Are County Nursing Homes a Bad Deal for Seniors or Getting a Bad Rap?

Joan Grimes of Rockaway in Morris County wasn’t satisfied with the private nursing home where her husband was living. The place looked magnificent. Its main lounge featured a fireplace, piano and chandelier. Patients’ rooms were carpeted. The halls were decorated with paintings.

But Grimes felt her husband, who has Alzheimer’s disease, wasn’t getting enough medical attention. "I’m a nurse, so I kind of know what’s supposed to happen," she said. Grimes asked her doctor to suggest another place. When he mentioned , she was not sure that was such a good idea. After all, Morris View is owned by Morris County and county-owned nursing homes come with somewhat of a stigma.

That was more than two years ago and Grimes is glad she followed her doctor’s advice. "At Morris View, as soon as something happens, even if it's the slightest scratch, they notify you right away," Grimes said. "They're on top of things. I like that."

County Facilities Score Low on Federal Rankings

Morris View happens to be the only county-run nursing home in the state that currently gets "five stars" in the federal government’s ranking system for senior care facilities. In fact, New Jersey’s county nursing homes fared significantly worse than private facilities did on the ranking system issued by the Centers for Medicare and Medicaid Services (CMS).

A Patch analysis of the most recently available federal ratings for New Jersey’s 362 nursing homes found that half the facilities listed as county-owned received the lowest possible scores—one or two stars. In comparison, one third of the private facilities were at the bottom of the rankings.

Meanwhile, about 48 percent of the state’s private nursing homes received the highest scores, four and five stars, while just 22 percent of the county homes achieved those ratings.

Patch examined the federal rankings as part of its research on the challenges facing county-owned nursing homes. Struggling to keep taxes down and grappling with ongoing cuts in the Medicaid payments that provide the bulk of the funding for the facilities, county officials in New Jersey are asking themselves whether they can afford the multimillion-dollar deficits generated by their nursing homes.

Officials in counties that have sold their facilities say they believe their nursing home residents will get good care under private ownership, while taxpayers are being relieved of a massive burden.

In the past 16 months, Cumberland, Mercer and Salem counties sold their nursing homes to private operators. Bergen, Monmouth, Sussex and Union counties were weighing whether to .

Morris County officials, meanwhile, talked about the possibility of selling Morris View several years ago and last year brought in a private management company to try to cut the deficits at the facility. At present, Morris officials say they remain committed to keeping the home in county hands.

"I would have deep concerns if things were going to change at Morris View," said Grimes, whose husband George was admitted there in October 2009. "I'm very satisfied with the care."

County Nursing Homes Face Financial Challenges

The nature of county nursing homes’ financial structure creates challenges when it comes to providing top-notch care, according to industry experts. For the most part, county homes have significantly higher percentages of residents on Medicaid, the health insurance for people with low incomes, according to surveys by New Jersey’s county government lobbying group. And Medicaid pays the facilities at significantly lower rates than does Medicare or private insurance. At some places, the difference amounts to several million dollars per year.

"The more money you have, the more resources you can put into purchasing direct health care staff," said Paul Langevin, president of the Healthcare Association of New Jersey, a trade organization that represents more than 300 nursing homes and other facilities.

Administrators at senior facilities say staffing levels are a key factor in providing quality care. The federal ratings measure staffing levels at nursing homes as one of the factors used to determine the overall five-star ranking.

In fact, most county nursing homes in New Jersey scored higher on the ratings for staff levels than they did on their overall ranking, the records show.

Here’s a look at the CMS star ratings for some of the county facilities:

• Bergen County Health Care Center in Rockleigh had a three overall, including two for inspections, a five for staff and a three for quality measures.
• Middlesex County’s Roosevelt Care Center in Edison had a two overall rating, a one on inspections, a four on staff and a three on quality measures.
• Monmouth County’s Geraldine Thompson center in Wall had a one overall, a one on inspections, a three for staff and a three for quality measures.
• Monmouth County’s in Freehold had a three overall rating, a three on inspections, a three on staff and a four on quality measures.
• Morris County’s Morris View in Morris Plains had a five overall rating, a four on inspections, a five on staff and a three on quality measures.
• Union County’s in Berkeley Heights had a four overall rating, a three on inspections, a four on staff and a four on quality measures.

Is Federal Rating System Flawed?

Many nursing home administrators and industry experts say the rating system has flaws and its rankings should not be viewed as a fool-proof measure for comparing the quality of care provided at various facilities. In fact, the federal government this year is in the process of incorporating new quality measures into its ranking system.

"They’re useless," said Frank Byrne, vice president of LeadingAge New Jersey, the trade group that represents nonprofit nursing homes, referring to the ratings. "It’s a poor way to judge one facility versus another."

The ratings rely too heavily on the one-day annual inspection, Byrne said. "You could have a facility that’s really good get a bad rating because their survey was done on a bad day," he said. By the same token, inferior facilities could get lucky and have good inspections, he said.

The inspection results also can be affected by the expertise of the particular survey team assigned to a nursing home, according to Byrne. One team, for example, may be bettered versed in "life-safety issues," while another may include members whose specialty is dietary care, he said.

