One in seven Americans age 65 and older will spend time in one of the nation's 16,000 nursing homes this year and for those 85 and older, the chances are more than one in five. The numbers add up to about 3.3 million Americans. How will those millions of people and their families find a source of good care?
To help them out, U.S. News displays data about nearly every nursing facility in the United States, updating the information every quarter and using it to rate and rank the homes. The 2012 Honor Roll also lists 39 homes that received perfect five-star ratings for four consecutive quarters.
The U.S. News rankings are built on data from Nursing Home Compare, a consumer web site run by the federal Centers for Medicare and Medicaid Services. CMS sets and enforces standards for all nursing homes enrolled in Medicare or Medicaid. (For government purposes, a nursing home is defined as a Medicare or Medicaid facility that provides 24-hour nursing care and other medical services. We don't rank retirement or assisted-living communities, which aren't covered by Medicare or Medicaid.) The data for Nursing Home Compare come from regular health inspections carried out by state agencies and from the homes themselves. Based on that information, CMS assigns an overall ratings of one to five stars to all nursing homes other than a few too new for meaningful data to be available. Homes are also given one to five stars in how well they do in the health inspections, in providing enough nurses, and providing a high level of quality of care.
At Nursing Home Compare, you can search for a specific home or for all homes in a particular state or within a certain distance of your city or ZIP code. But you can't assume that all homes that got five stars overall, or those with three or four stars, are of the same quality. There are so many homes at each level—2,486 overall five-star homes alone at the start of 2012—that the range of performance even within a single group is bound to be wide. Searching Nursing Home Compare also poses problems. Search terms cannot be combined, so if, say, you want only five-star homes within 50 miles of a specific city, you're out of luck.
Best Nursing Homes addresses these and other issues. Homes are presented in tiers within each star category, based on their total stars across the three major rating elements of health inspections, nurse staffing, and quality of care. The topmost tier, for example, consists of homes that not only got five stars overall, but five stars in each of the three underlying elements—a perfect 15. The next tier down is five-star homes that ran up 14 stars in the ratings categories, 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 practical, Best Nursing Homes lets you combine search terms to narrow the field. You can choose homes that are religiously affiliated, for example, or homes that accept Medicare residents. Or you can launch a multipronged search, perhaps for five-star religiously affiliated Medicare homes within 50 miles of a particular city.
All homes listed in Nursing Home Compare that are in the 50 states and the District of Columbia also are included in the U.S. News rankings. A small number that take only private-pay residents cannot be evaluated by CMS and likewise are omitted from Best Nursing Homes.
Here are more details about the CMS standards that determine a home's rating:
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 the checklist of 180-some items shows. 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 first-rate nursing care falls short if there isn't enough of it because of too few nurses who can spend 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. To receive five stars in the latest CMS ratings, nurses and aides had to provide slightly more than four hours of care a day to each resident, including 33 minutes from registered nurses. The time provided by each home is shown in the rankings.
Quality measures. CMS requires nursing homes have to submit clinical data for the most recent three quarters detailing 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 in cautioning that they are just a starting point. Nothing substitutes for in-depth visits. You can ask questions, observe residents and their families and caregivers, and get a feel of a home that stars can't communicate. "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. Moreover, "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 where a parent, or anyone you hold dear, can find good care.