There are too many bad U.S. nursing homes and too few good ones.

That's the conclusion of a new report, titled Nursing Home Quality Monitor, published in the September issue of Consumer Reports.

"We have seen little evidence that the quality of care has improved much since the first list came out in 2000," Charles Bell, programs director for Consumers Union, said at a Monday teleconference. 

"John F. Kennedy said once that the strength and durability of a society can be judged by how it treats its elderly," added Trudy Lieberman, director of Consumers Union's Center for Consumer Health Choices. "In America today, we are not always treating our elderly very well." 

This, despite the landmark law passed by Congress in 1987 intended to improve nursing home care for the elderly. 

The authors of the new report analyzed data for about 16,000 nursing homes across the United States, paying particular attention to three measures of quality -- deficiencies noted in official reports; staffing; and five indicators from the Centers for Medicare and Medicaid Services (CMS), such as decreased mobility of residents. 

The top 10 percent of the best performers and the bottom 10 percent of worst performers for each state are listed in the report.

"No monitoring system gives you certainty," said Dr. Charles Phillips, director of the Health Services Research Program at Texas A&M University's School of Rural Public Health. "We concentrated on identifying facilities that had what we believe is a high likelihood of providing good care or very poor care. We ended up classifying 4 percent of homes in the country as ones to consider and 3 percent to avoid." 

In general, not-for-profit homes delivered better care than for-profit ones, and independently run homes provided better care than chains. These days, however, for-profit entities tend to dominate the field. 

"Less than 2 percent of for-profit homes were likely to provide good care while more than 7 percent of not-for-profit homes were," Lieberman said. "At the other end of the spectrum, less than 1.5 percent of not-for-profits were likely to provide poor care while 3.5 percent of for-profits were." 

On average, not-for-profits provided almost one hour of additional nursing care each day per resident and twice as much care from registered nurses. 

The list also includes a "deficient dozen," or 12 facilities that have appeared five times on the poor performers' list. They are part of a larger group of 186 nursing facilities that are repeat poor performers. 

"This is basically a stunning indictment of the kind of care being delivered in these facilities as well as regulatory apparatus in those states that is allowing that care to continue," Lieberman said. 

One of the repeat offenders, the White Blossom Care Center, part of a for-profit chain in San Jose, Calif., had repeated failures to follow doctors' orders, monitor pressure sores or property sanitize dishes and utensils. Another provider, Healthcare Associates, in New York state, has been sued for abuse and neglect by the state attorney general. 

Enforcement also appeared to be lax. "States seem very reluctant to use their fining authority, which is not what we like to see," Lieberman said.

In 1999, the median fine was $4,800. In 2004, it had dropped to $3,000. Only 2 percent of nursing homes in the sample of three-to-four-time repeat offenders had received fines greater than $100,000. Four of the deficient dozen received only small fines from 1999 to 2004 while eight received no fine, the survey found.

Deficiencies are also getting watered down, with state inspectors now writing fewer deficiencies for severe violations, according to the survey. 

The most drastic action that can be taken is to shut down a home. This peaked in 1998 with 51 homes shut down. In 2005, only eight were closed.

Lieberman listed a number of steps families can take when looking for a nursing home for a loved one: 

Read the Nursing Home Quality Monitor for homes to avoid and homes to consider. Start with the well performing homes that are near where you or your loved one live. 

Remember that nursing homes change ownership frequently and that a poor-performing home can become a good one (or vice versa) within a matter of months.
 
Independent, nonprofit homes are generally the best place to start, but there are chains that rank in the middle of the pack that also provide good care. 
Read each home's Form 2567, the state's inspection survey of the facility. If the home won't make it available to you, be worried. "These documents are often hidden," Lieberman said. "One home in Louisiana told me a resident ate the report."
 
Make several unannounced visits to the facility. Danger signs would be seeing a lot of residents sleeping in the middle of the morning when you would want to see them up and about; substandard food at meals; or no snacks.