The Facility Description section includes some of the information found in the At-A-Glance section as well as additional information on the types of care available in nursing homes.

Special Focus Facility (Data Source: CMS Provider Data: through 10/31/2023)

The U.S. Centers for Medicare & Medicaid Services (CMS) created the Special Focus Facility (SFF) initiative to stimulate systematic improvements in quality of care. CMS has found that a small number of nursing homes have more serious problems than most other nursing homes or problems that have persisted for at least three years. CMS requires that SFF nursing homes be visited in person by survey teams twice as frequently as other nursing homes to ensure improvements are being made. CMS limits California to 6 nursing homes on the SFF list at one time. For more information, see the CMS website.

Facility type (Data Source: CMS Provider Data; CDPH Licensed and Certified Healthcare Facility Listing: through 10/31/2023)

There are two basic types of skilled nursing facilities: freestanding or a distinct part of a hospital.

• Freestanding: Freestanding facilities provide 24-hour skilled nursing care to assist with short term recovery from a surgery, injury, or acute illness or provide on-going nursing home care for those who need more permanent long-term care.
• Distinct Part of acute care hospital: A Distinct Part facility is always associated with a hospital. It must be physically distinguishable from the hospital (separate address) and fiscally separate for cost reporting purposes. A Distinct Part facility provides the same services as a freestanding facility as well as treatment for acute illness or injury and intensive rehabilitation services. Most residents stay a brief time, usually a maximum of three weeks, and then are discharged to either a freestanding nursing home or back to their own home.

Resident population (Data Source: CMS Provider Data; CDPH Licensed and Certified Healthcare Facility Listing: through 10/31/2023)

A nursing home may serve only adults, only children (pediatric) or both adults and children.

Payments accepted (Data Source: CDPH Licensed and Certified Healthcare Facility Listing: through 10/31/2023)

All nursing homes in California accept insurance payments directly from insurance companies (including private insurance and long-term care insurance). In addition, many are certified to receive payment from the Medicare program for short term stays defined as the first 100 days (about 3 and a half months) of care. Medicare pays most costs (excluding co-pays) for those who are Medicare beneficiaries. Medicare does not pay for stays beyond 100 consecutive days, at which point residents are considered to be long-term care residents. Some, but not all, facilities accept payment from the Medicaid program (Medi-Cal) for long-term residents with low incomes and few assets. If the resident does not qualify for Medi-Cal, they will be billed for the cost of care.

Number of beds (Data Source: CDPH Licensed and Certified Healthcare Facility Listing: through 10/31/2023)

This indicates the number of licensed beds distributed among private and shared rooms that have been certified to be paid for by Medicare and/or Medi-Cal.

Type of Specialty Care Available

Nursing homes must be licensed by CDPH and/or certified by CMS to provide care and specifically be approved to provide specific types of more specialized care. This information is especially useful for selecting a facility that meets the specific medical and nursing needs of an individual who may need higher levels of care. Note that the different types of care and, in some cases, distinct types of facilities, have different staffing requirements based on the level of care provided. State average staffing hours will differ between nursing homes depending on the types of care they provide.

• Subacute Care (Data Source: CDPH Licensed and Certified Healthcare Facility Listing, 09/30/2022): More intense care than skilled nursing care, but less intense than acute hospital care. It involves intensive nursing and supportive and therapeutic care provided by licensed nurses for residents with fragile medical conditions.

• Ventilator Beds (Data Source: LTC (Long Term Care) Facility Integrated Disclosure and Medi-Cal Cost Report Data 12/31/2021): Ventilators or respirators are machines that mechanically assist patients with breathing and are sometimes referred to as artificial respiration. Ventilator beds are part of a subacute nursing home.

• Alzheimer’s/Dementia Program (Data Source: HCAI Long-Term Care Facilities Annual Utilization Report 12/31/2021): Almost all nursing homes will accept residents with cognitive impairment, including Alzheimer’s disease. However, there are nursing homes that specialize only in dementia care and others that may have a designated memory care unit.

• Hospice Program (Data Source: HCAI Long-Term Care Facilities Annual Utilization Report 12/31/2021): Hospice provides additional services from a team that specializes in end-of-life care. Hospice provides comprehensive comfort care including pain management as well as counseling services for residents and their families. Most nursing homes contract with an outside certified Hospice Provider.

• Long-term Rehabilitation (Data Source: HCAI Long-Term Care Facilities Annual Utilization Report 12/31/2021): Intensive rehabilitation services (such as intensive physical and occupational therapy) are designed to make a patient as independent as possible after a prolonged illness or major injury.

• Behavioral health/psychiatric (Data Source: CDPH Licensed and Certified Healthcare Facility Listing, 09/30/2022): In California, Behavioral Health facilities, also called Psychiatric Health Facilities, provide 24-hour inpatient care for people meeting legal definitions of mental disorder or incompetence. Specialty care includes, but is not limited to psychiatry, clinical psychology, psychiatric nursing, social work, rehabilitation, and drug administration.

• Continuing Care Retirement Community (Data Source: CMS Provider Data; CDPH Licensed and Certified Healthcare Facility Listing 09/30/2022): These facilities provide a continuum of services, including independent living, assisted living, and skilled nursing home care on a single campus. Residents can move between levels of care based on their changing needs.

Resident or family councils (Data Source: CMS Provider Data, 09/30/2022):

A resident council is an organized group of nursing home residents, supported by the nursing home administration, who meet regularly to improve the quality of care and quality of life in the facility and to promote and protect residents’ rights. California and federal law ensures the right of residents to organize and participate in a resident council. Family councils are optional, but are a similar facility supported organization that includes family members. This measure does not reflect how often the councils meet or the extent of involvement of residents and/or families.

Overview of Staffing Hours of Care

Nurse staffing levels are reported as hours-per-resident-per-day (HPRD). The hours in this measure have not been adjusted for residents’ complexity of care and reflect average numbers across all residents. These numbers do not represent the amount of nursing time each resident receives daily; rather it represents the average time a facility’s nurses have available to care for all the residents in a day (in a 24-hour period). Note that some residents require more or less care throughout their stay.

