Marie Wrigley's husband went back and forth between Abington Hospital and nursing homes in the three months before he died of heart failure in February after being misdiagnosed with pneumonia.
"Three different facilities, and each was worse than the last," Wrigley said.
Each time her husband left the hospital, Wrigley and her daughter received a list of at least three suggested nursing homes from the hospital.
"We looked them up on the computer. There were no bad things about them. They were close by, and we figured it was OK. But as time went on we found out it's not," said Wrigley, 80, of Roslyn.
"It's a crapshoot," she said.
Wrigley's experience highlights the challenge of picking a nursing home.
Experts said Wrigley did the right thing by consulting Nursing Home Compare, a website operated by Medicare that rates nursing homes on a 1-to-5-star scale based on quality of care and staffing information.
However, experts also cautioned that Nursing Home Compare, which undergoes regular revisions in methodology, can really only be trusted to eliminate the worst nursing homes from consideration.
"I think it's a little bit hard to know what to make of the star rating system under Nursing Home Compare," said Rachel Werner, a professor of medicine at the University of Pennsylvania who has studied the Medicare rating system.
"I think the ones that are poorly rated are not good. The one-star facilities should be avoided. The differences between the 3-, 4-, 5-star facilities are not totally clear, though," she said.
In the Philadelphia region, 164, or 69 percent, of the 237 nursing homes had overall ratings of at least 3 stars, according to the latest Nursing Home Compare data. Only 28, or 12 percent, had one-star overall ratings, leaving consumers to pick through an uncertain landscape.
What to do?
"It is hard because it's not something people plan for," said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy, a tax-exempt public-interest law firm in Washington that works on behalf of the elderly and disabled.
"People do go look at assisted living facilities and see if they think they would be interesting," Edelman said. "I've never heard of people planning to go to a nursing home and checking them out six months in advance. It's not what people do. It's not what they want."
Elizabeth White, geriatric nurse-practitioner and a predoctoral fellow in the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, said her top priority would be to assess the quality of nursing.
An indirect way to get at nursing quality is by looking at employee turnover.
"It can be difficult sometimes, but when you are taking your tour, ask to speak to one of the charge nurses, ask to speak to one of the nursing assistants, ask to speak to some of the direct care staff," White advised. Ask them: "How long have you worked here? If you're hearing less than six months, then that's a bad sign."
White, who is studying the effect of nurses' work environment on nursing-home outcomes, cited research by Nicholas G. Castle of the University of Pittsburgh showing "a consistent correlation between high nursing staff turnover and poor patient outcomes."
Three additional key factors for White, who worked as a nurse-practitioner in nursing homes in New York before coming to Penn, are proximity for family, the quality of medical care by doctors, and the physical environment.
Residents and family members of residents are another key source of information. Their perspectives are rarely reported as part of government ratings systems, so the only way to get those views is by talking to people.
Unfortunately, families often do not have much time to evaluate nursing facilities.
If a family is in a crisis situation, needing to move a family member to a nursing home quickly, Edelman suggested calling the local long-term care ombudsman, who can be found through the county office for aging services.
"Most of them are not going to make recommendations, but they might help interpret Nursing Home Compare," she said.
Sometimes a bad state inspection report need not scare a family away.
Diane Menio, executive director of the Center for Advocacy for the Rights & Interests of the Elderly, in Center City, was looking at a place for her mother that had some problems during a state inspection.
Menio, whose mother died six years ago, asked the facility what it did to fix the problems and was satisfied with the answers. "It turned out to be the best place for her. You just don't know," Menio said.
While it is hard to evaluate all health-care providers, it may be particularly so for nursing homes, said Werner, the Penn professor. "Nursing homes are different from hospitals because they provide custodial care as opposed to ongoing health care. It's very hard to measure quality in them," she said.
Wrigley, 80, had the help of a daughter, but was unable to do much legwork to evaluate facilities for her husband and ended up dissatisfied with the three nursing homes her husband was in.
Her summary: The first had great physical therapy, but not enough staff. The second had plentiful nurses, but they had bad attitudes. At the third facility, where she said her husband was misdiagnosed, staff would take her husband for therapy and then leave him there unattended.
Wrigley herself had a much different experience when she went to Wyndmoor Hills, in Wyndmoor, for rehabilitation after knee replacement surgery.
"It was just wonderful. Those nurses were on top of everything," she said.
How did she end up there?
"I have no idea," she said. "They gave me choices. That was a new one. I tried the new one."