Warning to my Readers: Nursing Home Compare isn’t Reliable

medicare nursing home compare

For a long time now, I’ve written about how consumers can use Medicare.gov’s tool, Nursing Home Compare, to get ratings for skilled nursing facilities in their area.  However, today I have decided that I can no longer endorse the use of Nursing Home Compare use as a tool for deciding between facilities.

There have been complaints about the accuracy of Nursing Home Compare’s ratings for a long time, but last week, several articles came out that make it impossible to ignore the problems.  According to the New York Times:

Only one of the three criteria used to determine the star ratings — the results of annual health inspections — relies on assessments from independent reviewers. The other measures — staff levels and quality statistics — are reported by the nursing homes and accepted by Medicare, with limited exceptions, at face value.

The ratings also do not take into account entire sets of potentially negative information, including fines and other enforcement actions by state, rather than federal, authorities, as well as complaints filed by consumers with state agencies.

The remainder of the article goes into greater depth about how ratings are calculated and instances in which highly-rated nursing homes did not provide adequate patient care.  (It’s a good article, and well worth the read if you have family members who need skilled nursing care.)

What should consumers do with this information?  Well, a few things:

You can still use the site to find nursing homes in your area.  It’s pretty straight-forward to type in your city, state, and ZIP code and narrow your search to a specific area.  This is super helpful if you’re just getting started and need a quick, all-in-one place to find rating information.

You can still use the site to find basic information about a community.  Nursing Home Compare still has a wealth of information: ownership, inspection reports, type of payments accepted, and location.  So, feel free to use the site to help you learn more about potential skilled nursing facilities.

You can’t trust the site to provide accurate ratings. Unfortunately, you just can’t trust what you see on Nursing Home Compare.  It’s too easy for nursing homes to game the system right now, and that means that the ratings just aren’t indicative of quality of care.  Even using it to weed out seemingly poor-performing providers isn’t a good recipe for finding the best nursing home.

However, here are a few other ways of checking the quality of care at a senior housing community:

  • Call your local ombudsman. Nursing home ombudsman are awesome resources that you can use free of charge.  You can find your ombudsman by searching the National Consumer Voice website and clicking “Locate an Ombudsman.”
  • Make multiple (sometimes unannounced) visits to the facility.  I’ve heard of unscrupulous marketing agents who spray deodorizing spray in the skilled nursing wing of a retirement community prior to a scheduled tour.  Of course, they do this because the nursing staff isn’t doing a good job of removing odor-causing soiled clothing, diapers, or wound dressings.  But, because you only arrived for the “official tour,” then you won’t see (or, rather, smell) the truth. Another reason to make multiple visits is that, especially when you’re not accompanied by marketing agent, you have a higher chance of observing staff members revert to their “natural behavior.”
  • Talk to other families in the parking lot or hallways.  Now is not the time to be a wallflower.  If you want to learn more about a skilled nursing facility, the best folks to ask are those who have been through the process with a loved one.  To that end, feel free to strike up a conversation with other families that you see in the facility.  They’re highly motivated to share “the gossip” with you and they don’t have any competing interests (unlike the marketing agent whose job is tied to filling beds). Note: Make sure you approach families in a respectful, discrete manner.  It’s one thing to do your own due diligence.  It’s another to infringe on a family who is going through a difficult time.  Please do the right thing, and don’t be obnoxious or ask them overly personal questions.

I’m continually reminded of the fact that skilled nursing, assisted living, and dementia care are not easy jobs.  The senior housing industry has a difficult problem: How can it make money, offer the highest possible level of care, and provide an affordable product?  So far, no one has been able to provide a good solution to that equation, and it’s only served to harm seniors during a very vulnerable time in their lives.

Unfortunately, the odds are not in a consumer’s favor, and it’s very difficult to find a good, one-stop source for senior housing information.  Especially after this week’s article, I can no longer recommend Nursing Home Compare as a viable option.

Want to learn more? Here are a few other links that you might find helpful:

Who to call when things go wrong

Signs of trouble in any community.

Five questions to asking during your senior housing visit.

Finding communities that share your beliefs.

Crisis management 101.

Should retirement communities be owned and run like a McDonald’s? (Part 2)

fast food4

 Note: This is Part 2 of two. Read “Should retirement communities be owned and run like a McDonald’s? (Part 1)” here.

The Bad News:

Managers don’t always care as much about customers. To be fair, this is an issue that every company faces. As a business owner or manager, your goal is to make money. Most of the time, you do that by making the customer happy. But, sometimes that goal can be obscured, especially when managers have bonuses or other competing interests at hand.

It’s worse in corporate situations where managers get bonuses based on financial performance. This can sometimes lead to short-term thinking, which is not always in the best interest of the customer.

For example, real estate investors and hedge funds are under enormous pressure to improve their return on investment, and sometimes this means taking more aggressive approaches to investing. Some of these plays will pay off. Others will blow up.