Having an adequate number of each type of nursing staff in a facility is essential to providing quality care. Adequate care also differs based on the level of care a resident requires. California requires nursing homes to provide different HRPD depending on the type of care the facility provides. If you are comparing different nursing homes, please check the Facilities Description page to see how the types of care offered differ between the facilities.

Most nursing homes provide general nursing care to a combination of individuals who are discharged from the hospital for rehabilitation or are in the nursing home for long term care. California requires these facilities provide at least 3 hours, 30 minutes of direct nursing care with at least 2 hours, 24 minutes of nursing assistant (NA) staffing per resident day. There are several types of nursing homes or sections of nursing homes that require greater HPRD than a standard nursing home. The table below shows California’s minimum direct care staffing requirements for standard and specialty care. The best nursing homes adjust the staffing based on the complexity of the types of residents in their facility each day; however, there is no specific requirement on how to make that calculation.

Nursing Hours per Resident per Day (Data Source: CMS Provider Data: 4/1/2023 through 6/30/2023)

Hours-per-resident-per-day (HPRD) is based on nursing staff hours worked (excluding time for vacations, sick time, disability, and other paid time off) and the total resident days of care during the reporting period. This does not indicate the number of nurses working at any given time, how they are allocated among shifts, or the amount of care given to each resident on an individual basis.

The different types of nurses and their staffing requirements based on California regulations are:

Registered nurse (RN) hours per resident per day: RNs have two to six years of professional education and are trained to evaluate and care for acute and chronic conditions and determine when medical attention is needed. Only RNs can complete resident assessments and care plans and provide complex nursing care. They also guide and provide supervision of lower level nursing staff. Experts suggest that residents should have at least 45 minutes of RN time.

Licensed vocational/practical nurses (LVN/LPN) per resident per day: LVN/LPNs have one year of training. They work under the supervision of RNs to pass medications, provide some treatments, and to evaluate residents’ responses to care. They may also serve as a unit charge nurse. If a nursing home has substantially more LVN/LPNs than RNs, that may result in a lower quality of care. Experts suggest that facilities should have at least 33 minutes of LVN/LPN time per resident.

Nursing assistant (NA) hours per resident per day: NAs provide most of the direct resident care, such as bathing, dressing, toileting, and eating. They work under the direction of a licensed nurse (RN or LVN/LPN). All NAs must become certified (CNAs) within four months of employment. In California, they must take 160 hours of training and pass an exam to become certified. At minimum, facilities must provide 2 hours, 24 minutes of CNA time; however, many experts recommend between 2 hours, 48 minutes and 3 hours, 12 minutes of CNA time. This is about one CNA for every 6 to 8 residents during the day and evening shifts, and one CNA for every 20 residents on the night shift.

Total number of nurse staff hours per resident per day: This measure shows the total number of hours of nursing staff time (RN, including supervisors; LVN/LPN; and NA) available to care for residents each day, including weekends, during the reporting period. The minimum hours per resident per day in California is 3 hours, 30 minutes total.

Total number of nurse staff hours per resident per weekend day: This measure shows the average number of hours of combined nursing staff time (RN, including supervisors; LVN/LPN, and NA) available to care for residents during the weekend (Saturday and Sunday). Nursing homes are required to meet the same minimum HRPD 7 days per week. However, many nursing homes reduce the number of staff on-site during weekends even though resident care needs do not change substantially. Comparing nursing staff hours per (week) day to per weekend day gives residents and family members an idea of how much nursing staff may be reduced during weekends.

Physical therapist staff minutes per resident per day (Data Source: CMS Provider Data: 4/1/2023 through 6/30/2023)

Physical therapist (PT) staffing level information shows the average minutes spent per resident per day across all residents, including those who have no need for therapy. This measure does not indicate the number of PTs working at any given time or the amount of care given to any one resident. The amount of physical therapy given depends on the needs of each resident and must be ordered by a physician, nurse practitioner, or physician assistant.

All PTs are licensed with the state of California and help residents improve their movement and manage their pain. PTs often work with primary care providers, nurses, and occupational therapists to create customized plans targeting muscle strength, joint flexibility, and the ability to walk or move to improve a resident’s physical function and well-being.

Nursing staff turnover (Data Source: CMS Provider Data: 4/1/2022 through 3/31/2023)

Nursing staff turnover (when staff leave the organization during the year) and retention (when staff remain employed with the organization all year) are frequently related. High rates of staff turnover are usually associated with lower staff retention rates. Occasionally, a nursing home may have both high nursing staff turnover (“poor” or “below average”) and high retention (“superior” or “above average”), meaning that most staff stayed all year, but a smaller number of positions had a lot of staff joining and leaving the facility during the year. This pattern may result from the management of the facility or a change in the type or number of patients, or a change in the number of staffed beds.

The turnover measure shows the percent of nursing staff who stopped working at the nursing home over a 12-month period. When nursing staff is constantly changing, it may be stressful and disruptive for residents to receive care from new staff who are unfamiliar with their routines or special needs. Evidence shows that the lower the nursing staff turnover rate at a nursing facility, the better the quality, continuity, and stability of care. Family members should ask the nursing home about their staffing if the facility’s staff turnover is rate is “below average” or “poor”.

Nursing staff retention (Data Source: LTC Facility Integrated Disclosure and Medi-Cal Cost Report Data: 1/1/2022 through 12/31/2022)

The retention measure reflects the percentage of the nursing staff who stayed in their job for the past 12 months. Nursing staff who remain in the nursing home are generally more satisfied with their jobs. Higher retention rates can be associated with higher quality of care because there is more stability of the nursing home workforce. Family members should ask the nursing home about their staffing if the facility’s staff retention is “below average” or “poor.”

Number of administrators who have left the nursing home (Data Source: CMS Provider Data: 4/1/2022 through 3/31/2023)

All nursing homes are required to have a licensed nursing home administrator (NHA) who is responsible for the overall management of the facility and typically lead the facility quality improvement efforts.

