Nursing Home Neglect Complaint
How to Choose a Nursing Home: Reading Inspection Reports and Red Flags
CMS publishes inspection reports for every Medicare-certified nursing home. Learn how to read deficiency ratings, what the five-star system means, and red flags to avoid.
Choosing a nursing home is one of the most consequential decisions a family can make — often made in crisis, under time pressure, with limited information. Yet the federal government publishes more data on nursing home quality than on almost any other type of healthcare provider. CMS's Care Compare website contains detailed inspection reports, deficiency histories, staffing data, and quality measures for every Medicare-certified nursing home in the country. Learning to read this data takes less than 30 minutes and can prevent years of suffering.
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CMS Care Compare: The Foundation for Any Decision
Where to go: medicare.gov/care-compare
What you'll find for each facility:
- Overall 5-star rating
- Individual star ratings for: health inspections, staffing, quality measures
- Full text of the last 3 years of inspection reports
- Deficiency citations with scope and severity ratings
- Civil monetary penalties imposed
- Staffing levels (total HPRD, RN HPRD, aide HPRD)
- Quality measures data (30-day rehospitalization, pressure ulcers, restraint use, etc.)
- Special Focus Facility status (worst-performing facilities)
- Ownership information
Using it effectively:
- Go to care compare and search by location
- Compare 3–5 facilities in your area before visiting any of them
- Print or save the inspection report for facilities you plan to visit
- Look beyond the overall star rating to the individual components
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Understanding the Five-Star Rating System
CMS rates nursing homes on a 1–5 star scale across three domains and then provides an overall rating:
Health Inspections (1/3 of overall):
- Based on the last 3 years of annual inspections and substantiated complaint investigations
- Lower star = more and/or more severe deficiencies
- 1 star: Far below average
- 5 stars: Well above average
Staffing (1/3 of overall):
- Based on payroll-based staffing data
- Measures: total HPRD, RN HPRD, weekend staffing
- Updated quarterly
Quality Measures (1/3 of overall):
- Clinical outcomes: pressure ulcers, falls with injury, rehospitalization, restraint use, infection rates, pain management, incontinence care
- Both short-stay and long-stay measures
Important caveats:
- A 4-star facility isn't necessarily better than a 3-star facility on every dimension
- Overall ratings can mask problems in specific areas
- Ratings are based on data that lags reality by several months
- Rural facilities often have lower ratings partly due to lower baseline standards of comparison
Reading Deficiency Citations: The Real Story
The inspection report (Statement of Deficiencies, CMS Form 2567) contains the actual findings from each inspection. This is more informative than the star rating.
Scope and Severity Grid:
| Severity | Isolated (1 resident) | Pattern (several) | Widespread |
|---|---|---|---|
| No actual harm with potential | A | B | C |
| No actual harm — minimal potential | D | E | F |
| Actual harm | G | H | I |
| Immediate jeopardy | J | K | L |
What to look for:
- G–L citations: These involve actual harm or immediate jeopardy — serious findings. Multiple G–L citations indicate a facility with serious care quality problems
- Repeated citations: The same deficiency tag cited in multiple inspection cycles shows a persistent problem the facility hasn't fixed
- Pattern and widespread scope: Issues affecting many residents, not isolated incidents
- Immediate Jeopardy (J–L): The most serious level — resident lives were at risk. Any J–L citation in the last 3 years is a red flag
The narrative matters: Each deficiency includes a narrative description of what was observed. Read it. An 'F-686' (pressure ulcer tag) with a narrative describing a Stage 4 ulcer developing on an ambulatory resident is far more concerning than the same tag for a medically fragile end-of-life patient.
