The study evaluated states on a scale of 100 based on a variety of factors, such as the number of nursing homes per 100,000 residents, occupancy rates, cost of residency and the percentage of nursing homes with no deficiencies. 

Iowa topped the list with a score of 70.67. Iowa was not a leading state in the individual categories, but was consistently in the top third of each category. Around 10% of Iowa homes had no deficiencies, which was well above the national average of 6%. 

Despite a top-five occupancy rate, California was the bottom-ranked state, with an 18.61 rating. This was partially because of its high cost. Private nursing home rooms in the state cost more than $12,000 per month, among the highest in the nation. The state also has the 2nd most deficiencies per facility on average.

Providing insight into nursing home care in the US is only growing more important as the population ages, said SonderCare CEO Kyle Sobko. 

“This data provides a clear insight into which states currently offer the best access to elderly care and outlines the factors contributing to this,” Sobko stated. 

Rural Southern and Great Plains states consistently received high scores in the study. The top 10, in order, were:

• Iowa
• Oklahoma
• Missouri
• Louisiana
• South Dakota
• Kansas
• Montana
• North Carolina
• Wisconsin
• Nebraska

Among more populous states, Texas, Pennsylvania, and Illinois ranked highest, at 11th, 15th and 16th, respectively. 

Sobko noted that there were some notable outliers in the SonderCare study.

“The most surprising finding from this study is that Alaska ranks overwhelmingly as the most expensive state for elderly care, both semi-private and private,” he said. “The cost of a room in a private nursing home in Alaska is $31,512 per month, this is more than $16,300 more than the second most expensive state, Connecticut.”

Those costs helped drag Alaska down to a ranking of 46th, rounding out a bottom five that also included the 2nd most expensive state, Connecticut, as well as West Virginia, Hawaii, and California. East coast states made up nine of the bottom 15.

The change reflects the heightened public awareness around staffing levels as federal officials weigh whether to move forward with significant, new requirements that would compel facilities to hire an estimated additional 102,000 nurses and nurse aides.

In all, more than 2,800 nursing homes, 19% of the 15,007 rated for the 2024 U.S. News list, were recognized as “Best Nursing Homes” for their short-term rehabilitation, long-term care, or both.

Nursing homes are evaluated on a battery of patient and resident outcomes, including infection rates and hospitalization; process measures, such as reliance on antipsychotic drugs; health inspection results; staffing levels and other quality metrics.

While the ratings do rely on specific data collected by the Centers for Medicare & Medicaid Services, analysts no longer include overall or domain-specific star ratings in their calculations. And in many cases — 445 this year — a nursing home awarded 4 or 5 overall stars by CMS may only net a 1 or 2 rating from U.S. News.

The major differentiators are the magazine’s increased reliance on patient and resident outcomes, staffing levels and process measures, which are emphasized over inspection results, said Ben Harder, chief of health analysis and managing editor at U.S. News.

“If a facility does well on its health inspection in the CMS methodology, they can get away with an awful lot in terms of not having much in the way of staffing and having pretty mediocre outcomes, and they may still get a pretty good rating from CMS,” Harder said. “In our methodology, we have this holistic approach to short-term care, and separately long-term care: If a nursing home is having lots of its patients or its residents end up in the hospital or its staffing is clearly below industry standards, they’re less likely to get a good rating in our system.”

Staffing has played a larger role in the U.S. News rankings over the last several years, as more Payroll Based Journal data, all of it auditable, has been made available publicly and with increasingly broader data points. Its growing use reflects both consumers’ interest in knowing there will be enough staff to care for them or their loved ones, but also a recent focus by both academics and policymakers on the issue.

The 2024 report found 436 nursing homes failed to meet the current RN rule for 8 hours of coverage, seven days a week, on 20% or more days.

