Choosing a Nursing Home or Skilled Nursing Facility: Navigating the Long-Term Care Crisis

Choosing a nursing home or skilled nursing facility (SNF) is a critical decision for seniors and families. A recent report from Nonprofit Quarterly, “The Triple Threat Facing Nursing Homes—And How to Overcome It, explains why many residents view nursing home life as being a "Fate Worse than Death." It highlights a crisis driven by private equity ownership, profit-driven care, and COVID-19’s lasting impact. Understanding these risks is essential to selecting a safe facility or planning to age in place with confidence.

This article will break down what the “triple threat” means for you, explain the risk, i.e., the balance of nonprofit versus for-profit facilities, show you how to choose safer nursing homes and how to identify private equity ownership, and why planning to stay out of an institution is more important than ever.

The Triple Threat: What It Means for You

The Nonprofit Quarterly report identifies three interconnected forces threatening nursing home care quality, which directly impact seniors and families considering institutional care:

• Commodification of Elder Care (“Gray Gold”): Nursing homes have shifted from care-focused to profit-driven models. The article references Timothy Diamond’s book Making Gray Gold, which describes how elder care became a marketable commodity, prioritizing financial gain over resident well-being. For you, this means some facilities may cut corners on staffing, resident meals, supplies, or services to boost profits, potentially leading to neglect, medication errors, or infections.

• Private Equity’s Aggressive Expansion: Private equity firms are increasingly acquiring nursing homes, using complex financial strategies like inflated service fees or property leasing to extract wealth. These practices often reduce resources for care, resulting in understaffing and substandard conditions. For seniors, this translates to a higher risk of harm in facilities owned by such firms, as seen in cases like the 2018 bankruptcy of HCR ManorCare, where care quality plummeted under private equity ownership.

• COVID-19’s Lasting Impact: The pandemic exposed and worsened existing flaws, with over 200,000 nursing home deaths highlighting staffing shortages and infection control failures. For families, this underscores the ongoing risk of infectious outbreaks in facilities with inadequate staff or protocols, making safety a top concern.

• What This Means for Quality of Care: These threats increase the risk of harm in nursing homes, particularly in for-profit facilities. A 2014 Department of Health and Human Services Office of Inspector General (OIG) report found that 33% of Medicare beneficiaries in SNFs experienced adverse events (e.g., hospital readmissions, permanent harm, or death), with 59% deemed preventable due to substandard care or errors. The triple threat amplifies these risks, making it essential to carefully evaluate facilities and prioritize alternatives like aging in place. There is significant incentive for executives too; in the case of HCR ManorCare, the final bankruptcy approved a payout to the former CEO of $116 million.

Nonprofit vs. For-Profit Nursing Homes: The Ratio and Why It Matters

Nationwide, there are approximately 15,000 nursing homes, serving over 1.3 million residents. The ownership breakdown is:

• For-Profit: 70-72% (roughly 10,500-10,800 facilities), increasingly dominated by private equity, REITs, and midsize chains.

• Nonprofit: 24% (about 3,600 facilities), often run by faith-based or community organizations.

• Government-Owned: 5-6% (750-900 facilities), typically public or VA facilities.

The vast majority of nursing homes are For-Profit; you may have to work to find a non-profit in your area.                                                                                                       

Why Nonprofits Are Safer: Studies consistently show nonprofits provide better care. A 2011 LeadingAge New York study found nonprofits had fewer hospitalizations, lower antipsychotic use, and higher staffing levels. A 2020 meta-analysis estimated that nonprofit facilities have 7,000 fewer pressure sores and provide 500,000 more nursing hours daily nationwide. For-profits, especially private equity-owned, have more deficiencies and lower quality ratings, as seen in the 2018 HCR ManorCare bankruptcy, where violations soared under Carlyle’s ownership.

What This Means for You: Prioritize nonprofit facilities when possible, as they’re less likely to prioritize profits over care. However, nonprofits are harder to find, with their share dropping from 30% in the 1990s to 24% today due to financial pressures and acquisitions. Use Nursing Home Compare to filter for nonprofit status and verify during tours.

Spotting Private Equity Ownership

Private equity-owned nursing homes are riskier due to profit-driven cost-cutting. A 2023 Good Jobs First report noted that midsize private equity chains often have fines averaging over $100,000 per facility for violations. Determining ownership cab seem a daunting task, particularly when ownership is not transparently offered to individuals considering that home. Here’s how to identify such ownership:

Check Ownership Details: Use CMS’s Nursing Home Ownership Data (go to data.cms.gov for other data sets) or state licensing records to find the facility’s parent company. Private equity firms often use complex structures with multiple subsidiaries (e.g., separate entities for operations and real estate). Look for names like Portopiccolo Group or HCP, Inc., (now known as Healthpeak Properties, Inc. after a 2019 rebranding, known for private equity or real estate investment trust (REIT) ties.

Look for Related-Party Transactions: Private equity firms may contract with affiliated companies for services (e.g., therapy, staffing), charging inflated fees that drain resources. Ask the facility for a list of contracted services and their providers. If multiple services come from related entities, it may signal profit extraction.

Research Recent Ownership Changes: Facilities that changed hands between 2016 and 2021 (over 20% of U.S. nursing homes) are more likely to be private equity-owned. Check news reports or Ziegler Investment Banking data for recent acquisitions. A 2024 KFF Health News article noted that 900 nonprofit nursing homes were sold to for-profit operators since 2015, often to private equity or REITs.

