Find the Right Nursing Home

Until last year, Norm Guivens didn't have the most favorable impression of nursing homes. Having visited various friends and relatives in these facilities, the 57-year-old Braintree, Mass., bridge teacher was struck mostly by the odor of soiled linens and by drab institutional decor. "It seemed like every time you went into a nursing home, the interior was mauve," he says.

Then late last year, after being diagnosed with dementia and suffering several falls, Guivens's 87-year-old father moved to the nursing home within his Charlton, Mass., retirement community. To create a homelike atmosphere, the immaculately clean, cheerful facility houses residents in groups of about 20 around central kitchens, dining areas, lounges and libraries. Residents are free to wake up and go to bed when they please, and they are encouraged to decorate their rooms with their personal possessions.

And Guivens's father, whose sedentary lifestyle while living alone had caused his muscles to atrophy to the point where he struggled to stand, has thrived in the nursing home. With ample attention from nursing aides, he's now moving around with a walker, chatting with other residents and playing bingo. "Healthwise, he's much better where he is now than he was in the apartment," Guivens says.

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For baby boomers like Guivens and their elderly parents, there's no question that the nation's best nursing homes can provide outstanding care in a homelike setting while helping residents preserve their dignity and autonomy. The big question is this: With more than 15,000 nursing homes nationwide, how do you find these cutting-edge facilities?

With growing piles of data showing that many nursing-home residents suffer preventable harm, finding the answer to that question is more challenging than ever. A February report from the Department of Health and Human Services' inspector general found that one-third of Medicare beneficiaries in nursing homes experienced medication errors, infections or other harm during their stay -- and nearly 60% of these incidents were "clearly or likely preventable."

Other trends are compounding the challenges of finding a quality facility. With more people "aging in place" at home, the people who wind up in nursing homes are often those with multiple medical conditions. At the same time, nursing homes are increasingly functioning as short-term rehabilitation centers for people who are leaving a hospital. When seniors are being discharged after a hospital stay, their families have little time to do their homework on local nursing homes. Often, people "don't look at the reality of nursing-home care until it's really in their face, and they have to make a rushed decision," says Brian Lee, executive director of Families for Better Care, a Tallahassee, Fla., advocacy group.

When seniors and their families plan ahead, they can make multiple visits to facilities. "You can't pick a nursing home like a microwave," says Pat McGinnis, executive director of California Advocates for Nursing Home Reform. "You need to go visit."

Begin the search. The federal government's online tool Nursing Home Compare can be a good starting point for consumers—as long as they recognize the tool's limitations. Go to www.medicare.gov/nursinghomecompare to see star ratings for all nursing homes in your area that participate in Medicare or Medicaid. The ratings range from one to five stars (more stars are better) and are based on the facility's performance on health inspections, staffing hours for nurses and nursing assistants, and "quality measures," such as the prevalence of pressure ulcers and falls among residents.

Seniors and their families should be wary of any one- or two-star facility, advocates say. Nursing Home Compare also identifies homes that have been deemed "special focus facilities," which have severe problems and should be avoided.

While the ratings can help you steer clear of the most troubled nursing homes, they won't necessarily help you find the highest-quality facilities. One reason: Two of the three major components of the star rating -- the staffing data and quality measures -- are based on information that is self-reported by the nursing homes.

The Centers for Medicare & Medicaid Services in October announced changes aimed at improving the reliability of the data underlying the star ratings. The agency said it would electronically collect payroll data, for example, instead of relying on nursing homes' self-reported staffing numbers. Although the agency will begin implementing the changes in 2015, consumers won't see some of the improvements until 2016.

Despite its limitations, Nursing Home Compare can help consumers zero in on issues that are important to them. Families of people with Alzheimer's, for example, may focus on a facility's use of antipsychotic drugs, which are widely overused in nursing homes to sedate people with dementia who become agitated, consumer advocates say. Click on "quality measures" to see information on a facility's use of antipsychotic drugs and how that compares to state and national averages.

Expand your probe. When it comes to quality of care, no nursing-home rating system or state health department Web site can tell the whole story. And sometimes, they may not even hint at major problems at a facility. An October report from the California state auditor, for example, found that the state's health department had a backlog of more than 11,000 open complaints and incidents self-reported by long-term-care facilities.

To get a fuller picture, consumers should collect data from numerous sources. New consumer-oriented online tools can help you compare nursing homes' inspection results and run-ins with regulators.

ProPublica, an investigative news organization, launched Nursing Home Inspect (http://projects.propublica.org/nursing-homes) in 2012. The online tool enables consumers to compare nursing homes in their state based on problems found by regulators and the financial penalties imposed.

The government rates nursing-home "deficiencies" -- or failures to meet regulatory standards -- on a scale of A to L, with L being the worst. Nursing Home Inspect shows the letter ratings for each facility. If you see deficiencies rated G or worse, ask the facility what it has done to correct the problems, says Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.

Call your state department on aging and your local long-term-care ombudsman's office. Ombudsmen advocate for long-term-care residents' rights and help revolve resident complaints. Ask about any state sanctions and consumer complaints against facilities you're considering. You can find links to your state programs at the Eldercare Locator (www.eldercare.gov). Also ask if your state offers its own nursing-home ratings.

