America's Best Nursing Homes: How We Decide

Best Nursing Homes includes almost all of the nursing homes in the nation—"almost" because 169 are too new to rate or do not have complete data. And an unknown but small number of other homes are left out because they accept only private-pay residents or others whose care is not covered by Medicare or Medicaid.

Here is more detail on those three yardsticks CMS uses to rate nursing homes.

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 and investigate health-related complaints. "Health" is broadly defined in the 180-some items on the checklist. Besides such matters as safe food preparation and adequacy of infection control, the list covers residents' rights and quality of life, among other issues. A home's rating is based on the number, seriousness, and scope of deficiencies reflected in the three most recent health inspections and in complaint investigations during the previous three years. Best Nursing Homes displays the full range of survey findings. State inspection teams also check for compliance with fire safety rules. Their findings are displayed on Nursing Home Compare and on Best Nursing Homes, but they don't factor into the ratings.

Nurse staffing. Quality suffers if nursing home residents don't get an adequate amount of nursing care. So homes have to 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 regular inspection. The information is compared with the number of residents during the same period and displayed in Best Nursing Homes and Nursing Home Compare as the average amount of time per day for each resident.

Individual quality measures. Nursing homes have to provide the most recent three quarters of data showing every Medicare and Medicaid resident's status on 19 different indicators, such as the percentage of residents in moderate or severe pain and the percentage whose ability to get around has worsened. Best Nursing Homes and Nursing Home Compare both display all 19 for each home, but the ratings are based on 10 that are considered especially important, valid, and reliable.

However good or bad a home might look, CMS is adamant that the data and ratings should be used only as a starting point. Nothing substitutes for in-depth visits to 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 when the revamped ratings were released last December. The agency doesn't want anyone taken out of a home because of a low rating, either. "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."