Ask Directly: During tours, ask administrators about ownership structure and whether the facility is part of a for-profit chain or investment group. Be wary of vague answers or reluctance to disclose.

Choosing Safer Nursing Homes: Key Steps

If institutional care is necessary, selecting a safer facility is critical. Here’s how to navigate the process:

Evaluate Staffing Levels: Staffing is the strongest predictor of care quality. Check the facility’s nurse-to-resident ratio on Nursing Home Compare. CMS’s 2024 minimum staffing rule requires 3.48 hours of direct care per resident day (including RNs and aides). Avoid facilities with frequent staff shortages, as these are linked to higher rates of infections and falls. Ask about staff turnover rates during tours—lower turnover suggests better working conditions and care consistency. Check to make sure that there is at least one RN on staff 24 hours each day.

Investigate Infection Control: Post-COVID, infection prevention is crucial. Ask about the facility’s infection control protocols, vaccination rates, and history of outbreaks. A 2024 OIG report found that 24% of for-profit SNFs failed to meet infection preventionist staffing requirements, increasing risks.

Tour and Observe: Visit potential facilities repeatedly, unannounced, if possible, at different times to observe cleanliness, staff responsiveness, and resident well-being. Red flags include unanswered call bells, unclean rooms, or residents appearing neglected (e.g., unassisted with meals or hygiene). Observe whether staff members know the names of residents and each other. Speak with residents and families about their experiences.

Assess Meal Quality: Nutrition is vital for your loved one’s health and well-being in a nursing home, yet some facilities, may cut costs by offering bland, repetitive meals. When evaluating a facility, visit during mealtime, spend time in the dining room, and request to sample a meal. Inquire about options for dietary needs, such as vegetarian, kosher, heart-healthy, or diabetic diets, and ask residents if they enjoy the food. A high-quality nursing home will confidently demonstrate its dining experience, prioritizing flavorful, nutritious meals tailored to residents’ needs. Poor-quality, unappealing food lacking variety can lead to malnutrition, mental decline, and serious health issues, diminishing your loved one’s quality of life. Choose a facility that invests in its dining program to ensure both health and happiness.

Review Inspection Reports: State inspection reports, available via Nursing Home Compare or state health departments, detail violations. Avoid facilities with repeated or severe deficiencies, such as failure to prevent pressure ulcers or medication errors.

Consider and Compare Costs, Expenses, and Fees: When considering a nursing home, meet with the admissions office to thoroughly review costs, fees, and expenses; lack of transparency can lead to unexpected financial burdens. Candor and transparency might reveal the home as less concerned with "getting a contract and starting billing" and more concerned with a transparent, cooperative, mutually rewarding relationship. Request a detailed, written breakdown of costs before deciding, clarifying what’s included in the base price and which services (e.g., therapy, specialized care) incur extra fees. Discuss Medicaid coverage with the facility’s social worker, even if it’s not immediately needed; some facilities guide families through the application process, potentially saving thousands in legal fees, while others offer little or no support. Inquire about policies for scenarios like hospitalization or hospice care, as these can trigger additional costs. 

Many families are unprepared for the complexity of long-term care financing, and facilities may not fully disclose fees upfront. Medicare and Medicaid often don’t cover all services, and some facilities may not accept both programs, leaving families to face out-of-pocket expenses, disputes, or even discharge. Proactive planning, including exploring Medicaid asset protection with an elder law attorney, can safeguard your finances and ensure your loved one’s care.

Use Multiple Rating Tools: Start with Medicare’s Nursing Home Compare to review a facility’s star rating (1-5 stars) based on health inspections, staffing, and quality measures, but recognize its limitations; you can read multiple articles about the these limitations and weaknesses by selecting the label "Nursing Home Compare" at the lower right of this page (or simply click on the link to perform the search). Complement it with: 

• U.S.N&W.R.:  U.S. News & World Report’s Nursing Home Ratings evaluates nearly 15,000 nursing homes annually, rating them for short-term rehabilitation and long-term care based on CMS data but with a proprietary methodology that emphasizes outcomes like rehospitalization rates (ideally below 20%) and resident satisfaction.

• NusingHome411: NursingHome411’s Problem Facilities Dataset, sponsored by the Long Term Care Community Coalition, this rating service and dataset flags Special Focus Facilities and one-star homes, often for-profits. Use this tool to avoid low performers.

• State-Specific Tools: Many states host their own alternatives to the federal CareCompare, some simply reporting CareCompare information, but many providing more granular data for specific homes in that state.  State-specific tools like Minnesota’s Nursing Home Report Card or Massachusetts’ Survey Performance Tool offer local insights. These alternatives provide a fuller picture of care quality, and align with the need to prioritize nonprofits, offering potentially better outcomes.

• Ohio Nursing Home Quality Navigator: Offers a searchable map, CMS star ratings, staffing stats, resident satisfaction, and violation counts for Ohio’s 960 nursing homes.

• Ohio Long-Term Care Consumer Guide: Offers inspection summaries, satisfaction surveys, and costs, ideal for nonprofit comparisons (24% of facilities, 7,000 fewer pressure sores).

• Missouri DHSS Facility Search: Delivers detailed inspection reports and deficiencies for 1,111 facilities, helping identify risky for-profits.

These tools help prioritize nonprofits and high-quality homes.

