Do you have an elderly relative who can no longer live independently? Does he or she need 24-hour nursing care and supervision?
Is this person chronically ill, or in need of intensive rehabilitative care? Does your relative need help with most daily living activities, such as getting out of bed, eating, bathing, dressing and using the bathroom?
If you answered “yes” to most of these questions, then you and your relative may have reached the point at which you should consider choosing a nursing home.
- What Kinds of Services Can a Nursing Home Offer?
- Who Pays for Nursing Home Care?
- What Does Every Good Nursing Home Have?
- How to Compare & Contrast Nursing Homes
- Quality Measures
- How to Get Your Loved One Admitted to The Nursing Home of Your Choice
What Kinds of Services Can a Nursing Home Offer?
A quality nursing home offers a full array of personal, dietary, therapeutic, social, recreational and nursing services. Meals, laundry, housekeeping and medical services are provided. In addition, most not-for-profit homes offer religious services and counseling programs.
Who are the providers of primary services in a nursing home?
- The board of trustees in a nonprofit home determines the general policies the home will follow to implement its mission of care and service. Trustees are volunteers who often are leaders of the local community.
- The administrative staff is responsible for the day-to-day planning and operation of the home. Personnel usually include an administrator or executive director, and admissions, personnel and financial directors.
- The nursing staff offers daily care to residents. The director of nursing is usually a licensed registered nurse who manages the daily activities of other RNs, licensed practical nurses (LPNs), and nursing assistants.
- Therapists provide, among other services, physical, occupational and speech therapy programs directed to specific disabilities of the residents.
- The medical director is a physician appointed to ensure the adequacy and appropriateness of the medical services provided to the residents. A consultant medical staff also will make available psychiatric care and various medical specialties.
- The activities coordinator is a trained therapist or someone designated to assess residents’ individual needs and create programs that provide recreation, entertainment and therapy for residents.
- The social service staff consists of social workers and perhaps psychologists and counselors who assist residents in coping with the emotional and psychological aspects of aging.
- The food service director oversees a nursing home’s daily meal program. Many homes also employ a consulting dietitian to ensure that meals are appetizing and varied and meet the individual dietary requirements of residents.
- Pastoral care staff consists of ordained, professional or lay persons trained to meet the spiritual needs of residents through worship, study, meditation and counseling.
- Volunteers are members of the community who assist staff by spending many hours interacting with residents and helping them perform their daily activities.
Who Pays for Nursing Home Care?
Nursing home care, like all good health care, is costly. Before you agree to pay for services, understand completely all the financial arrangements of the home you have selected. Nursing homes charge a basic daily or monthly rate.
Many residents or their families pay for nursing home care out of their own private funds. One way to help defray nursing home expenses is to purchase private long-term care insurance.
The nursing home admitting office or other fiscal/financial department should be available to discuss payment options with you. Be aware that nursing facilities are prohibited from requiring a waiver of Medicare or Medicaid coverage. It is also unlawful for a nursing facility to require a third party such as yourself to guarantee payment as a condition of admission.
Within broad national guidelines provided by the federal government, each state establishes its own Medicaid eligibility standards, determines the type, amount, duration and scope of services, sets the rate of payment for services and administers its own program.
There are a variety of ways to pay for nursing home care:
There are a variety of ways to pay for nursing home care:
- The traditional Medicare “fee-for-service program” is generally available to qualified individuals 65 years of age or older and those under age 65 who have been disabled for at least 24 months.
Medicare is divided into two parts, Part A Hospital Insurance Benefits and Part B Supplemental Medical Insurance:
Part A covers hospitalization, skilled nursing care in a skilled nursing facility (SNF/NF), home health care and hospice care. There is automatic enrollment for Part A.
There are deductible and co-payments for hospital and nursing home care.
To qualify for skilled nursing care in a SNF/NF, the following five requirements must be met:
- The resident requires daily skilled nursing or rehabilitation services that can be provided only in a SNF/NF
- The resident was hospitalized for at least three consecutive days, not counting the day of discharge, before entering the SNF/NF
- The resident was admitted to the facility within 30 days after leaving the hospital
- The resident is admitted to the facility to receive treatment for the same condition(s) for which he or she was treated in the hospital
- A medical professional certifies that the resident requires skilled nursing care on a “daily basis.” A Resident requires skilled nursing or skilled rehabilitation services on a daily basis when services are medically necessary and provided seven days a week. There is an exception if they are only provided by the facility for five days per week due to staffing levels at the facility. Additionally, there may be a one- to two-day break if the resident’s needs require suspension of the services.
Where these five criteria are met, Medicare may provide coverage of up to 100 days of care in a SNF/NF. The first 20 days of covered services are fully paid for; and the next 80 days (days 21 through 100) of the covered services are paid for by Medicare subject to a daily coinsurance amount for which the resident is responsible. The Medicare Part A co-insurance amount for 2003 is currently $105 per day.
With limited exceptions, a resident who requires more than 100 days of SNF/NF care in a benefit period will be responsible for private payment of all charges beginning with the 101st day.
A new benefit period may begin when the resident has either not been in a facility or has not been receiving a covered level of care in a SNF/NF for at least 60 days, returns to the hospital for another three-day stay, and then re-enters the SNF/NF.
Part B Supplemental Medical Insurance covers physician services, ambulance, durable medical equipment, screening for pap smear, screening mammography, X-rays, out-patient care and prescriptions (very limited). Part B is voluntary and requires a monthly premium payment of $58.
Medicare payment for the above services is based on Medicare’s “reasonable charge” standard rather than the actual bill.
