Q&A: What to look for in a nursing home

Despite numerous deficiencies reported at the Avocado Post Acute nursing home in El Cajon, the facility is still operating.

Tony Chicotel, a lawyer with the California Advocates for Nursing Home Reform (CANHR), said those deficiencies reflect poorly on federal regulators. He said regulators are afraid to shut down inferior long-term care facilities because of a perceived shortage of nursing home beds.

Avocado is just one of many nursing homes in the state found to have provided substandard care for their residents. Last month, staff members at Atria Park of San Mateo in Northern California accidentally served three residents cleaning fluid that they thought was fruit juice. One resident died as a result. Days later, an elderly man died from a food-related incident at a sister facility, Atria Walnut Creek.

Incidents like those raise the question, are there any good nursing home facilities out there? Chicotel spoke with KPBS to answer questions that people may have about nursing homes and assisted living facilities.

The answers have been lightly edited for clarity and conciseness.

What’s the first step that people in need of nursing home-level care should take to find a high-quality facility? What resources exist to help them?

Chicotel: There are probably three essential things that potential consumers would want to do, or their families would want to do before deciding on a nursing home.

The first would be going to the federal Care Compare website. That's the access point to a lot of information related to federal oversight of nursing homes. An individual nursing home has a star rating, and it's up to five stars, and what you want to do probably is look in your city or county area and eliminate all of the one- and two-star facilities. Boom! Don't even consider them because that's probably going to be bad news. Hopefully, you live in a community that has more than a few nursing home choices.

Then you're looking at the three-, four-, five-star facilities — hopefully, four- and five-star facilities. It's not that I would say that those facilities are proven to be good. It's just those would be the ones that I would start to keep as my pool for consideration. We can look at some of their regulatory records on the Care Compare website, and then I would take that list and go to the state website, which is called Cal Health Find and there you can get some of the same information that's on the federal website. But you can also get information about state regulatory records, which is sometimes different and more illustrative than the federal information.

Then once you've narrowed it down to a couple of choices. I would make some calls to facilities and ask them some specific questions, and I would also personally go to the facility and look around. What you're doing is you're looking for signs of a high quality, very active, upbeat kind of place. You want to see lots of staff interacting with residents. You want to see residents up, you know, during the regular daylight hours. You want to seem up and active and engaged as opposed to sitting off staring blankly into space, sleeping in the middle of the day, disinterested, disengaged and neglected.

KPBS investigations reveal abuse, negligence at San Diego area senior care facilities

One facility that has stood out throughout our reporting is Avocado Post Acute in El Cajon. Our most recent stories revealed that the 256-bed home has received more than 620 complaints since 2019, which is four times the state average for facilities with 100 or more beds.

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What factors should consumers consider when choosing a nursing home?

Chicotel: Definitely the regulatory record, the five-star rating. If they've got a lot of complaints filed against them, they've had a lot of violations cited against them in the last few years. The owners of the facilities can be important. Some of the nursing home chains are certainly better than other nursing home chains, so you can identify performance usually attached to what chain it's part of — if it's part of a chain.

Definitely want to ask about visitation policies. That's become really important during the COVID pandemic. Some facilities are much more interested in facilitating robust visitation than others. So you want to make sure that the facility is going to be able to give access to the visitation that you want.

Also probably want to know about the vaccination rates of the staff and booster rates of the staff. That's something else that's relatively new and can be found through the federal government website. CMS.gov has the vaccination rates and booster rates for both the staff and the residents of the facilities.

In California, we actually have a pretty high rate of vaccination for the staff and for the residents. But there is some variation, and it probably bears taking a look at.

I also definitely want to look at the staffing level. That's one of the most important factors in choosing a nursing home is looking at the staffing level. And some of it you can find on the Care Compare website. But if you really want a much more detailed look at a facility staffing rate, there's another website. It's from the Long-term Care Community Coalition. Their website has quarterly staffing data that's uploaded from the facilities payroll records, and you can see the facilities' average daily staffing rate per their staffing records, which is probably the most accurate records we have, and you can compare them to other facilities.

What are some of the concrete tells/clues if a nursing facility is subpar?

Chicotel: This is pretty easy and simple. One- and two-star facilities probably. if you go for a personal in-person visit, and the place looks empty, there's no staff there. Or the staff are all in one area, and they're not taking care of residents. That's definitely a sign that your residents are probably not going to get good care there. If it smells, if it's disorderly, disorganized. If you look in the hallway and there's medicine carts everywhere, and tables and chairs and people seem like they're not quite organized. That's another sign of a subpar facility.

