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Best Nursing Homes: Behind the Rankings
By Avery Comarow

On a given day, 1.5 million people are living in the nation's 16,000-plus nursing homes, and in a typical year more than 3.2 million Americans will spend at least some time in one. That's a lot of families who need to find good care, which is why U.S. News ranks and displays data about nearly every one and updates the information every quarter. The Honor Roll lists the 11 homes that have received perfect ratings for four consecutive quarters.

The U.S News rankings rely on Nursing Home Compare, a program run by the federal Centers for Medicare and Medicaid Services. CMS analyzes information on all homes enrolled in Medicare or Medicaid other than about 150 too new to provide data and gives them ratings of one to five stars overall. The homes also receive ratings of one to five stars in each of three areas: health inspections, nurse staffing, and measures of care.

At Nursing Home Compare you can search for a specific home or for all nursing homes in a particular state or within a certain distance of your city or ZIP code. But you can't assume that all five-star homes, or those with three or four stars, are of the same quality. There are so many homes in each rating—1,855 in the five-star and 3,661 in the four-star categories alone—that the range of performance is bound to be very wide. Nor can search terms be combined if, say, you want only five-star homes within 50 miles of a specific city.

America's Best Nursing Homes addresses these and other issues. Homes are presented in tiers within each star category, based on their total stars in all three of the major areas. The topmost tier, for example, consists only of five-star homes that got 15 stars.

The next tier down is five-star homes with 14 total stars, and so on. Within each tier, homes are listed alphabetically. If you're hunting for a home by state, region, city, or ZIP code and turn up too many to be readily managed, search terms can be combined in order to narrow the results to homes that have a religious affiliation, for example, or that accept Medicare residents. Or you can launch a multipronged search, perhaps for religiously affiliated five-star Medicare homes within 50 miles of a particular city.

All of the homes in the 50 states and the District of Columbia that are included in Nursing Home Compare are in the Best Nursing Home rankings; CMS cannot evaluate a small number that take only private-pay residents. Here are more details about the measures that go into the CMS ratings.

Health inspections. Because almost all nursing homes accept Medicare or Medicaid residents, they are regulated by the federal government as well as by the states in which they operate. State survey teams conduct health inspections on behalf of CMS about every 12 to 15 months. They also investigate health-related complaints from residents, their families, and other members of the public. "Health" is broadly defined, as is evident in the 180-some items on the checklist. Besides such matters as safety of food preparation and adequacy of infection control, the list covers such issues as medication management, residents' rights and quality of life, and proper skin care.

A home's rating is based on the number of deficiencies, their seriousness, and their scope, meaning the relative number of residents who were or could have been affected. Deficiencies are counted that were identified during the three most recent health inspections and in investigations of public complaints in that time frame. State inspectors also check for compliance with fire safety rules, although their findings do not factor into the CMS ratings. Best Nursing Homes displays the full range of health and fire inspection results online.

Nurse staffing. Even the best nursing care is not enough if there are too few nurses to spend much time with residents, so CMS determines average nursing time per patient per day. Homes report the average number of registered nurses, licensed practical nurses, licensed vocational nurses, and certified nurse aides who were on the payroll (agency temps are not counted) during the two weeks prior to the most recent health inspection and their number of hours worked.

The information is compared with the average number of residents during the same period and crunched to determine the average number of minutes of nursing time residents got per day. A home had to provide at least 33 minutes per patient to receive five stars in the latest ratings. The actual numbers appear in the rankings online.

Quality measures. Nursing homes have to furnish the latest three quarters of clinical data showing the status of each individual Medicare and Medicaid resident in 19 indicators, such as the percentage of residents who had urinary tract infections or who were physically restrained to keep from falling from a bed or a chair. The Best Nursing Homes rankings and Nursing Home Compare display data for each home on all 19. The ratings, however, are based on 10 that are considered the most valid and reliable, such as the two above and measures related to pain, bedsores, and mobility.

Good ratings or bad, CMS is adamant that they are only a place to start. Nothing substitutes for in-depth visits, when you can ask questions, observe residents and their families and caregivers, and sample the look and feel of a home. "There are many satisfied residents and families of residents in nursing homes...at the one-star level," states an FAQ posted on the CMS website.

And the FAQ emphasizes that "no resident should be moved solely on the basis of a nursing home's ratings.... [Transferring] your loved one to a facility that has a higher rating should be balanced with the possible challenges of adjusting to a new nursing home." That is one of many hard truths about finding a home.

Ask Congress to Protect Quality Nursing Home Care

Helpful Tips:

• If you are looking for a nursing home, make sure the facility has a current state license. Ask to see the facility's state inspection report. If you get the run-around or if the report contains any unexplained health, safety, or quality of life deficiencies, consider dropping that facility from your consideration.
• If Medicaid or Medicare are paying for the care, make sure the facility is a certified Medicare and/or Medicaid provider.
• Talk with your physician about the level of care and any specific services that are needed and make sure the facility can meet those needs. Find out what medical, therapeutic, and other specialty services are available.
• What services are included in the basic daily rate? Ask for a complete list of specific services and benefits not covered in the basic rate.
• Make a worksheet for evaluating each facility you are considering. Select the criteria you feel are important and "weight" the different criteria based on what is most important to you and what is less important.
• When evaluating a nursing home, it's important that you get answers to whatever questions you may have, that you not feel intimidated, and that you have a tour of the entire facility. Spend plenty of time at each of the facilities. Make return visits to the facilities that look promising.
• Talk with everyone from the administrator to the director of admissions, nurses, visitors, volunteers, family members of residents at the facility. Notice the interaction between staff and residents, interaction among the staff, and the activity level of residents. Is family involvement encouraged and, if so, how?
• When trying to decide on which homes to visit, talk to your physician, friends who have had experiences with local facilities, hospital social workers, and religious organizations. Referrals from someone you know and trust are often your best source.
• Both the Texas Health Care Association and the Texas Association of Homes and Services for the Aging have checklists for helping select a quality nursing home that best meets your needs. See "Who to Contact for Additional Information" above for the addresses and phone numbers.
• Keep in mind that in-home and community-based services may be options that can allow a person to remain in their own home or in the community as long as possible. Consider checking out some of these options, such as home health care, personal assistance services, homemaker/chore services, adult day care and respite care.
• If you have a problem involving a nursing home, contact the State Long-Term Care Ombudsman at (512) 444-2727.