Leverage User Reviews: Check the name of a home or institution against the Blog for the National Association to Stop Guardianship Abuse.  The Blog has a convenient search tool, and is one of the most comprehensive sources for news about nursing home cases of abuse and neglect.  Check Yelp, Facebook, or similar platforms for resident and family feedback or stories on staff responsiveness and care quality, but cross-reference with data-driven tools due to potential bias.

Monitor Consumer Feedback and News: Check X for resident/family posts using hashtags like #NursingHomeAbuse or #ElderCare. In Ohio, I was able to identify posts describing lawsuits against Majestic Care of Fairfield (March 2025) regarding alleged staffing-related deaths, and a Warrensville Heights death (January 2025), exposing monitoring failures. In Missouri, one-star Kansas City homes (March 2025) face abuse citations, and a 2024 report noted unnecessary confinement of mentally disabled residents. On the other hand, nonprofits like Friends Care Community, Ohio, earn praise on X for resident satisfaction. These are, of course anecdotal, and like all social media subject to bias, misinformation, misunderstanding, and misattribution. In some cases, though, you may find information critical to your decision.

Beware of Guardianship Abuse: Even if unnecessary you should ask the nursing homes how it handles guardians and conservators, and whether it has an affiliated entity that can serve as a guardian or conservator if needed.  You should ask what percentage of its residents have court appointed guardians/conservators.  Some nursing homes have made guardianship a separate business. For-profit nursing homes may exploit guardianship petitions to collect debts or secure Medicaid payments, overriding valid Powers of Attorney (POAs) or family wishes. A 2024 report noted New York facilities coercing payment through guardianship, costing families up to $10,000 in legal fees.  Facilities may refer petitions to attorneys or nonprofit “guardianship mills,” not formal subsidiaries, to manage finances, but this practice—seen in 12% of Manhattan cases (2002-2012)—is profit-driven, and not resident-focused.  Be wary if the institution has a close relationship with a guardianship business or non-profit, particularly if it is directly affiliated with the nursing home.  A nursing home that prefers working with court-appointed guardians and conservators is possibly a threat to your independence and decision-making, and a possible threat to family directed care and financial management.

   

Choosing Safer Nursing Homes: What to Avoid

Don't Overestimate the Value of Proximity- While proximity is often a top priority for seniors and families selecting a nursing home—wanting a facility close to the senior’s home or a family member’s residence—it shouldn’t overshadow care quality. Being nearby makes it easier to visit and monitor your loved one’s treatment, but a closer facility with frequent lapses in care, such as injuries, staff conflicts, or resident disputes, can lead to more unexpected trips and stress, reducing meaningful time with your loved one. A higher-quality nursing home, even if farther away, may require a longer drive but offer better care, fewer emergencies, and more rewarding visits. Balance proximity with quality to ensure your loved one’s safety and well-being.

Avoid Crisis Decision-making: When a parent or loved one’s Medicare hospital benefit nears its end, families often face intense pressure to find a nursing home quickly, tempting them to settle for the first available bed. This crisis-driven approach can lead to choosing a facility with substandard care, especially in for-profit homes influenced by private equity or REITs where quality may suffer. Instead, plan ahead while your loved one is healthy, researching and shortlisting high-quality, preferably nonprofit facilities. Alternatively, explore options at the onset of a hospitalization or a chronic condition diagnosis. By proactively evaluating choices, you can avoid risky “last resort” facilities and ensure safer, more compassionate care.

Look Beyond the Surface- Don't Be Fooled By Appearance: When selecting a nursing home, don’t be swayed by appearances alone. A sparkling new facility with elegant decor and cutting-edge technology may catch your eye, but true quality lies in the care provided. Older, less glamorous nursing homes with low patient-to-staff ratios, dedicated staff, and a genuine commitment to residents often offer safer, more compassionate care than luxurious but poorly managed homes. Fancy furnishings and white linen tablecloths mean little if a facility is overcrowded or understaffed. While modern infrastructure is a one-time investment (plus ongoing maintenance), quality staff, effective management, and continuous training are daily expenses that profit-driven facilities might skimp on. Focus on the bigger picture—prioritize the care your loved one will receive over superficial charm.

Why Plan to Age in Place

The triple threat underscores why avoiding institutional care through aging in place is a smarter strategy. Here’s why and how to plan:

Lower Risk of Harm: Nursing homes carry inherent risks, with 20-23.5% of Medicare patients rehospitalized within 30 days, often due to preventable issues like infections or medication errors. Home-based care reduces exposure to institutional risks, as shown by Medicare’s Independence at Home program, which cut hospitalizations and saved $2,700 per beneficiary annually.

Better Quality of Life: Aging in place allows seniors to stay in familiar surroundings, maintaining independence and emotional well-being. The Nonprofit Quarterly article emphasizes amplifying resident voices, which is easier at home with family or caregiver support.

Cost Savings: Nursing home care is expensive, averaging $8,700/month for a semi-private room (2024 NPR report). Medicaid covers costs for eligible seniors but requires depleting assets, threatening family legacies like farms or homes. Home care, while not cheap, can be more affordable with Medicare home health benefits or long-term care insurance.

How to Plan To Age in Place

Legal Planning: Work with an elder law attorney to create an Aging in Place Planning Trust and/or Medicaid Asset Protection Trust or update your estate plan from a simple will or simple probate avoidance revocable trust to state your wishes, and protect your assets and decision-making. Powers of attorney and advance directives for health and dementia help ensure your care preferences are honored.

Home Modifications: Install grab bars, ramps, or stairlifts to make your home safer. A certified aging-in-place specialist can assess needs.