Overall Quality Measures

This section provides details about measures that can inform residents, their families, and others about the quality of care in nursing homes (also called skilled nursing facilities [SNF]) and how the quality is measured. In general, nursing homes should ensure that they are working with residents and families to address the residents’ goals of care. They should also have systems in place to prevent harm (e.g., falls, pressure injuries, infections) to residents and have a process for ongoing quality improvement.

Patients who are newly admitted to the nursing home from the hospital and are receiving rehabilitation services and/or intensive nursing care are usually considered short-stay residents. While they may have up to 100 days paid by Medicare, the average patient spends a few weeks in the nursing home for rehabilitation and then finishes their rehabilitation at home. When short-stay residents have achieved their short-stay goals or are no longer making any progress in their rehabilitation, they no longer qualify for Medicare coverage, at which point they are discharged home or transitioned to long-stay.

The ultimate goal for short-stay residents is to be discharged back to their homes to live independently; improving and sustaining gains in their function and ability to care for themselves should be high priorities for the nursing home to support.

Long-stay residents are in the nursing home either as a direct-admission from home without a qualifying hospital admission; as short-stay residents who convert to long-stay because they are no longer making progress in rehabilitation; or because they reached the Medicare 100-day maximum coverage. Patients who are not Medicare beneficiaries can also be admitted to the nursing home from the hospital or home – the rules for those residents depend on their insurance status.  These residents pay for services through Medi-Cal, long term care insurance, or pay out of pocket.

The goals for long-stay residents are to maintain the highest functional ability possible or at least to slow the loss of functional abilities and to maintain the best possible quality of life.

CMS 5-Star rating for short stay (Data Source: CMS Provider Data: through 10/31/2023)

The US Centers for Medicare & Medicaid Services (CMS) created a five-star quality rating system to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions. Nursing homes with five stars are considered to have above average quality, and nursing homes with one star are considered to have below average quality. For more information, see the CMS website. This rating is a composite rating of six select short-stay measures:

Derived from Claims Data:

• Percentage of short-stay residents who were re-hospitalized after a nursing home admission
• Percentage of short-stay residents who have had an outpatient emergency department visit
• Rate of successful return to home and community from a SNF

Derived from Minimum Data Set Assessment:

• Percentage of short-stay residents who got antipsychotic medication for the first time
• Percentage of short-stay residents who improved in their ability to move around on their own
• Percentage of residents with pressure ulcers/pressure injuries that are new or worsened

CMS 5-Star rating for long stay (Data Source: CMS Provider Data: through 10/31/2023)

The US Centers for Medicare & Medicaid Services (CMS) created a five-star quality rating system to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions. Nursing homes with five stars are considered to have above average quality, and nursing homes with one star are considered to have below average quality. For more information, see the CMS website. This rating is a composite rating of nine select long-stay measures:

Derived from Claims Data:

• Number of hospitalizations per 1,000 long-stay resident days
• Number of outpatient emergency department visits per 1,000 long-stay resident days

Derived from the Minimum Data Set Assessment

• Percentage of long-stay residents who got an antipsychotic medication
• Percentage of long-stay residents experiencing one or more falls with major injury
• Percentage of long-stay, high risk residents with pressure ulcers
• Percentage of long-stay residents with a urinary tract infection
• Percentage of long-stay residents who have or had a catheter inserted and left in their bladder
• Percentage of long-stay residents whose ability to move independently worsened
• Percentage of long-stay residents whose need for help with activities of daily living increased

Older adult residents are particularly vulnerable to COVID-19, influenza (flu), and pneumonia. Vaccines are important tools for preventing serious disease and death. This section reports vaccination rates for three types of disease: COVID-19, influenza (flu), and pneumonia.

COVID-19 Vaccination Rates (Data Source: CMS COVID-19 Nursing Home Data: 7/1/2023 through 12/31/2023)

Studies have shown that nursing home residents who are eligible for and receive COVID-19 vaccinations, including booster shots, have significantly fewer hospitalizations and deaths from this serious disease. Likewise, nursing home staff vaccinated for COVID-19 and boosted also experience no or less serious illness and are less likely to transmit the virus to residents and co-workers. The Centers for Medicare & Medicaid Services (CMS) uses vaccine data that nursing homes report to the Centers for Disease Control and Prevention to calculate vaccination rates. CMS does not risk-standardize any vaccine measures.

The COVID vaccine rates reported here reflect the highest weekly rate reported by the nursing home during 2023 Quarters 3 and 4. This definition includes rates reflecting the newest CDC COVID-19 vaccination definition (which cites the 2023-2024 updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine) and the CDC definition that immediately preceded this one (which required a “bivalent vaccine within last 2 months” of this reporting period). Based on COVID-19 vaccine effectiveness studies, the earlier vaccines should provide immunity through 2023. COVID-19 vaccines and requirements will change over time and this measure will be updated accordingly.

Vaccine status is updated weekly on the CMS website. Due to frequent updates, we recommend checking the CMS Care Compare site and asking the nursing home for their current vaccination rates.

• Staff COVID-19 vaccination

This measure represents the percent of all staff who work in the nursing home for at least one day per week and are up to date with the 2023-2024 updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine or met the bivalent COVID-19 vaccine requirement as of November 2023.

Currently, there are some nursing homes with inadequate staff COVID-19 vaccination rates. Staff who have not been vaccinated or are vaccinated with a COVID-19 vaccine prior to Fall 2023 have reduced ability to fight against the COVID-19 virus compared to those who have had the 2023-2024 updated vaccine. Nursing homes with higher staff vaccination rates are given a better rating.

• Resident COVID-19 vaccination

This measure represents the percent of all residents within the nursing home who have been vaccinated with the 2023-2024 updated Pfizer-BioNTech, Moderna, or Novavax COVID-19 vaccine or met the bivalent COVID-19 vaccine requirement as of November 2023.

Influenza Vaccination (Data Source: CMS MDS Quality Measures: 4/1/2022 through 6/30/2023)

The Centers for Disease Control and Prevention (CDC) require that influenza (flu) vaccinations be offered to residents and staff to prevent the spread of flu in nursing homes.  The staff flu vaccination rate data are not publicly available, so we are unable to report it here; however, residents and families may want to ask the nursing home about their staff flu vaccination rates.