The resident in a SNF/NF is responsible for private payment of therapy charges and any other ancillary charges above the Medicare Part B coverage limitation.
The Facility can bill and receive payment if the resident fills out a Medicare assignment of benefits form. If the resident completes an assignment of benefits form, a health care provider cannot charge the resident above the Medicare approved charge.
Contact the Social Security Administration to determine the Resident’s Part B coverage.
- Managed Care Medicare HMO
- This insurance is supposed to provide the same benefits as the Medicare fee-for-service program, but many people find out that this is not the case.
- Enrollees are limited as to which facilities are providers in their HMO, as well as the types of coverage. The HMO will require reports on the residents progress on a regular basis to determine the residents need for continued coverage.
- This is a joint federal and state program designed to cover the cost of certain medical expenses incurred by individuals with limited resources and to pay for the cost of their nursing home stay.
Individuals who are age 65 or older), certified blind or certified disabled are eligible for this program. Please be aware that there are income and resource limitations. Individuals are eligible for Medicaid:
- If they receive Supplemental Security Income
- If they are determined to be “medically needy”
- If their income is below a state-designated cap
When a nursing home resident is married and his/her spouse resides in the community, certain action may be taken to accelerate the Medicaid eligibility of the nursing home resident by protecting assets for the spouse at home at the time of the initial eligibility determination of the nursing home resident.
In a spousal situation before an institutionalized person’s monthly income is used to pay for the cost of institutional care, a minimum monthly maintenance needs allowance must be established to bring the income of the community spouse up to a moderate level.
This means there may be instances where the community spouse is permitted to keep his/her income as well as the income of the institutionalized spouse.
Check your state’s eligibility requirements.
- Private Pay
- Individuals who are not eligible for Medicare or Medicaid or those who have exhausted their benefits, and who have no insurance or other sources of payment, will be responsible for paying the costs of nursing home care. Daily nursing home rates should be posted in a common area of the facility.
- Managed Care
- Residents who are members of a managed care benefit plan that is under a contract with a facility to provide specified services to plan members will receive those services with full coverage so long as the resident meets the eligibility requirements of the managed care benefit plan.
- The resident is then financially responsible only for those services that are not included in the list of covered services, co-payments and deductibles. Residents who have not received a list of covered services and eligibility requirements from their managed care benefit plan are advised to contact their social worker and/or managed care benefit plan.
- Medigap Insurance
- Medigap is supplemental health insurance which will provide payment for Medicare deductibles and co-payments. There are numerous insurance companies which sell these policies. The plans range from Plan A through Plan J and vary in terms of coverage.
See New York’s Medigap Insurance page (www.hiicap.state.ny.us/mgap) for more information on Medigap, and the federal government’s Medicare Personal Plan Finder (www.medicare.gov/MPPF/Home.asp) to search for available plans.
- Private Insurance
- Residents who are covered by a private insurance plan that does not have a contract with the facility must exhaust all available insurance coverage before seeking Medicare or Medicaid coverage.
- If the insurance proceeds under the private plan are insufficient to cover the cost of care, the resident will be responsible for any difference.
- The coverage requirements for nursing home care vary depending on the terms of the insurance policy. Questions regarding private insurance coverage should be directed to the social work staff and/or the resident’s insurance carrier or agent.
- Long Term Care Insurance
- These policies are purchased to cover the cost of nursing home care and/or home care services. There are many different features that require careful review before purchasing.
- Veterans Administration (VA) or Other Government Insurance Exclusive of Medicaid/Medicare
- The Department of Veterans Affairs contracts with community facilities to care for VA patients. A rate is usually established annually and provides for a small percentage above the facility’s Medicaid rate.
- The VA rate, however, is generally all inclusive, and the facility may not be able to bill another source, such as Medicare B, for physician services, lab, x-ray, therapies, etc.
- As with managed care contracts, the facility must be sure that the agreed-upon rate covers the cost. Additionally, most contracts cover the veteran for six months for service-related conditions and three months for non-service related issues. The facility must be sure to make provisions for another payer source when the benefits for the veteran end.
Ask admissions staff at the nursing home of your choice what the basic monthly fee is and what it includes. Ask if the home charges extra for non-ambulance transportation, medications, laundry, special feeding, frequent linen changes or special supplies such as wheelchairs and walkers. Are therapies included in the basic charge? Is a deposit required?
In addition, if your relative is a veteran of the U.S. armed forces, it will be to your advantage to investigate services available through the Veterans Administration.
The nursing home may ask for financial disclosure to determine the appropriate payment mechanism. Admissions personnel will assist you in determining what information is necessary and what forms need to be filed to expedite placement.
Because some nursing homes have waiting lists, you might want to have the paperwork done in advance in the event that an emergency placement needs to be made.
What Does Every Good Nursing Home Have?
Look for the following when choosing a nursing home:
- A current operating license from the state.
- An administrator who has a current state license.
- Certification for Medicare and Medicaid if these programs are important to you now or in the future.
- A location that suits the resident and makes regular visits by family and friends possible.
- Handrails in hallways, grab bars in bathrooms and other features aimed at accident prevention.
- Clearly marked exits and unobstructed paths to these exits. All nursing homes must comply with state and/or federal fire safety codes.
- Bedrooms that open onto a corridor and have windows, as required by law.
- A physician who is available for emergencies.
- No heavy odors, whether pleasant or offensive. A good home will not use highly scented sprays to mask odors.
- Hallways wide enough to permit two wheelchairs to pass with ease and wheelchair ramps for easy access into and out of the home.
