Explanation of Inspection Scoring

The results tables are a set of performance measures where each category is indicated by stars. The more stars (up to 5) that are shown, the better the facility scored on that particular measure. The broadest measure of performance is Overall Inspection. The eight other categories represent different pieces of the Overall Inspection rank. Each of the performance measures represents how a nursing home ranked within its geographic region.

The regions are defined as follows:

North

• Region 1: Escambia, Okaloosa, Santa Rosa, Walton
• Region 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holms, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington
• Region 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union
• Region 4: Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia

Central

• Region 5: Pasco, Pinellas
• Region 6: Hardee, Highlands, Hillsborough, Manatee, Polk
• Region 7: Brevard, Orange, Osceola, Seminole

South

• Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota
• Region 9: Indian River, Martin, Okeechobee, Palm Beach, St. Lucie
• Region 10: Broward
• Region 11: Miami-Dade, Monroe

As stated above, these ranks indicate only relative rankings within a region. All of the nursing homes in a particular region could perform better than the statewide average. Therefore, a low rank does not necessarily indicate a "low quality" facility. Similarly, all of the nursing homes in a particular region could perform lower than the statewide average. Therefore, receiving a high rank does not necessarily indicate a "high quality" facility. All facilities listed have met the requirements for being licensed as a nursing home.

Any performance measure will have strengths and weaknesses. These are discussed below.

Inspection

The goal of the Inspection measures is to assess how well the nursing home complies with the federal laws governing nursing homes that accept Medicare or Medicaid payments. While the laws are federal, the state of Florida conducts the actual inspections as a subcontractor to the federal Centers for Medicare and Medicaid Services (CMS).

For nursing homes that accept neither Medicare nor Medicaid these federal laws do not apply. Therefore, they can only be inspected for compliance with state of Florida laws. The scoring procedure for these nursing homes is very similar to that used for the other nursing homes. On average, less than 2% of nursing homes do not accept Medicare or Medicaid. For the nursing homes that do accept Medicare or Medicaid, the general scoring procedure is discussed next.

Complete inspections are conducted on average once per year. They are unannounced and typically last four to five days. In addition, AHCA may conduct additional inspections of nursing homes, if concerns or complaints of regulatory violations arise.

If the nursing home is found to be out of compliance during an inspection, deficiencies are issued to the facility. The deficiencies are assigned a severity (e.g. is a resident merely at risk for being harmed, or has a resident experienced actual harm) as well as a scope (e.g. is only one resident affected or are many residents affected). Deficiencies are given points according to the level of the scope and severity (the more serious the deficiency, the more points assigned). Points are doubled for deficiencies that represent substandard quality of care.

Total deficiency points are used to compute a score for the nursing home. This score takes into account the number of deficiencies, their scope, and their severity over the past 30 months.

The ranks shown are based on the facility's score over the past 30 months divided by the number of complete inspections. This time period will typically encompass at least two inspections. If the ownership of the facility has changed within the past 30 months, then the ranks will include deficiencies involving both the new owner and the previous owner(s).

Five stars overall indicates that the facility had a lower score relative to most other facilities in its region. Having only one star indicates that the facility had a higher score relative to most other facilities in its region.

Facilities have the right to appeal the deficiencies. The underlying scores do not include deficiencies that were overturned after appeal at the federal level.

The overall score is broken down into the three categories: Quality of Care, Quality of Life, and Administration. Combining the deficiencies from the three categories comprises the Overall Inspection rank.

• Some of the more common deficiencies in the Quality of Care category involve the unsanitary storage, preparation, and distribution of food; improper treatment to prevent and treat pressure ulcers; and failing to maintain a resident's nutritional status.
• Some of the more common deficiencies in the Quality of Life category involve improper use of physical or chemical restraints, failing to treat the resident with dignity, and failing to accommodate resident needs and preferences.
• Some of the more common deficiencies in the Administration category involve the inaccuracy of comprehensive assessments of the residents' health status, and failing to develop adequate comprehensive care plans for the residents. The Administration category also includes physical aspects of the facility such as inaccessible fire exits and lack of fire prevention.

