nursing home indicators of quality janis omeara

JOURNAL OF GERONTOLOGICAL NURSING 5
The poor quality of care in some
of the nation’s nursing homes
has been the focus of a number of
Institute of Medicine [IOM] reports
(IOM, 1996; 2001) and many federal
reports (U.S. Centers for Medicare
and Medicaid Services [USCMS],
2001; U.S. General Accounting
Office [USGAO], 1999; U.S. Health
Care Financing Administration
[USHCFA], 2000). The public has a
vested interest in the caliber of care
in the nation’s nursing homes
because 1.6 million residents current-
ly receive care in the country’s
16,500 facilities (IOM, 2001). The
changing demographic composition
of the U.S. population indicates as
many as 3 million residents will
receive care in a formal long-term
care setting by 2030 (IOM, 2001;
Sahyoun, Pratt, Lentzner, Dey, &
Robinson, 2001). Some residents
receive short-term post-acute care,
and others will live in nursing homes
for the rest of their lives. Internet-
based information related to the
quality of care in nursing homes
(facilities) can help individuals, as
well as their families and friends,
make important decisions about
selecting a facility, and can be used
for monitoring the quality of care in
facilities over time (Mukamel &
Spector, 2003).
Although many professionals
play an important role in the selec-
tion and monitoring of nursing
home care, none are as important as
registered nurses (RNs), case man-
agers, discharge planners, clinical
nurse specialists, and nurse practi-
tioners. They advise individuals and
families on selecting facilities, pro-
vide care to individuals living in
facilities, and monitor the quality of
facility care. They can also play a
central role in advocating for and
supporting decisions related to
nursing home care and alternative
settings for care. Nurses’ responsi-
bility for providing assistance and
guidance about quality can be
Nursing Indicators of
Quality in Nursing Homes
A Web-based Approach
Websites can be helpful tools when evaluation
nursing home quality if they evaluate the most
important quality indicators
Charlene Harrington, PhD, RN, FAAN, Janis O’ Meara, MPA,
Eric Collier, MS, RN, and John F. Schnelle, PhD
ABOUT THE AUTHORS
Dr. Harrington is Professor, Ms. O’Meara is Website Project Coordinator, and Mr.
Collier is doctoral student and Research Assistant, University of California, San
Francisco, San Francisco, California. Dr. Schnelle is Professor, Borun Center for
Gerontology Research, University of California, Los Angeles, Reseda, California.
Prepared for and funded by the California Health Care Foundation #99-504. The views
expressed in this article are those of the authors and may not reflect those of the Foundation.
Address correspondence to Charlene Harrington, PhD, RN, FAAN, Department of
Social and Behavioral Sciences, University of California, San Francisco, 3333 California
Street, Suite 455, San Francisco, CA 94118.
Innovations in Long-Term Care
ABSTRACT
This article is an examination of websites providing consumer information
about nursing home quality of care, including existing federal and state web-
sites and a new comprehensive website designed for California nursing
homes. The article focuses on research and information related to nursing
indicators of quality used for the California nursing home website. It includes
staffing levels (e.g., hours, types, turnover rates), financial indicators (e.g.,
direct care expenditures, wages, benefits), and complaints and deficiencies.
Overall, nursing indicators of quality are a major approach for evaluating
nursing home quality and can be used by nurses, consumers, and advocates.

6 OCTOBER 2003
strengthened using information
available on the Internet to evaluate
the performance and quality of care
in nursing homes.
This article focuses on the devel-
opment of websites providing con-
sumer information about nursing
care indicators of quality in nursing
homes. It provides descriptions of
federal and state websites on nursing
homes and a new comprehensive
website designed for California nurs-
ing homes. The article includes an
examination of the research and the
information related to nursing indica-
tors of quality used on the California
nursing home website. The purpose
is to show a new approach of
informing consumers about nursing
indicators of quality as a way to eval-
uate nursing home care.
