars. That single number is assembled from three components, each with its own star score, and they measure genuinely different things:

• Health inspections. What state surveyors found on unannounced visits over roughly the last three years, weighted toward the most recent one and toward the severity of what they cited.
• Staffing. Hours of nursing care per resident per day, reported from payroll records rather than from the home's own estimate, plus staff turnover.
• Quality measures. Clinical outcomes drawn from resident assessments, such as pressure ulcers, falls with injury, and use of antipsychotic medication.

Read the three separately. A four-star overall rating built on excellent quality measures and a two-star inspection record is telling you something specific, and it is not the same home as a four-star built the other way round.

Staffing is the component most tied to daily life inside the building: whether someone answers a call light, whether a resident is turned often enough, whether anyone notices a change. It is also the component with the clearest measurement problem.

CMS added annual staff turnover to the rating in 2022, but adopted a definition that only counts employees working at least 120 hours within 90 days. Researchers at the University of Maryland and the Robert Graham Center rebuilt the measure using payroll records and counted every new hire instead. By 2022 and 2023, 45% of nursing hires fell outside the CMS definition. When they re-ranked facilities on the inclusive measure, only 30% stayed in the same turnover decile, and the homes that moved most were those leaning hardest on short-term and contract staff.

What that means for you is practical. A home can post a respectable turnover figure while much of its floor is covered by agency staff who rotate through. The number is not fake, it is narrow. So use it, then ask the question it cannot answer: how much of the care here is delivered by agency staff, and has that changed in the last year.

If the homes within driving distance look worse on paper than the ones an hour away, that pattern has been measured, and it is about money and geography rather than anything about the residents.

A study of more than 15,000 certified nursing homes found that registered nurse hours per resident per day are lower in homes located in more economically distressed communities, and that the gap widened through the pandemic years. Certified nursing assistant hours followed the same pattern. Registered nurses are the staff who catch a change in condition early, so fewer RN hours is not a paperwork difference.

American nursing homes also remain segregated. A systematic review in The Gerontologist found most studies documented both segregation across facilities and a negative effect of that segregation on facility quality. A 2025 study in the Journal of the American Geriatrics Society tested it directly and found segregation associated with widening gaps in inspection deficiency scores, concluding that the target for policy is systemic disinvestment in the homes that serve a high proportion of Black residents.

Read that as information, not as a verdict on any one building. It tells you the average is shaped by funding, and that the individual home's own record is what you have to check.

Ownership is public, it is on the Medicare record, and it is worth ten minutes. A case study of one nursing home chain traced how money moved out of resident care through related-party contracts under individual, private equity, and real estate investment trust ownership. In hospice, a 2024 study in JAMA found caregiver-reported quality was lower at agencies owned by private equity firms and publicly traded companies.

None of that condemns a specific home, and plenty of for-profit homes are well run. It tells you which question to ask on the tour: who owns this building, is it part of a chain, and has ownership changed in the last year. Medicare flags a recent ownership change on the record, and a home that changed hands in the last twelve months is one where the inspection history may describe a different operator than the one you are meeting.

• All three component ratings, not the overall star alone.
• Total nursing hours per resident per day, and the registered nurse hours specifically.
• Whether CMS has flagged the home for abuse. Medicare marks these facilities with a warning icon on the public record.
• The inspection deficiencies themselves. The severity and scope of what surveyors cited matters more than the count.
• Ownership type, chain affiliation, and any ownership change in the last year.
• Certified beds and average daily residents. A home running far below capacity may be struggling to staff.

Go at an ordinary hour, not a scheduled tour slot. Late afternoon and early evening are when short staffing shows. What to notice:

• How long call lights stay on, and whether anyone acknowledges them in passing.
• Whether residents are up, dressed, and out of their rooms, or whether most are in bed mid-afternoon.
• Whether staff address residents by name.
• Smell. Persistent odour is a staffing signal, not a housekeeping one.
• Whether the staff you meet have worked there long. Ask them directly.

Ask to see the most recent state inspection report. Every certified home is required to keep it available to the public on request, and how readily it is handed over is itself information.

We publish the Medicare record for every certified nursing home in the country, grouped by city, with the star ratings, staffing scores, ownership and inspection results side by side, so you can see the real range near you rather than working through one facility at a time. Start with nursing homes by state. If the person you are caring for needs dialysis, dialysis centers carry their own Medicare ratings, including how often each one gets patients onto the kidney transplant waitlist. For care at home instead, home health agencies are rated too. And if you are still looking for a doctor who will hear you, you can find a Black clinician in our directory.