Good turnover data, if they were available, would be a much better indicator of the quality of staffing. It is not unusual for a home to have annual nursing turnover of 50 or 100 percent or even higher. Because of low pay and demanding physical requirements, turnover is especially high among aides, who have the most frequent direct contact with residents. The payroll data that would allow calculating turnover are not now collected. CMS plans to begin requiring homes to submit the information, but that could be a year or more away. It is a topic very much worth raising when you visit. Step 3 will give you turnover rates to compare with the answers you get.
Buddy up to an advocate. Every state has a long-term care ombudsman whose responsibilities include pursuing complaints made about a specific nursing home, usually by a resident's family member or friend. The ombudsman is likely to know whether a facility has improved or has recently attracted a slew of complaints and should be willing to share these insights. You should also get his or her reaction to a nursing home's star ratings in the Best Nursing Home rankings for overall quality, health inspections, staffing, and medical measures. "Ask if they think the ratings are accurate," suggests Janet Wells, director of public policy at the National Citizens' Coalition for Nursing Home Reform. Advocacy groups such as hers are another information source worth tapping—and the local ones may be more ready to dish about especially good or bad nursing homes, she says. The National Citizens' Coalition for Nursing Home Reform lists contact information for all state ombudsmen and advocacy groups.
Ombudsmen and advocacy organizations should also be able to clue you in to disturbing events, such as an outbreak of C. difficile or MRSA infections, which are common in hospitals and nursing homes. And they can discuss a particular state's nursing home regulations, which can be more stringent than federal standards, as well as details of citations for any violations. If a nursing home is implicated in a resident's death in California, for example, the state ombudsman's office can disclose the violation. Publicly available federal data might not reflect the specifics of the incident. "It might say there was a [citation that put residents in] jeopardy, but it might not be in there at all," says Toby Edelman of the Washington, D.C.-based Center for Medicare Advocacy. Some state watchdogs are better than others, she adds. And the quality and level of knowledge varies widely: An ombudsman may be a part-time volunteer, for example, or might not be a particularly dogged advocate for nursing home residents.
Exploit state information. Some states have their own nursing home quality measures and post the results online. The trick is finding the information. It may be hosted by the department of public health or buried in nursing home "licensing and certification" sections. Dig around on the state's home page, its department of public health page, and anything you can find on nursing homes or certification and licensing. Terms to guide your clicking: violations, deficiencies, state surveys, inspections, and 2567 forms.
The details can be telling. While some states simply rehash the federal information, others unveil specific results from the previous health and fire inspection as reported by the surveyors on federal form 2567, which describes investigations that earned violations for the facility—staff neglect that contributed to a resident's injury from a fall, for instance, or a resident's violent agitation because nurses failed to follow medication instructions. The Illinois Department of Public Health Website, for example, posts some 2567 forms online with their nursing homes. They also have a roundup section that lists, by quarter, the fines slapped on specific nursing homes, though not the details of the violations that garnered them. The California Department of Public Health website has a separate page that allows users to identify homes the state found responsible in the death of a resident and to read the 2567 forms to see what happened.