THE INTERNET AS A TOOL
The use of internet-based infor-
mation systems to acquire health
care information is gaining populari-
ty (Souvira & Bodagh, 2002). For
example, in 1999 approximately 60
million individuals, or 68% of those
using the Web, searched for health
care information (Frank, 2000). The
Internet is a versatile, convenient,
and increasingly valuable tool for
consumers and health care profes-
sionals to access health-related infor-
mation. Internet sites that display,
summarize, and analyze data collect-
ed during federal and state inspec-
tions of the nation’s long-term care
facilities can be particularly useful
for consumer advocates evaluating
the quality of care in nursing homes.
Consumers have articulated the
criteria they use to judge the credi-
bility of health care information on
the Internet. Consumer focus groups
have revealed that the authority, cre-
dentials, and qualifications of the
website’s owners and author(s) and
source(s) of data are rated as impor-
tant (Eysenbach & Kohler, 2002).
Consumers have also indicated a
preference for websites that incorpo-
rate data and analyses originating
from identifiable public institutions
or government sources versus private
entities. Webites that are current,
readable, and professional in appear-
ance, and those free of unexplained
technical language or commercial
advertisements are also preferred
(Eysenbach & Kohler, 2002). These
needs must be taken into account
when providing meaningful quality
indicators to consumers
(Harrington, O’Meara, Kitchener,
Simon, Schnelle, 2003).
FEDERAL WEBSITE FOR
NURSING HOMES
In recent years, the federal gov-
ernment, along with a number of
states and various private, commer-
cial, and some non-profit and non-
governmental organizations have
developed Web-based information
systems. In 1999, the USCMS creat-
ed an internet-based nursing home
information system called Medicare
Nursing Home Compare
(www.Medicare.gov/NHcompare/
Home.asp). The website provides
comparison data for all 16,500 nurs-
ing homes in the United States cer-
tified to provide Medicare and
Medicaid services. The Nursing
Home Compare website provides
information about facility character-
istics, federal deficiencies and com-
plaints, and staffing levels. Quality
measures (or indicators) were added
to the website in November 2002
(Morris et al., 2002). The informa-
tion has proven to be in demand—
the website receives approximately
100,000 visits each month (U.S.
House of Representatives, 2002).
The Nursing Home Compare
website uses administrative data for
facility characteristics, staffing, and
deficiencies and complaints primari-
ly from the On-Line Survey
Certification and Reporting
(OSCAR) system. The OSCAR
information is collected during fed-
eral or state surveys of the nation’s
nursing homes occurring every 12
to 15 months for each certified facil-
ity in the United States (IOM, 2001)
or on complaint visits. The federal
government contracts with state
Licensing and Certification (L&C)
agencies to inspect nursing homes
for compliance, to compile data, and
to enforce the federal regulations.
The website also uses data from the
mandatory resident assessments
required on a periodic basis, using
the uniform Minimum Data Set
(MDS) forms (USCMS, 2003). The
quality measures (indicators) data
are constructed from the MDS
assessment information submitted
to USCMS every quarter in a com-
puterized file by each nursing home
(Morris et al., 2002). The quality
measures can be used by consumers
to evaluate and to compare the
quality of care in nursing homes.
Nurse staffing data are available
on the Nursing Home Compare
website, including the total nursing
staff hours per resident day (hprd) in
each facility and staffing hours by
type of nurses (e.g., RNs,
LPNs/LVNs, nursing assistants
[NAs]). These data are submitted by
all certified nursing facilities at the
time of the annual survey for a 2-
week period. Although the accuracy
has been criticized because the data
are not audited by the state survey
agencies, they are the only available
data in a uniform format for all certi-
fied facilities (USCMS, 2001;
USHCFA, 2000). These staffing data
provide the basis for the quality
indicators discussed in this article.
STATE WEBSITES ABOUT
NURSING HOMES
A recent Internet survey showed
25 states have developed their own
nursing home websites (Harrington,
Collier, et al., 2003). The state web-
sites vary in the type and depth of
information they provide; some
states provide information similar to
the Medicare Nursing Home
Compare site, and others provide
state-specific information. Many
states have their own standards facil-
ities must meet in addition to the
federal standards. Therefore, some
states have additional data available

regarding compliance not available
on federal data sets. Most states do
not, however, provide data about
nurse staffing on their state website.