And data collected this summer also showed that fewer than 5% of evaluated nursing homes could meet both the existing 8-hour requirement and newly proposed staffing requirements for 24/7 RN coverage, 0.55 hours of direct RN care per patient day and 2.45 hours of direct certified nurse aide care per patient day. Those that met both present and possible staffing requirements were 54 times more likely to be rated a “Best Nursing Home” by U.S. News than those that consistently failed to meet the current standard. 

The magazine went beyond CMS reporting to determine how many RN hours were being spent directly with patients.

“There has been concern about nurses in administrative roles, who have a nursing degree, but may not be actually providing bedside care, and so, how meaningful is that, compared to another facility where they have a similar number of RNs, but they are actually engaged in bedside care?” Harder said. “And a shortage of nurse aides can be really crippling for care, particularly in that long-term care setting, a shortage of therapists can also be a problem for short-term care.”

While the goal of the ratings is to boost consumer choice at a time when they may be forced into making a rushed decision, Harder said good results have also paid off for nursing homes.

Increasingly, they’re being used in outreach to patients and other stakeholders, ranging from hospital systems to Medicare Advantage plans.

“When a nursing home, particularly on the post-acute side, is getting good outcomes and has the staffing necessary to keep getting good outcomes and, therefore, keep doing well in our rating system, that’s something they want not just local patients and families to know, but also other healthcare organizations,” Harder said.

Full results, including facilities sorted by location are available for free at U.S. News & World Report. 

The Evangelical Lutheran Good Samaritan Society remains the nation’s largest not-for-profit provider when ranked by nursing beds, of which it has 8,423. The South Dakota-based organization has nearly 16,000 units, including senior living, across 124 locations, according to the latest LZ200 report released Friday.

Each year, the report, which is produced by LeadingAge and investment banking firm Ziegler, lists the largest not-for-profit systems providing site-based aging services in the United States. The 2023 report is based on the number of total owned market-rate units as of Dec. 31, 2022.

The top nine nonprofit providers ranked by nursing home beds remained the same, though Acts Retirement moved ahead of Presbyterian Homes & Services to take the No. 7 spot this year and Cassia of Minnesota moved up from No. 10 to No. 9. Massachusetts-based Covenant Health was the only newcomer to the top 10.

1. The Evangelical Lutheran Good Samaritan Society, SD 
2. Ascension Living, MO
3. The Carmelite System, NY
4. Benedictine, MN 
5. Trinity Health Senior Communities, MI
6. ArchCare, NY 
7. Acts Retirement-Life Communities, PA
8. Presbyterian Homes & Services, MN 
9. Cassia, MN
10. Covenant Health, MA

Last year’s No. 9, Christian Horizons of Missouri, fell to No. 17.

Good Samaritan, also ranked No. 2 overall when considering beds and units, announced a major restructuring right after the close of the data period for the 2023 LZ200. The organization has begun selling off 35 facilities as part of an effort to concentrate service delivery in seven core states.

Even so, with almost 5,000 beds more than Ascension, CEO Nate Schema has said Good Samaritan expects to remain “one of, if not the largest, not-for-profit providers of long-term care even after the transition.”

When it comes to overall seniors housing and care services, Good Sam and the other providers in the top 10 represent nearly 30% of the total number of units for all systems in LZ 200. 

In addition to providing rankings by size, the LZ200 helps to identify trends in senior living and each year looks at a range of additional topics, from technology adoption to growth rates.

“The LeadingAge Ziegler 200 demonstrates the significant role that LeadingAge’s member organizations play in the aging services sector,” Katie Smith Sloan, president and CEO of LeadingAge, said in announcing this year’s report. “They are mission-driven innovators, bringing creativity to complex challenges and living their promise to go above-and-beyond.” 

Last year, that meant limited growth and reshuffling of licenses and beds as skilled nursing in particular faced ongoing labor and census issues in the face of record inflation.

