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Six Steps to Evaluating Nursing Homes with Elder Guide's Tools

Published: Nov 18, 2020. Last Updated: Dec 1, 2020.

1. Finding Elder Guide’s Provider Pages

Once you have made your list of potential nursing homes, we recommend assessing the quality of each facility by visiting the facility’s provider page on Elder Guide. You can find provider pages in several ways, including:

  • Searching for a particular facility by name in the search tool on our homepage;

  • Searching for a particular city, town or zip code in the search tool on our homepage and then selecting a nursing home from the list of facilities in that city;

  • Going to a state page (you can find our state pages by scrolling down to the bottom of our national nursing home page and selecting the state you are looking for). Once on a state page, you can see how facilities in the entire state fared in our evaluations, as well as how the nursing homes in various cities and towns scored. You can then select a city or town by scrolling down to the bottom of the state page. Each city or town page will include a list of the nursing homes in that location (as well as the surrounding area) ranked by overall grade.

2. Understanding Elder Guide Overall Grades

Start by looking at each nursing home’s overall grade in the first paragraph. We grade on a scale of A+ (best) through F (worst). This first section will also indicate whether the facility has been flagged for abuse in the past three years. If a facility has been flagged for abuse, we cap its overall grade so you may notice that its overall grade is less than the average of its category grades. You may want to break the nursing homes into tiers as follows: We consider facilities that received a grade of A- or better to be elite. Our second tier would be facilities that received a B or B+, which is still a quality score. Our third tier

Tier 1: This tier should be reserved for nursing homes with an Overall Grade of A- or better. We consider these facilities to be elite. This typically means they performed well in all four categories we assessed, were well-staffed and had favorable quality metrics.

Tier 2: This tier should typiclaly include nursing homes with an Overall Grade of B+ or B. These are still very good facilities which likely performed well in most categories. In this range, it is possible that the facility might have had a single weak area in one of our categories.

Tier 3: Nursing homes with an Overall Grade of B- or C belong in this tier. For most people, this will be the last tier you seriously consider as an option. These are often respectable nursing homes, which may even be surprisingly strong in a single area such as rehabilitation or long-term care. However, they typically have at least one weak category grade, so you want to review their category grades carefully.

Tier 4: Finally, tier 4 includes nursing homes with an Overall Grade of D or F. These are our lowest rated facilities. In some cases, grading algorithms may be unfair to certain nursing homes that have highly complex patients or other extenuating circumstances. However, generally speaking grades in this range are a bad sign about a nursing home’s staffing levels and recent inspection reports, as well as critical quality metrics which we will discuss below. You may also want to include in this tier any facility that was flagged for abuse, as a special focus facility or for a category L deficiency, depending on how selective you would like to be. At a minimum, we would recommend placing a caution flag next to these facilities to make sure you investigate this issue if you tour the place.

If you live in an area with more facilities, you can certainly afford to be more selective. If you live in an area with limited options, you may still need to consider these facilities.

You probably want to begin your analysis by focusing on the nursing home in the first two tiers and then move down your list if you have sufficient time or require specialized care that the higher rated facilities don’t offer. We generally don’t recommend crossing nursing homes off your list solely based on our grades, but that is a personal decision. Just remember that there is a reason why they scored so poorly in our assessment and it will typically be self-evident when you read our evaluation. We certainly wouldn’t blame you if you refused to consider facilities that have been flagged for abuse or dinged with severe deficiencies in recent inspection reports.

3. Using the Elder Guide Staffing Calendar

Hopefully after you completed Step 2 above, you had enough nursing homes in the first three tiers that you were able to find a few highly rated nursing homes in your area. The easiest way to narrow that list down is to weed out any nursing homes that don’t offer the services you need. For this, we would recommend using Elder Guide’s staffing calendars.

You can find each nursing home’s staffing calendar below the introductory paragraph on each provider page, right above our analysis of the facility’s category grades. You can filter these calendars to present either medical staffing or therapy staffing. You can also filter by specific staffing roles to see how a facility stacks up if you require very specialized care.