CALIFORNIA’S NURSING HOME
SEARCH WEBSITE
The California HealthCare
Foundation launched its California
Nursing Home Search (Calnhs)
website in October 2002 (available
at: www.calnhs.org), and received
more than 2 million visits in the
first 2 weeks of operation. Calnhs is
a product of the collaborative
efforts led by the authors at the
University of California, San
Francisco and an interdisciplinary
team of researchers at the Borun
Center for Gerontological Research
at the University of California, Los
Angeles; RAND; and the
University of Wisconsin, Madison.
The Calnhs website offers improve-
ments over USCMS’s Nursing
Home Compare website by rating
facilities, interpreting the informa-
tion, and guiding consumers in
selecting and comparing facilities
(Harrington et al., 2002a).
The framework used to design the
content of the California website can
serve as a model for states or groups
designing new websites or updating
existing sites. The particulars of the
framework are discussed elsewhere,
but the approach is based on the
structural, process, and outcome
indicators identified during a com-
prehensive literature review of nurs-
ing home research (Harrington et al.,
2002a; Harrington, O’Meara, et al.,
2003). These indicators can be used
by nurses and consumer advocates as
a framework for evaluating the qual-
ity of care in a given nursing home
or within a geographic region.
The indicators presented on
Calnhs website include (Harrington
et al., 2002a):
● Facility characteristics and
ownership.
● Resident characteristics and
casemix.
● Staffing indicators.
● Quality indicators.
● Deficiencies, complaints, and
enforcement actions.
● Financial indicators.
Although these indicators are pre-
sented on the Calnhs website, this
article focuses specifically on the
nursing indicators considered the
most important indicators of quality.
These include staffing levels (e.g.,
hours, types, turnover rates), finan-
cial indicators (e.g., direct care
expenditures, wages, benefits), and
complaints and deficiencies.
DATA SOURCES
Three major activities were
undertaken to construct the Calnhs
website (Harrington et al., 2002a):
● Building a comprehensive data-
base on California nursing homes.
● Analyzing the data.
● Conducting a validation study
of selected quality indicators.
A number of state and federal
databases were combined to create a
database on each of the 1,400
California nursing facilities. The
data used to create the website
staffing and financial database
included two financial databases
(one for hospital-based, the other
for free-standing nursing facilities)
created from separate cost and usage
reports all facilities are required to
submit annually for payers to the
California Office of Statewide
Health Planning and Development.
The California L&C database,
Automated Certification and
Licensing Administrative
Information and Management
Systems (ACLAIMS), contains
information obtained when a facility
is licensed and surveyed during the
annual Medicare and Medicaid certi-
fication process (California
Department of Health Services,
2000). The ACLAIMS data were
used to provide information about
the number of beds, certification
type, ownership, and complaints,
deficiencies, and citations. The feder-
al OSCAR data were used to report
on special beds, resident and family
councils, chain organizations, and
resident need for assistance. The fed-
eral MDS was used to obtain the
Resource Utilization Groups
(RUGs) for each facility to deter-
mine resident care needs categories
and the resident need score (casemix
index [Fries et al., 1994]). Selected
quality indicators reported on the
MDS were obtained from USCMS
for use on the website. The website
features the most recent data, which
are updated periodically as new
information becomes available.
NURSE STAFFING LEVELS
Nurse staffing is a structural indi-
cator of quality that is one of the
most important predictors of quality
processes and outcomes of care
(IOM, 2001; USCMS, 2001).
Residents in facilities providing high-
er nursing hprd tend to have better
outcomes, including (Harrington et
al., 2000a; IOM, 1996, 2001; Kayser-
Jones, 1997; USCMS, 2001):
● Lower mortality rates.
● Improved nutritional status.
● Better physical and cognitive
functioning.
● Lower rates of urinary tract
infections.
● Lower incidences of pressure
ulcers.
● Fewer admissions and transfers
to acute care hospitals.