“In the last 10 years, the average annual growth rate in total units is 2.2%, with independent living and assisted living growth each year, but decline in the number of nursing care beds,” the LZ200 reported. “Most of the growth in recent years has been from within existing campuses in the form of unit expansions. At the same time, organizations continue to dispose of dated nursing homes or financially stressed communities. Recent years have also seen an uptick in the number of organizations growing through affiliation, acquisition or merger.” 

Memory care units, however, have a growing importance, with 69% of the listed providers offering them.

The report also noted considerable growth in home-based services, with 45% of ranked providers now offering some type of home- and community-based services to non-residents. In 2022, the continuing care at home model was offered by more than 10% of the LZ 200, 3% more than a year earlier.

But the best are often plucked from the just-returned cart. You know, the place where books that other people have checked out go for re-shelving.

These are, almost without fail, a treasure trove of interesting titles. I figure someone has done some research and already found the cream of the crop.

It’s the same feeling I get when I read Top 10-type lists. Recently, we were all inundated with lists of things to look for in 2018, not to mention “best of” 2017 compilations. The national journal Health Affairs, for example, recently noted its most popular articles of last year — deep pieces that interested consumers, researchers, regulators, and many others — not just long-term care providers.

Direct-to-consumer telehealth and doctors’ work time priorities were Nos. 1 and 2 on the 2017 list.

It was No. 10, however, that really caught my eye: “Initiative To Reduce Avoidable Hospitalizations Among Nursing Facility Residents Shows Promising Results.”

Avoiding (re)hospitalizations gets more time in the sun.

The readers making this so popular were not just long-term care stakeholders. It was also thousands of people from all walks of life indicating that a nursing home-related issue was one of the most interesting topics of 2017. It was hospitals, doctors, specialists and others needing to know how to find better care partners. It was and is a compass indicating an enduring story line.

Hospitals — and more recently, nursing homes — can be penalized large sums of money if their rehospitalization rates are too high. This ship has not only sailed, it’s returned to the dock and is taking on more well-informed passengers all the time.

So, sure, look into the crystal ball out there to speculate about the rest of 2018. But remember, too, that examining the past is also a good way to know the road ahead.

In this case, (re)hospitalizations is it. Knowledge about clinical and business practices that can keep your residents out of the hospital will make you a valued partner, and more likely to be an operator with a full house.

What a thrilling story that would be.

Minnesota has built its renowned system of long-term services and supports largely by devising a strategic plan that has buy-in from providers, advocates and other stakeholders, said Loren Colman, assistant commissioner of continuing care for the state’s Department of Human Services. He also said it’s important to build strong partnerships with nursing homes rather than seeing them as “the enemy” preventing home- and community-based care. And he recommended that states take risks and not be afraid of unsuccessful initiatives, as these will enable course corrections that lead to progress.

The importance of a strategic plan was hardly news to Mississippi panelist Kristi R. Plotner, director of the Office of Policy, Planning and Development at the Division of Medicaid, Office of the Governor. Mississippi put a comprehensive plan together in 2001, Plotner said at the start of her remarks. She also said that her office and others built partnerships with nursing homes, with assurances that expanding HCBS was not meant to put skilled facilities out of business. And she said, “It’s important to take risks and step out there and do things that haven’t been done before.”

In other words, Colman and Plotner have essentially the same approach to improving long-term care in their respective states. So why is Minnesota at the top of the heap and Mississippi near the bottom of the AARP scorecard?

There are some clues. Hewing to a well-publicized strategic plan for long-term care enabled steady progress even as different political parties came into power in Minnesota, Colman said. Mississippi’s plan never got funded, and expansion of home- and community-based care has occurred largely as a byproduct of a freeze on nursing home reimbursements in the Magnolia State, Plotner said.

A few other interesting tidbits from the AARP report: Minnesota scored a 5.24 for “legal and system supports for family caregivers” while Mississippi scored a 3 (below the national average of 3.45). And out of 16 health maintenance tasks, Minnesota allows all 16 to be delegated to long-term services and supports workers. Mississippi allows three to be delegated.

