Running a five-star nursing home

Top-rated facilities had more registered nurses, less staff turnover

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Administrator Angela Buckland regularly walks the halls of the Woodview Healthcare nursing home in Fort Wayne, Indiana, to monitor how well residents are being treated.

It’s just one part of a resident-first philosophy that includes quarterly satisfaction surveys, a confidential suggestion box and the inclusion of family members in the care planning process.

The facility has “a team approach with everyone,” said Buckland, who has been an administrator since 2006. The staff at Woodview are a critical element of the team, she said, and the home maintains a consistent staffing level throughout the entire year. 

In 2012 that consistency in staffing contributed to Woodview’s earning the top rating from the federal government for overall quality — a 5-star score on a 5-star scale from Nursing Home Compare, a website the government uses to help the public comparison shop for  nursing homes. Consistency is especially important because critics believe many homes “staff up” just before annual inspections in order to earn a higher rating from the federal government. Nursing home administrators and a leading industry group deny those charges.

Woodview was one of four dozen nursing homes nationwide that had both consistent staffing levels and a five-star rating, according to an analysis by the Center for Public Integrity. The Center’s analysis of more than 10,000 nursing homes found consistently higher levels of reported staffing, particularly among registered nurses, on the public website Nursing Home Compare than the average daily levels calculated through Medicare cost reports that are largely out of public view.

In 2005 the Centers for Medicare and Medicaid Services, the agency responsible for nursing home oversight, said the Medicaid cost reports that have much of the same information as the Medicare documents are generally more accurate than the self-reported data found on Nursing Home Compare. 

The Center looked at a range of variables, including size, occupancy rate, ownership status and the percentage of days paid for by Medicaid. Those four dozen top-rated nursing homes differed little from the rest of the facilities on many of these variables, but the average staffing levels for registered nurses at these top-rated homes were about 50 percent higher than the average for all homes, according to the Center’s analysis.

The total daily staffing levels at those top-rated homes were about 4.1 hours per resident per day, the Center’s analysis of cost reports data found.

Robyn Grant, director of policy at the Consumer Voice for Quality Long-Term Care, the nation’s top nursing-home advocacy group, said the five-star rating system has some limitations but asserted that the top-rated nursing home providers nevertheless deserve praise for their staffing levels and quality of care.

“[These providers] can and should be models for the others. They show us it can be done within the current system without receiving additional funding,” said Grant.

A number of academic studies have found that staff continuity and the amount of care, particularly from registered nurses, can play a critical role in residents’ quality of care. Greater continuity of care is associated with residents’ having better health outcomes, the studies said.

Jack Wagoner, administrator of the Carlton Shores Health and Rehabilitation Center in Daytona Beach, Florida, said several of the nurses at his five-star facility were long-time employees who started in other jobs — certified nursing assistants who had participated in the company’s tuition reimbursement policy. These opportunities for professional training and advancement contributed to greater stability and a lower-than-average turnover rate among nurse assistants,he said.

Wagoner estimated that the level of aide turnover at Carlton Shores in the past year was between 20 percent to 30 percent — far lower than the industry average of 52 percent, according to a 2012 report by nursing home industry group the American Health Care Association. Buckland estimated that half of the staff at Woodview had worked there at least a decade, with a number of employees having been at the facility for 30 years.

Another distinctive feature of the top four dozen facilities: a lower percentage of days paid for by Medicaid, the federal health care assistance program for low-income Americans. Residents with a lower level of days paid for by Medicaid tended to be more physically able and to receive more care than those living in facilities with a higher percentage of days paid for by the program, according to the Center’s analysis. The top-ranked facilities averaged just below half of their days paid for by Medicaid, while the average was about 55 percent for all of the homes analyzed. Bita Kash, professor of Health Policy and Management at Texas A & M University, said Medicaid’s comparatively low reimbursements help explain the difference in care levels.

The Woodview facility where Buckland works was almost exclusively a private-pay facility.

Buckland said her staffing commitment would remain constant even if she had a higher percentage of Medicaid residents, but she acknowledged that a higher Medicaid load can impact administrators’ ability to provide the staff  that are needed.

"I would still maintain the same staffing numbers," she said. "Maybe public funded [facilities] that have a high census of Medicaid, their payment factors are going to be an issue."

But it’s an issue that can be handled, as Matt Hartley and his staff of dozens at Portland Health and Rehabilitation Center in Oregon have proven.

The Portland facility had 86 percent of its days paid for by Medicaid, yet it also earned the highest rating and has shown consistent staffing levels. Hartley cited the home's employee ownership, a supportive headquarters office, a robust level of staff appreciation and opportunities for advancement as critical in creating an environment that allows the staff to consistently deliver high-quality care to the diverse group of about 50 residents.  

"I’ve worked for other nonprofits and other entities," said Hartley, who's been at Portland Health and Rehabilitation for six years and a licensed nursing homes administrator since 1997.  "It's a breath of fresh air to be in a place that has so many things in place to help you stay organized and provide good patient care."

Hartley previously worked at other nursing homes. He said he's never seen facilities "staff up" for an inspection.

Charlene Harrington, professor emeritus of nursing at the University of California, San Francisco, struck a more skeptical note.

She said the results for the more than four dozen highly-rated homes speak highly of their staffing levels and commitments to resident care and staff development, but added that many other nursing homes don’t act in the same manner.

“I would say that those homes are not trying to game the system; they’re trying to do the right thing to provide the staff and the care,” Harrington said. “Unfortunately, you see a lot of homes that just don’t understand or aren’t willing to invest in the staff. They’re trying to game the system during the two weeks [of the survey] and don’t invest the rest of the year.”

This story was written with support from the Fund for Investigative Journalism 

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