Best nursing homes 2013 (Silvia Jansen | Getty Images)

An estimated 3.3 million Americans will live in the nation's nearly 16,000 nursing homes during 2013. That number translates to 1 in 7 people ages 65 and up, and more than 1 in 5 of those 85 and older. They and their families will want and need a way to find a source of the best possible care. For many, it won't be easy.

To help them, U.S. News has collected meaningful data and ratings about nearly every nursing facility in the United States, and built from them a searchable database designed to highlight the highest-rated homes likely to meet each user's needs.

The data behind Best Nursing Homes come from Nursing Home Compare, a website run by the federal Centers for Medicare & Medicaid Services. CMS sets and enforces standards for nursing homes enrolled in Medicare or Medicaid, as most are. The agency also collects information from states and individual homes and assigns each home (other than a few too new to have built up enough months of data) a rating of one to five stars in each of three categories:

  • State-conducted health inspections
  • Nursing and physical therapy staffing
  • Quality of medical care

On January 2013, 3,036 nursing homes earned an overall rating of five stars from the federal government.

Top Places to Find Nursing Home Care

When it comes to finding a top-quality nursing home, residents of some states face a far easier task than others. While California and nine other states have at least a hundred top-rated nursing homes in U.S. News & World Report’s Best Nursing Homes ratings, several states have only a handful of nursing homes that meet the same standards.

In general, larger and more populous states have more nursing homes, but they don’t necessarily have more good ones. Tennessee, for example, has over 300 nursing homes, compared to Connecticut’s 231. But more than one quarter of Connecticut’s homes—64 of them—earned a top rating of five stars, putting that small state at No. 18 on the national list. Meanwhile, less than one-sixth of Tennessee’s homes earned a top rating, and the state failed to make the top 20.

Twenty states with the most five-star nursing homes:

  1. California (with 312 top nursing homes)
  2. Pennsylvania (160)
  3. Illinois (156)
  4. Florida (141)
  5. Ohio (137)
  6. Texas (130)
  7. New York (116)
  8. Massachusetts (111)
  9. Iowa (103)
  10. Wisconsin (100)
  11. Michigan (87)
  12. Indiana (87)
  13. New Jersey (85)
  14. Minnesota (79)
  15. Missouri (78)
  16. Kansas (78)
  17. North Carolina (69)
  18. Connecticut (64)
  19. Virginia (60)
  20. Georgia (59)

On the opposite end of the spectrum, four states and the District of Columbia have fewer than 10 top-rated nursing homes. They are Alaska (just 5 top-rated homes), New Mexico (8), Vermont (8), Washington, DC (7), and Wyoming (5).

To rate nearly 16,000 nursing homes, U.S. News drew on data from Nursing Home Compare, a government-run source of data on all nursing homes that accept Medicare or Medicaid.

CMS does not regulate retirement or assisted-living communities, since their cost is not covered by Medicare or Medicaid, and U.S. News does not evaluate them or include them in the Best Nursing Homes database.

Here are the details of the elements that determine each home's star ratings:

Health inspections

Because almost all nursing homes accept Medicare or Medicaid residents, they are regulated by the federal government as well as by the states in which they operate. State survey teams conduct health inspections on behalf of CMS about every 12 to 15 months. They also investigate health-related complaints from residents, their families, and other members of the public. "Health" is broadly defined. Besides such matters as safety of food preparation and adequacy of infection control, the list covers such issues as medication management, residents' rights and quality of life, and proper skin care. A home's rating is based on the number of deficiencies and their seriousness and scope, meaning relatively how many residents were or could have been affected. Deficiencies are included if they were identified during the three latest health inspections and in investigations of public complaints in that time frame. State inspectors also check for compliance with fire safety rules, although their findings are not factored into the CMS ratings. Best Nursing Homes displays the full range of health and fire inspection results online.

Nurse staffing

CMS determines the amount of time per day patients receive from the nursing staff, because even first-rate nurses and nurse aides can't deliver quality care if there aren't enough of them. Homes report the average number of registered nurses, licensed practical nurses, licensed vocational nurses, and certified nurse aides and assistants on the payroll during the two-week period before the latest health inspection. The number of hours they worked is also reported. Agency temporary employees do not count toward a home's totals. That information is compared with the average number of residents during the same period and crunched to determine the average number of daily minutes of nursing time. To receive five stars in the latest CMS ratings, the nursing staff had to provide nearly 4½ hours of care a day to each resident, including about 43 minutes from registered nurses. The time for each home is shown in the ratings. Last year CMS also began displaying the number of hours residents receive from physical therapists.

Quality measures

CMS requires nursing homes to submit clinical data for the latest three calendar quarters detailing the status of each individual Medicare and Medicaid resident in 18 indicators, such as the percentage of residents who had urinary tract infections or who were physically restrained to keep from falling from a bed or a chair. Best Nursing Homes, like Nursing Home Compare, displays all 18 data points for each home. The ratings, however, are based on nine—seven for long-term and two for short-term residents—that are considered the most valid and reliable, such as the two above and other measures related to pain, bedsores, and mobility.

Good ratings or bad, CMS is adamant in cautioning that they are just a starting point. We agree. Nothing substitutes for in-depth visits. You can ask questions, observe residents and their families and caregivers, and get a feel of a home that stars can't communicate. "There are many satisfied residents and families of residents in nursing homes...at the one-star level," states an FAQ posted on the CMS website, which also advises that "no resident should be moved solely on the basis of a nursing home's ratings.... [Transferring] your loved one to a facility that has a higher rating should be balanced with the possible challenges of adjusting to a new nursing home." That is one of many hard truths about finding a home where someone you hold dear can find good care.

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