These staffing calendars are one of the most critical tools we can offer. When building this site, we spoke with a number of physicians and other professionals who emphasized that one of the most difficult issues with placing a patient in a nursing home is knowing whether they adequately offer the services the patient requires. If you are being placed in a nursing home for short-term rehabilitation and you require physical therapy, respiratory therapy and wound care for instance and you, your physician or a hospital case manager call the facility, the nursing home will simply confirm whether or not they offer those services. However, there is a wide range of offerings among facilities that offer those services, ranging from facilities with multiple full-time registered nurses, physical therapists and respiratory therapists on staff to facilities that only bring in part-time outside contractors to provide these services and primarily rely on aides to work with patients. Our staffing calendars take the mystery out of this aspect of the placement process by showing most nursing home’s staffing levels over the past three years.

In addition to being able to see which facility’s offer the specialized care you need, you can also see how care levels fluctuate seasonally throughout the year. For instance, some facilities increase staffing levels in the winter when their patient count typically increases. There may be scenarios where a nursing home would ordinarily be a good fit but perhaps it isn’t at the moment due to an increased patient count or temporarily reduced staffing levels.

Finally, these staffing calendars allow you to see when a nursing home was inspected by government inspectors. Ordinary inspections are shown with a red square outlining the inspection date on the calendar. Inspections triggered by a resident complaint are filled in with red on the applicable inspection date.

4. Weighing Elder Guide Category Grades

At this point, you should have a list of respectably graded nursing homes that offer the specialized services you require. The next step is reviewing those nursing homes’ performance in the specific categories which are most relevant to you. In fact, you may now want to break your tiers up into categories A and B

Our overall grades are based on a weighted average of four categories: inspections, short-term care, long-term care and nursing. We cap overall grades for facilities that were flagged for abuse or as special focus facilities by CMS, so in limited cases a facility’s overall grade may be below any of its category grades. Below is a summary of some of the more important metrics we factor into each category grade. Please keep in mind that these are not the only metrics we use in determining these grades.

Inspection Grades

Inspection grades are critical for every prospective resident, regardless of whether you need long-term care, rehabilitation, or some kind of specialized care. Inspection grades are based primarily on the deficiencies, substantiated complaints and government fines received by a facility. This category is unique in that every criteria we look at for this category is a negative indicator. In other words, our hope is that the facility has zero deficiencies, zero fines and zero complaints. The best nursing homes have nothing whatsoever to report here. These nursing homes will have A+ inspection grades. However, only around one in ten nursing homes can report zero deficiencies over the last three years and even fewer have zero complaints and fines as well. As a result, we must put these negative indicators into perspective.

Just because a nursing home has a few minor deficiencies, a complaint or two and perhaps even a small fine, that simply does not mean it is a bad option. On the other end of the spectrum, there are nursing homes with really serious deficiencies that threatened residents' lives, some of which have also been flagged for abuse or branded as special focus facilities. Roughly eighty percent of the nursing homes fall somewhere in the middle. We needed a mechanism for evaluating this wide swath of facilities and our inspection grades are our best attempt to qualify a facility's most negative attribute and translate it into

Deficiencies

Without question, the most significant factor in our inspection grades is the number and severity of deficiencies a nursing home received in the past three years. Deficiencies are broken out into 12 categories which are labeled A through L, which can be broken down as follows.

Minor Deficiencies: Most deficiencies fall into categories A through F, which are relatively minor. We don’t ding nursing homes much for these minor deficiencies. Nevertheless, you also want to take note of a facility that had an excessive number of these deficiencies as that could still be a negative indicator regarding the level of care.

Severe Deficiencies: Deficiencies in categories G through I are significantly more concerning than minor deficiencies. These deficiencies have the potential to cause actual patient harm. However, unlike the most severe deficiencies described below, CMS does not consider these deficiencies to place patient safety in immediate jeopardy. Due to the seriousness of these deficiencies, we penalize a nursing home five times as much for one of these deficiencies as for a minor one.

