The first thing to know when seeking a nursing home is that the Social Security Act spells out nursing home requirements relating to residents’ rights. See here subparagraph (c).

Once informed of the rights you or your loved one will have, Medicare Compare is by far the best source available to most Virginians when evaluating a nursing home before a necessary personal visit. But it is imperfect. The author will share with readers here his experiences on what information in Medicare Compare is useful and what is not.

Please open the Medicare Compare page for Parham Health Care and Rehabilitation Center in Richmond. We will walk through it.

In the next article, the author will report on important information for analysts that is not in Medicare Compare. But today we’ll work with information that CMS designs for everyone.

Overall rating. The first thing you see is the Overall rating. I urge you to ignore it. The algorithm that CMS uses to compile the Overall rating is potentially corrupted by two other measures:

• The Health Inspection rating can be flawed by the age of the inspections. The importance of health inspection results in the Overall algorithm assumes they are conducted every year. In Virginia, federal inspections have been conducted roughly every three years because of staff shortages at the Virginia Department of Health (VDH) Office of Licensure and Certification (OLC). OLC shortages are being corrected aggressively by the Youngkin administration and should be completed by the time of the turnover to the new administration.
• The Quality Measures rating is worse than useless.

Here is how the Overall rating is calculated, and why the author ignores it:

1. Step 1: Start with the Health Inspection rating.
2. Step 2: Add one star to the Step 1 result if the Staffing rating is five stars; subtract one star if the Staffing rating is one star. The Overall rating cannot be more than five stars or less than one star.
3. Step 3: Add one star to the Step 2 result if the Quality Measure rating is five stars; subtract one star if the Quality Measure rating is one star. The overall rating cannot be more than five stars or less than one star.
4. Note: If the Health Inspection rating is one star, then the overall rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings.

Health Inspection Rating.

Parham has a one-star Health Inspection rating. That means it ranks in the bottom 20% in the Commonwealth. Health Inspection star ratings are based on a statewide Bell Curve because different states are found to have different ranges of grading outcomes. That results in cut points for the Bell curve, which are unique to that state, to establish star ratings. That rating can be very useful if the last inspection was recent or VDH has visited recently on a complaint inspection, but its utility fades as time goes on.

Click on the box “View Inspection Results” below Parham’s Health Inspections rating. You see useful information.

First, you see that Parham’s most recent federal Health Inspection (called a survey) in CMS records was 04/27/2022. OLC conducts those surveys for CMS, as does every state’s survey agency. You can read the full report, but you likely won’t because of its age. The total number of health citations includes the most recent standard survey, as well as complaint and infection control surveys from the most recent 12 months. Parham is listed with 17 citations (of violations of federal regulations in that federal certification survey).

You will also see that Parham has had no recent complaint inspections. So, you could discount the Health Inspection rating in your review of Parham.

But you would know that there were 38 complaints in the past three years that resulted in a citation. That means that OLC investigated complaints and cited the facility for a violation of federal regulations in each case. That is a very high number.

Staffing Rating. Parham has a one-star Staffing rating. That means it ranks in the bottom 20% in the nation after the CMS multi-variable staffing algorithm is applied to each. The staffing ratings compare each facility to the results posted by every other facility nationwide. There is no zero rating, so one-star is bottomless. So, let’s look.

Go to Parham. The number of beds in the facility is on the main page.
Click “View Staffing Information”, and let’s look at how badly staffed it is.

Hard numbers. You will see the average number of residents per day. If you divide that by the number of beds, you will get the occupancy rate. In Parham’s case, the average occupancy is 95%. At Parham, the data show:

• • Total nurse staffing hours per resident per day (HPRD) is not quite 2 1/2 hours, with a national average of nearly 4 and a Virginia average of 3 3/4 hours
  • Registered nurse HPRD is 16 minutes vs. the national and state averages of 41 minutes.
  • Nurse aides do the very hard physical work of helping residents with the activities of daily living and physically moving residents to assist in medical care. Parham nurse aides are indicated by the numbers to be dangerously overscheduled.
  • Good luck on the weekends.
  • 62% RN turnover. Few will work in the worst facilities for very long.

Not a chance you’ll pick Parham. But it stays nearly full. Regulators may wish to investigate exactly how they do that.

Staffing is the most up-to-date and reliable information offered in Medicare Compare. It provides an assessment of staffing that is not colored by artificial targets negotiated in the General Assembly, but rather shows how each facility fared in the existing marketplace for qualified staff.

Nationally, the average staffing rating is 2.86. In Virginia, it is 2.46. Much of that difference is due to the outsized presence in the Commonwealth of out-of-state for-profit chains that are understaffed as a key part of their business models.

Just for interest, I removed just the New Jersey-based chain facilities from the Virginia list, and our average staffing rating in September jumped to 2.76. Take out the New York-based chain facilities as well, and the Virginia average staffing rating is 2.91, well above the national average.

For those who still may claim that the local staffing market is different, they can check out other facilities in our state and in their region and see how they were staffed compared to one another.

The reliability of the Staffing rating is traceable to the strict and auditable standards for the data. Federal law requires that long-term care facilities (or their chains for them) submit direct care staffing information electronically every quarter, including hours worked and staff roles. The submissions are called Payroll-Based Journal (PBJ) data because every nursing home in the United States is required to align its payroll system to CMS data architecture standards. The reporting is contained in two databases: PBJ daily nurse staffing and PBJ daily non-nurse staffing. Those databases are critically important to regulators, but perhaps not to regular folks looking for a nursing home. But they form the basis for the nurse staffing ratings.

This extensive description of the provenance of the staffing data is meant to inform those looking for a nursing home for mom to:

• Lean on the Staffing rating as a cut point, and
• Open the Medicare Compare staffing page for any facility you are considering.

Quality Measure (QM) Rating.

QM rating is the most manipulable, and thus the most manipulated, measure reported in Medicare Compare. It should be thrown from the Medicare Compare system.

A couple of datapoints back up the suggestion:

The author just ran a screen on the 14,752 nursing homes in America that are certified for Medicare or Medicaid, or both. The screen was for staffing rating = one, and QM rating = five; 557 facilities passed that screen. That represents a lot of “loaves and fishes” miracles.

Closer to home, there are 22 facilities with one-star staffing and five-star QMs in Virginia.

• Twelve of them belong to Virginia’s worst chain, Lifeworks Rehab (rebranded this year from Medical Facilities of America and Innovative Healthcare Management after the Colonial Heights scandal). Forty-five Virginia facilities have been rebranded in 2025. Chains often rebrand for the same reason we change our socks. The old ones are dirty.
• Seven more are outposts of other out-of-state chains with poor performance in Virginia.

The reason the author also rejects the Overall rating is that not one of those 557 had a one-star Overall rating. Not one. For the reason, see above how the Overall rating is calculated using QM factors.

Bottom line. The author recommends the following steps, which should take less time than reading this explanation of why the author recommends them.

1. Make a list of nursing homes in your local area. Medicare Compare can help with that. Here is a list of Virginia facilities. You can substitute your city or county for “Virginia” in the upper left box. If mom is looking in another state, plug that one in.
2. Check the staffing rating first. If staffing is a one-star or two-star rating, cross each of those off your list.
3. For the facilities remaining on your list, if any,

• • Check out the detailed staffing data with a click, as we did above for Parham, to see if there is anything of particular concern.
  • Check if the last federal health inspection was within the last 15 months. If so, consult it from the Medicare Compare Health Inspection page for that facility and read the report.

Then call and ask the admissions department at the nursing home about the current occupancy rate and bed availability. Then schedule a visit.