● Fewer deficiencies.
Higher staffing levels have been
consistently associated with
improved care processes (i.e., treat-
ments that are directly provided to
residents) in nursing homes. Spector
and Takada (1991) found that higher
staff levels and lower RN turnover
were related to functional improve-
ment, lower urinary catheter use,
better skin care, and higher rates of
resident participation in organized
activities. Kayser-Jones (1997) and
Kayser-Jones, Schell, Porter,
Barbaccia, and Shaw (1999) reported
the relationship between inadequate
nurse staffing to inadequate feeding
assistance and poor oral health in
nursing home residents.

8 OCTOBER 2003
Schnelle et al. (in press) conduct-
ed a study to determine if differ-
ences existed in the quality of care
processes among California nursing
homes with different staffing levels.
Among the 34 nursing homes in this
study, facilities in the highest decile
of staffing (those with 7.6 residents
per each NA) performed signifi-
cantly better on 12 of the 16 care
processes implemented by NAs.
Schnelle (2002) also compared the
results of these staffing-related find-
ings with studies of eight separate
quality indicators (i.e., weight loss,
bedfast, physical restraints, pressure
ulcers, incontinence, loss of physical
activity, pain, depression), and con-
cluded that staffing levels are a bet-
ter predictor of high quality care
processes than the eight quality
clinical indicators. Therefore, con-
sumer information systems should
specifically identify nursing homes
that provide higher staffing levels
for residents.
Staffing Hours
Nurse staffing levels are reported
as hprd, calculated by dividing the
total nursing hours worked by the
total resident days of care per year.
Data on total staffing levels for all
types of nurses and for specific
types of nursing staff (i.e., RN,
LPN/LVN, NA), are available from
federal and state data bases
(Harrington et al., 2002a, 2002b)
and used in the Calnhs website.
The Calnhs website rates each
facility based on their staffing levels.
Total nurse staffing levels were com-
pared to the California minimum
staffing requirement (set at 3.2 hprd
in 1999, excluding directors of nurs-
ing). Facilities not meeting the mini-
mum standard are given a one-star
rating, and facilities that meet the
standard are given two stars.
Approximately 44% of California
nursing homes failed to meet the
state’s minimum staffing standards in
2000 to 2001—even when the hours
for directors of nursing and other
nursing administrators were includ-
ed—and 48% were able to meet this
standard (Harrington et al., 2002a).
To receive a three-star rating (the
highest level) on Calnhs, a facility
was required to meet a staffing goal
based on the federal government
funded study by the USCMS in
2001. This study showed that
staffing levels below 4.1 hprd (for
residents living in facilities longer
than 90 days) could harm or jeopar-
dize residents (USCMS, 2001). The
study showed that 2.8 NA hprd are
needed to conduct minimum care
activities in facilities with low resi-
dent care needs (casemix); 3 hprd are
needed for facilities that have resi-
dents with moderate care needs; and
3.2 hprd are needed for facilities with
residents who have heavy care needs
(USCMS, 2001). When NA hours
are adjusted for resident care needs
and added to the total care needs, it
can be concluded that facilities with
low resident needs require 4.1 hprd.
Facilities with average resident needs
require 4.3 hours, and facilities with
high resident needs require 4.5 hprd.
Calnhs used resident assessment
data reported by California nursing
facilities to USCMS to calculate the
average RUGs for California facili-
ties. Facilities with residents in the
lowest 25 percentile were classified
as having low resident casemix
(with lower staffing needs, requiring
4.1 hprd). Facilities with residents in
the top 25% were classified as hav-
ing residents with high casemix
(with high staffing needs, requiring
4.5 hprd), and the remaining facili-
ties were classified as having average
casemix (with average staffing
needs, requiring 4.3 hprd).