Most Severe Deficiencies: The most severe deficiencies are labeled category J through L. These deficiencies have the potential to cause patient harm and are deemed so severe that they place patient safety in immediate jeopardy. The worst of the worst are category L deficiencies which indicate that the relevant deficiency was widespread at the facility.

Complaints

Complaints filed by residents are a significant factor. However, it may be difficult to distinguish between significant complaints and some of the more frivolous complaints that probably should not impact our decisions. When a facility has received a significant quantity of complaints, it's probably safe to assume it has some issues.

If a government agency is concerned about a facility's complaints, it may schedule an inspection. You can also go back to our staffing calendars (described above) to see if a particular nursing home had any complaint-driven inspections. The dates with complaint given inspections are solid red boxes. However, if a facility had one of these inspections but still has an excellent inspection grade, this means the government inspectors were satisfied with their findings. Ideally, we prefer nursing homes to have inspection grades of A- or better. In these cases, you probably shouldn't overreact to the fact that the facility had a complaint or two, or even a complaint-driven inspection.

Fines

FInes are commonly used as punishment for repeated violations. Typically, this is an indication that a facility has been dinged for the same deficiencies repeatedly over a period of several years. The more significant the repeat deficiency, the greater the fines. Generally, single fines in excess of $10,000 suggest the source of the fine was more than just a minor deficiency. Once again, we suggest putting a fine or two into perspective and focusing on the bigger picture. If the facility received a fine along with some severe deficiencies and a subpar inspection grade, it is a big deal. However, if the inspection grade is strong and there is no sign of severe deficiencies, a small fine is not the end of the world. Your assessment of a nursing home should take a multitude of factors into consideration and this is only one factor.

Short-Term Care Grades

Short-term care grades are most important for people requiring rehabilitation. Rehabilitation patients tend to stay in nursing home for a shorter period of time, typically less than three months. Since these patients are typically recovering from an injury or surgery, they usually require more advanced medical care than a typical nursing home resident. The additional care required may include wound care and administration of IV medications.

Skilled Staffing

Due to the increased medical needs, short-term care patients also require different types of therapy, including physical therapy, occupational therapy, respiratory therapy and other services. Consequently, when assessing staffing levels for this category, we apply substantial weight to the more highly skilled staff members, including registered nurses and physical therapists.

With regard to staffing levels for specific individuals, it may make sense to view our short-term care grades alongside the facility's staffing calendar (discussed above). There are several areas of staffing which are seldomly required so we don't necessarily factor them all into our short-term care grade. However, if you know you require a particular type of care and it is available at a particular facility, this may be more important to you than our short-term care grade, which is based more on conventional rehabilitation.

Patients Returning Home

In additional to looking at the most important staffing components, we also focus on the facility's discharge rate, which is the percentage of short-term patients who are able to return home. This is a strong measure of rehabilitation, as most patients' ultimate objective is to leave the nursing home and get back to their own home. However, you should keep in mind that this metric is more indicative of the performance for some facilities than others. Certain nursing homes may be handling sicker and older patients who simply are less likely to ever be able to leave a nursing home. We would not write off a facility with a low discharge rate if it has performed well in the other short-term care metrics, particularly metrics relating to staffing levels.

Vaccinations

Finally, we also look at the percentage of a nursing homes' residents who have been vaccinated for flu and pneumonia. Most nursing homes provide these vaccines automatically unless a resident explicitly opts out. In some cases, a lower rate of vaccination may be outside of a facility's control if it has a significant percentage of residents refusing vaccines. Nevertheless, we would argue that this is still something you should take into consideration as many seniors would prefer to be in a facility with nearly a 100% vaccination rate. It is worth noting that vaccination levels for these vaccines may also be predictive of how many people at a given facility will refuse vaccination once a COVID-19 vaccine is available.