I'd also say, facilities that are resistant to sharing their visitation policies when you ask about their visitation. I would take that as a red flag, and certainly, if they're restricting visitation in a meaningful way, meaning family might not have access on certain days or certain hours. That's definitely a red flag.

If the facility has AA citation or an A citation, those are indicative of a serious injury or death of a resident caused by facility negligence. Definitely, that's a red flag.

So the A, AA citations, or at the federal level, what they call "immediate jeopardy" violations. And you, again, can find these on the federal website. So if they have any of these really horrific kinds of regulatory violations probably want to go somewhere else.

Do good nursing homes even exist?

Chicotel: The answer is, yes, good nursing homes do exist. I don't think that there's nearly enough of them. And the majority of them I would categorize as something less than good. But there are good nursing homes, the Atria facilities that you mentioned. Those are assisted living facilities, which is a different kind of long-term care facility than nursing homes. In my opinion, very broadly speaking, assisted living facilities tend to get better outcomes and provide a higher quality of care for the residents than nursing homes do primarily because they're — I think the short answer is — because they're private pay.

There are good nursing homes. I have a great nursing home. I think it's one of the best nursing homes around in my backyard. It's just a few blocks from my house. So I know that there are good ones that exist. They're usually nonprofit. They're usually not part of a large chain. They have great leadership. They have a great staff culture, very low turnover, that they're good places to work. They're (also) good places to live. That sort of works in conjunction with one another.

I just feel that the prevailing business model is such that it doesn't really matter if the resident outcomes are great, good or bad because the funding pretty much is the same regardless, and that's something that we really need to change.

Where I see the good facilities are places where the bottom line is sort of secondary to the quality of care. But in most places. That's not the case. Most places, the goal is simply: No. 1 is to make money. If good quality care comes with that, then great. But it's not. It's definitely not the primary goal.

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What if a caretaker has no choice but to send their loved ones to a nursing home?

Chicotel: I also say, related to this question, check with some experts about whether you really need to — and that might be just doing your own research, too — about whether a nursing home is really the only choice. Because I talk to people pretty routinely that have this idea that a nursing home might be the next step for themselves or for their loved ones, and it turns out that there are several options that they had not considered that are pretty viable.

I was just looking at a memo from the federal government that in recent years, the annual spending on long-term care by Medicaid that is not connected to nursing homes is $125 billion. The amount connected to nursing homes is $75 billion. So we're now, as a country, spending a fair amount more on non-nursing home long-term care than nursing home long-term care. So there are a lot of options out there that are non-institutional, not nursing homes, more home and community-based and oftentimes higher quality of care, and have better outcomes for residents. So I understand. Sometimes there is no choice. The nursing home is the right level of care. But I would be really hesitant to just take a single person's word for it.

What are some of the alternatives to nursing homes?

Chicotel: The common ones are in-home care. There is a Medicaid-connected program for in-home supported services that serves a lot of people in the state of California, for people with disabilities that require assistance with their activities. Someone comes into their home and provides that care and depending on their level. There are adjustments for the hours that they get per week. There are adult day programs, which are particularly great where the resident or the patient or person with needs is taken to a center one or two or up to five days a week for several hours a day for activities and programming exercise, sometimes rehabilitation engagement, keeping them active in the community.

Of course, family and friends sometimes pitch in to provide in-home care. And then, of course, there's assisted living. It's slow, but there has been progress made in funding assisted living for people who can't afford it — can't afford the private pay rate — through an assisted living waiver program. So those are some of the real popular programs that have, you know, thousands and thousands of participants in California.

If someone already in a nursing home is having trouble getting the care they need, what help exists to aid them?

Chicotel: That's a good question and, fortunately, there are a fair number of resources available for people who are having some trouble or dissatisfaction in a nursing home. I'd recommend they take a look at our website, canhr.org. And on our website, we have something like 80 to 90 fact sheets on various aspects of long-term care, paying for long-term care, assisted living, nursing homes, and then some issues that are sort of in the elder law community that overlaps with long-term care issues.