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Red Flags That Should Give You Pause
Immediate red flags (reconsider the facility):
- Special Focus Facility (SFF) status: CMS designation for consistently poor performers
- Civil monetary penalties in excess of $50,000 in the last 2 years
- Immediate Jeopardy (J–L) citations in the last year
- Denial of payment for new admissions in recent history
- Multiple G–H citations across consecutive inspection cycles
Yellow flags (investigate further before deciding):
- 1–2 star overall or health inspection rating
- High staff turnover indicators (high agency use, inconsistent staffing data)
- Poor performance on specific quality measures relevant to your loved one's needs (e.g., pressure ulcer rates if they're immobile)
- Repeated citations for the same deficiency
- Ownership changes in the last 2 years (new owners may mean disrupted care quality)
Not necessarily a red flag:
- A small number of D-level (no actual harm) citations across 3 years — these are common
- Citations in areas not relevant to your loved one's specific condition
- Improvement trajectory (improving from 2-star to 4-star over 3 years is positive)
What to Ask During a Facility Visit
Use Care Compare data as the foundation for questions during in-person visits:
About inspection results:
- 'I saw you had a citation for [specific deficiency] in your last inspection. Can you tell me what happened and how it was resolved?'
- 'What changes have you made since your last inspection?'
About staffing:
- 'What is your average nurse-to-resident ratio during the day? At night? On weekends?'
- 'What percentage of your staff are permanent employees versus agency staff?'
- 'What is your staff turnover rate?'
About care capabilities:
- 'Do you have a dedicated Memory Care unit?'
- 'How do you handle aggressive behavior or elopement risk?'
- 'What is your policy for communicating changes in a resident's condition to family?'
About food and activities:
- Ask to see the menu and activity calendar
- Visit during a meal if possible
- Talk with current residents and family members if you can
Follow up on specifics: If a deficiency involved the exact type of care your loved one will need — say, a pressure ulcer citation and your parent has mobility limitations — ask specifically about that care protocol.
Beyond Care Compare: Additional Research Steps
State survey agency website: Most states also publish inspection reports on their own websites, sometimes more current than Care Compare.
Court records: Search your county court records and PACER (federal court) for lawsuits against the facility or its owners. Multiple nursing home negligence lawsuits suggest a pattern.
Ownership research: Look up the facility's ownership on Care Compare's 'Ownership' tab. If the facility is owned by a private equity company or a large chain with multiple facilities, research the chain's overall performance. Private equity-owned facilities have been associated with lower staffing ratios on average.
Glassdoor and Indeed: Employee reviews on job sites can reveal staffing shortages, morale problems, and care quality concerns from the staff perspective.
Community resources: Your local Long-Term Care Ombudsman program knows the facilities in their area well. Call them and ask which facilities in your area they have concerns about — they can be candid in ways that published data can't.
Still have questions? Read the FAQs below — or let the AI handle it for you →
Frequently Asked Questions
Quick answers to the most common questions on this topic.
How current is the CMS Care Compare data?
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Quality measure and staffing data update quarterly. Inspection reports are posted after surveys are completed, which can lag actual inspections by 3–6 months. The most recent inspection reported may be 6–18 months old depending on the survey cycle. Always note the date of the most recent inspection when reviewing the data.
What is a Special Focus Facility and should I avoid them entirely?
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Special Focus Facilities (SFF) are the worst-performing approximately 1% of facilities nationwide — those with persistent serious problems. Facilities on SFF status receive more frequent inspections. They should be avoided if other options exist. Sometimes a formerly poor facility has improved significantly but not yet graduated from SFF status — review the trend carefully.
My only nearby option has a 2-star rating. What should I do?
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Don't rule it out based solely on the star rating. Visit in person, review the specific deficiencies (minor vs. serious), talk with current residents and families, and speak with the administrator about their improvement efforts. A 2-star facility actively working to improve may be better than a 3-star facility with a concerning specific deficiency relevant to your loved one's needs.
Can I request older inspection reports that aren't on Care Compare?
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Care Compare shows the last 3 years. For older inspection reports, contact your State Survey Agency — they maintain records going back further. For legal purposes, these older records can be important if the facility has a history of serious violations.
Is a higher price always associated with better quality?
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Not necessarily. The correlation between cost and quality is weak in nursing home research. Some of the most expensive facilities have mediocre quality ratings, while some lower-cost facilities perform well. Use the quality data, not price, as your primary guide to care quality.