These measures report the percentage of short-stay and long-stay residents who were: given, and appropriately received, the influenza vaccine during the most recent flu season. Residents are excluded if they have an allergy to the influenza vaccine, have a clinician order not to immunize, are moderately to severely ill, have a history of Guillain-Barre Syndrome, or have a weakened immune system.

Pneumonia Vaccination (Data Source: CMS MDS Quality Measures: 4/1/2022 through 6/30/2023)

Pneumonia vaccines are strongly recommended for children with certain medical conditions and for most adults aged 65 years or older who have a healthy immune system. Like the flu vaccine, pneumonia vaccines also are required to be offered to all nursing home residents who are eligible.

Pneumonia is a significant cause of death from a bacterial disease in older adults. These measures report the percentage of short-stay and long-stay residents aged 65 or older who have an up-to-date pneumonia vaccine during the 12-month reporting period. Residents are excluded if they have an allergy to the pneumonia vaccine; have an order not to immunize or a history of Guillain-Barre Syndrome; are moderately to severely ill; or have a weakened immune system.

The short-stay measures section includes assessment and outcome measures for short-stay residents, who may stay in a nursing home (also called a skilled nursing facility [SNF]) for up to 100 days after acute hospitalization for the purpose of rehabilitation. Each of these measures may have some residents who are excluded; for example, they are enrolled in hospice or have serious brain injuries.

Rehospitalizations and Emergency Department Visits

• Percentage of short-stay residents who were re-hospitalized after a nursing home admission (Data source: CMS Medicare Claims Quality Measures, 04/01/2021 – 03/31/2022)

The measure reports the percentage of short-stay residents who initially entered the nursing home from a hospital and were then re-admitted to a hospital for an unplanned inpatient or observation stay within 30 days of the start of the nursing home stay for any condition that could have been prevented. This CMS measure adjusts for resident characteristics such as age, prior functional status, complexity of medical conditions, and co-occurring illnesses. Nursing homes should ensure that short-stay residents can be safely discharged home in a stable condition. High rates of hospital readmissions may indicate that the nursing home did not prevent complications when caring for the resident.

• Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (Data source: CMS SNF Quality Reporting Program-Provider Data, 7/1/2019-6/30/2021)

This measure estimates the risk-adjusted rate of unplanned, potentially preventable readmissions for short-stay nursing home residents within 30 days of discharge from the nursing home. This CMS measure adjusts for resident characteristics such as age, prior functional status, medical conditions, and co-occurring illnesses. Some residents are excluded such as those with a planned hospital readmission, multiple nursing home admissions, or who left against medical advice. Hospital readmissions place residents at greater risk of infections, falls, and pressure injuries, are costly, and are often avoidable. Nursing homes should ensure that residents are medically stable and ready for safe discharge and should teach residents and families about the resident’s medications, treatments, and conditions to monitor. Most residents will qualify for a home health visit after a SNF discharge, which may also help prevent rehospitalization. Better staffing has been shown to decrease the rate of potentially avoidable readmissions.

• Percentage of short-stay residents who have had an outpatient emergency department visit (Data source: CMS Medicare Claims Quality Measures, 04/01/2021 – 03/30/2022)

This measure reports the percentage of short-stay residents who entered the nursing home from a hospital and were sent to an emergency department within 30 days of the start of the nursing home stay, but in which the ED visit did not result in an inpatient or observation stay. High rates of ED visits may indicate that the nursing home is not providing adequate care. Nursing homes must assess short-stay residents frequently for subtle signs that their condition is getting worse, notify their primary care provider about early changes of condition, and implement appropriate treatments. This CMS measure adjusts for resident characteristics such as age, prior functional status, complexity of medical conditions, and co-occurring illnesses.

Medications

• Percentage of short-stay residents who got antipsychotic medication for the first time (Data source: CMS MDS Quality Measures, 07/01/2021 – 06/30/2022)

Antipsychotic medications are used to treat a very specific group of mental health conditions such as schizophrenia; however, these drugs historically were used to manage agitated behaviors in residents without schizophrenia or other appropriate medical conditions. This measure reports the percentage of short-stay residents who received an antipsychotic for the first time in the nursing home. This class of medications can cause serious harm and should not be given to control mood or behavior, particularly in residents with dementia. Some residents were excluded from this measure such as those already on an antipsychotic at admission or who have a diagnosis of schizophrenia, Tourette’s syndrome, or Huntington’s disease, for which antipsychotics are appropriate. High rates of antipsychotic use may indicate poor quality of care.  Nursing homes should use alternative methods to reduce agitation such as increased exercise, improved pain management, music therapy, and other non-drug interventions. This measure is not adjusted for resident characteristics.

• Percentage of short-stay residents whose medications were reviewed and who received follow-up care when medication issues were identified (Data source CMS SNF Quality Reporting Program-Provider Data, 1/1/2021 – 12/31/2021)

When residents transfer from the hospital to the nursing home, there is an increased risk for medical errors particularly in the type of medications that are to be stopped from the hospital and ones that need to be started in the nursing home. This measure reports the percentage of short-stay residents who had a medication review at admission that showed significant problems with medications and had a timely follow-up with a clinician to address the problems. Resident conditions may change rapidly during the post-hospitalization stay in the nursing home and may require frequent changes in medications. Nursing homes should ensure that primary care providers are notified promptly of changes in condition and that timely medication changes, if ordered, are implemented. This measure is not adjusted for resident characteristics.

Resident Safety

• Percentage of residents with pressure ulcers/pressure injuries that are new or worsened (Data Source: CMS SNF Quality Reporting Program- Provider Data: 1/1/2021 – 12/31/2021)

This measure reports the percentage of residents who develop new or worsening Stage II-IV pressure ulcers (also known as pressure sores or injuries). Pressure ulcers are areas of damaged skin caused by the resident staying in one position for too long; prolonged pressure in that area causes breakdown in the skin and underlying tissue resulting in a pressure sore. Residents who develop new pressure ulcers/injuries are likely not being turned and repositioned properly or frequently enough, which can result in serious consequences including pain, infection, and death. If the resident cannot turn independently, nursing home staff should turn and reposition residents frequently (usually every 2 hours), keep their skin dry, use appropriate support surfaces (e.g., special beds), and minimize injury from medical devices that cause pressure on the skin. This CMS measure is adjusted for resident characteristics.