Care Coordination: Explore home health aides or telehealth services (e.g., virtual care hubs like Good Samaritan’s 2022 initiative) to manage medical needs. Medicare covers skilled home health for qualifying conditions.

Financial Planning: Purchase long-term care insurance early (ideally in your 50s-60s) to cover home care costs. Budget for private-pay caregivers if needed.

Community Support: Engage family, friends, or local senior services (e.g., Area Agencies on Aging) to build a support network, reducing reliance on institutional care.

Additional Considerations

Advocacy and Oversight: The Nonprofit Quarterly article suggests advocating for stronger regulations and ombudsman programs. Families should connect with Long-Term Care Ombudsmen (available in every state) to report concerns or monitor facility quality. Joining resident or family councils empowers you to demand better care.

Medicaid Funding Gaps: Low Medicaid reimbursement rates strain facilities, especially for-profits, leading to closures or quality cuts. Support policies increasing Medicaid funding to improve care options.

For-Profit Risks: Beyond private equity, for-profit chains like Skyline Healthcare (bankrupt in 2018) have left residents stranded. A 2024 CBS News investigation found neglect patterns in for-profit facilities, with cases like a 92-year-old left alone and injured. Scrutinize for-profit facilities, especially midsize chains with opaque ownership.

Conclusion: Plan Smart, Stay Safe

The triple threat—commodification, private equity, and COVID-19’s fallout—has made nursing homes riskier, particularly for-profit facilities, which dominate 70-72% of the market. For seniors and families, this means, in the worst case, prioritizing nonprofit facilities, thoroughly vetting ownership, and checking staffing and quality metrics before choosing a nursing home. The safest and most fulfilling option is to plan for aging in place, leveraging legal, financial, and home modifications to stay independent. By working with elder law professionals and exploring home-based care, you can avoid the risks of institutional care and protect your health, assets, and legacy.

For personalized guidance, contact our office to discuss aging in place planning, Medicaid planning, long-term care options, or home safety assessments. Visit Medicare.gov for facility comparisons, and reach out to your state’s Long-Term Care Ombudsman for support. Your future deserves careful planning—start today.

Nursing Homes Found Guilty in Criminal Understaffing Case= Individual Defendants Acquitted

In a rare case in which a nursing home business faced criminal charges over staffing misconduct, two Pennsylvania facilities owned by Comprehensive Healthcare Management Services were recently found guilty of healthcare fraud and other crimes.

Prosecutors alleged two different schemes to enrich the nursing homes’ operations. In the first, leaders were accused of falsifying payroll documents to make it appear the nursing homes were meeting required staffing levels, including having non-working direct care staff clock in for shifts they never intended to work. In the second, administrators were accused of changing assessments to make it appear patients were clinically depressed or needed more therapy as a means of delaying discharge and driving Medicare or Medicaid reimbursements.  

Both schemes appear to be occasional, if not common, practice of some nursing homes.  The Trump Administration, for example, began demanding payroll records of nursing homes, because CMS found that some nursing homes misrepresented staffing levels on routine reports. Moreover, the financial incentive of these institutions to misrepresent a patient's condition or need for treatment, underlies many of the ongoing battles to ensure better quality of care for patients.  

After five weeks of testimony in the complicated case involving Brighton Rehabilitation and Wellness Center and Mt. Lebanon Rehabilitation and Wellness Center, the jury returned verdicts against the institutions charged. The US Attorney’s Office for the Western District of Pennsylvania also prosecuted five company and facility leaders for their roles in a scheme that led to overbilling; the jury found all five not guilty.

Brighton Rehab itself was found guilty of healthcare fraud and five counts of falsification of records in a federal investigation, while Mt. Lebanon was found guilty of one count of falsification of records related to healthcare matters and three counts of falsification of records in a federal investigation. The nursing home defendants are scheduled to be sentenced in May before US District Judge Robert J. Colville.

According to Kimberly Marselas, reporting for McKnights' Long Term Care News, neither prosecutors nor defense attorneys offered a solid explanation why the jury reserved its convictions for the corporate defendants. US Attorney Eric Olshan, nonetheless, assured told McKnight’s Long-Term Care News that his office would pursue similar cases in the future, if warranted:

“Our legal system entrusts the jury with making determinations of guilt, and as in all cases, we respect the jury’s verdict. Today, the jury held the two corporate defendants criminally liable for a total of 10 counts of making false statements and obstructing CMS’s critically important work of ensuring that nursing facilities comply with the law.  This office and our law enforcement partners will continue to seek accountability for any individual or business that pursues profit through deceit and does so at the expense of vulnerable members of our community.”

Several counts in the indictment carried up to $250,000 in fines, or jail times in the case of individuals. In a press release issued by the US Attorney’s Office , prosecutors said the companies faced a maximum of five years probation, $500,000 in fines, or both, on the counts for which they were convicted.

According to McKnights, 

"Brighton, with 589 beds, is one of the state’s largest nursing homes and was plagued by problems during the pandemic. The facility was hit with at least  $62,000 in fines for infection control deficiencies, and the state later selected a temporary manager to come in and clean up operations. 

The 121-bed Mt. Lebanon facility also has had its share of problems, including a 2-star overall rating and an abuse citation noted on the Care Compare site.

Both facilities are managed by Comprehensive Healthcare Management Services, an entity affiliated with Ephram “Mordy” Lahasky. He has a 10% direct ownership stake in Brighton, while Halper has a 12% ownership stake.