So taking a look at those fact sheets, I think, would be really helpful for what you've identified as sort of self-advocacy. And then, if that doesn't work. Then there's always the Long-Term Care Ombudsman Program. There's a long-term care ombudsman assigned to every nursing home in the state through a federal and state program, and every county has a local long-term care ombudsman program, and they send staff and volunteers to facilities throughout their community. So they're really good at handling most of the day-to-day problems and facilities. Then, there are licensing organizations, primarily the State Department of Public Health. You can file complaints with the Department of Public Health. They investigate those complaints and sometimes lead to a pretty good resolution for the resident. Not always, but sometimes.

And then there are consumer advocacy organizations like CANHR. They take calls and emails from consumers and their friends and family all the time and try to help them through their problems.

What about going out of state? Are any states getting it right?

Chicotel: The answer is no. Unfortunately, I don't know of any states that have a sort of model nursing home program that works significantly better than any other states. So much of it is federally funded, and the rules are somewhat based off all the state rules that are oftentimes based off the federal rules. And the system is really set up to have taxpayers pay for the care of residents and the residents, and the facilities get paid kind of regardless of whether the care is good or bad.

That's just the system that's suboptimal, and I don't know of any state that really does it any significantly differently. There are some variations among the states, but I wouldn't identify any state as doing it right.

For some Southern California residents going across the border for care may be a possibility. Do you have any insight on what to consider when looking at places like Tijuana or Rosarito as an option?

Chicotel: I don't have any experience with Mexican long-term care facilities to know if they're good or bad, how you pay for them. What I am a little more familiar with is people coming from the United States to Mexico to get in-home care because it's so much cheaper, and I think that can be attractive, especially to people who live near the border to relocate and to be able to stay in an independent home and afford a private caregiver or multiple private caregivers. I think the big benefit is: it's significantly less expensive. And so a dollar goes a lot farther in Mexico than it does in the United States in terms of how much care you can buy.

I think the risk, of course, is you worry a little bit about the home health care worker. Is it part of an agency, or what is the agency, bonded and insured? And what kind of vetting do they do for their workers? If you're hiring just someone who answers a call for an ad, do you know how reliable they are going to be? How do you come up with a contract? Do you do a contract? How do you pay (them)? Do you have to submit taxes for them as an employee? That could, I imagine, get complicated.

There are, throughout the state of California, Caregiver Resource Centers. The Caregiver Resource Centers are set up to advise people on how to set up home health care, and they may have some sample contracts, and they may have some information about getting care in another country. I'm not sure if they do or not, but that's probably where I would refer a caller to the Caregiver Resource Centers in California. And I'm sure there are probably some books or internet guidance written from people who have made that move from the United States to Mexico or another country to get long-term care.

I know there's a community in Mexico, San Miguel de Allende, where a lot of older Americans relocate to. It's very senior-friendly. And there are a lot of caregivers that provide care professionally in that community. So there are probably internet groups and information about how that gets set up. I think it is an option that some people would find worthwhile. So basically, just do your due diligence even across the border. Know, your regulatory agencies and look them up and things like that.

Any last words of advice?

Chicotel: How the long-term care system works is that most people don't have a lot of time to think about nursing home placement. Almost all nursing home residents come from the hospital following some sort of medical emergency. So for most people, they're living independently at home happily. And then some event happens where they have to go to the hospital, and there's going to be a somewhat long recovery time, and that precipitates the nursing home stay. And they're in the hospital, and they're usually only given a day or two to decide where they're going to go next. And sometimes the hospital can be helpful in finding places, and sometimes not so helpful.

So usually, when we get calls, it's not from people who say, "You know, sometime in the next five years, I might need this. Let me talk about options." It's usually, "The hospital has given us a deadline of noon tomorrow to get out. What do we do?"

In those situations, I think the most important advice I can give broadly is that you probably have more time than you think. Hospitals are pretty good at pressuring people to get out right away, but leaving a hospital and going to another level of care is a medical decision. It's a very important medical decision that sometimes can be critical to your long-term health and you should demand time to deliberate reasonably over that decision.

Hospitals can't just throw people into the street and say, "Oh, you know we gave you a chance to find a place to go, and you didn't." They will not throw you out. They will take care of you for a reasonable amount of period while you do your due diligence and look for what your options might be. Sometimes you have to send a letter to the hospital to say, "Hey, we're putting the brakes on this. This is a very important move. We want to get it right. We really care about this person, and frankly, we care about them more than you do. So we're going to be in charge of where they go. Not you. Give us the time that we need."

So definitely put the brakes on a little bit, check out the website, and if people are having problems, they can certainly give us a call or send us an email.