- Kitchens that separate food preparation, garbage, and dishwashing areas and keep perishable foods refrigerated.
- Toilet facilities designed to accommodate wheelchair residents.
- An attractive resident dining room with tables convenient for wheelchairs and food that looks appetizing. Notice, too, whether residents who need help are receiving it.
- Residents who look clean and are dressed appropriately for a full day of activity and social interaction.
- A policy that encourages residents to go outside. Even city homes should have a lawn or garden area for residents to get fresh air.
- Commitment to a philosophy of care in which physical and chemical restraints are used minimally or not at all.
- An activity room or designated space for residents who are able to be involved in reading, crafts and social activities.
- A friendly and available staff who appear pleasant, caring and accommodating to residents and visitors.
- A volunteer program.
- An active resident council or some type of resident participation program that enables residents to recommend changes within the home.
- A residents’ bill of rights or a stated policy that identifies and respects residents’ individual rights.
How to Compare & Contrast Nursing Homes
Nursing Home Details
Total Number Of Beds
This number represents only the number of beds in the nursing home that are Medicare and/or Medicaid certified.
Nursing Homes may have a combination of Medicare, Medicaid, and/or private-pay beds. Please consult the facility for the total number of available beds.
Total Number of Residents
This is the measure of the actual number of residents in the facility at the time of inspection by the state government (conducted on average every 9 – 15 months), a single day out of the entire year!
In order to find out the true average census, contact the nursing home. This is most useful when viewed in correlation with the number of staff-on-hand and the number of staff hours per resident.
Percentage of Occupied Beds
This is the percentage of actual residents in the facility at the time of the government inspection and is often referred to as nursing home census. A lower percentage of occupancy is not necessarily a negative indicator. It may be due to:
- The facility specializes in temporary care which requires only brief stays
- Increased competition with a new facility opening within the vicinity
- A new facility that has not been completely filled
- A new wing may have opened
Other reasons may include:
- Result from an outbreak of infection or other emergency situation
- Deficiency (poor inspection findings) had a widespread effect on the perception of resident care
The positive indication for high occupancy may include:
- High demand and potential waiting lists
- Access to specialized services
- Stable long-term care residents
- Community perception of high quality
The lesson is clear: Find out about it. Do your homework. Speak with staff and residents.
Medicare or Medicaid Certified
This is the federal insurance program for seniors and certain disabled individuals that generally provides limited coverage for nursing home care.
Short-term stays such as rehabilitation, stroke, or post-surgery recovery may be covered by Medicare in the nursing home. A facility may be certified for Medicare or Medicaid or both.
Individuals are eligible for Medicaid:
- If they receive Supplemental Security Income
- If they are determined to be “medically needy”
- If their income and assets are below a state-designated cap
Type of Ownership
The type of ownership does not necessarily coincide with the quality of care and respect the resident will receive. An informed consumer must evaluate any prospective facility in both an objective and subjective manner.
Types of ownership for nursing homes include:
- For-profit – Corporation
- Nonprofit – Corporation
- For-profit – Partnership
- Government – Federal, state, or county
- Nonprofit – Church related
This indicates whether the nursing home is affiliated with a hospital and located in the vicinity of the hospital.
Advantages of a hospital owned nursing home include:
- Resources of the hospital (full continuum of care), including physicians and emergency, laboratory and radiology services (x-ray, MRI, etc.)
- No wait (or no need) for an ambulance
However, whether it is hospital-based, hospital-affiliated, or free-standing, it is not necessarily indicative of the quality of care provided by the facility.
This indicates that the nursing home is part of a chain, which generally has two or more homes, or that the owner of a facility also owns other homes. They are typically owned and operated by the same entity.
This is not indicative of the quality of care available in the home. In fact, quality of care may vary from facility to facility.
Resident and Family Councils
Residents, by law, are permitted to form a council to address issues and communicate with the nursing home administration and staff. Residents, when able, are in the best position to evaluate facility performance in meeting their needs and desires.
The use of a council allows them to present a unified voice. A prospective resident (and family member) may wish to speak with members of the council to find out whether the home has been receptive to suggestions and concerns.
Family members of residents (and even friends of residents!), by law, are permitted to form a council. This is a useful tool for communicating with the facility to address specific issues and to solicit information. A prospective resident and family member may wish to speak with members of the council to find out whether the home has been receptive to suggestions and concerns.
Inspections are conducted by the state Department of Health and/or the Center for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS).
A team of several professionals of various technical backgrounds (such as nurses, sanitarians, social workers and dietitians) enter the nursing home and evaluate the facility’s compliance with applicable regulations.
Inspections can involve repeat visits.
The survey team will pre-select a sample of residents but may look at other residents. They will question nursing home staff and administration, tour the facility, review medical records, observe meals and daily activities, and hold individual and/or group meetings of a select sample of residents and/or family members to ask questions.
Consumers should note that the survey is merely a snapshot in time. Minor problems can be overemphasized (such as peeling paint) and serious problems can be overlooked. Inspectors generally survey facilities every nine to fifteen months but may conduct surveys more often in problem facilities.
The survey date generally refers to the date the standard survey is conducted.
Date of Correction
Upon receipt and review of the Statement of Deficiencies, a report of the inspector’s findings, the nursing home has to submit a Plan of Correction. The Date of Correction is the date that the facility has corrected the negative finding.
Failure to comply with any rule, regulation, law, or statute applicable to running the nursing facility.
The number of residents affected by, or potentially affected by, a deficiency.
- Isolated (One or a Few)
- Indicates that this deficiency affects one or the fewest number of residents, staff, or indicates one or the fewest number of occurrences.