Attorneys for the individual defendants framed the case as one of sloppy record keeping and government malfeasance, rather than intentional fraud, TribLive reported.  The Pittsburgh Tribune-Review reported that attorneys also attacked the credibility of 20 former nursing home employees as each having an axe to grind: some were fired, others quit, and some were offered immunity in exchange for their testimony.

Attorney Kirk Ogrosky represented Sam Halper, Brighton’s CEO and 12% owner and an officer at Mt. Lebanon. Orgosky argued there was no evidence Halper was involved in ordering or completing incorrect staffing records but instead told the jury that a handful of staff members came up with a scheme to cheat the buildings’ corporate owners.

“Throughout this case, all defendants cooperated with the US Department of Justice in every way possible. Yet, DOJ pursued individuals without regard for the truth,” Halper said in a statement shared with TribLive. “Thankfully, the jurors were able to hear the evidence and find that the facts did not support DOJ’s claims.”

Regardless, the case is representative of just how complicated is the challenge to ensure care quality,  and just how difficult it can be for the government, even when properly motivated, to protect the vulnerable by holding third parties responsible.  Individuals and institutions pursuing their own self interest at the expense of senior residents and patients is a common theme in cases like the one reported.  

Of course, the case does not ask or resolve the question of whether a health care system devised and regulated by a government bureaucracy overly concerned with reducing costs at the expense of quality can ever attain a high quality of care for patients.  Aging in Place is a discreet goal of a well-crafted estate plan because a person with family and loved ones can often better control the circumstances of their care at home or at less institutional alternatives.

More is not Always Better - CMS Adds Staffing Information to Care Compare

The Centers for Medicare and Medicaid Services (CMS) recently announced that it will add data on staff turnover rates and weekend staffing levels to its Care Compare website, giving consumers another tool when choosing a nursing home.  The official Medicare website, previously called Nursing Home Compare,  offers up to five-star ratings of nursing homes based on health inspections, staffing, and quality measures. Users can search for nursing homes by location and directly compare one institution to another.  

CMS will post the following additional information for each nursing home on its website:

• Weekend Staffing: The level of total nurse and registered nurse staffing on weekends provided by each nursing home over a quarter. 
• Staff Turnover: The percent of nursing staff and number of administrators that stopped working at the nursing home over a 12-month period. 

CMS will begin adding the information to the Care Compare website in January, but the information will not be incorporated into the rating system until July 2022. 

The staffing information could not come at a more meaningful time.  Nursing homes are plagued by chronic understaffing and high turnover rates.  The problem has existed for years, but is exacerbated by the COVID-19 pandemic. A study reported in Health Affairs found that the turnover among nursing staff was 94 percent in 2017 and 2018 and mean turnover rates were as high as 140.7 percent among registered nurses, 129.1percent among certified nursing aides and 114.1 percent among licensed practical nurses. 

CMS previously noted a relationship between turnover and ratings. CMS noted in a memo that:

"facilities with lower nurse turnover may have more staff that are familiar with each resident’s condition and may therefore be more able to identify a resident’s change in condition sooner. In doing so, the facility may be able to implement an intervention to avoid an adverse event, such as a fall, acute infection, or hospitalization, which are indicators of quality. Similarly, facilities with lower nurse turnover may be more familiar with the facility’s policies and procedures and can potentially operate more efficiently and swiftly to deliver a higher quality of care to residents. Lastly, facilities with lower administrator turnover may have greater leadership stability, direction, and operations, which may help staff provide care more consistently or effectively to residents."

Regardless of the reasons for the association between turnover and quality, CMS acknowledging the relationship is encouraging.  

CMS has also acknowledged that  the additional information is important and is thus valuable to consumers.  For example, regarding weekend staffing, CMS acknowledged that consumers may not realize that nursing home staffing levels can vary on weekends. CMS hopes to encourage facilities to hire more weekend staff by adding weekend staff numbers to the nursing home rating system.

The fundamental underlying question, though, is whether adding additional information will help transform a questionable and unreliable system into a more meaningful system for consumers.  There is good reason to remain skeptical; there are numerous reports and examples suggesting that the federal ratings are inaccurate or misleading.  Consider the following:   

• NYT: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public;
• Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death;
• Nursing Home Compare Does Not Accurately Reflect Patient Safety In Nursing Homes;
• Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators.

Worse, even if information regarding nursing homes is more accurate, it does little to help the most vulnerable seniors, those being transferred from acute care in a hospital to a nursing home for rehabilitation; patients are simply given little guidance or information to help them direct accurately their own care decisions: 

• Patients Are Not Given Quality-Of Care Information When Discharged From Hospitals to Nursing Homes.

Providing additional information through Care Compare will only be comforting for consumers and planners when the reporting deficits underlying the system are fixed, and seniors are provided quality of care information prior to transfer. 

Industry reaction to the change has been "mixed," according to Amy Novtney, writing for Mcknight's Longterm Care News.  David Grabowski, professor of healthcare policy at Harvard Medical School, told  industry stakeholders during a LeadingAge conference call, that the timing of the change “feels like a gut punch to nursing homes who are really struggling right now.”

Grabowski called on providers, however, to view the move as a positive development for the industry in the long run. Grabowski said the data could provide benefits such as shedding light on the fact that there aren’t staff available to work on the weekends, that turnover is high and that there’s a high use of contract nurses. That, in turn, could lead to policy changes.