Comparing resident casemix needs
to actual staffing data for the
California facilities with both types
of data available, 92% of California
nursing homes did not meet the
staffing goal and only 8% of facili-
ties received a three-star rating
The research literature shows that
staffing levels vary widely by facility
characteristics and by the sources of
reimbursement or types of payment
accepted (Grabowski, 2001;
Harrington et al., 2000a). In general,
not-for-profit facilities and those
accepting Medicare beneficiaries tend
to have higher staffing levels
(Aaronson, Zinn, & Rosko, 1994;
Harrington, Woolhandler, Mullan,
Carrillo, & Himmelstein, 2001). In
contrast, facilities accepting primari-
ly Medicaid recipients often have
lower staffing and more quality
problems reflected in the higher
number of deficiencies (Harrington
et al., 2000a, 2001). The website con-
tains cautions to consumers about
these staffing variations.
Type of Nursing Staff
Having an adequate number of
each type of nurse in a facility
(RNs, LPNs/LVNs, and NAs) is an
important determinant of quality.
According to the USCMS (2001)
study, facilities should have at least
.75 RN hprd, or 45 minutes per res-
ident day. Some experts recommend
a ratio of 1 RN or 1 LPN/LVN for
every 15 residents during the day
shift, 1 to every 20 residents in the
evening, and 1 to every 30 residents
at night (Harrington et al., 2000b).
In 2000 to 2001, the average
California facility had .5 RN hprd
and 89% of all California facilities
had .7 hprd or less (Harrington et
al., 2002a). Most nursing homes
employ LPN/LVNs, who may have
as little as 1 year of training, to
work with RNs. The study found
that facilities should have at least .55
LPN/LVN hprd, or 33 minutes per
resident day (USCMS, 2001). In
2000 to 2001, only 58% of
California nursing facilities reported
having LPN/LVN hours at the level
recommended in the USCMS 2001
report (i.e., .55 hprd or more)
Nursing assistants provide the
most direct resident care such as
assistance with bathing, dressing,
toileting, eating, and other activities
of daily living in nursing homes. All
NAs in California must become

certified nursing assistants (CNAs)
within 4 months of employment by
taking 160 hours of training and
passing an examination to show
they can complete their basic duties.
The USCMS (2001) study found
that, ideally, facilities should have
2.8 to 3.2 NA hprd, or 168 to 192
minutes per resident day. This
would be approximately 1 NA for
every 6 to 8 residents during the
day and evening shifts, and 1 NA
for every 20 residents on the night
shift in each unit of the facility. In
2000 to 2001, the average facility
had 2.2 NA hprd and 91% of all
California facilities reported NA
hours below the recommended 2.8
hprd (Harrington et al., 2002a).
TURNOVER RATES
Nursing staff turnover rates can
affect quality because they deter-
mine continuity and stability of
care (USCMS, 2001; IOM, 2001).
An American Health Care
Association (2002) national survey
reported U.S. turnover rates in
nursing homes of 78% for NAs,
56% for staff RNs, 54% for
LPN/LVNs, and 43% to 47% for
directors of nursing and RNs with
administrative duties in 2001. High
turnover may result in poor staff
morale, staff shortages, and poor
quality of care (USCMS, 2001).
Turnover may be directly related to
heavy workloads, low wages and
benefits, poor working conditions,
and other factors (Bowers &
Becker, 1992; IOM, 2001).
Harrington and Swan (2003)
examined the predictors of total
nurse and RN staffing hprd sepa-
rately in all free-standing California
nursing homes, using staffing data
from state cost reports in 1999. This
study showed that total nurse and
RN staffing hours were negatively
associated with nurse staff turnover
rates and positively associated with
resident casemix. Facilities with a
high proportion of Medicare resi-
dents had higher staffing hours, and
facilities with a higher proportion of
Medicaid residents predicted lower
staffing hours and higher turnover
rates. Nursing assistant wages were
positively associated with total
nurse staffing hours. For-profit
facilities and high occupancy rate
facilities had lower total nurse and
RN staffing hours. Medicaid reim-
bursement rates and multi-facility
organizations were positively asso-
ciated with RN staffing hours
(Harrington & Swan, 2003).
