En español | If you're looking for a high-quality nursing home, the advice from experts is loud and clear: Do your homework.
They advise future residents and their families to dive into government records and conduct their own facility inspections.
They also recommend not rushing to choose a facility. However, many people are discharged directly from hospitals to one of the nation's 15,600 nursing homes, leaving little time for research.
So caregivers and the recipients of that care should avoid last-minute searches by getting to know facilities in their area in advance, according to government agencies, industry groups and senior advocates across the country.
Narrow your search, visit in person
The bottom line is that some nursing homes have serious flaws, the experts say. Some are short-staffed. Some serve unsavory, unhealthy food.
Some are riddled with serious infections, such as the nursing home in New Jersey where 11 children on ventilators died last year from a virulent adenovirus.
That's why experts warn families, friends and their loved ones not to procrastinate.
Some states’ online tools
Check to see if your state offers online tools about facilities. Some that do:
• California provides a handy searchable database.
• Colorado has an easy option for filing complaints.
• Florida allows you to report infections online.
• Illinois gives step-by-step instructions on choosing a home.
• Pennsylvania posts inspection reports on the internet.
• Texas has a user-friendly website to figure out how to pay.
• West Virginia Legal Aid lists ombudsmen statewide.
Note: Check with your state's long-term care ombudsman's office or your state health or aging agencies to find out specifics.
Start online. Fortunately, the days are long gone of having to visit state regulatory offices to rifle through paper files. Much of that research can be done from your home computer, thanks to online libraries of ratings and inspection reports.
The best known is Medicare's Nursing Home Compare, which uses star ratings from 1 to 5 and posts recent inspection documents. ProPublica's Nursing Home Inspect, a project of the nonprofit investigative news outlet, provides more detailed data, including the unredacted portions of government reports, and puts rankings in perspective.
Use government or nonprofit sites to narrow possibilities. One way not to choose a home is via online sites not run by Medicare or respected not-for-profits.
Medicare's Nursing Home Compare has strengths and weaknesses, but if Richard Mollot didn't have much time for research, the executive director of the New York City-based nonprofit Long Term Care Community Coalition said he would choose homes only with the highest rankings, four or five stars.
Keep close to home. One smart move is to look at facilities located near relatives and friends, as long as they are highly rated, experts said. That way, a nursing home patient will have frequent visitors and facility employees will know that those visitors are scrutinizing the care they're providing.
Look at residents’ grooming. But no online search can replace visiting homes and searching for clues, experts said.
"Listen in the hallways. Look at the hair, clothing, teeth, and fingernails of the residents,” Tony Chicotel, staff attorney at the San Francisco-based patient advocacy group California Advocates for Nursing Home Reform, said in email.
"Families should observe the environment and ask themselves, ‘Is the center calm and quiet or chaotic and noisy?’ ” Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, said in a written statement. The trade association is the nation's largest for long-term care.
Observe staff. Pay attention to whether staff members interact closely with residents and know their names.
Infections not always reported adequately
Studies have found problems in the nation's nursing home system.
An estimated 21 percent of Medicare beneficiaries experienced adverse events during their nursing home stays, according to a 2018 report from the Office of Inspector General of the U.S. Department of Health and Human Services.
And in June 2019, Sens. Bob Casey and Pat Toomey, a Democrat and a Republican, respectively, who represent Pennsylvania, leaked a so-called federal “secret list" of more than 400 nursing facilities with persistent records of poor care.
Fungal infections. One issue sparking serious concern is the danger of high infection rates in nursing homes. In September 2019, The New York Times reported on drug-resistant infections, such as Candida auris, a highly contagious fungus, that are spreading in nursing facilities. Few states do sophisticated monitoring of such infection problems, and some rely on county public health departments to collect data.
For instance, California hospitals have been required to report so-called health care-acquired infections since 2009, but no such law applies to nursing homes, said Mark Smith, a spokesman for the California Department of Public Health. Nursing homes in that state are required to report unusual occurrences of infectious diseases and outbreaks to his department and to local public health agencies.