A handful of states, including Ohio, Maryland and Minnesota, also offer consumer satisfaction data for nursing homes -- a key piece of information that's missing from Nursing Home Compare, says Robert Applebaum, gerontology professor at Miami University in Oxford, Ohio. In a recent study, Applebaum and his colleagues compared the federal star ratings to satisfaction surveys of Ohio nursing-home residents and their families.

The result: "It's a mixed bag," he says. While one-star nursing homes generally had lower satisfaction scores than five-star facilities, plenty of five-star facilities had low consumer satisfaction scores. "It's hard to measure quality in a nursing-home setting because most residents are not going to improve," Applebaum says. "So you're really trying to get at quality of life, which is harder to measure."

Consider a home's quality of life. A number of nationwide initiatives are focused on improving quality of life in nursing homes by making the facilities feel more like home and residents feel more like members of a family. These "culture change" efforts give residents more choices and flexibility to set their own schedules and eat what they like.

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Simple steps such as loosening rigid visiting hours and mealtimes can make a big difference, advocates say. Nursing aides don't need to haul sleeping residents out of bed at 7 a.m. so they can get to the dining room for breakfast, says Lynda Crandall, executive director of the Pioneer Network, a nonprofit group that promotes culture change in nursing homes.

Rather than making incremental changes, some culture-change advocates are starting from scratch. The Green House Project, for example, builds skilled-nursing facilities that house about 10 residents around an open kitchen. Each resident has a private room with a private bath. There are no nursing stations, room numbers, call bells or medication carts, says David Farrell, senior director of the Green House Project. Each Green House is "built from the ground up to look and feel like a real home," Farrell says. To find out if there's one in your area, go to www.thegreenhouseproject.org.

To find other facilities that are breaking from the institutional model, go to the Web site of the Eden Alternative (www.edenalt.org) and click "Eden Registry Members in Your Area." Or find your state's culture-change coalition at www.pioneernetwork.net/coalitions/find.

Take a look. Visiting the nursing home is critical to finding quality care. Take the tour during regular business hours. But also have a meal, and schedule another visit late in the evening or on a Sunday afternoon, to get a flavor of round-the-clock life in the facility.

In addition to basics such as cleanliness and food quality, observe whether residents are engaging in activities or sitting around listlessly. Check the bulletin boards for information on resident and family council meetings. Leaders of these groups, which advocate for residents in the home, can provide insight on any concerns about the facility.

Staffing is among the top factors to consider. "Staffing is the key to quality care," Lee says. "And if you don't have the staff, it doesn't matter what the lobby looks like or if they're serving a five-star meal."

During your visit, observe whether residents are sitting around waiting to be fed at mealtimes or waiting to go to bed after dinner. If so, the facility probably doesn't have enough staff, McGinnis says. Ask about the level of staff turnover, which tends to be fairly high in nursing homes. If they've had four administrators in one year, "it's a yellow or even red flag," Crandall says.

Turnover among the nursing aides who provide most of the day-to-day care for residents is also exhausting for residents and families. Joi Holcomb, 56, a medical illustrator in Austin, Tex., says she has had to explain to a constantly changing cast of nursing aides how to care for her 95-year-old mother, who has dementia. Aides who don't know her mother well, for example, will simply give her fresh clothes and leave the room, not realizing that she needs help getting dressed. "We have a care meeting every three months, and we're addressing the same problems all the time," says Holcomb, who visits the facility at least twice weekly.

Ask the facility if it practices "consistent assignment," meaning that the same aide is assigned to care for the resident each day. In facilities that don't use consistent assignment, residents can have as many as 20 or 25 different people caring for them in a month. If you have to teach that many people how you want things done, "you just give up," Crandall says. "Who wants to exert that much energy?"

Ask about the total number of nursing hours per resident per day. Research has shown that at least 4.1 hours are needed to reduce risks of harm to residents, Grant says. Also ask about the ratio of staff to residents. A good minimum ratio would be about one to five during the day, one to ten in the evening, and one to fifteen at night, Grant says.

Find out if there's a registered nurse on site around the clock. Federal requirements mandate that nursing homes have an RN on site just eight hours per day, which is "woefully inadequate," Grant says. RNs are the only members of the nursing staff licensed to assess a resident when his medical condition changes.

Read the contract. The high cost of care means that many nursing-home residents who enter a facility intending to pay privately will ultimately run out of money. Medicare only pays for limited nursing-home care. Therefore it's best to focus on facilities that accept both Medicare and Medicaid -- information that's available on Nursing Home Compare.

When reading the facility's admissions contract, families should be aware of any provisions asking for a financial guarantor. "Federal law prohibits a nursing facility from requiring a financial guarantee as a condition of admission," says Eric Carlson, a directing attorney at the National Senior Citizens Law Center. Some facilities have asked relatives to "volunteer" to be financially responsible, he says. "Don't sign anything to take on financial liability," Carlson says.

Another red flag in the agreement: a waiver of liability, such as language suggesting that falls, dehydration and other harm are common and unavoidable. Also look for broad language authorizing eviction without proper cause, such as when a resident is unmanageable or uncooperative. And watch out for arbitration agreements, which remove the resident's right to take the facility to court if a dispute arises.