Staffing turnover data can convey
important information about the
quality in a nursing home, but these
data are not currently collected by
USCMS. In contrast, the Calnhs
website has included detailed infor-
mation on staffing turnover rates
consumer advocates can use to eval-
uate the stability of a facility’s work
force. California nursing homes
have high nursing staff turnover
rates (on average 78% in 2000 to
2001) (Harrington et al., 2002a).
Although the average California
turnover rate is the same as the
national average rate of 78% for
NAs in 2001, the turnover rate
ranged from 4% to 196% in
California facilities in 2000 to 2001.
Facilities with turnover rates in the
lowest one-third were rated with
three stars, those in the middle one-
third received two-star ratings, and
those in the highest one-third
received a one-star rating (Harring-
ton et al., 2002a). These ratings
should help consumers determine
the stability of staffing and make
comparisons across facilities.
FINANCIAL INDICATORS
Cost reports for nursing facili-
ties provide detailed data on rev-
enues and expenditures that can be
used to provide useful consumer
information (Harrington, O’Meara
et al., 2003). Two types of financial
indicators related to nursing were
considered important and were
reported on Calnhs—expenditures
per resident day for direct care ser-
vices, and wages and benefits for
nursing personnel.
Direct Care Expenditures Per
Resident Day
These indicators show how much
is spent for the different services
and activities for an average resident
on a daily basis. Direct care expen-
ditures (e.g., nursing care, social ser-
vices, activities, ancillary expenses)
for free-standing nursing homes
ranged from 22% to 84% of total
expenses in California in 2000 to
2001 (Harrington et al., 2002a).
Direct care expenditures for free-
standing California nursing homes
averaged $73 per resident day in
2000 to 2001 (52% of total expendi-
tures). These expenditures vary
widely by region, so regional com-
parisons were made using eight geo-
graphic regions within the state.
Calnhs provides information on
direct care expenditures per resident
day by rating facilities within the
highest one-third of facility expen-
ditures with three stars, those in the
middle one-third with two stars,
and those in the lowest one-third
with one star within each region.
Facilities allocating more funds per
day generally have higher staffing
levels and, thus, these facilities may
provide higher quality of care
Wages and Benefits
One of the factors related to the
quality of care in nursing homes is
inexperienced, poorly trained, and
poorly paid NAs (IOM, 2001;
USCMS, 2001). Nursing assistants’
wages are less than a living wage and
not competitive with wages in other
sectors, such as the fast food indus-
try (USGAO, 2001). These may be
low because managers decide to keep
them low to maximize profits, or
because the facility is having finan-
cial problems. They may be kept low
in facilities with a high percentage of
Medicaid residents because Medicaid
reimbursement rates are typically
lower than those for all other payers.
Low wages can result in staff
shortages (USCMS, 2001; Harring-
ton & Swan, 2003). Adequate wages

10 OCTOBER 2003
and benefits are needed to recruit and
keep well-qualified, experienced staff
(Harrington & Swan, 2003; IOM,
2001; USCMS, 2001). The higher the
wages and benefits, the more likely
employees are to remain at their job,
have better continuity of care, and
receive better quality care. Many
other issues are involved with staff
retention, including workload, quali-
ty of work life, and management fac-
tors (Bowers & Becker, 1992).
Average wages for NAs were
$9.57 per hour in California nursing
facilities in 2000 to 2001, which
contributes to the high staff
turnover rates and shortages of
nursing staff in many facilities
(Harrington et al., 2002a). In 2000
to 2001, California nursing home
administrators received an average
wage of $29.69 per hour, and
licensed nurses received an average
wage of $19.64. The average benefits
rate for nursing home employees
was $3.78 per hour, including
administrative staff who generally
receive higher benefits than NAs
DEFICIENCIES, CITATIONS,
AND COMPLAINTS
The federal and state governments
regulate and monitor the care pro-
vided in the nation’s nursing homes.
Surveyors from state L&C agencies
inspect nursing homes to evaluate
compliance with more than 185 fed-
eral statutes and a variety of state
standards or regulations (USHCFA,
2000). Compliance with federal stan-
dards is a prerequisite for initial and
continuing Medicare certification of
nursing homes. When a surveyor
determines a nursing home is not
meeting one or more regulatory
standards, a citation or deficiency for
noncompliance with state or federal
regulations may be issued. Facilities
are expected to address and correct
any problems.