Deadly bacteria. New patients can bring infections with them, straight from hospitals, including Clostridioides difficile, which causes extreme diarrhea that can lead to death.
One in 11 people older than 65 died of a health-care-associated C. diff infection within a month of diagnosis, according to the federal Centers for Disease Control and Prevention. It spreads by tiny spores left on bedside tables and other surfaces, making thorough cleaning essential.
Contagious viruses. Influenza can spread fast as well.
"If you're sick, don't go into a facility. You could be more dangerous to them than they are to you,” said Jayla Sanchez-Warren, director of Denver's Area Agency on Aging, part of the eight-county Denver Regional Council of Governments.
Discount the ‘chandelier effect'
Some people may be tempted to choose a nursing home because of fancy décor — nicknamed the “chandelier effect” — or because the price is higher than other facilities nearby.
Experts interviewed caution against that approach.
"I don't think you can trust the cost to decide if the care's going to be better or worse,” said Alexa Schoeman, Texas deputy state ombudsman for long-term care.
Ombudsmen can help you. She is one of hundreds of such advocates nationwide who can offer guidance on nursing homes.
"If you're going to pay a BMW price, you expect to get a BMW — but you may get a Chevy,” said Brian Lee, a former Florida state ombudsman who now directs the advocacy group called Families for Better Care, in Florida and Texas.
In Pennsylvania, Nate Wardle, spokesman for the state's Department of Health, wrote in an email that officials there expect all nursing home operators to provide safe care no matter what price residents are paying.
Nursing home care always expensive. The 2019 national median for monthly nursing home costs was $7,513 for a shared room and $8,517 for a private room, according to a 2019 Genworth Cost of Care Survey. The company has sold long-term care insurance for more than 40 years.
"I've investigated homes [in Colorado] where people got charged $19 for a Kleenex box. At some facilities, it's open blinds, $1.50, and close the blinds, $1.50,” Sanchez-Warren said.
Complex Medicare payment rules
Medicare pays for nursing home care only if you meet specific criteria.
The arithmetic is complex. Under specific limited circumstances, Medicare Part A, the component of original Medicare that includes hospital insurance, provides coverage for only short-term stays in skilled nursing facilities, most often in nursing homes. Some Medicare Advantage plans may differ.
Payment starts with doctor's order. A doctor might send your loved one to a skilled nursing facility for specialized nursing care and rehabilitation after a hospital stay. If the patient had a stroke or serious injury, recovery could continue there.
In such instances, original Medicare can pay a portion of the cost for up to 100 days in a skilled nursing facility. But the patient must be admitted to the skilled nursing facility within 30 days of leaving the hospital after being a hospital inpatient for at least three consecutive days, and the nursing care must be for the same illness or injury or a condition related to it.
No continuous care. To qualify again for new nursing home coverage, the patient must not be hospitalized or receiving skilled care for 60 days. Then a new hospitalization as an inpatient for three days or more can kick off another 100 days of partial coverage.
Without Medicare, seniors can pay out of their own pockets or “spend down” their assets until they qualify for Medicaid. Private-pay rates at nursing homes can be expensive, and so are the amenities.
Pay attention to ratings details
When you finally make that decision about the best nursing home for your loved one, beware of skimming over details in the Medicare five-star system, said Roy Herzbach, regional ombudsman-director and Legal Aid attorney in Charleston, West Virginia.
Some homes earn the coveted five stars but get one or two stars for their staffing levels, a key measure of a home's quality, he said.
"Or you may have a one-star home where staffing is five stars. The numbers can be faulty,” Herzbach said. And in West Virginia, which has a severe shortage of nursing home beds, those ratings have real clout, he added. “If it's a five-star, chances are it has a long waiting list.”
Deborah Schoch is an independent journalist who helped found the California Health Care Foundation Center for Health Reporting at the University of Southern California. She earlier worked for 18 years at the Los Angeles Times.