Example: 60 of 70 residents in the nursing home are incontinent. The nursing home failed to provide adequate care of services to restore or improve bladder function in 2 of these residents.
- Pattern (Some)
- This deficiency affects more than a limited number of residents, staff, or indicates more than a limited number of occurrences.
Example: 60 of 70 residents in the nursing home are incontinent. The nursing home failed to provide adequate care of services to restore or improve bladder function in 10 of these residents.
- Widespread (Many)
- This deficiency is found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.
Example: 60 of 70 residents in the nursing home are incontinent. The nursing home failed to provide adequate care of services to restore or improve bladder function in half of these residents.
Level of Harm
Outlines the potential for harm.
The potential for Minimal Harm
- This deficiency has the potential for causing no more than a minor negative impact on the resident. Example: The nursing home’s statement of deficiencies was not posted, nor was there any sign indicating where it was. The nursing home keeps the statement of deficiencies in the business office and shows it to residents upon request.
- or Potential for Actual Harm
- This deficiency results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident’s ability to achieve his/her highest functional status.
- Example: Staff were observed not washing hands properly between resident treatments. There is no evidence of the transmission of infection between residents by staff.
- Actual Harm
- This deficiency results in a negative outcome that has negatively affected the resident’s ability to achieve his/her highest functional status.
Example: A resident was “active and vocal” on admission to the nursing home. The nursing home restrained the resident 6 months ago, despite the lack of medical symptoms for doing so. The resident is now withdrawn, does not attend activities, and is “down in the dumps.”
- Immediate Jeopardy – – Actual or Potential
- This deficiency places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the nursing home. Immediate corrective action is necessary when this deficiency is identified.
Example: A resident with dementia was found outside during an inspection, heading toward a nearby highway. The nursing home had no working system in place to monitor residents with dementia.
Through this severity “rating scheme” or “ranking system”, inspectors attempt to impart to you the level of impact the violation has, or could potentially have, on nursing home residents.
In other words: How much are residents at risk of being harmed? The rankings are based on the severity (degree of actual or potential harm to residents) and the scope (the number of residents affected) of the violation.
The measure is in the form of a letter: A through L. A is the “least serious” and L is the “most serious.”
|Severity||Scope of Violation||Level of Risk||Numerical Ranking||Level of Harm|
|A||Isolated||minimal or even no risk at all; home in "substantial|
|1||Potential for Minimal Harm|
|B||Pattern||minimal or even no risk at all; home in "substantial|
|1||Potential for Minimal Harm|
|C||Widespread||minimal or even no risk at all; home in "substantial|
|1||Potential for Minimal Harm|
|D||Isolated||potential to cause "more|
than minimal harm"
|2||Minimal Harm or Potential for Actual Harm|
|E||Pattern||potential to cause "more|
than minimal harm"
|2||Minimal Harm or Potential for Actual Harm|
|F||Widespread||potential to cause "more|
than minimal harm"
|2||Minimal Harm or Potential for Actual Harm|
|G||Isolated||cause "actual harm"||3||Actual Harm|
|H||Pattern||cause "actual harm"||3||Actual Harm|
|I||Widespread||cause "actual harm"||3||Actual Harm|
|J||Isolated||causes or has the potential to cause death or serious|
injury; "immediate jeopardy violation"
|K||Pattern||causes or has the potential to cause death or serious|
injury; "immediate jeopardy violation"
|L||Widespread||causes or has the potential to cause death or serious|
injury; "immediate jeopardy violation"
Category of Deficiency
The following are the types of deficiencies reported by the government:
- (1) Administration Deficiencies
- It is the facility’s responsibility to provide and maintain the highest level of physical, psychological, and emotional well-being of the resident. The facility must be licensed under state law and comply with federal, state and local laws. Laboratory, radiological and other diagnostic services should be provided, as well as assistance in making transportation arrangements. Clinical records must be maintained for each resident and kept private and confidential. The staff should be trained and demonstrate competency in the jobs they perform, including disaster and emergency preparedness.
- (2) Environmental Deficiencies
- The facility must provide a safe, clean, functional and hazard-free environment for the residents. Every facility must be in compliance with safety and fire codes. Effective housekeeping and maintenance services maintain the environment.
- (3) Mistreatment Deficiencies
- A resident has the right to be free from physical and chemical restraints, any form of abuse — including verbal, sexual, physical and mental — misappropriation of property and neglect. This need not rise to the level of maliciousness constituting actual abuse to be considered a mistreatment deficiency. It may also arise from lack of care or omissions creating risk of harm. The facility must have policies and procedures in place for screening and training employees to prevent abuse, mistreatment and neglect of any kind.
- (4) Nutrition and Dietary Deficiencies
- The food must be stored, prepared, and served in a sanitary manner and at the proper temperature. Each resident must be properly nourished on a timely basis (i.e. no more than 14 hours between evening meals and breakfast and a snack must be available at bedtime) and the food must be nourishing, palatable and attractive and meet the nutritional and special dietary needs of the resident. The dining experience should enhance the quality of life for the resident. A dietitian and support staff must be employed. If a resident refuses food, a proper and comparable substitute of similar nutritional value must be provided.
- (5) Pharmacy Service Deficiencies
- Pharmaceutical services must be offered by a facility pharmacist or a consultant. The facility must assure medications ordered are available, properly labeled, handled and stored in accordance with State and Federal laws. The pharmacist/consultant must review the drug regimen for adverse reactions or interactions.
