How to Find a Good, Well-Staffed Nursing Home

By Jordan Rau for KFF Health News

Few people want to go into a nursing home, but doing so can be the right choice if you or a loved one is physically or cognitively disabled or recovering from surgery. Unfortunately, homes vary greatly in quality, and many don’t have enough nurses and aides to give residents the care they need.

Q: How do I find nursing homes worth considering?

Start with Medicare’s online comparison tool, which you can search by city, state, ZIP code, or home name. Ask for advice from people designated by your state to help people who are older or have disabilities search for a nursing home. Every state has a “no wrong door” contact for such inquiries.

You can also reach out to your local area agency on aging, a public or nonprofit resource, and your local long-term care ombudsman, who helps residents resolve problems with their nursing home.

Find your area agency on aging and ombudsman through the federal government’s Eldercare Locator website or by calling 1-800-677-1116. Identify your ombudsman through the National Consumer Voice for Quality Long-Term Care, an advocacy group. Some people use private placement agencies, but they may refer you only to homes that pay them a referral fee.

Q: What should I find out before visiting a home?

Search online for news coverage and for reviews posted by residents or their families.

Call the home to make sure beds are available. Well-regarded homes can have long waiting lists.

Figure out how you will pay for your stay. Most nursing home residents rely primarily on private long-term care insurance, Medicare (for rehabilitation stays) or Medicaid (for long-term stays if you have few assets). In some cases, the resident pays entirely out-of-pocket. If you’re likely to run out of money or insurance coverage during your stay, make sure the home accepts Medicaid. Some won’t admit Medicaid enrollees unless they start out paying for the care themselves.

If the person needing care has dementia, make sure the home has a locked memory-care unit to ensure residents don’t wander off.

Q: How can I tell if a home has adequate staffing?

Medicare’s comparison tool gives each home a rating of one to five stars based on staffing, health inspection results, and measurements of resident care such as how many residents had pressure sores that worsened during their stay. Five is the highest rating. Below that overall rating is one specifically for staffing.

Be sure to study the annual staff turnover rate, at the bottom of the staffing page. Anything higher than the national rate — an appalling 52% — should give you pause.

You should also pay attention to the inspection star rating. The “quality” star rating is less reliable because homes self-report many of the results and have incentives to put a glossy spin on their performance.

Q: Does a home with three, four, or five stars provide good care?

Not necessarily. Medicare’s ratings compare the staffing of a home against that of other homes, not against an independent standard. The industry isn’t as well staffed as many experts think it needs to be: About 80% of homes, even some with four and five stars, are staffed below the standards the Biden administration will be requiring homes to meet in the next five years.

Q: How many workers are enough?

There’s no straightforward answer; it depends on how frail and sick a nursing home’s residents are. Medicare requires homes to prominently post their staffing each day. The notices should show the number of residents, registered nurses, licensed vocational nurses, and nurse aides. RNs are the most skilled and manage the care. LVNs provide care for wounds and catheters and handle basic medical tasks. Nurse aides help residents eat, dress, and get to the bathroom.

Expert opinions vary on the ideal ratios of staffing. Sherry Perry, a Tennessee nursing assistant who is the chair of her profession’s national association, said that preferably a nursing assistant should care for eight or fewer residents.

Charlene Harrington, an emerita professor of nursing at the University of California-San Francisco, recommends that on the day shift there be one nurse aide for every seven residents who need help with physical functioning or have behavioral issues; one RN for every 28 residents; and one LVN for every 38 residents. Patients with complex medical needs will need higher staffing levels.

Staffing can be lower at night because most residents are sleeping, Harrington said.

Nursing home industry officials say that there’s no one-size-fits-all ratio and that a study the federal government published last year found quality improved with higher staffing but didn’t recommend a particular level.

Q: What should I look for when I visit a home?

Watch to see if residents are engaged in activities or if they are alone in their rooms or slumped over in wheelchairs in hallways. Are they still in sleeping gowns during the day? Do nurses and aides know the residents by name? Is food available only at mealtimes, or can residents get snacks when hungry? Watch a meal to see whether people are getting the help they need. You might visit at night or on weekends or holidays, when staffing is thinnest.

Q: What should I ask residents and families in the home?

Are residents cared for by the same people or by a rotating cast of strangers? How long do they have to wait for help bathing or getting out of bed? Do they get their medications, physical therapy, and meals on time? Do aides come quickly if they turn on their call light? Delays are strong signs of understaffing.

Medicare requires homes to allow residents and families to form councils to address common issues. If there’s a council, ask to speak to its president or an officer.

Ask what proportion of nurses and aides is on staff or from temporary staffing agencies; temp workers won’t know the residents’ needs and likes as well. A home that relies heavily on temporary staff most likely has trouble recruiting and keeping employees.

Q: What do I need to know about a home’s leadership?

Turnover at the top is a sign of trouble. Ask how long the home’s administrator has been on the job; ideally it should be at least a year. (You can look up administrator turnover on the Medicare comparison tool: It’s on the staffing page beneath staff turnover. But be aware the information may not be up to date.) You should also ask about the tenure of the director of nursing, the top clinical supervisor in a home.

During your tour, observe how admissions staff members treat the person who would be living there. “If you walk in to visit with your mom and they greeted you and didn’t greet your mom or focused all their attention on you, go somewhere else,” advised Carol Silver Elliott, president of the Jewish Home Family, a nonprofit in Rockleigh, New Jersey.

Q: Does it matter who owns the home?

It often does. Generally, nonprofit nursing homes provide better care because they can reinvest revenue back into the home rather than paying some of it to owners and investors.

But there are some very good for-profit homes and some lousy nonprofits. Since most homes in this country are for-profit, you may not have a choice in your area. As a rule of thumb, the more local and present the owner, the more likely the home will be well run. Many owners live out of state and hide behind corporate shell companies to insulate themselves from accountability. If nursing home representatives can’t give you a clear answer when you ask who owns it, think twice.

Finally, ask if the home’s ownership has changed in the past year or so or if a sale is pending. Stable, well-run nursing homes aren’t usually the ones owners are trying to get rid of.