Risk is magnified.  Aggressive growth strategies in a large provider of senior housing can blow up quickly if the market shifts at the wrong time.  What’s worse is that communities that are perfectly healthy and vibrant can be dragged down by disasters in other parts of the country.  For instance, declines in real estate in one part of the country can impact sales at retirement communities in that area.  If these communities are owned by a regional provider, then no one outside of that area is really impacted.  However, a national provider that has trouble in one market might be tempted to pull cash from an otherwise healthy community to help cover the costs.

Parting Thoughts:

None of these benefits or drawbacks are set in stone.  There are plenty of corporations that begin shaving services and customer care as they get bigger.  Also, there are plenty of companies that are huge behemoths and yet still manage to make customers happy every single day.  The success or failure of a national chain of senior housing communities depends largely on the way the company is run, which is why it’s really, really important that these companies hire good managers.

I can’t say for sure if the consolidation trend is good or bad. In fact, it doesn’t matter because it’s going to happen one way or another. It will certainly impact residents’ lives, although not necessarily in bad ways.

My instinct is to rattle my saber and declare war against the invasion of Wall Street. Seniors shouldn’t have to worry about their home being sold at a bankruptcy auction after hotshot managers make silly decisions and invest foolishly. But, then again, that sort of thing happened in the industry prior to Wall Street arriving.

Ultimately, I think the rules of the game will have to be rewritten a bit, and, unfortunately, it will be big corporations wielding the pen.  Competition will continue. Consolidation will continue. There will be bankruptcies, but, by and large, the ramifications will be felt only for managers and debt holders, not seniors themselves. However, the benefits of consolidation mean that seniors might see better amenities and more activities.

Read Should retirement communities be owned and run like a McDonald’s? (Part 1)

Want to learn more about senior housing? Check out these articles:

Five questions to ask during your visit to senior housing.

Why do CCRCs charge an entrance fee?

What is adult daycare?

Take your pet with you to the retirement community.

Should retirement communities be owned and run like a McDonald’s? (Part 1)

fast food 7

Note: This is Part 1 of two. Read “Should retirement communities be owned and run like a McDonald’s? (Part 2)” here.

Five or ten years ago, there weren’t that many really large companies building continuing care retirement communities. Sure, Brookdale and Sunrise were big, as was (and is) Emeritus and Atria. But, they largely focused on nursing homes and assisted living.  Most CCRCs were owned by smaller, regional companies or by nonprofits.

Since the market crashed in 2008, that has changed dramatically. Senior housing has become an increasingly attractive play for anyone from hedge funds to real estate investors.  This has spurred a round of consolidation that is relatively unprecedented.  It’s very possible that in the next decade, the majority of retirement communities in the United States could be owned by the same two or three companies.

Is that a bad thing? 

We tend to distrust big corporations, and I think for good reason.  But, yet, we all tend to eat at chain restaurants, shop at chain stores, and buy products from the same big online retailers.  Is it really a big deal if retirement communities follow suit? Would having a few national chains control the entire market impact consumers?

I see several benefits and drawbacks to this scenario:

Most large firms have better access to capital. Smaller retirement communities have to work harder to get credit in the event of financial difficulty, and it’s more expensive.  Larger firms can negotiate for loans and financing on a much more national basis, making it easier to finance campus improvements or new communities.  They also have better access to development consulting and other services, which might be prohibitively expensive for smaller companies. Overall this is good for residents, since providers can get the funding their need in a more efficient manner.

Standards and procedures will be more uniform. Ever visited a family restaurant that just didn’t function well? The cash register was too close to the buffet line, and the tables didn’t leave enough room for servers to walk? Well, most of those issues have been solved in chain restaurants.

As firms get larger, they learn which strategies work the best, and they optimize their organizations.  That’s good news for senior housing where staff have to handle a large array of situations and can benefit from additional training that smaller companies might not have been able to provide.

Lifestyle improvements. Larger corporations will probably be better-suited for creating amenities and activities that improve residents’ quality of life:

  • Better activities:  Smaller companies usually rely on one dedicated activity coordinator to handle all aspects of resident life.  If there were a few national providers, these organizations could pay a department of people to craft activities, travel, or other amenities that would help improve resident quality of life.  Since large corporations can negotiate on a grand scale, these services might also be cheaper.
  • Travel agreements among communities in the same chain would allow seniors to effectively visit any city in the country and always have a place to stay.
  • Large corporations can afford to investment in aging in place technology, which might help seniors stay independent for longer.

Read Should retirement communities be owned and run like a McDonald’s? (Part 2)

Want to learn more about senior housing? Check out these articles:

What to expect on your first visit to a retirement community.

Three sneaky sales tactics and your best defense!

How to find a CCRC.

What is LifeCare?