- (6) Quality Care Deficiencies
- Quality of care includes assessment of resident needs, developing a plan to meet those needs, implementation and follow-up. The goal is to attain and maintain the highest practicable physical, mental and psychosocial well being of the resident. This includes activities of daily living and overall functional ability (eating, walking, toileting, etc.). Nutrition, hydration, weight maintenance, prevention of pressure sores and urinary tract infections, unnecessary drug use, hearing and vision, range of motion and mobility and special needs also fall into this category.
- (7) Resident Assessment Deficiencies
- The facility must formulate a comprehensive care plan that includes a competent, accurate and thorough assessment of resident needs, as well as establish a plan of care and actually provide adequate services in accordance with that plan of care.
- (8) Resident Rights Deficiencies
- The facility must inform residents both orally and in writing of their rights. Resident rights include:
- Dignity and respect
- Privacy and confidentiality
- Access to a physician
- Means for communication
- Full Information (to resident and other interested parties)
- Access to legal representative
- Access to family and friends
- Protection and management of personal funds and property
- Freedom from any physical restraint unless required for treatment
- Written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property
- Adequate employment screening (background checks, etc.)
- Protection from abuse, whether sexual, verbal, physical, psychological or emotional
- Protection from punishment and forced seclusion
- Adequate staff training and monitoring
- Policies and procedures for reporting, investigating and taking corrective action upon any allegation of abuse, neglect or mistreatment
- Encouragement of residents’ participation in planning and making decisions regarding own care and quality of life
- Reasonable accommodation of individual needs and preferences, without infringing on other residents
- Non-discriminatory treatment
- Complaint procedures, coupled with quick and adequate response and protection from backlash
- Access to mail
- Access to telephone
- Access to clinical records
The Quality Measure is a benchmarking tool which you can use to compare nursing homes within the state or nationwide. These are not the same as the 24 Quality Indicators that facilities use internally to monitor their quality of care. The measures can be misleading. We explain this in further detail under each Quality Measure.
The Quality Measures target both long stay and short stay residents. Long stay residents refer to those types of patients who enter a nursing facility typically because they are no longer able to care for themselves at home. These residents tend to remain in the nursing facility anywhere from several months to several years. Short stay residents, on the other hand, refer to those who are admitted to a facility and typically stay for less than 30 days. Short stay residents usually come from hospitals to nursing homes for intense rehabilitation or complex medical care. Generally, the lower the percentages are the better.
The 15 Quality Measures are:
Long Stay Residents
- Percent of residents whose need for help with daily activities has increasedThis shows the percent of residents whose need for help doing basic daily tasks such as feeding oneself, moving form one chair to another, changing positions while in bed, and going to the bathroom alone, has increased from the last time it was checked.Residents are routinely checked to see how they function doing these basic daily activities. Some loss of function may be expected in the elderly. If they are in poor health or if they are ill (like if they have pneumonia, an infection, a recent injury, or a chronic problem like asthma that has flared-up) they may have a temporary loss of function. Sudden or rapid loss of one or more of these basic daily tasks could mean the resident needs medical attention.Most residents value being able to take care of themselves. It is important that nursing home staff encourage residents to do as much as they can for themselves. In some cases, it may take more staff time to allow residents to do these tasks than to do the tasks for them. Residents who still do these basic daily activities with little help may feel better about themselves and stay more active. This can affect their health in a good way. When people stop taking care of themselves, it may mean that their health has gotten worse. The resident’s ability to perform daily functions is important in maintaining their current health status and quality of life. Some residents will lose function in their basic daily activities even though the nursing home provides good care.
- Percent of residents who have moderate to severe painThis shows the percent of residents who are reported to have moderate to severe pain during the 7-day assessment period. This pain record is merely a snapshot in time. While the symptom may be recorded, efforts to remedy it and progress might not be. This measure is shown to get you to talk to the nursing home staff about how they check and manage pain, and to make you aware of how important it is.Pain can be caused by a variety of medical conditions. Checking for pain and pain management are very complex. Comparing these percentages is different from the other measures because the percentages may mean different things. Generally, a lower percentage on this measure is better. However, this isn’t always true. For example, two nursing homes could provide the same quality of care and have the same number of residents with pain. However, if one of the nursing homes does a better job checking the residents for pain, they could have a higher percentage on this measure. Or, if for personal or cultural reasons, more residents in one of the nursing homes refuse to take pain medication, that nursing home’s percentage would be higher. In these examples, although the percentage for one nursing home is higher, it does not mean they are not providing good care.Residents should always be checked regularly by nursing home staff to see if they are having pain. Residents (or someone on their behalf) should let staff know if they are in pain so efforts can be made to find the cause and make the resident more comfortable. If pain is not treated, a resident may not be able to perform daily routines, may become depressed, or have an overall poor quality of life.
- Percent of high-risk residents who have pressure soresThis shows the percent of residents with a high risk for getting pressure sores, or who get a pressure sore in the nursing home. A resident is said to be “high risk” for getting a pressure sore if he or she is in a coma, doesn’t get the necessary nutrients like water, vitamins and minerals, or unable to move or change position on his or her own.A pressure sore, also known as pressure ulcer, bed sore or decubitus, is a skin wound that usually develop on bony parts of the body such as the tailbone, hip, ankle, or heel. They are usually caused by constant pressure on the skin from chairs, wheelchairs, or beds. Pressure sores may be painful and cause other complications such as skin and bone infections. Severe pressure sores may take a long time to heal. As a result, some of the pressure sores included in this data may be ones that facilities are in the process of successfully treating and improving.There are several things that nursing homes can do that may help to prevent or treat pressure sores, such as frequently changing the resident’s position, proper nutrition, and using special devices to reduce pressure on the skin. Some residents may get pressure sores even when the nursing home provides good preventive care.