There were many specific areas of interest expressed by consumers while developing this report. The five of greatest interest are included as the Components of Inspection. Because of their narrow focus, these components collectively represent 18 deficiencies. However, in many cases they represent the more frequently cited deficiencies at the higher severity and scope levels.

On November 28, 2017, CMS directed the state agencies to utilize a new regulatory set of deficiencies. Therefore, the Guide is a combination of the old and the new deficiencies.

Star Summary (Review):

The Nutrition and Hydration component deficiencies for failure to comply
Up through November 27, 2017	F325: Facility must ensure that residents maintain their nutritional status F326: Facility must provide therapeutic diet when necessary F327: Facility must provide sufficient fluid intake
November 28, 2017 to present	F692: Facility must ensure that residents maintain their nutritional status; must provide the therapeutic diet when necessary; and must provide sufficient fluid intake.

The Restraints and Abuse component deficiencies for failure to comply
Up through November 27, 2017	F221: Residents must not be physically restrained for discipline or convenience F222: Residents must not be chemically restrained for discipline or convenience F223: Residents must not be verbally, mentally, or physically abused F224: Residents must be free of mistreatment and neglect
November 28, 2017 to present	F600: Residents must be free from abuse, neglect, and corporal punishment F602: Resident must be free from misappropriation of property and exploitation F603: Resident must be free from involuntary seclusion F604: Residents must not be physically restrained for discipline or convenience F605: Residents must not be chemically restrained for discipline or convenience

The Pressure Ulcers component deficiency for failure to comply
Up through November 27, 2017	F314: Residents must receive proper treatment to prevent and heal pressure sores
November 28, 2017 to present	F686: Residents must receive proper treatment to prevent and heal pressure sores

The Decline component deficiencies for failure to comply
Up through November 27, 2017	F309: Facility must provide necessary care for highest practicable well being F310: Facility must ensure that ADLs do not decline unless unavoidable F311: Facility must give each resident treatment to improve or maintain ADLs F312: Facility must provide proper services for ADL dependent resident F317: Residents must receive proper therapy to prevent reduced range of motion F318: Residents with limited range of motion must receive appropriate treatment
November 28, 2017 to present	F675: Facility must create an environment that humanizes and individualizes each resident’s quality of life F676: Facility must ensure that ADLs do not decline unless unavoidable and must give each resident treatment to improve or maintain ADLs F677: Facility must provide proper services for ADL dependent resident F684: Facility must provide necessary care for highest practicable well being F688: Residents must receive proper therapy to prevent reduced range of motion; those with limited range of motion must receive appropriate treatment F697: Facility must ensure that the residents receive the treatment and care related to pain management F698: Facility must ensure that residents who require dialysis receive such services F744: Facility must ensure that residents who display or are diagnosed with dementia, receive the appropriate treatment and services

Note: ADL stands for Activities of Daily Living and include the resident's ability to move, walk, dress, eat, toilet, comb hair, brush teeth, etc.

The Dignity component deficiencies for failure to comply
Up through November 27, 2017	F241: Facility must treat residents with dignity and respect F242: Residents are free to choose their activities, health care, and visitors F245: Residents are free to participate in their chosen religious and social activities F246: Facility must accommodate reasonable preferences of each resident
November 28, 2017 to present	F550: Facility must treat residents with dignity and respect and must consider the resident’s life style and person choices F558: Facility must provide an individualized, home-like environment for each resident F561: Facility must accommodate reasonable preferences of each resident

Star Summary (Review):

• The more stars a facility receives in any of these categories or components, the more the facility was found to be in compliance with the regulations governing nursing homes.
• The fewer stars a facility receives, the more the facility was found to be in noncompliance with the regulations governing nursing homes.

Months will typically pass between inspections. Much could change for the better or worse in a facility between inspections. Therefore, you must always inspect the facility yourself before making such an important decision.