Signs of Trouble in any Community

danger

It doesn’t matter if you’re looking at independent living, assisted living, or skilled nursing, there are some things that are bad news in every community:

Lack of maintenance. Communities in financial danger or communities with incompetent management will sometimes postpone maintaining the property in order to save some cash in the short term.  This is a bad idea, since small maintenance issues can grow quickly into large problems.  If you see things like unkempt grass, out-of-order toilets, torn carpet, trash in the hallways, or other indicators of maintenance problems, you can bet that there are other things that are wrong that staff isn’t working to fix.

Bad odors. You might be tempted to forgive foul smells in a nursing home, but doing so is a mistake.  The only aroma that you should smell in any retirement community is that from cleaning supplies or food service.  Anything else is a sign that something is awry.  Even nursing homes, where staff have to change adult diapers, should have measures in place to remove the soiled linens from the building.  While there are exceptions to this rule, it’s generally a good bet to skip communities that have a foul smell in the air.

Ill-tempered staff. Regardless of wage rates and turnover, no one wants to live in a place where angry, unhappy people work.  If you see any staff member lose their temper or lash out (especially if management is around to see the episode), see yourself to the door.

Thinly-stretched staff.  There is a lot of staff turnover in the senior housing industry.  For one, most people who work at retirement communities aren’t paid very much.  They also do manual labor jobs like lifting patients or cleaning rooms.  As competition has increased in the senior housing industry, managers are forced to cut wages and staffing ratios even more.  That means that people burn out faster at their jobs.

Staffing ratios (the number of patients to one nurse) have been stretched in recent years due to market pressures.  But, good communities will make sure that staff members aren’t overworked such that they can’t care for patients.  So, if you visit a community where everyone always appears to be in a state of panic, consider other options.

Untrained staff. Unfortunately, staff in retirement communities need to know how to handle many different types of situations not normally experienced in other unskilled positions. When emergencies occur, untrained staff can be downright hazardous to themselves and to residents.  Make sure to ask about the training and background checks that staff members receive prior to joining the community’s workforce.

Angry residents or families. While there will always be at least one resident who is not happy living in the community, pay attention to the attitude and demeanor of the folks who live on the property.  If they’re not happy, then you probably won’t be happy either.

Please remember that it’s ok to listen to your instincts.  If something doesn’t feel right, then you’re perfectly fine to end the meeting and leave.  Also, remember that your decision doesn’t have to be made in one day.  Feel free to do multiple visits to the community.  You can also request lunch or dinner with some current residents to get a feel for the place.  Sometimes retirement communities will also offer you a one night stay in their guest suite to give you an idea of what it’s like to live there.  Feel free to take them up on this offer and to get an idea for how the community functions on a daily basis.

Want to learn more about senior housing? Check out these other articles:

Pushing for a move to senior housing isn’t a good idea.

What is adult daycare?

How to “test drive” a community.

Pets and senior housing.

Paying for a CCRC.

Senior Housing Overview

In case you missed it the first time, here’s an overview of seniors housing.

facade_large

Although there are several options for retirement living in America today, industry standards include:

  • Active adult living: For seniors age 55+ who require no assistance; active adult living generally consists of age-restricted neighborhoods or apartment complexes where residents might pay an association fee but receive no other services
  • Independent living: For seniors age 62+ who require no assistance; independent living is generally offered in either apartment or cottage settings and generally includes meals, housekeeping, and social events
  • Assisted living: For seniors requiring assistance with activities of daily living
  • Memory support/Dementia care: For seniors with cognitive decline due to advances Alzheimer’s or other disease
  • Skilled nursing: For seniors in the end-stage of life who require care 24 hours a day

CCRC’s

Although there are many different types of senior housing communities, a particularly popular arrangement is called a “continuing care retirement community,” (“CCRC”), which includes the following services:

  • Independent living
  • Assisted living/Memory support (generally combined in one wing)
  • Nursing

These communities range in size from 40 independent living units to over 1,000 independent living units, with the industry averaging approximately 150 independent living units per campus. The target demographic is generally seniors age 75 or older.

CCRC’s generally follow an entrance fee model whereby residents pay an up-front entrance fee ranging from $100,000 to $1,000,000 (depending on the community and the size of the apartment or cottage) and a monthly fee ranging from $1,500 to $5,000. The entrance fee is refunded to the resident or the resident’s estate following death or move-out.

This arrangement is unique for several reasons, the most important of which is that it allows the community to offer discounts on health care and other services. Accordingly, most communities consider an entrance fee contract to be a type of long-term care insurance.

Because of the insurance nature of entrance fee pricing, most retirement communities require prospective residents to provide proof that their financial resources meet required thresholds and that they are in good health (a community accepting a resident in poor health and/or with limited financial resources can be obligated to care for that resident for the rest of his/her lifetime.