- Percent of low-risk residents who have pressure soresThis shows the percent of residents with a low risk for getting pressure sores, or who get a pressure sore in the nursing home. A resident is said to be “low risk” for getting a pressure sore if he or she is active, able to change positions, and get the necessary nutrients like water, vitamins and minerals.
- Percent of residents who were physically restrainedThis shows the percent of residents in the nursing home who were physically restrained daily during the 7-day assessment period.A physical restraint is any device, material, or equipment attached or adjacent to a resident’s body, that the individual cannot remove easily, which keeps a resident from moving freely or prevents them normal access to their body. Examples of physical restraints include special types of vests, chairs with lap trays, lap belts, and enclosed walkers. Bed rails or side rails are also considered restraints in certain situations, but they are not used in the calculation of this measure.Restraints should only be used when they are necessary as part of the treatment of a resident’s medical condition. Only a doctor can order a restraint. Restraints should never be used to punish a resident or to make things easier for the staff. Facilities are not allowed to use restraints based solely on a family’s request, unless there is a documented medical need and a doctor’s order. A resident who is restrained daily can become weak, lose his or her ability to go to the bathroom by themselves, and develop pressure sores or other medical complications.
- Percent of residents who have become more depressed or anxiousThis shows the percent of residents who have become more depressed or anxious in the nursing home since the last time they were checked.Depression is a medical problem of the brain that can affect how you think, feel, and behave. Signs of depression may include fatigue, a loss of interest in normal activities, poor appetite, and problems with concentration and sleeping. Anxiety is excessive worry. Signs of anxiety can include trembling, muscle aches, problems sleeping, stomach pain, dizziness and irritability. Feeling depressed or anxious can lessen your quality of life and lead to other health problems. Nursing home residents are at a high risk for developing depression and anxiety for many reasons, such as loss of a spouse, family members or friends, chronic pain and illness, difficulty adjusting to the nursing home, and frustration with memory loss. Identifying depression and anxiety can be difficult in elderly patients because the signs may be confused with the normal aging process, a side effect of medication, or the result of a medical condition. Proper treatment may include medication, therapy, or an increase in social support.
- Percent of low-risk residents who lose control of their bowels or bladderThis shows the percent of low risk residents who often lose control of their bowels or bladder. Residents are said to be ‘low risk’ for losing bowel and bladder control if they do not have severe dementia (memory loss) or if they do not have very limited ability to move on their own.Loss of bowel or bladder control is not a normal part of aging and can often be successfully treated. Loss of bowel and bladder control can be caused by physical problems such as constipation, muscle weakness, or a bladder infection, location problems like the bathroom is too far away, reaction to medication, limited ability to walk or move around, diet and fluid intake, toilet routine, certain medical conditions, and whether someone can provide assistance when needed.Finding the cause, and treating a problem with bowel or bladder control is important for many reasons. Physically, it can help prevent infections and pressure sores. Mentally, treatment can help the well being of the resident by restoring dignity and social interaction.
- Percent of residents who have/had a catheter inserted and left in their bladderThis shows the percent of residents who had a catheter inserted and left in their bladder for a period of time during the 14-day assessment period.A catheter is a thin, soft tube that is left in place and attached to a bag that collects the urine. It may be inserted into the bladder of people who lose control of their bladder or cannot use a toilet. Catheters may be used because there is a physical reason the urine cannot drain naturally, to keep a patient with pressure sores around the buttocks or tailbone that are not healing clean and dry thus promote healing, or to measure the amount of urine being produced.A catheter should only be used when it is medically necessary. Residents may need a lot of help to get to the toilet, or they may have to go frequently. A catheter should not be used for the convenience of the nursing home staff. Using a catheter may result in complications, like urinary tract or blood infections, physical injury, skin problems, bladder stones, or blood in the urine. Some studies have shown that long-term use of catheters (over many years) may increase the rates of bladder cancer in patients with spinal cord injuries.
- Percent of residents who have lost too much weightThis shows the percent of residents who have experienced a weight loss of more than 5% of their body weight in one month or 10% of their body weight in six months. Persons who are receiving hospice care are excluded from this percentage.Excessive weight loss can make a person weak, change how medicine works in the body or cause the skin to break down, which can lead to pressure sores. Weight loss may mean that the person is ill, is refusing to eat, is depressed or has a medical problem that makes eating difficult.There are several things that a nursing home can do that may help prevent unhealthy weight loss. It is important that the resident’s diet is balanced and nutritious, assistance and support is provided with eating when necessary and medical problems are promptly addressed.Sometimes it may be necessary for a person to lose weight for medical reasons. In these cases, the medical staff may plan in advance for the resident to lose weight on a special weight loss program, but the person should not lose more than 5% of their body weight in one month.
- Percent of residents who spent most of their time in bed or in a chairThis shows the percent of residents who spent most of their time in bed or in a chair in their room during the 7-day assessment period.A decline in physical activity may come with age due to muscle loss, joint stiffness, worsening illness, or depression. Residents who spend too much time in bed or a chair may lose the ability to perform activities of daily living, like eating, dressing, or getting to the bathroom. Staying in a bed or chair may affect the resident in many ways. Unused muscles get weaker. It becomes difficult to participate in physical and social activities. Sleep quality can suffer. The risk of heart disease, stroke, diabetes, or blood clots can increase. Depression and anxiety can worsen. Staying in one position and constant pressure on the skin can increase the chance of pressure sores. It is important for residents to be as active as possible. Nursing home staff can help residents be more active. For instance, they can encourage residents to take part in physical activities, or take them for regular walks if they need help. Most residents value being able to take care of themselves. It is important that nursing home staff encourage residents to do as much as they can for themselves and stay as active as physically possible. Some residents will choose to remain in bed or in a chair, even though the nursing home staff makes a good effort to keep them more active. It is also important to note that some residents may be counted in this measure if their assessment period occurs when they are temporarily ill and remaining in bed due to a short-term problem.