It seems obvious that Minnesota lawmakers are much more committed to supporting long-term care improvement than those in Mississippi. Perhaps this is why LeadingAge CEO and President Larry Minnix opened the question-and-answer session by asking how the panelists have tried to get legislative support.

The panelists did have some interesting answers to Minnix’s question, and it’s certainly possible that advocates from Minnesota or Oregon might be able to share lobbying strategies with lower-ranking states. Yet it also seems clear that some state governments are more open to boldly reforming long-term care than others, due a mixture of historical forces, economic health, resident demographics and other factors.

All this leads me to think that it’s a bad idea to present reports like this one as “state scorecards” or “state rankings.” Doing so does generate buzz — everyone likes to see how his or her state compares. But these lists suggest there’s a kind of competition going on, and that Mississippi could catch up to the leader states simply by learning from them. In fact, the top and bottom states might already be pursuing similar strategies, and some states will succeed to a far greater extent than others because of factors that are all but set in stone.

The authors of the AARP report basically acknowledge as much. While “state leadership and vision make a difference,” the “first” takeaway from their report is that “we need a rational approach at the federal level to guide the states and to establish standards for LTSS system performance below which no state should fall.” My interpretation: The deck is stacked against reform in certain places, so we need Congress to actually do something more than, say, convening a commission to draw up a hasty report.

This message got lost somewhere. It’s not until the last sentence of the official AARP press release that the word “federal” appears, in a quote from SCAN Foundation President and CEO Bruce Chernof, M.D. (chairman of a certain Congressional commission that drew up a hasty report). Writing about the scorecard for Forbes, the great long-term care journalist Howard Gleckman never used the word “federal,” and he said that the report showed how states could make improvements if they just “look a little harder” or “committed the resources.”

I think the AARP scorecard is a great document, full of interesting and revealing statistics. A ton of work obviously went into it. But if the authors really believe that federal intervention is so urgently needed, I recommend they frame their findings differently next time. How about a title like, “Long-term services and supports: Minnesota shines, Congress stinks.”

I think that report still would grab people’s attention, and it might shift the conversation into more productive territory.

Tim Mullaney is McKnight’s Senior Staff Writer. Follow him @TimMullaneyLTC.

As a professional caregiver in a long-term care facility, you’re doing the emotionally taxing and sometimes clinically complex work of seeing people through their dying days — and you’re dealing with interfering family members, according to one recent story that provoked quite a bit of reader response.

You also must contend with a sometimes crushing burden of documentation and other bureaucratic delights, courtesy of Uncle Sam. Nurses spend an average of five hours completing a comprehensive assessment for a resident, according to a recently released survey from the American Association of Nurse Assessment Coordination.

As if it’s not hard enough to complete these assessments, Minimum Data Set coordinators are spending about 18 hours in meetings every week, that survey found.

These are among the challenges once you’ve landed a job in long-term care nursing, but just getting the necessary credentials can be frustrating. Nursing programs turned away more than 53,000 qualified applicants last year, due to faculty shortages, lack of funds and lack of clinical placement sites, according to the latest data from the American Association of Colleges of Nursing.

With these stories in mind, I dug a little deeper to find out why U.S. News had ranked the nursing and therapist jobs in the top 10. Three factors were given the most weight: median salary, the employment rate and future job prospects (described as “the ease of landing a job in the future.”) Nurses and physical therapists scored well on all these measures, and U.S. News noted that demand for nurses and therapists is particularly strong in long-term care and other settings where aging baby boomers will seek services.

When it came to the more subjective elements of the rankings, such as job satisfaction, these caregiving jobs didn’t shine quite so bright. Registered nurses’ upward mobility and flexibility were characterized as “average,” while their stress level was designated “above average.” Physical therapists enjoy “above average” flexibility but “below average” upward mobility.