Scoring and Ranking Algorithm

For the more than 650 freestanding nursing homes that accept Medicare or Medicaid, the details of the scoring procedure is discussed next. Other nursing homes are scored slightly differently, and are discussed further down.

We compile all deficiencies over the most recently available 30 month period. As the annual inspections at each nursing home should occur on average every 12 months, and no later than every 15 months, this 30 month period should include at least 3 annual inspections. If a facility has been open for less than 30 months, then clearly it could easily have fewer than 3 annual inspections. We also compile all deficiencies from all complaint inspections that occur in this 30 month window.

We assign points to each citation. CMS also assigns a letter to each possible severity and scope combination. These letters and their corresponding points are shown in the table below.

Severity	Scope
	Isolated	Pattern	Widespread
Immediate Jeopardy to Resident Health or Safety	J=32	K=45	L=60
Actual Harm that is not Immediate Jeopardy	G=16	H=22	I=28
No Actual Harm with Potential for more than Minimal Harm	D=5	E=8	F=11
No Actual Harm with Potential for Minimal Harm	A=0	B=1	C=3

The federal Centers for Medicare and Medicaid Services (CMS) has a set of statutory provisions that it considers to be "Critical". When noncompliance with these Critical provisions is cited, then we assign twice the points shown above.

The more commonly cited Critical provisions for noncompliance
Up through November 27, 2017	F221: Residents must not be physically restrained for discipline or convenience F241: Facility must treat residents with dignity and respect F309: Facility must provide necessary care for highest practicable well-being F314: Residents must receive proper treatment to prevent and heal pressure sores F316: Incontinent residents must receive appropriate treatment F325: Facility must ensure that residents maintain their nutritional status
November 28, 2017 to present	F550: Facility must treat residents with dignity and respect and must consider the resident’s life style and person choices F604: Residents must not be physically restrained for discipline or convenience F684: Facility must provide necessary care for highest practicable well being F686: Residents must receive proper treatment to prevent and heal pressure sores F692: Facility must ensure that residents maintain their nutritional status; must provide the therapeutic diet when necessary; and must provide sufficient fluid intake

You can see the full listing when you are looking at a particular nursing home. On the profile page of a Nursing Home, click on Inspection Details where you will see a listing of what cites the nursing home has received over the past 30 months. If you click on the provision of interest in the Short Provision Description column, you will be taken to a page that provides the statutes that contain the relevant provision, as well as whether it is considered a Critical provision or not. This page will also show you which of the 3 broad categories a provision is placed in, as well as if it is in one of the 5 narrow components.

The points for a given facility are added up and divided by the number of annual inspections the facility had in the 30 month window. The result is called the facility's score. These scores are then ranked within each of the 11 geographical regions separately. The lowest score is given a rank of 100, and the rest of the scores are spread out evenly between 100 and 0. A high rank (i.e. low score) indicates that the facility had fewer deficiencies and/or less serious deficiencies relative to most other facilities in their region. A low rank (i.e. high score) indicates that the facility had more deficiencies and/or more serious deficiencies relative to most other facilities in their region.

This procedure is repeated for the 3 broad categories, as well as the 5 narrow components. In each case, only the deficiencies within that category or component are included in the scoring and ranking.

If facilities are tied at a point where the number of stars is in transition (e.g. between 4 stars and 5 stars), then the tied facilities are given the higher number of stars (in this example 5 stars). Therefore, more than 20% of the facilities could end up with 5 stars and fewer than 20% of the facilities could end up with 1 star.

The nursing homes that are not certified to accept Medicaid or Medicare payments are not subject to the same federal laws that the other nursing homes are. Instead of one of twelve severity and scope levels for each federal level citation, they receive one of three class levels for each state level citation. Class 1 is the most serious, while Class 3 is the least serious. Under our method a Class 3 cite warrants 5 points, a Class 2 cite warrants 22 points, and a Class 1 cite warrants 45 points. Except for these differences, the scoring method for these 6 nursing homes is the same as for all the other nursing homes.

Explanation of the Performance Measures (Stars)