- Percent of residents whose ability to move about in and around their room got worseThis shows the percent of residents whose ability to move about, either by walking or using a wheelchair, in their room and the hallway near their room got worse since their last assessment.A decline in physical activity may come with age due to muscle loss, joint stiffness, worsening illness, fear of injury, or depression. Residents who lose mobility may also lose the ability to perform other activities of daily living, like eating, dressing, or getting to the bathroom. In some cases, however, the decline measured may be temporary and due to a short-term illness the resident is experiencing at the time of the assessment. A lack of movement may affect the resident in many ways. It becomes difficult to participate in physical and social activities.Nursing home staff can help residents move around more. For instance, they can encourage residents to take part in physical and social activities, or take them for regular walks if they need help. Most residents value being able to move about on their own and take care of themselves. It is important that nursing home staff encourage residents to do as much as they can for themselves and stay as active as physically possible. Some residents will decline in their ability to move about, even though the nursing home staff makes a good effort to keep them more active.
- Percent of residents with a urinary tract infectionThis shows the percent of residents who had an infection in their urinary tract anytime during the 30 days before their most recent assessment.A urinary tract infection (UTI) is an infection in the urethra that left untreated, can spread to the bladder and kidney and cause further infection. If the area where waste (urine and bowel movements) leaves your body is not kept clean, bacteria from your colon may multiply and enter the urethra (the tube that passes urine from your bladder to outside your body), causing a UTI. A UTI may also be caused by bacteria on a catheter (a soft tube used to drain urine) being used to drain the urine from the bladder.Most urinary tract infections can be prevented by keeping the area clean, emptying the bladder regularly, and drinking enough fluids. Nursing home staff should make sure the resident has good hygiene. Finding the cause and getting early treatment of a UTI can prevent the infection from spreading and becoming more serious or causing complications like delirium. It is important to find out whether the UTI is caused by a physical problem so proper medical treatment can be given.
Short Stay Residents
- Percent of short stay residents with deliriumThis shows the percent of short stay residents who have symptoms of delirium.Delirium is severe confusion and rapid changes in brain function, usually caused by a treatable physical or mental illness. Delirium is often misdiagnosed. Delirium may be caused by infection; a stroke; dehydration; reaction to surgery; anesthesia or medication; certain diseases; uncorrected vision or hearing problems; improper restraint usage; or depression. Symptoms may develop over a short period of time, and change during the day and may include:
- Sudden problems with attention, or not able to focus or concentrate thoughts or behavior
- Problems thinking and communicating
- Loss of a sense of time or place
- Changes in sensation and perception
- Changes in level of alertness, consciousness or awareness
- Changes in sleep pattern
- Loss of short-term memory
- Changes in personality
Delirium is not a normal part of aging. It should not be confused with dementia. Delirium is a serious condition requiring urgent medical attention. When left untreated, the death rate is high. Finding and treating the cause of delirium can ensure proper treatment of a physical or mental problem, and help restore the resident’s health and quality of life.
- Percent of short stay residents who had moderate to severe painThis shows the percent of residents who are reported to have moderate to severe pain during the 7-day assessment period. This pain record is merely a snapshot in time. While the symptom may be recorded, efforts to remedy it and progress might not be. This measure is shown to get you to talk to the nursing home staff about how they check and manage pain, and to make you aware of how important it is.Pain can be caused by a variety of medical conditions. Checking for pain and pain management are very complex. Comparing these percentages is different from the other measures because the percentages may mean different things. Generally, a lower percentage on this measure is better. However, this isn’t always true. For example, two nursing homes could provide the same quality of care and have the same number of residents with pain. However, if one of the nursing homes does a better job checking the residents for pain, they could have a higher percentage on this measure. Or, if for personal or cultural reasons, more residents in one of the nursing homes refuse to take pain medication, that nursing home’s percentage would be higher. In these examples, although the percentage for one nursing home is higher, it does not mean they are not providing good care.It is important to note that most residents who are in a nursing home following a hospitalization are recovering from an acute illness, surgery, or an injury like a broken bone. It is common to have pain after surgery or an injury. Physical therapy to restore functioning can also be associated with some degree of pain that is unavoidable, so a nursing home that specializes in rehabilitation may have more residents with pain. However, it is still important to identify and treat pain.
- Percent of short stay residents with pressure soresThis shows the percentage of short stay residents who have developed pressure sores, or who had pressure sores that did not get better between their first and second assessments in the nursing home.Severe pressure sores may take a long time to heal. As a result, some of the pressure sores included in this data may be ones that facilities are in the process of successfully treating and improving. . Further, because healing can be slow, subsequent records will indicate continued presence of the pressure sore despite treatment and added measures of care.