Long-Term Care Grades

Our long-term care grades are most important for older, sicker residents who are likely to spend the rest of their lives in a facility, yet don't necessarily require the more highly skilled nursing care or therapy associated with rehabilitiation. Long-term care residents primarily need assistance with activities of daily living, help taking medications and perhaps some routine medical care. The purpose of this type of care is generally to improve the quality of the residents' lives, rather than to heal them or get them back to their own homes. One common ailment that tends to lead to longer term stays in nursing homes, yet doesn't necessarily require sophisticated medical care, is Alzheimer's and other forms of dementia. In addition to the metrics described below, we also consider several other metrics in our long-term care grades which are also factored into other categories. These include vaccinations, pressure ulcer rates and substantiated complaints.

Long-Term Care Staffing

The most important metric for long-term care residents is usually just total nurse staffing. It generally makes little difference whether this care is provided by nurse's aides or more highly skilled nurses such as registered or licensed nurses. Long-term care residents often require care around the clock seven days per week. An extra hour or two of skilled staffing won't make much difference, but if these folks are left unattended and stop receiving regular care, poor outcomes are likely.

Hospitalizations

One way to measure the level of care being received by long-term care residents is to look at a facility's hospitalization rate. Hospitalizations are often the results of falls, urinary tract infections, pressure ulcers and other common outcomes for frail patients receiving inadequate care. Nevertheless, it is important to realize that hospitalizations may naturally be higher at certain facilities receiving patients with more complex medical conditions. In other words, just becasue a nursing home has a high hospitalization rate doesn't necessarily mean you're going to end up in the hospital if you go to that nursing home. We recommend considering this metric as one piece of the puzzle, just like most other metrics.

Nursing Grades

Our nursing grades are based on a combination of all levels of nurse staffing, as well as a serious of qualitative metrics. We consider this to be the most comprehensive assessment of a facility's nursing staff that we can offer based on the available data.

Nurse Staffing

In this category, we factor in staffing levels of registered nurses, licensed nurses and nurse's aides. We weight each category based on the skill level of those nurses. For instance, we weight an hour performed by a registered nurse several times more than we weight an hour performed by a nurse's aide. Once again, for long-term care residents, you still probably should focus more on the facility's long-term care grade than its nursing grade since this high level nurse staffing may not be as relevant for you.

Qualitative Measures

What really sets apart our nursing grade from the assessments found in our other categories is the emphasis on nursing qualitative measures. Most importantly, we look at the rate of pressure ulcers and major falls resulting in injury. Our reasoning here is that patients receiving more care are far less likely to sustain a fall or a pressure ulcer. This isn't true in every single situation, but it is true most of the time. For instance, simply moving a patient once per day has been proven to prevent pressure ulcers. Similarly, when patients are left unsupervised, they are far more likely to fall. As a result, most of the medical professionals we consulted with emphasized that these metrics were critical to evaluating the nursing care at these facilities.

5. Evaluating Individual Metrics

Each category grade is based on a group of individual metrics. We highlighted some of the most important metrics above which are weighted most heavily in computing those category grades. We weighted these metrics the most because we determined that these metrics had the most predictive value. In other words, they were more closely correlated with overall quality of care. You can find many of these individual metrics for each facility at the bottom of their provider page, below our category grades. Aside from our staffing measures (such as nursing and physical therapy hours) and inspection inforation (such as deficiencies, complaints and fines), some of the most important qualitative metrics to look at are as follows:

  • pressure ulcers;
  • major falls resulting in injury;
  • return to home rate (aka discharge rate); and
  • hospitalization rate.

Nevertheless, there are other important metrics you may want to consider which are not factored heavily into our category grades. These metrics include:

  • urinary tract infections;
  • prescription of anti-psychotic and anti-anxiety medications;
  • vaccinations;
  • management of depression;
  • residents maintaining autonomy;
  • mobility; and
  • ER visits.

We simply did not weight these metrics as heavily in our category grades because we did not find that they were as predictive of overall quality. As a result, we recommend you look at these metrics, but do not overreact to a bad metric.

