America's Best Nursing Homes: How We Decide

In a typical year, about 3.2 million Americans will spend at least some time in a nursing home. To help find a good choice from among the nation's more than 15,500 homes, U.S. News created America's Best Nursing Homes. All data and other information are updated quarterly. The new update is effective as of October 1.

At the core of the rankings is the data and ratings found on Nursing Home Compare, a federal website created by the Centers for Medicare and Medicaid Services. The CMS collects and analyzes information on almost all nursing homes—all that accept Medicare or Medicaid residents—and rates the facilities on numerous measures, from safe food preparation to the amount of nursing care per resident. We added major features to boost reliability, speed, and flexibility in searching for the right home. An Honor Roll lists homes at the very top of the heap.

CMS freely acknowledges that its rating and tracking systems could be better. Homes are given an overall rating of one to five stars, based on how well they measure up in three major areas (described below), which also are scored from one to five stars. One star means far below average, five stars far above average. Users can search for a specific home or for all homes in a certain location, such as within a state or a certain distance from a city or ZIP code.

One problem, however, is the large number of homes within each star rating—1,926 five-star and 3,833 four-star homes, for example. With so many, you can't assume that the quality of all of the homes with the same overall rating is about the same. A second drawback is that search terms cannot be combined if, say, you want to look only for five-star homes within 50 miles of a specific city. And a third difficulty is that if you're not sure of the name of a home or where it's located, you have to plow through long lists of homes in likely cities (all those Goshens and Middletowns!) or a state or a region, one by one, until you hit your target.

The Best Nursing Homes rankings resolve these and other issues. For a more precise indication of quality, we created tiers within each star rating based on the total number of stars in all three of the categories CMS uses as yardsticks: health inspections, nurse staffing, and individual quality measures. The topmost tier of five-star homes, for example, consists only of homes that got 15 stars across the three yardsticks, the highest number possible; they make up the Honor Roll. Of all 15,542 CMS-rated nursing homes, 34 made the Honor Roll in the latest update. The next tier down is comprised of five-star homes with 14 stars in the three yardstick categories, and so on. Note that within tiers, homes are ordered alphabetically, not ranked.

You can also combine different search approaches. If initially hunting by state, region, city, or ZIP code turns up too many homes, the results can be winnowed to homes with a religious affiliation, for example, or ones that accept Medicare residents. Or a new, multifaceted search can be launched for, say, religiously affiliated five-star homes within 50 miles of a particular city that take Medicare.

We also extend a helping hand. Suppose you're not positive you've got the right name of a home, or you've forgotten where it is. On our search page, you don't need the precise location. If you enter as much of the name as you remember and click on Search, you'll get a matching list of homes in all parts of the country. Typing "Sun" and hitting Search, for example, yields about 200 homes with "sun" somewhere in the name (Sunrise, Sunset, Sunny...). If you want all of the homes in a specific city, just starting typing the city name. After a few characters, a list of cities whose names start with those letters appears. Entering "mid," say, brings up an assortment such as Middleboro and Middletown. You can click on any of them to find homes there.

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."