• Percentage of short-stay residents who experience one or more falls with major injury during their SNF stay (Data Source: CMS SNF Quality Reporting Program – Provider Data, 1/1/2021 – 12/31/2021)

Falls with a major injury are considered a “never event” (because they should never happen) and may reflect lower quality of care. This measure reflects the percentage of short-stay residents who experience one or more falls associated with a major injury such as a fracture, loss of consciousness, or head injury while in the nursing home.  Risk of falls must be balanced with the importance of resident mobility, so the key is to prevent injury if there is a fall. Nursing homes should have some type of fall prevention program in place to help prevent major injuries from falls. This measure is not adjusted for resident characteristics.

• Percentage of infections patients got during their SNF stay that resulted in hospitalization (Data source CMS SNF Quality Reporting Program-Provider Data, 10/1/2020 – 9/30/2021)

Healthcare-associated infections (HAIs) are infections that patients can get while receiving care in a SNF. These infections are usually the result of a lack of prevention strategies like hand washing and using personal protective equipment. This measure shows the rate of healthcare-associated infections that patients get during their SNF stay that result in hospitalization. This measure includes infections developed starting on day 4 of the nursing home stay and within 3 days after discharge.

Resident Change in Ability and Mobility

• Percentage of successful return to home and community from a nursing home (Data source: CMS SNF Quality Reporting Program-Provider Data, 7/1/2019-6/30/2021)

This measure reports the percentage of short-stay residents admitted to the nursing home from a hospital who were then discharged to the community within 100 calendar days of admission, and who remained in the community for at least 30 consecutive days following discharge to the community. This is a CMS-risk-standardized measure based on resident characteristics such as age, prior functional status, and medical conditions and comorbidities. If nursing homes have high numbers of residents who are readmitted to the hospital after discharge, it may indicate they are not adequately preparing residents for discharge or appropriately evaluating residents’ readiness to successfully care for themselves at home.

• Change in residents’ ability to move around (at discharge) (Data source CMS SNF Quality Reporting Program-Provider Data, 1/1/2021 – 12/31/2021) 

This measure estimates the average change in the residents’ mobility score between admission into the nursing home and discharge. Greater mobility improves the residents’ independence and ability to care for themselves once they are discharged. Scores above 0 mean that mobility improved and scores below 0 mean that mobility worsened. This measure is risk-standardized by CMS, which means that the residents’ age, chronic conditions, and pre-existing conditions are taken into consideration.

• Percentage of residents who are at or above an expected ability to move around at discharge (Data source CMS SNF Quality Reporting Program-Provider Data, 1/1/2021 – 12/31/2021)

This measure estimates the percentage of short-stay residents who meet or exceed the expected discharge mobility scores. The scores range from 15-90 and are risk-standardized based on resident characteristics such as age, prior functional status, and complexity of medical conditions. Mobility items include activities such as the ability roll from side to side, change positions from lying to sitting to standing, move from bed to chair or toilet, and walk or climb stairs.

• Percentage of short-stay residents who improved in their ability to move around on their own (at discharge) (Data source: CMS MDS Quality Measures, 04/01/2021 – 06/30/2022)

This measure estimates the CMS risk-standardized change between the short-stay residents’ discharge mobility score and the admission mobility score. Risk-standardized means that the resident’s age, prior functional status, medical condition, and comorbidities are considered. The measure is reported as the average change in mobility scores among all residents. Mobility scores include activities such as the ability to roll from side to side, change positions from lying to sitting to standing, move from bed to chair or toilet, and walk or climb stairs. Residents are rated on a 6-point scale and scores range from 15-90. Nursing homes should ensure that every effort is being made to improve resident mobility.

• Change in residents’ ability to care for themselves (at discharge) (Data source CMS SNF Quality Reporting Program-Provider Data, 1/1/2021 – 12/31/2021)

This measure estimates the average change in the residents’ self-care score between admission into the nursing home and discharge. The goal of the short-stay nursing home stay is to improve the residents’ ability to care for themselves so that they can return safely to home or the community. Scores above 0 mean that the self-care core improved and scores below 0 mean that the self-care score worsened. This measure is risk-standardized by CMS, which means that the residents’ age, chronic conditions, and pre-existing conditions are taken into consideration.

• Percentage of residents who are at or above an expected ability to care for themselves at discharge (Data source CMS SNF Quality Reporting Program-Provider Data, 1/1/2021 – 12/31/2021)

This measure estimates the percentage of short-stay residents who meet or exceed the expected self-care score at discharge. It is important that nursing homes prepare residents to care for themselves when they are discharged home. Scores range from 7-42 and are risk-adjusted based on resident age, prior functioning, and medical conditions. Self-care activities, such as eating, oral hygiene, toileting, bathing, upper and lower body dressing, are evaluated using a 6-point scale for each item.

• Percentage of SNF residents whose functional abilities were assessed, and functional goals were included in their treatment plan (Data source CMS SNF Quality Reporting Program-Provider Data, 01/01/2021 – 12/31/2021)

This measure reports the percentage of short-stay residents who had a functional assessment at admission, a care plan that addresses function, and another assessment at discharge. Functional goals include bathing, grooming, dressing, and walking. Residents with incomplete nursing home stays are excluded. Ensuring positive functional outcomes is essential for person-centered care and a safe discharge from the nursing home. This measure is not risk-standardized.

The measures in this section apply to residents who reside in the nursing home (also called a skilled nursing facility [SNF]) for an extended period of time. For residents who were admitted from an acute care hospital to the nursing home, it is the date when the resident no longer qualifies for short stay rehabilitation. In any case, Medicare only covers the first 100 days of a SNF admission. These residents may stay in the nursing home for months, years, or the rest of their lives. In general, the goals of long-term care are to maintain physical and mental function, prevent harm, and provide an environment to enhance the quality of life for residents. The care should be focused on the individual resident and family goals for care.