A great illustration of where an important metric may not be very predictive is if you look at the use of psychiatric drugs. These drugs receive alot of attention because some nursing homes have received negative publicity for overmedicating their residents in order to simply make them less mobile and cognizant so that they are easier to manage. The use of these drugs for this purpose is disgraceful and warrants all of the negative press it receives. However, a memory care facility where most of the residents have Alzheimer's (or other types of dementia) is naturally going to prescribe anti-psychotic and anti-anxiety drugs at a higher rate than a typical nursing home. This is simply a byproduct of its resident population. This doesn't mean it's a bad nursing home or that it's abusing these drugs. Consequently, we suggest that you take note if a facility prescribes pschiatric drugs at a higher than average rate. Then consider the patient population and whether this phenomenon makes sense. Also, when you tour the facility you can observe the residents and ask questions about the usage of these drugs. There may be a perfectly logical explanation. On ther other hand, you may emerge from your tour convinced that these drugs are being abused at that facility and simply cross it off your list.

Urinary tract infections (UTI's) is another example where a metric can be very predictive of poor care in some cases and not in others. Many medical professionals view a higher rate of UTI's as strong evidence of poor hygiene and bad nursing care. However, the standards for diagnosing UTI's varies from facility to facility and state to state. A facility may simply have a higher rate of UTI's because it has a practice of diagnosing them earlier and treating them more frequently. Nevertheless, if you tour a nursing home and find that it has an aroma of urine and that residents look unclean and poorly cared for, then you should take a high rate of UTI's extremely seriously. As always, make sure you ask the right questions and get to the bottom of any poor metric.

We would recommend asking the nursing home administrator or nursing director about any metric where the nursing home received a grade of D or F in our scoring system. If they seem unaware that they are weak in that area or don't have a plausible explanation, this may influence your decision. In other cases, their explanation may put your mind at ease. For instance, during the COVID-19 pandemic some states and counties imposed restrictions on discharging residents from nursing homes in order to reduce the spread of the virus. In these areas, you will likely find that all of the nursing homes have poor discharge rates which are pulling down their short-term care grades. In these cases, you may also want to look at nursing homes' historical grades in certain categories to see if they previously fared better in a particular area.

6. Putting this Data into Perspective

Between our overall grades, category grades, metrics and staffing calendars, we do our best to provide you as much information as possible to assess the nursing homes in your area. These tools are incredibly helpful for breaking a large list of nursing homes into relative tiers and determining which ones may or may not be fits based on your needs. We also hope to have armed you with enough information to ensure that you will not be deceived by unscrupulous placement agent or inexperienced case manager steering you towards a subpar facility. Nevertheless, this is only part of the equation.

We still recommend that you consult with your physicians and other medical professionals, as well as friends and family who have had experiences with particular nursing homes. At the end of the day, there is simply no substitute for touring a handful of facilities and seeing them with your own eyes. You are going to gather information during an in-person visit that we simply cannot capture from the data alone. You also want to consider the other factors we outline in our Guide to Choosing a Nursing Home, such as financial considerations or whether the facility accepts certain government benefits you may qualify for. Some individuals may also prefer to be in specific types of facilities, such as veterans facilities or church affiliated facilities. Choosing a nursing home is a difficult process and we recommend that you and your family take the process seriously. We will do our best to provide you with quality resources to guide you through this process, every step of the way.

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About the Author

Nick Lata

Co-founder

Elder Guide LLC

Nick Lata is one of the co-founders of Elder Guide. He is a licensed attorney who has advised many seniors on a variety of issues over the years. Nick has dedicated countless hours to better understanding the long-term care decision making process and the myriad of complex issues that come with it, ranging from senior living options to Medicaid and other government benefits. He has sought out advice from hundreds of attorneys, doctors, nurses, physical therapists, accountants, financial planners and other professionals in his effort to produce the most informative content for Elder Guide users. Nick is a graduate of Brandeis University and the University of Connecticut School of Law. He lives in Sarasota, Florida with his wife Sarah who is a local primary care physician and their three children, Veronica, Christian and Patrick.