According to Novtney, Grabowski continued: 

“I do think longer term this data will add value and can serve as a signal to all of us that we need to invest more in direct care staff. We get the turnover we pay for and since we aren’t paying enough, we’re seeing high turnover. That’s not something nursing homes can fix on their own. I really believe we need more reimbursement from Medicaid and Medicare to make that happen.”

Other industry associations agree that the decision’s timing is unfortunate given the ongoing challenges related to the pandemic. 

Others criticized the addition information as impotent to improves staffing issues. “While we support transparency and agree that staffing hours and turnover metrics are important, more reporting will not solve this issue,” the American Health Care Association/National Center for Assisted Living said in a statement to McKnight’s this week. “The addition of this reporting requirement when we are in the middle of the worst labor shortage the nursing home sector has ever faced is tone deaf. We need public health officials to do more than acknowledge these challenges, but stand up to address them. By offering funding and policy solutions that will help us attract and retain the caregivers we so desperately need, policymakers can ensure nursing home residents are well supported.”

To read CMS’s announcement about this new policy, click here.

NYT: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public."

The headline of a  recent New York Times article posed succinctly the challenge nursing home rating systems present to an unwary public: "Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public."  The subtitle to the article indicts the industry: "Nursing homes have manipulated the influential star system in ways that have masked deep problems — and left them unprepared for Covid-19."  The role of government, from benign neglect, incompetence, and/or complicity, is also discussed in the article.

The article is rich with examples of institutions with fundamental problems and flaws that nonetheless attain "high marks" and good ratings, masking dangers and risks to unwary consumers.  For readers of this blog, this reality is not revelation.  The case for aging in place could not be more profound.

The article is largely reprinted below [tables, pictures, and graphics omitted]:  

Infection Control Citations Exceed 12,000 Amid Pandemic; SNF Ratings Stagnant

Despite more than 12,000 infection control-related citations issued during the COVID-19 pandemic, most U.S. nursing homes saw no  ratings change in updated Five-Star guidance published recently, according to an article in McKnight's Long-term Care News.

According to McKnight's, Formation Healthcare Group found in analyzing the data that the prevalence of citations has not changed drastically during the pandemic, with the average health tags cited per facility dropping to 8.1 from a prior average of 8.2.  

Among more than 22,000 citations issued, more than 12,000 were related to infection control, a factor the Centers for Medicare & Medicaid Services (CMS) initially said would not affect star ratings used by the public. The agency reversed course in December.  Many were critical of the reversal, even as the new ratings were published.

Jessica Curtis, Formation’s managing partner, explained to McKnight's that infection control citations are being driven by the mandated infection control-focused surveys during the pandemic. A group of six frequent F-tags accounted for more than 8,000 citations.

Despite the inclusion of infection measures in the star calculation, nearly 12,000 facilities saw no change in their health inspection ranking, according to an analysis by Steven Littlehale, Chief Innovation Officer at Zimmet Healthcare Services Group. .

About 2,800 gained one star or more for improved RN staffing ratings, while fewer than 2,400 saw that factor drop one star or more. Nationally, staffing levels were higher in January 2021 than they were in January 2019 and 2020.  In 2019, one-third of institutions saw a rating drop specifically due to staffing levels, thanks in part to a new survey method preventing institutions from misrepresenting their level of staffing.  In all other categories, the number of institutions gaining a star or more was essentially the same as the number losing one or more.

Overall, 9,937 facilities, or about 66% nationwide, kept the same overall star rating.  

“From a macro view, this is a lot to do about nothing,” Littlehale told McKnight’s Long-Term Care News. “If you’re the provider holding the bag, being dropped from a preferred provider network, triggering loan covenants or consternation from a family member, it means something.” 

He noted that the update includes two quarters worth of COVID-impacted outcomes. He suspects a “national dip” is more likely once all of the 2020 MDS-based outcomes are calculated.

As for the “abuse” icon adopted by CMS in 2019, 459 facilities will see the icon disappear from their listing based on the latest numbers, while 262 facilities will get one.  That doesn't suggest that the incidence of reported abuse has declined, however, just that the number of facilities with a reportable incidence of abuse has declined.   Moreover, while the rating system is helpful in comparing institutions, the rating system does not accurately reflect resident safety.   

The latest star ratings also reveal major variations in how and how well states are performing their inspection duties.  “The percentage of facilities receiving deficiencies during infection control surveys vary considerably across the states,” Littlehale said. “Some states see over 60% of their facilities with IC deficiencies, while other states (are) as low as 6%.”

Littlehale told McKnight's  that the wide variation was not directly attributable to COVID outbreaks.

Analysts at Formation Healthcare likewise found discrepancies between states in reporting. Shockingly,  several states are far behind in conducting health inspections. For example, Oregon (37%), Georgia (31%), Maryland (26%) and Virginia (21%) led the nation in the share of SNFs last inspected more than two years ago.   In other words, in some states, the data on nursing homes may be inaccurate or outdated for almost one-third of the state's institutions. 

The pandemic, governments' response to the pandemic, and institutional safety and quality are only making more arguments for the already overwhelming case for aging in place.  Plan now. 