There are general exclusions in some of these measures for residents who are in hospice care, or who are comatose or paralyzed, or who have severe brain injuries. Other measure-specific exclusions are described below.

Hospitalizations and Emergency Department Visits (Data Source: CMS Medicare Claims Quality Measures: 4/1/2022 through 3/31/2023)

• Number of hospitalizations per 1,000 long-stay resident days

This measure reports the number of unplanned inpatient admissions or outpatient observation stays at an acute care or critical access hospital that occurred in the target period while the individual was a long-term care nursing home resident. Residents with a planned hospital inpatient admission, who were not a Medicare beneficiary, or were in hospice are excluded. This is a CMS risk-standardized measure based on resident characteristics such as age, and complexity of medical conditions.

• Number of outpatient emergency department visits per 1,000 long-stay resident days

This measure represents the number of unplanned outpatient emergency department visits for any reason that do not result in an outpatient observation or inpatient hospital stay and that occurred in the target period while the individual was a long-term care nursing home resident. Residents who were not a Medicare beneficiary or were on hospice are excluded. This is a CMS risk-standardized measure based on resident characteristics such as age and complexity of medical conditions.

Medications (Data Source: CMS MDS Quality Measures: 7/1/2022 through 6/30/2023)

• Percentage of long-stay residents who received an antipsychotic medication

Antipsychotic medications are used to treat a very specific group of mental health conditions such as schizophrenia; however, these drugs historically have been used to manage agitated behaviors in residents without schizophrenia or other appropriate medical conditions. This measure reports the percentage of long-stay residents who received an antipsychotic medication during the reporting period. This class of medications can cause serious harm and should not be given to control mood or behavior, particularly in residents with dementia.  Those who have a diagnosis of schizophrenia, Tourette’s syndrome, or Huntington’s disease were excluded from this measure as antipsychotics are appropriate for these residents. Nursing homes should employ alternative methods to reduce agitation such as increased exercise, improved pain management, music therapy, and other non-drug interventions. High rates of antipsychotic use may indicate poor quality of care.  Nursing homes should have non-pharmacological programs to manage resident behavioral issues. This measure is not risk-standardized by CMS.

• Percentage of long-stay residents who got an antianxiety or hypnotic medication

This measure reports the prevalence of antianxiety or hypnotic medication use for long-stay residents during the target period. Residents were excluded if they were in hospice care where these medications may be helpful. Nursing homes should look for underlying causes of resident anxiety or inability to sleep prior to use of medications because both classes of medications may have serious side effects such as excessive sleepiness. These side effects could lead to falls with injury and pressure ulcers among other problems. This measure is not risk-standardized by CMS.

Resident Safety (Data Source: CMS MDS Quality Measures: 7/1/2022 through 6/30/2023)

• Percentage of long-stay residents experiencing one or more falls with major injury

Falls with a major injury are considered a “never event” (because they should never happen) and may reflect lower quality of care. This measure reports the percentage of resident stays during which one or more falls with a major injury (bone fracture, joint dislocation, closed head injury with altered consciousness, or subdural hematoma) occurred. Falls must be balanced with the importance of resident mobility, so the key is to prevent injury if there is a fall. Nursing homes should have some type of prevention program in place to help prevent major injuries from falls. This measure is not risk-standardized by CMS.

• Percentage of long-stay, high risk residents with pressure ulcers

Pressure ulcers (also known as pressure injuries or sores) are areas of damaged skin caused by the resident staying in one position for too long; prolonged pressure in that area causes breakdown in the skin and underlying tissue resulting in a pressure sore, ulcer or open wound. Long-stay residents who have at least one of the following conditions are considered to be at high-risk for pressure ulcers: impaired mobility (difficulty moving), difficulty staying nourished (poor nutrition), or are in a coma. This measure reports high-risk, long-stay residents who have pressure ulcers/injuries. These residents are dependent upon the nursing staff to turn and reposition them frequently to avoid pressure ulcers/injuries. Nursing homes should have a strong pressure ulcer/injury program that emphasizes frequent repositioning in residents at high risk. This measure is not risk-standardized by CMS.

• Percentage of long-stay residents who were physically restrained

The measure reflects the percentage of long-stay residents who were physically restrained on a daily basis during the reporting period. Restraints are defined as any manual, physical, or mechanical device, material or equipment that prevents or restricts the resident from being mobile. Examples include vests, straps or belts, limb ties, wheelchair trays or bars that cannot be removed by the resident, as well as bed siderails, particularly siderails that extend the full length of the bed. Physical restraints have been known to cause significant injury and death and should rarely be used. Nursing homes should ensure that residents with any type of restraint always be able to be directly observed by staff for safety reasons. Alternative options for restraints may include lowering the bed and placing a floor pad next to it to protect the patient if they roll off the bed or fall when getting up. This provides a safer environment that allows a resident more freedom. This measure is not risk-standardized by CMS.

Resident Change in Ability and Mobility (Data Source: CMS MDS Quality Measures: 7/1/2022 through 6/30/2023)

• Percentage of long-stay residents whose ability to move independently worsened

This measure reports the percent of long-stay residents who experienced a decline in independence of locomotion (bed mobility, transferring, or walking) during the target period. Residents are excluded from this measure if they are comatose, in hospice or with prognosis of < 6 months to live or were totally dependent on previous assessments. Nursing home staff should provide restorative care or physical therapy to prevent these losses when possible. This CMS measure is risk-standardized based on resident characteristics such as age, and complexity of medical conditions.

• Percentage of long-stay residents whose need for help with activities of daily living increased

This measure reports the percentage of long-stay residents who have an increased need for help with activities of daily living (ADLs) since the last assessment. It measures four specific activities thought to be lost only late in life: bed mobility, bed transfers, eating, and toileting. Residents are excluded if they were totally dependent for all four activities or 3 of 4 activities in prior assessments, are comatose, have a life expectancy < 6 months, or are on hospice. While some loss of these functions might be expected in some residents, nursing homes with very high scores may indicate poor quality of care. Nursing home staff should provide restorative care or occupational or physical therapy to prevent these losses when possible. This measure is not risk-standardized by CMS.

