Finding a Nursing Home

Having to place a loved one in a nursing home is a daunting task. The stresses are considerable and you may not be thinking clearly. It is important not to let anxiety rule you and to proceed with deliberation. If you don’t know where to begin, a good place to start is a tool from the Centers for Medicare and Medicaid Services (CMS) called Nursing Home Compare. It actually rates nursing homes, from one to five stars.

Most likely you will want a nursing home not far from where you live, which you can visit easily. You can use Nursing Home Compare to find all the nursing homes within a radius that you specify. Once you locate them, you can compare their ratings.

It is important to understand just what these ratings mean. They are not a foolproof guide to the relative quality of nursing homes. They provide a very rough indication only and should not be considered a reliable predictor of your actual experience with the nursing home. Nevertheless, these ratings constitute the best evaluation tool available to the general public. Hopefully they will be improved in the near future (more on this later), but they will never be foolproof.

Let us now examine these ratings in detail. There are four ratings categories, as follows:

Overall Rating. This is a composite of the three ratings described below.

Health Inspections. These ratings are based on the three most recent annual surveys by the state health department.

Staffing. This rating indicates direct-care staffing levels, including Registered Nurses (RNs), Licensed Practical Nurses and Licensed Vocational Nurses (LPNs and LVNs), and Certified Nurses’ Aides (CNAs).

Quality Measures. These ratings are based on specified indicators of quality of care, such as percent of residents who have pressure sores, severe pain, or are receiving antipsychotic medication.

Each of these categories has flaws. Health inspections are often not nearly as thorough as they should be. Staffing and quality measures data are self-reported, reflecting the nursing home’s own assessment of its performance. The overall rating, based on these three flawed measures, should be taken only as a rough estimate of total quality.

From my own experience I have found the quality measures category to be practically useless. It should probably be disregarded unless it is very low. Many nursing homes with low ratings in the other categories report five-star quality measures. That simply does not make sense, and indicates the subjectivity of that criterion.

Health inspections are important, but because they are brief and often incomplete, they may not give you an accurate assessment of the quality of care.

Staffing numbers can be artificially inflated: sometimes a home will anticipate the arrival of the annual survey and temporarily increase its staff during that period. While the annual surveys are supposed to be unannounced, most homes can predict approximately when they will occur, and some take advantage of that to make some very short-lived extra preparations.

Nevertheless, even given these shortcomings the ratings are still useful. A low rating in spite of the loopholes just mentioned is reason for concern. And in my own experience (remember that your results may vary, but this is what I have found), of all of these measures the most reliable one is staffing. I would even consider it a better indicator of quality of life than the overall rating (which incorporates the flaws of all three).

It is true that staffing, like quality measures, is self-reported, and it is also true that sometimes the staffing figure is inflated. However, it is harder to take liberties with the staffing figure than with quality measures. This situation will hopefully get even better in 2016 when the system is expected to start relying on payroll data to assess staffing levels, providing the staffing rating with a more objective basis. So in comparing nursing homes, I would rely first on the staffing level, then on health inspections, then on the overall rating, and only then (if at all) on quality measures. A staffing rating of four or five stars may be inflated or it may be genuine. A staffing rating of three stars or less should be considered a red flag.

Another reason to give priority to the staffing rating is that is has the most impact on the quality of life of most residents on a daily basis. Health inspections cite occasional infractions often affecting a small number of residents, like failure to give a flu vaccine, not fixing a broken sprinkler, or even putting a lock on a closet (which is now prohibited for safety reasons). Of course a health inspection may turn up a serious lapse in an individual resident’s care. But staffing levels affect every resident every day. A good staffing level is essential in ensuring that residents are changed on time, fed on time, bathed when they should be, and put to bed when they want to be. Without adequate staff to accomplish these tasks in a timely manner, residents will be less comfortable, more unhappy, and their health may suffer significantly. There is no criterion more important than staffing level.

To sum up, Nursing Home Compare is useful both in locating nursing homes near you and getting a rough estimate of the quality of the home. Once you do identify a number of nursing homes to consider, the next step would be to visit them. Many nursing homes offer tours, and scheduling a tour is one way to see the home from the inside.

There is much you can observe from actually seeing the home: Are the floors clean? Are there noticeable nasty smells? Are the residents occupied in recreational activities, or are they all lined up in the corridors like objects in a warehouse? Do staff members seem friendly and attentive, or surly and aloof? Does the home have a healthy complement of volunteers to engage with residents and transport them to activities? How does being physically inside the home make you feel? No nursing home is perfect in all these respects, but some are better than others.

Finally, a word about the admission agreement. This is essentially a contract between you and the nursing home, which you are asked to sign upon the admission of your loved one. Do not sign it hastily, but take time to study it carefully. Raise questions about any provisions that you do not understand or that may seem inappropriate.

Sometimes a nursing home will include a provision making the signee guarantee payment as a responsible third party, similar to cosigning a loan. This is actually illegal and you can point out that such a provision should be deleted. Another questionable practice you might perhaps encounter is a clause foregoing your right to legal action in case of a dispute and requiring the referral of all such matters to arbitration. This is not necessarily illegal but it is questionable. If you see either of these provisions in your admission agreement, you can cross them out and sign your initials. Often the home will not object, since the doubtfulness of these practices is known.

So do not sign anything you don’t understand, and do not rely solely on the information in this article but consult an attorney if you have significant doubts or questions. If you do need to make changes in the agreement before you sign it, you will have more leverage if you can manage to sign the agreement after your loved one has already entered the home.

Overseeing the transition of a loved one into a nursing home is always stressful. But if you go about it with eyes open and an awareness of the resources available to you, you can feel at least a little bit more in control.