Moreover, Byrne said, inspection findings could be skewed by whether a surveyor is having a particularly good or bad day. "The human element is not consistent."

Byrne said the inspections almost always are stacked against county nursing homes. Their buildings are typically larger, older and somewhat antiquated—factors that affect certain scores in the evaluation. Also, he said, their residents tend to be older and sicker, which means they present more difficulties in providing adequate care.

Folks who are looking for a suitable nursing home for their loved ones or themselves are better off taking tours of the facilities than simply making the decision based on the federal government’s ranking. LeadingAges’s website provides a check-list of factors families can use to make their decisions.

Byrne said people should simply show up and ask to be shown around. "If a facility doesn’t want to tour you, I wouldn’t consider that place," he said.

Supporters Tout Care Provided by County Facilities

Ernest Salvati said he is more than satisfied with the care at Union County’s Runnells nursing home, where he has been living since 1999. For the past eight years, the 67-year-old, who has muscular dystrophy, has been chairman of the facility’s residents’ council. Runnells is the only nursing home Salvati has lived in, but he likes it much better than the private facility where his mother stayed for two-and-a-half years in the 1980s.

"Just the smell of the place is so much better," he said.

The residents’ council meets monthly with hospital administrators and Salvati says the group isn’t shy about voicing complaints. If a new staff member, for example, has a bad attitude or seems uncaring, the council lets the administration know about it, he said.

"When we bring out problems, we get answers and we get the problems taken care of," said Salvati. "They want us to get the best care possible."

Salvati said he likes the fact that Runnels has a doctor on staff and that the care workers are vigilant about bed sores. He also likes the activities Runnels provides its residents, including trips to Somerset Patriots baseball games, Point Pleasant and concerts in local parks.

"Being here and knowing what I know about other places, this is the best situation for me," said Salvati. "It feels like family here."

John Greco Sr., who lives in Watchung, started volunteering at Runnells when his wife was a resident and has continued to do so even after she passed away. His wife had been staying in an assisted living facility, until the $7,000 per month fee depleted their savings.

Moving her to Runnells was a good decision, Greco said. "I can’t say enough about the place, believe me," said Greco. "They took good care of her."

Greco doesn’t understand the talk that the county might sell the facility. "To me, they’re doing a good job with the people who go there with the situations they have. They’re doing a wonderful job."

Runnells' administrators are proud of their track record. For six straight years last decade, the nursing home had a perfect record on state inspections—not a single deficiency among the several hundred areas that evaluated in the survey, said Joan Wheeler, Runnels’ director. In last year’s inspection, Runnels had one clinical deficiency, said Wheeler.

One of the strategies that Runnells uses to keep high-level care is the way residents are assigned to different wings of the facility, Wheeler said. Years ago, the practice had been to follow a "heterogeneous" system, under which people with all types of conditions were grouped together. But then Runnells tried something different. Residents were assigned to different wings depending on their condition and, for example, people for cognitive impairments were grouped together.

Wheeler also credited the emphasis on medical staff. Runnells has a full-time medical director and also has an arrangement with a company called Hospitalists that provides doctors to staff the nursing home. Under the contract, Runnells spends nothing on the Hospitalists, which gets paid through the residents’ insurance.

At Morris View, New Jersey top-rated county nursing home, according to the CMS rankings, providing staff with extra training has helped keep care at high levels, said Cathy Engler, the nursing home’s director. For example, the facility’s infection control “preventist” goes through extra clinical instruction, she said.

Morris View pays for the training, but administrators view it as a cost effective move. “It would cost more for us to care for people with horrible wounds,’’’ Engler said.

During the day shift, Morris View provides nursing assistant for every seven residents, and in evenings each nursing assistant handled nine residents, Engler said. The state requires that every nursing home resident get a minimum of 2.5 hours per day of nursing care and at Morris View residents get about 3.4 hours per day, Engler said.

Officials: Federal Ratings Aren't Accurate Reflection of Care

Officials at county nursing homes that scored badly on the federal rating system said the scores were not an accurate reflection of the care their facilities provide.

William Heine, Monmouth County’s spokesman, said some of the deficiencies cited in state inspections had nothing to do with medical care. For example, Heine said, Monmouth was cited for a record book being left open on a staff member’s desk. Another problem involved a staff member not washing his hands long enough. "It wasn’t because they didn’t wash their hands, it was because they didn’t wash them long enough," said Heine.

At Roosevelt Care Center in Middlesex County, officials say its low overall ranking on the federal CMS system largely stems from antiquated buildings. For example, Roosevelt’s dietary and sanitary departments both are housed in the same building basement, a factor that resulted in deficiencies on the inspection reports, said Frank Damiani, the facility’s top administrator.

In regard to Roosevelt’s two-star rating, Damiani said, "I don’t think it reflects the reality of the care here, but that’s what we have."

As proof of Roosevelt’s health care success, Damiani pointed to its 60-bed sub-acute rehab center. About 1,000 patients per year go through that program and about half of them make enough improvement to be discharged to their homes instead of to long-term care facilities, he said.