Special Note on Risk Adjustments and Exclusions
The following six (6) Quality Measures have been Risk Adjusted at the Resident Level:
- Percent of Residents Who Have Moderate to Severe Pain
- Percent of Residents Who are More Depressed or Anxious
- Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse
- Percent of Short-Stay Residents With Delirium
- Percent of Short-Stay Residents Who Had Moderate to Severe Pain
- Percent of Short-Stay Residents With Pressure Sores
Please note that Resident-Level Risk Adjustments have been applied to these Quality Measures due to the reality that individual residents in different facilities have different risks as a result of variations in their health condition and their levels of functionality. A resident may have a health condition that could increase or decrease the likelihood of their being counted in a specific Quality Measure, regardless of the true quality of care provided by the nursing home. The intent of Risk Adjustment is to enable the public to evaluate and compare facilities in a fair and accurate manner, despite the unavoidable differences in resident characteristics.
For example, a resident may have a cognitive impairment (difficulty thinking and communicating) that impacts his/her ability to clearly express levels of pain. This difficulty in expressing how he/she feels could decrease the likelihood of triggering the “pain” measure regardless of the nursing home’s quality of care. Therefore, the quality measure for long-term residents with pain is risk adjusted to take into account residents that have cognitive impairments. Consider two nursing homes that provide the same quality of care to their residents and whose residents are exactly the same except for one feature: “Nursing Home A” has many residents who are cognitively impaired while “Nursing Home B” does not. Before risk adjusting, Nursing Home A’s percentage of residents in pain is lower than Nursing Home B’s. After risk adjustment, the scores should be the same.
All of the Quality Measures have been calculated subject to certain Exclusions.
Exclusion factors are used to limit the measures to a relevant group of residents. In other words, certain residents may be excluded from the calculation of the Quality Measure. Exclusions may be due to missing resident assessment data or the clinical condition of the residents excluded. For example, “the percent of residents whose need for help with daily activities has increased” excludes residents in a coma from consideration since they cannot perform basic daily activities. If residents in a coma were included in this measure, it could affect that nursing home’s percentage on the quality measure, thereby making it difficult to compare with other nursing homes which might not have any residents in a coma. In instances in which a resident assessment is missing the data elements needed to calculate the quality measure, the resident is excluded from that measure.
In short, does the facility have enough staff to give adequate care to all residents. Average nursing care hours provided to residents, is determined by the number of nursing staff hours worked in one day, divided by the number of residents in the facility. This measure does not necessarily show the number of nursing staff present at any point of time, or reflect the amount of care given to any one resident. Additionally, the nursing care hours you will see during your search may not accurately reflect the facility’s staffing because:
- It is a snapshot of the staff present in the two weeks prior to the survey.
- A facility may be brand new and is not at full capacity, but has full staffing, which will overstate the nursing care hours.
- There was incorrect reporting, e.g the facility only reported one week of staffing instead of the two weeks asked for by the survey team. This would understate the facility’s nursing care hours.
- The facility uses other or additional staffing sources such as contract agencies.
There is no current codified federal standard for nursing staff hours per resident. Currently, by regulation, facilities must post their daily nursing staffing levels in a prominent location within the facility. This is a more accurate reflection of the facility’s staffing.
State and National Averages may also be skewed. Staffing concerns should be discussed with the facility.
How to Get Your Loved One Admitted to The Nursing Home of Your Choice
There are three primary ways to get admitted:
- From the Hospital
- The discharge planner or Social Service Department is the usual liaison between the hospital and the nursing facility. The needs of the patient are considered by the discharge planner who will meet with the patient and/or the family in order to discuss continuing care options. The Social Service Department is available to assist in implementing placement procedures. However, while the patient is in the hospital, see our sections on Choosing and Finding a Nursing Home to be a truly informed consumer. You do have choices!
- From Home
- After using our Find a Nursing Home search engine and narrowing your results, call the admissions coordinators of the nursing homes you have selected. They are very helpful and will address your individual circumstance. The facility will guide you regarding the admission requirements. You can also get help from the community social worker and other professionals who specialize in the placement of prospective nursing facility residents.
- From Another Facility
- When you plan a transfer from one facility to another because of changing care needs, dissatisfaction, or location concerns, and have narrowed your search for the new location using our Find a Nursing Home search engine, utilize the resources provided by the admissions coordinator at your facility. Inform the social worker/discharge planner about your plans to transfer if it is not the same person.
Preparing for Admission
If you have chosen a facility to meet your short-term or long-term needs, you might understandably have some apprehension about entering the facility, despite having done your research.
Nursing homes have resources available to you to help you adjust on both a physical and emotional level. Social workers, admissions staff, psychological support services staff, and Resident Council members are generally available to help you make the transition or for general support.
If you feel you need to talk openly with someone, do not hesitate to ask the facility about access to these services.
Talking to Your Loved One
We recognize that this is a difficult time for both you and your loved one. Many factors come into play and entire lives can be disrupted. If this is a short term stay, it may be merely a matter of discussing the patient’s care needs.
If this is anticipated to be a long-term placement, you have to recognize the individuality of the situation. To the greatest extent possible, potential residents should be involved in the decision-making process.
Cognitive ability, emotional history, current state of mind, and physical status may impact on their ability to take part in the selection process. Be honest, be forthright and, most of all, be supportive.
What to Bring
We suggest you bring the following:
- Clothing that is comfortable and does not require dry-cleaning and preserves the resident’s dignity and right to choice in what he/she wears
- Photographs and memorabilia
- Personal effects such as makeup and hygiene products
- Eyeglasses, dentures, hearing aids, and prosthetic devices
We suggest you do not bring (without checking with the facility):
- Personal furniture
- Electrical equipment
- Personal medications
- Food and snacks
Check with the facility for its policy on the following:
- Labeling clothing
- Telephone, television, and computer access
- Storage and security of personal items