Trump Administration Improves Transparency about Nursing Home Abuse and Neglect

Today, the Trump Administration and the Centers for Medicare and Medicaid Services (CMS) announced a major enhancement of the information available to nursing home residents, families, and caregivers on the Agency’s Nursing Home Compare website. Later this month, CMS will – for the first time – display a consumer alert icon next to nursing homes that have been cited for incidents of abuse, neglect, or exploitation. By making this information accessible and understandable, CMS is empowering consumers to make the right decisions for themselves and their loved ones. This critical move toward improved transparency is yet another way CMS is delivering on the Agency’s five-part approach to ensuring safety and quality in nursing homes, which Administrator Seema Verma announced in April 2019:

“The Trump Administration and CMS are committed to ensuring that nursing home residents are safe from abuse and neglect. Through the “transparency” pillar of our five-part strategy to ensure safety and quality in nursing homes, we are giving residents and families the ability to make informed choices,” said Administrator Seema Verma. “With today’s action, the Trump Administration is putting critical information at consumers’ fingertips, empowering them and incentivizing nursing homes to compete on cost and quality.”

The Nursing Home Compare tool displays an array of information about nursing homes – including whether a facility meets federal standards with respect to health and safety compliance inspections, staffing levels, and quality measure performance. Previously, consumers could investigate past instances of abuse citations at a nursing home, but finding this information from its health inspection reports available on Nursing Home Compare required multiple steps. CMS is minimizing the steps, making it easier for patients, residents, and their families and caregivers to quickly identify nursing homes with past citations for abuse.Patients and families will see CMS’ new alert icon for Nursing Home Compare, shown below.

Beginning October 23, the new alert icon will be added to the Nursing Home Compare website for facilities cited on inspection reports for one or both of the following: 1) abuse that led to harm of a resident within the past year; and 2) abuse that could have potentially led to harm of a resident in each of the last two years. To ensure CMS is providing the latest information, the icon will be updated monthly, at the same time CMS inspection results are updated. This means consumers will not be forced to wait for CMS’s quarterly updates to see the latest -related information – and nursing homes will not be flagged for longer than necessary if their most recent inspections indicate they have remedied the issues that caused the citations for abuse or potential for abuse and no longer meet the criteria for the icon. This icon will supplement existing information, including the Nursing Home Five-Star Ratings, helping consumers develop a more complete understanding of a facility’s quality.

There are many factors that indicate a nursing home’s quality, and the Star Ratings may not capture some nuances. For example, a nursing home cited for an incident of abuse may have adequate staffing numbers and provide excellent dementia or rehabilitative care. Previously, consumers would clearly see this facility’s performance in these areas through the Star Ratings, but abuse complaint allegation information may not have been as clear. Under the CMS action announced today, this facility would have an alert icon displayed, allowing consumers to see both its Star Ratings and the icon, helping them easily weigh the facility’s quality. In addition, we are continuing our work to improve the usefulness of the Star Ratings.

As you might expect, the industry is not fond of the change.  Calling the alert icon a "Do Not Proceed," alert, industry representatives called for their own "halt" of it's use.  As reported in McKnight's Long-Term Care News:

Mark Parkinson, president and CEO of the American Health Care Association, said the plan should be halted until there is more clarity.

“We support transparency so that potential residents and their families can make an informed decision on care,” Parkinson said in a statement. “We appreciate CMS’ efforts to improve Nursing Home Compare but as we have previously suggested, we believe that CMS should create a standard and rational definition of both abuse and neglect and then report them separately. That would help provide consumers with the information that they need.” 

“In addition, CMS should add customer satisfaction to Nursing Home Compare because that is the best way for consumers to select facilities. It’s surprising that we can look for customer reviews of restaurants and hotels that we select, but that information isn’t available for nursing homes. We should have a way to let families and residents think of the facilities they are considering,” Parkinson added.

Fortunately, we now have better information for consumers than is available for restaurants and hotels, particularly given that the residents of nursing homes, unlike patrons of restaurants and hotels, are not always able or competent to report "bad service."   

 

Medicare Ratings Fall for Short-Staffed Nursing Homes- One-Third of Nursing Homes See Ratings Drop

Aging in Place as a discreet planning objective is well justified and documented. Recent improvements to government reporting of data regarding quality of care at nursing homes, while welcome, only underscore the benefits of Aging in Place planning.

According to Kaiser Health News (KHN), the Centers for Medicare & Medicaid Services (CMS), gave its lowest star rating for staffing, one star on its five-star scale, to 1,638 homes, in its update to Nursing Home Compare,  According to a recent KHN article, most nursing homes were downgraded because their payroll records reported no registered-nurse hours at all for four days or more, while the remainder failed to submit their payroll records or sent data that could not be verified through an audit.  KHN characterized the recent action as an "acceleration" in the federal government's "crackdown on nursing homes that go days without a registered nurse by downgrading the rankings of one-tenth of the nation’s nursing homes on Medicare’s consumer website"

According to KHN:

"CMS has been alarmed at the frequency of understaffing of registered nurses — the most highly trained category of nurses in a home — since the government last year began requiring homes to submit payroll records to verify staffing levels. Before that, Nursing Home Compare relied on two-week snapshots nursing homes reported to health inspectors when they visited — a method officials worried was too easy to manipulate." 

CMS announced the changes last March:

"CMS is setting higher thresholds and evidence-based standards for nursing homes’ staffing levels. Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic one-star rating when a Nursing Home facility reports “no registered nurse is onsite.” Currently, facilities that report seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days." 

“Once you’re past four days [without registered nursing], it’s probably beyond calling in sick,” David Grabowski, a health policy professor at Harvard Medical School, told KHN. “It’s probably a systemic problem.”

The American Health Care Association, a trade group for nursing homes, calculated that 36% of homes saw a drop in their ratings while 15% received improved ratings. AHCA has issued a response critical of the changes, and the accuracy and fairness of the ratings. 