Health Care Quality (Data Source: CMS MDS Quality Measures: 7/1/2022 through 6/30/2023)

• Percentage of long-stay residents who have symptoms of depression

This measure reflects the percent of long-stay residents who have had symptoms of depression. The symptoms are measured by loss of interest or pleasure, feeling down, depressed, or hopeless either verbally expressed in an interview or observed by staff. Residents who are comatose are excluded. Depression is not uncommon in older adults and may reflect a poor quality of life. Some residents may need medications, which must be ordered by their primary care or psychiatric care provider. However, caution should be taken as some medications may increase risk for falls or have serious side effects. Nursing homes should engage residents in meaningful ways with individual and group activities such as music therapy, socialization with friends and family, and efforts to improve their mobility and participation in activities of daily living to prevent or reduce symptoms of depression. This measure is not risk-standardized by CMS.

• Percentage of long-stay residents who lose too much weight

Unexpected or unintentional weight loss is often associated with poor health outcomes and could be associated with an underlying illness. However, it may also be associated with certain medications, difficulty chewing or swallowing food, poor dental health, and depression among other causes. Nursing home staff should monitor each resident’s weight regularly and if there is unintentional, significant weight loss (5% or more in the last month or 10% or more in the last 6 months), they should notify the primary care provider who may order diagnostic tests, a dietary consultation, and changes in the type of diet. This measure is not risk-standardized by CMS.

• Percentage of long-stay residents with a urinary tract infection

This measure reports the percentage of long-stay residents who have had a urinary tract infection (UTI) within a 30-day period, where the resident has positive signs or symptoms and laboratory findings requiring medication. UTIs are common in nursing homes and may be prevented with proper hydration, nutrition, mobility, improved voiding habits, and better perineal hygiene. Higher numbers of residents with UTIs may indicate poor care.  Nursing homes should use regular hydration processes and prompted or scheduled voiding processes, which may reduce the incidence of UTIs. This measure is not risk-standardized by CMS.

• Percentage of low-risk long-stay residents who lose control of their bowels or bladder

A catheter is a tube placed in the body to drain and collect urine from the bladder, which may be necessary for residents who have lost bladder function. This measure reports the number of residents who have a catheter left in their bladder during a 7-day reporting period. Residents with neurogenic bladder (the bladder is damaged due to a central nervous system disease or injury and does not empty normally) or obstruction in the urine system are excluded from this measure because an indwelling catheter (left in place) is necessary. Residents with indwelling catheters are at high risk for bladder infections. One alternative is intermittently inserting a catheter and removing it once the bladder is empty, which helps to reduce the risk of bladder infections. This CMS measure is risk-standardized.

• Percentage of long-stay residents who have or had a catheter inserted and left in their bladder

A catheter is a tube placed in the body to drain and collect urine from the bladder, which may be necessary for residents who have lost bladder function. This measure reports the number of residents who have a catheter left in their bladder during a 7-day reporting period. Residents with neurogenic bladder (the bladder is damaged due to a central nervous system disease or injury and does not empty normally) or obstruction in the urine system are excluded from this measure because an indwelling catheter (left in place) is necessary. Residents with indwelling catheters are at high risk for bladder infections. One alternative is intermittently inserting a catheter and removing it once the bladder is empty, which helps to reduce the risk of bladder infections. This CMS measure is risk-standardized.

The California Department of Public Health state inspectors conduct nursing home inspections on behalf of the federal government (Centers for Medicare and Medicaid) and the state to ensure that facilities are meeting federal and state health and safety standards. Examples of standards include adequate staffing, managing medications properly, storing and preparing food properly, protecting residents from physical or mental abuse or neglect.

There are multiple types of inspections including standard health inspections that occur approximately every 9-15 months, complaint investigations, infection control investigations, and special incident investigations. CMS issues federal citations for serious health and safety violations that are found during these inspections. Similarly, the state of California issues citations to enforce the state’s nursing home quality and safety standards. Details below show the specific areas where health and safety violations occurred. Readers can use this information to ask questions of nursing home administrators about corrections the facility is making to address problem(s). Residents and family members have the right to review the inspection reports issued by CDPH.

Combined Federal and State Health Inspections Rating (Data Source: Cal Long Term Care Compare)

This rating is based on the number and type of state citations issued between July 2019 and June 2022, and federal citations that were found during the nursing home’s two most recent health inspections. More weight is given to the most recent health inspection and, therefore, the most recent violations. The state may cite a facility for the same violation that the federal government identifies, while other times the federal and state violations are completely different.

Complaints about nursing home quality of care may be filed with the California Department of Public Health by residents, family members, nursing home staff, or long term care ombudsman from the California Department of Aging. Complaints are investigated within 24 hours of a death or serious harm and 10 days for other potential violations. Complaint investigations must be completed within 60 days. These complaints may result in one or more federal and/or state citations and possible fines.

Substantiated complaints from last three years (Data Source: CMS Provider Data: through 9/30/2023)

This number represents the total number of complaints made about the facility that were substantiated by state inspectors following an investigation.

This section shows details about the federal deficiencies where citations were issued for health-related violations.

Number of federal health inspection deficiencies (Data Source: CMS Health Deficiencies: see dates in the table)

This measure shows the number of federal deficiencies issued for serious violations by the nursing home based on health and infection control inspections and complaint and special incident investigations.

Dates of two most recent health inspections (Data Source: CMS Health Deficiencies: see dates in the table)

This shows the dates of the nursing home’s last two standard health inspections by the California Department of Public Health. More recent dates are better because residents and family members can be more confident that the reported measures reflect the nursing home’s current safety and quality of care and adherence to laws and regulations. Very few nursing homes received health inspections in 2020 and 2021 due to the COVID-19 pandemic, which is why some dates may be earlier than 2020.