Complaints are formal griev-
ances filed against a nursing home
with the state or federal govern-
ment that may be initiated by resi-
dents, family members, friends,
ombudsmen, health professionals,
facility staff, or other interested
parties. Serious complaints must be
investigated by the state L&C
agency, and may lead to deficiencies
and citations if the claims are sub-
stantiated. Complaints are a mea-
sure of consumer dissatisfaction
with a particular facility and an
indicator of quality, and often indi-
cate problems with nursing care.
For example, the average California
nursing home had five substantiat-
ed complaints between 1999 to
2002, and of those 50% were for
quality of care problems and 20%
were for resident abuse, which
includes verbal and physical
aspects. Facilities were rated with
three stars for those with lowest
one-third on complaints, with two
stars for the middle one-third on
complaints, and one star with the
highest one-third on complaints
Nursing home deficiencies were
grouped on the Calnhs website into
the following eight categories that are
then rated on a scope and severity
scale (Mullan & Harrington, 2001):
● Resident assessment.
● Quality of care.
● Resident rights.
● Administration.
● Environment.
● Pharmacy.
● Nutrition.
● Abuse.
The federal scope and severity
rating is a 12-letter scale (with “A”
being the least harmful and “L”
being the most severe). Scope is
based on the number of residents
who are affected or could be affected
by a deficiency. Severity refers to the
level of harm that has occurred or is
likely to occur if a deficiency is not
corrected (i.e., A = isolated scope
and minimal severity; L = wide-
spread scope and immediate jeop-
ardy). State citations are also classi-
fied into categories based on how
seriously harmed residents either
were or could have been if problems
were not corrected. Residents or
their advocates searching for good
quality nursing homes should con-
sider the type and seriousness (as
well as the numbers) of deficiencies,
complaints, and citations a nursing
home has received. Facilities with
recurring and serious deficiencies are
shown on the Calnhs website.
The Calnhs website gives each
certified California nursing home a
rating indicating the level of compli-
ance with federal and state regula-
tions and the type and severity of
any violations. The problem of
compliance was considerable from
1999 to 2002, with only 23% of
California facilities in substantial
compliance with federal regulations.
Sixty-two percent had serious defi-
ciencies, 12% had very serious defi-
ciencies, and 3% had a substandard
care rating (Harrington et al., 2002a,
2002b). The quality of care and
quality-of-life deficiencies, in par-
ticular, can indicate poor nursing
care and should be considered a key
indicator for a website.
DISCUSSION
Web-based consumer information
sites, such as Calnhs, provide
detailed information to allow con-
sumers to compare nursing homes
against objective criteria. This veri-
fied and validated data can be viewed
as an independent source of informa-
tion for consumers. When nurses use
Web-based information systems to
advise consumers, they must empha-
size the need for consumers to avoid
selecting facilities based solely on
convenient geographic location,
price, or “word of mouth.” Instead,
consumers should be urged to focus
on indicators that show the quality
of nursing care, such as staffing lev-
els and turnover rates, the total
direct care expenditures per day,
wages and benefits, and complaint
and deficiency ratings.
Nurses and advocates should be
encouraged to use websites such as
Calnhs to monitor changes in quality
over time. The information can

empower consumers by educating
them about nursing care and inform-
ing them about whether a facility
meets state and federal standards.
They can also use the information to
lobby elected representatives to
encourage improvements in staffing
and quality. Nurses and health pro-
fessionals, as well as facility man-
agers and owners, can use the infor-
mation on the website to plan target-
ed quality improvement activities,
such as those that will increase their
compliance with staffing standards.
The availability of data on the
Internet should help in examining
compensation packages to help facil-
ities remain competitive and reduce
turnover rates. Web-based consumer
information systems can also be used
by policy makers to monitor quality
and to guide public policy changes.
Finally, and most importantly, Web-
based information sources can be
used to identify facilities providing
optimal care for residents.
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