KHN has an interactive tool, Look-Up: How Nursing Home Staffing Fluctuates Nationwide.  The tool reveals the rating Medicare assigns to each facility for its registered nurse staffing and overall staffing levels. The tool also shows KHN-calculated ratios of patients to direct-care nurses and aides on the best- and worst-staffed days.  Because staffing is closely related to quality of care, the KHN tool is useful for those investigating, comparing, and evaluating institutional care alternatives.  

New Rating System for Nursing Homes Launches Today

The Nursing Home Compare website and Five-Star Quality Rating System were created to help consumers, their families, and caregivers compare nursing homes and identify areas of possible inquiry when considering and comparing nursing home care providers. Highly anticipated changes to the federal Five-Star Quality Rating System for nursing homes are supposed to commence today, ending a freeze on survey results. Providers will learn whether they have gained or lost stars, or, as is expected for about half of facilities, remained the same.

Nursing Home Compare has a quality rating system that gives each nursing home a rating between 1 and 5 stars. Nursing homes with 5 stars are considered to have above average quality and nursing homes with 1 star are considered to have quality below average. There is one Overall 5-star rating for each nursing home, and a separate rating for each of the following three factors:

• Health Inspections: Inspections include the findings on compliance to Medicare and Medicaid health and safety requirements from onsite surveys conducted by state survey agencies at nursing homes.
• Staffing Levels: The staffing levels are the numbers of nurses available to care for patients in a nursing home at any given time.
• Quality Measures: The quality of resident care measures are based on resident assessment and Medicare claims data.

CMS has periodically made improvements to the website and ratings system. Each update has been part of CMS’s ongoing effort to increase the accuracy of information available to consumers and to encourage quality improvement at nursing homes across the country.

The set of changes also will bring the addition of new measures tied to long-stay hospitalizations and emergency room transfers, along with removing some “duplicative and less meaningful” metrics. The Centers for Medicare & Medicaid Services has said it wanted separate quality ratings for short-stay and long-stay residents, and it has revised rating thresholds to better pinpoint quality variations among SNFs for consumers.

CMS to "call-out" Nursing Homes Publicly On Safety Lapses

Centers for Medicare & Medicaid Services (CMS) is considering possible changes to Nursing Home Compare to better capture patient safety concerns, according to an article in McKnight's Long-Term Care News.  The current comparison tool captures only a “subset of harm” that is inflicted on residents in nursing facilities. CMS is seeking to reform the current system by developing a composite measure of healthcare-acquired infections, which would be incorporated into the rankings.

“While we view patient safety and quality improvement as a continuum, we agree that specifically ‘calling out’ facility performance on patient safety can resonate with and be beneficial to consumers,” wrote Kate Goodrich, M.D., the agency’s chief medical officer and  director of the Center for Clinical Standards and Quality in a Health Affairs blog.

A recent study demanded that changes be made to the standard measure for capturing quality at nursing homes.  The study concluded that the current five-star rating system failed to paint an accurate picture of patient safety. The study authors compared nursing homes’ performance in standard quality measures with six noted patient safety standards, including pressure sores, infections, falls and medication errors, and concluded that the relationship was weak between the two measures, “leaving consumers who care about patient safety with little guidance.”

Goodrich emphasized that SNF patient safety is a “crucial strategic priority” for the federal government. She countered the study’s conclusions by writing that Nursing Home Compare does contain measures that either directly capture harm or are highly correlated with it, such as inappropriate antipsychotic use, which may be linked to falls and other events.

Along with the infection-related composite measure, Goodrich wrote CMS will “continue to explore additional facets of and measures associated with safety in nursing homes going forward.” In addition, the agency recently developed measures to gauge the transfer of health information between providers and the patient. Those were designed to meet the requirements of the IMPACT Act, and CMS is intending to propose adopting them for the SNF Quality Reporting Program, Goodrich wrote: “[w]e believe these measures will address the important safety issue of improving the hand-off of medication information during critical care transitions.”

There is no discussion whether or when reporting of intentional actions such as sexual and physical assault by residents and staff will improve.

Nursing Home Compare Does not Accurately Reflect Patient Safety In Nursing Homes

The standard measure for capturing quality at nursing homes does not paint an accurate picture of patient safety, and changes are needed to aid residents in their decision making, reports an article in McKnight's Long-term Care News.

That’s according to a new study, published in the November issue of Health Affairs. Researchers took a closer look at data from the Certification and Survey Provider Enhanced Reporter (CASPER) and the Nursing Home Compare archives, aiming to see if star ratings accurately represented potential safety dangers at SNFs.  The researchers compared nursing homes’ performance in standard quality measures with six noted patient safety measures — including pressure sores, infections, falls and medication errors. They noted that the relationship was weak between the two measures, “leaving consumers who care about patient safety with little guidance.”

Changes must be made to give potential residents a better sense of the safety landscape, said Daniel Brauner, an associate professor in the Department of Medicine at the University of Chicago and lead author of the study.  “Nursing home compare should look more specifically at these safety measures because consumers are quite concerned about those things, for their loved ones,” he told McKnight’s. “The rating system should take these specific safety measures more seriously and make them a bigger part of its methodology.”

Results were gathered using data for the first quarter of 2017 from NHC and CASPER, representing more than 15,600 facilities. They found that, overall, performance on falls and urinary tract infections for long-stay residents, along with pressure sores for short-stay, showed “little meaningful difference” across star ratings. Meanwhile, medication errors and pressure sores for long-stay residents tracked more closely with star ratings, though with a weak correlation.