Star search: How to choose a nursing home

“Lisa no longer works here.” This is a familiar refrain when I attend meetings in nursing homes. In this case, Lisa was the Director of Social Services, but the turnover is similar for Directors of Nursing, and slightly less so for Nursing Home Administrators (they make more money). These are the trinity of “building leadership.”

The nursing home industry is highly regulated, which is mostly good and necessary, but it is driven by inflexible benchmarks that keep administrators on the defensive and don’t always serve to improve care. Paperwork is King, and middle managers such as the “trinity” dance between corporate owners, state and federal regulators and our most vulnerable citizens, each with a unique amalgam of needs not neatly lumped into spreadsheet categories. By my observation, it is exhausting work. Every time a significant position turns over, facilities get stalled on improvement projects and simple upkeep. There is a loss of institutional knowledge at the very least, and in some cases, loss of the main stability in the building. Research evidence also shows that high turnover of key staff lowers quality downstream.

Despite leadership challenges, many frontline employees such as certified nursing assistants (CNA’s) and activities staff remain remarkably dedicated to the residents, but are also plagued by high turnover. My sense is that most feel a calling, because they make little more than minimum wage (and sometimes less), so they move around a lot searching for more earning potential, but often to another nursing home. Interestingly, direct care workers such as CNA’s include a high percentage of recent immigrants from a wide range of countries (depending on the region of the U.S.), and many have a knack for caregiving that seems more cultural and instinctive than learned. This is juxtaposed with others from all backgrounds that may have more training, but only “go through the motions.” Despite the fact that they are the main caregivers in nursing homes, CNA’s are only required to have 4-12 weeks of training depending on the state (plus a GED or high school diploma in most states).

Nursing homes are rated on a 5 star system measured by the Centers for Medicare and Medicaid Services (CMS), that is dependent on state surveys. There are 180 or so regulations captured by three different domains: health inspections, staffing and quality of care.

You can read all the specifics at Medicare Nursing Home Compare

There is also a Nursing Home Checklist with some helpful tips.

This survey does not account for turnover of employees, or for the warmth of the direct caregiving staff. It is also (understandably) focused more on finding what’s going wrong than what’s going right.

Based on my experience of being in scores of nursing homes in several regions of the country, I have observed great care in 2- star small facilities and lousy care in 5 star resort-style ones, and everything in between. I think it is important to consider the star rating, and make sure the building is clean with a competitive staff ratio but it misses some important things. If I were looking for a nursing home for a loved one, here are the other questions I would ask and things I would look for.

What is your is your turnover rate over the last 3 years for the three key positions? Nursing Home Administrator (NHA), Director of Social Services? Director of Nursing?

How much do you pay your CNA’s per hour? How does that compare to other nursing homes in the area? To the minimum wage? What is your overall turnover rate of CNA’s?

Do you have a formal training program for managing dementia behaviors without using medications?

Can I observe a meal or social gathering during my visit?

You will choose a facility based on many things, including convenience, availability of good food, transportation, and the star rating. Just don’t forget to ask about turnover, how owners reward excellence, and what hiring practices are used to recruit and retain not only the most competent, but also the kindest caregivers. This is where the rubber meets the road.