In other words, these rankings might actually be saying that nurses and therapists bring home nice paychecks and have enviable security, but their daily experience on the job isn’t all that great. An analysis of the rankings might suggest the experience of being a healthcare professional actually is much worse than the experience of being a software developer — the U.S. News No. 1 job, and one associated with workplaces that are like “labyrinthine play areas.”

Of course, I realize that the rankings also didn’t give much weight to the tremendous job satisfaction that comes from making a positive difference in people’s lives. Given the recent studies and surveys showing the difficulties of being a nurse or therapist, I think the U.S. News list offers an apt opportunity to focus on the aspects of these jobs that really do make them exceptional.

Not being a nurse or therapist myself, I’m hardly the best person to say what the best parts of being a nurse or therapist are. So I invite all you caregivers who are reading to leave a comment below, and say whether you agree that you have one of the best jobs in the country, and why.

I will note that when I got to thinking about the rewards of being a professional caregiver, I thought of Walt Whitman’s poem The Wound Dresser, which reflects Whitman’s own experience as a nurse in the Civil War. The elderly narrator of the poem looks back on his life, and in particular his time as nurse:

Thus in silence in dreams’ projections,

Returning, resuming, I thread my way through the hospitals,

The hurt and wounded I pacify with soothing hand,

I sit by the restless all the dark night, some are so

young,

Some suffer so much, I recall the experience sweet and

sad …

I think Whitman’s eloquence makes the U.S. News rankings seem like an almost laughable way of evaluating a job like nursing, but I can’t resist one last rankings-related observation: Software developers certainly have contributed hugely to society, and even to improved healthcare outcomes, but it’s hard for me to imagine similarly powerful words being written about coding and debugging.

Tim Mullaney is a Staff Writer at McKnight’s. Follow him @TimMullaneyLTC.

Brookdale Senior Living led the pack again, followed by Emeritus Corp., Holiday Retirement, Sunrise Senior Living and Life Care Services LLC. The rankings are based on the companies’ self-reported resident capacity as of Jan. 1, 2013.

The deal with the most noteworthy impact on ALFA’s list was Genesis HealthCare’s $215 million acquisition of Sun Healthcare Group last summer. This boosted Genesis from No. 36 to No. 24. Another major deal was the fall 2012 announcement that Health Care REIT was purchasing Sunrise. 

Overall, the 80 companies on ALFA’s list represented a capacity of 514,000, up 2% from last year. The sector is poised for further expansion in 2013, with investment experts and industry executives telling ALFA that mergers and acquisitions will continue to drive growth.

The full list is available here.

But these days, it’s not just nursing homes that the government is publicly grading. The Centers for Medicare & Medicaid Services has also set up comparison shopping sites for physicians, hospitals, home health agencies and even dialysis firms. Nothing wrong with that.

But a newly announced plan to mine data from Medicare Advantage plans might give many operators an unexpected spine shiver.

CMS will soon showcase the “best practices” that Medicare Advantage plans provide. From a care quality standpoint, it’s hard to argue against such an initiative. And should a similar practice morph over to the Nursing Home Compare site, many providers might benefit.

But then again, if the government is going to point out the good examples, it’s probably fair to wonder if the bad examples might not be far behind. And that’s where things could get a smidge uncomfortable.

Would you like to have your facility held up as a place where notably poor care is delivered? Especially if the information used to create that picture was dated, or wrong?

It also makes one wonder how else CMS might decide to carve up and package the mountains of data it is now collecting on nursing homes.

Intel CEO Andrew Grove once famously said that you are not paranoid if the world is out to get you. CMS may not be out to get nursing homes. But there are probably more than a few bean counters in Washington that are still harboring a grudge.

The fact is, many people at CMS still believe that nursing home operators basically scammed the system out of $4 billion when the MDS 3.0 system was unveiled. I’m not saying they’re right — I’m saying that’s how they feel.

And if there is one thing any wronged person will make time for, it’s payback. Even if it means setting a bad example.