Type, Scope and Severity of Deficiencies (Data Source: CMS Health Deficiencies: see dates in the table)

Type of health deficiencies 

The standard health inspection is unannounced and usually occurs approximately once per year. It covers 10 topics: Freedom from Abuse, Neglect, and Exploitation, Quality of Life and Care, Infection Control, Resident Assessment and Care Planning, Nursing and Physician Services, Pharmacy Service, Resident Rights, Nutrition and Dietary, Environmental, and Administration. This shows the number of deficiencies issued within each category.

Severity and scope of health deficiencies

CMS instructs inspectors to assess the severity and scope of health deficiencies and select the appropriate enforcement action. Severity reflects the level of harm from a deficiency and is categorized into four levels: no actual harm with potential for minimal harm; no actual harm with a potential for more than minimal harm that is not immediate jeopardy; actual harm that is not immediate jeopardy and; immediate jeopardy to resident health or safety. Immediate jeopardy means the situation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

Scope reflects how many residents were affected or potentially affected by an event resulting in a deficiency. There are three scope categories: “Few” means that the event is isolated to one or a small percentage of residents with no apparent pattern; “Some” means that a particular event represents a pattern among a smaller group of residents; and “Many” means it is a widespread problem for residents throughout the nursing home. Note that a citation related to “few” residents is not necessarily reflective of the severity of the event (death vs. a fall with no injury). Likewise, a widespread problem that affects many may not be severe though it still requires correction.

For more details about the scope and severity weights table, see: https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/downloads/usersguide.pdf

These data show the number of state citations issued for serious health and safety violations by the nursing home. (Data Source for all state citations information: CA Health Facilities State Enforcement Actions: 07/01/2019 through 06/30/2022).

State citations are similar to federal citations but focus on violations of state laws and regulations in 15 health and safety categories. Deficiencies may result in a citation. Deficiencies may arise from complaint or special incident investigations, or annual health inspections, or even from facility self-reported problems. State and federal citations sometimes overlap. The citations are classified by severity into 3 categories: Class AA, Class A and Class B.

Number of class AA citations (resident death) (Data Source: CA Health Facilities State Enforcement Actions: 7/1/2020 through 6/30/2023)

Number of class AA citations (resident death)

Class AA citations are issued when health and safety violation(s) by a facility have been shown to cause a resident death. Fines range between $25,000 to $100,000 per incident. These citations are the most severe but are rare.

Number of class A citations (resident danger) (Data Source: CA Health Facilities State Enforcement Actions: 7/1/2020 through 6/30/2023)

Class A citations are issued when residents experience imminent danger (i.e., probability of serious harm or death) due to violations of state or federal laws and regulations. They are more serious and less common than the Class B citations. Fines range between $2,000 to $20,000 per violation.

Number of class B citations (resident care) (Data Source: CA Health Facilities State Enforcement Actions: 7/1/2020 through 6/30/2023)

Class B citations are issued for health and safety violations that are less serious than Class A or AA violations. These are the most common citations. Fines range from $100-$2,000 per violation.

Total number of state citations (Data Source: CA Health Facilities State Enforcement Actions: 7/1/2020 through 6/30/2023)

This is the total number of citations issued during the reporting period.

In addition to federal and state citations, the U.S. government (Centers for Medicare and Medicaid Services-CMS) and the California Department of Public Health may issue financial penalties to nursing homes for serious health and safety violations or their failure to correct violations over a long period of time. The penalty can be a lump sum, a daily fine until corrections are complete, or CMS may withhold Medicare payments or restrict new admissions to the nursing home until the facility corrects the violation(s). If corrections are not made in a timely manner, a nursing home can lose its federal certification and/or state license and be forced to close, in which case residents would need to move to another certified and licensed facility.

Federal fines issued for violations from the last three years ($) (Data Source: CMS Penalties)

This is the dollar amount charged by CMS to the nursing home for violating health and safety standards during their last two health inspections. Fine amounts vary according to the scope (how many residents were or could be affected) and to the severity (the seriousness of potential or actual harm ranging from death to administrative violations). Most nursing homes do not have any federal fines.

State fines issued for violations ($) (Data Source: CA Health Facilities State Enforcement Actions: 7/1/2020 through 6/30/2023)

This is the dollar amount charged by CDPH to the nursing home for violating health and safety standards during July 1, 2020 – June 30, 2023. Fines are classified into three categories described above in the State Citations section: Class AA, Class A, and Class B. Most nursing homes do not have any state fines.

Fines are classified into three categories described above in the State Citations section: Class AA, Class A, and Class B.

Total federal and state fines ($) (Data Source: CMS Penalties; CA Health Facilities State Enforcement Actions)

This is the total dollar amount charged to the nursing home for violating federal and/or state health and safety standards. Most nursing homes do not have any federal or state fines.

Number of days the facility was denied payment due to unresolved violations (Data Source: CMS Penalties)

This is the number of days the nursing home was denied payment by Medicare for newly admitted residents because of violations that have not been resolved. Most nursing homes do not have any denials of payment.

Total number of fire safety and emergency preparedness citations (Data Source: CMS Fire Safety Deficiencies: see date in the table)

This is the nursing home’s total number of fire safety and emergency preparedness citations reported from their last two fire safety and emergency preparedness inspections.  Federal law requires state fire authorities to conduct annual fire safety inspections of the nursing home building design and construction and operational features as well as review the facility’s emergency preparedness plan. Inspections cover 18 different topic areas: Smoke, Emergency Preparedness, Gas and Vacuum and Electrical Systems, Egress, Services Construction, Electrical, Automatic Sprinkler Systems, Corridor Walls and Doors, Emergency Plans and Fire Drills, Fire Alarm Systems, Interior, Hazardous Area, Illumination and Emergency Power, Laboratories, Medical Gases and Anaesthetizing Areas, Smoking Regulations, Miscellaneous. Nursing homes must make the results of the most recent inspection available for anyone to review.

Date of most recent fire safety and emergency preparedness inspection (Data Source: CMS Fire Safety Deficiencies: see date in the table)