What Consumers Say About Nursing Homes in Online Reviews

What Consumers Say About Nursing Homes in Online Reviews Abstract Background Although patient-centered care is an expressed value of our healthcare system, no studies have examined what consumers say in online reviews about nursing homes (NHs). Insight into themes addressed in these reviews could inform improvement efforts that promote patient-centered NH care. Research Design and Methods We analyzed nursing home (NH) Yelp reviews. From a list of all NHs in California, we drew a purposeful sample of 51 NHs, selecting facilities representing a range of geographical areas and occupancy rates. Two research teams analyzed the reviews using grounded theory to identify codes and tracked how frequently each code was mentioned. Results We evaluated 264 reviews, identifying 24 codes, grouped under five categories: quality of staff care and staffing; physical facility and setting; resident safety and security; clinical care quality; and financial issues. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness. Yelp reviewers also often posted about NHs’ physical environment. Infrequently mentioned were the quality of health care provided and concerns about resident safety and security. Discussion and Implications Our results are consistent with those from related studies. Yelp reviewers focus on NH aspects that are not evaluated in most other NH rating systems. The federal Nursing Home Compare website, for instance, does not report measures of staff attitudes or the NH’s physical setting. Rather, it reports measures of staffing levels and clinical processes and outcomes. We recommend that NH consumers consult both types of rating systems because they provide complementary information. Assessment of condition, Quality of care, Quality of life, Qualitative analysis, Satisfaction Every year more than a million older adults enter nursing homes (NHs), yet there is limited information about how they choose a facility or what they think about the facility after their stay (Shugarman & Brown, 2007). When decision-makers search Google for help with finding a good NH—a commonly reported strategy—they often are directed to NH checklists and lists of questions to ask NH staff (Findlay, 2016; Konetzka & Perraillon, 2016; Shugarman & Brown, 2007). Some of these guides point consumers to websites that compare NHs (Ramnarace, 2012). The oldest of these is the Center for Medicare and Medicaid Services’ (CMS’) Nursing Home Compare (NHC) site (Centers for Medicare & Medicaid Services, n.d.) CMS and Statewide NH Rating Sites Launched in 1998, NHC is a web-based report card that publicly rates the quality of virtually every NH in the nation based on measures of care quality, staffing sufficiency, and survey deficiencies. The purpose of the site is to provide standardized care quality information to help consumers make informed decisions when selecting a NH. Following CMS’s lead, 19 states now publish their own NH report cards online (Castle & Ferguson, 2010). Despite these sites’ years of operation, recent studies have found that many consumers are unaware of NHC, and relatively few visit the statewide NH rating sites (Findlay, 2016; Konetzka & Perraillon, 2016; Shugarman & Brown, 2007). Consistent with these reports, research has shown that public reporting of standardized NH quality measures has had minimal influence on consumers’ decision making (Grabowski & Town, 2011). Consumer Review Websites More recently, use of online consumer review websites for businesses has increased. One of the most popular sites, Yelp.com, now has more than 80 million unique desktop visitors each month, up 33% from 60 million monthly visitors in 2012 (Yelp, 2015). The cumulative number of health care-related Yelp reviews also has increased, jumping from 160,000 in 2008 to 7.26 million in 2016 (Arrington, 2008). Growth in health care-related reviews is expected to continue as Yelp focuses on this aspect of its business. In August, 2015, Yelp partnered with ProPublica, an investigative journalism agency, to incorporate health care information into Yelp business pages, including CMS-culled statistics for all NHs reviewed on Yelp (Stoppelman, 2015). According to the CEO of Yelp, this change is meant to empower consumers by giving them “even more information... when they are in the midst of the most critical life decisions, like…which nursing home will provide the best care for aging parents (Stoppelman, 2015).” Lack of Knowledge of Consumer Perspectives on NHs Although patient-centered, family-oriented care is now an expressed value of our health care system (U.S. Dept. of Health and Human Services, 2017), our literature search found only one study that examined what consumers say in online reviews about hospitals and no study that did so for NHs. Thus, there is a dearth of research on the consumer perspective of important aspects of NHs. Insight into topics and categories addressed in online consumer reviews of NHs could inform improvement efforts that promote patient-centered care. They also could guide the development of online resources that empower consumers to make informed decisions. To bridge this gap in knowledge, we analyzed the content of Yelp reviews for a sample of NHs in California. Theoretical Framework for the Study This study is centered on a theoretical framework known as Total Quality Management (TQM), sometimes referred to as Continuous Quality Improvement (CQI). Borrowed from other types of industry (e.g., car manufacturing) and introduced to health care practice in the 1990s, TQM emphasizes “the continuous improvement of (multidisciplinary) processes in health care in order to better meet customers’ needs (Grol, Bosch, Hulscher, Eccles, & Wensing, 2007, p. 117).” Among its basic principles—and one that sets it apart from many other improvement theories—is its focus on patients and caregivers, the consumers of health care services (Grol et al., 2007). The TQM model views consumers as both a target of services and a source of knowledge about how to improve services. TQM uses plan-do-study-act (PDSA) cycles to drive continuous improvement (American College of Physicians, n.d.). The study component of PDSA cycles includes customer feedback, including feedback obtained through consumer reviews such as those posted on Yelp. Through continuous quality improvement cycles, TQM tenets suggest that topics found in NH Yelp reviews can inform improvement efforts that promote patient-centered care. Also in line with TQM principles, Yelp feedback can guide the development of online resources that empower consumers to make informed decisions. With this in mind, our study sought to better understand issues important to NH consumers. Methods We conducted a qualitative study of NH reviews posted on Yelp.com. NH Data and Sample We used data from the California Office of Statewide Health Planning and Development (OSHPD) to identify our NH sample. Long-term care facilities, including skilled nursing facilities, group (or congregate) living facilities, and stand-alone hospices, submit annual utilization reports to OSHPD, which then compiles them into a complete data set. We used the 2014 data set, which provided an initial list of 1092 licensed NHs. Excluded from this list were congregate (or group) living facilities and stand-alone hospices. From this initial NH list, we eliminated facilities without NHC ratings, leaving a total of 991 (90.8%) NHs. Between September and November of 2016, we searched Yelp for each NH on this list of 991 NHs. Each individual who posts a Yelp review rates the NH on a five-point scale (1 = the worst rating; 5 = the best rating). Yelp also reports an overall rating, which represents the average rating across all consumer reviews posted for that NH. The average rating is rounded to the nearest half-point. We collected the overall Yelp rating as well as all the Yelp reviews for each NH and the individual five-star ratings assigned to those reviews. We then drew a purposeful sample of 51 NHs certified by Medicare and/or Medicaid (known as Medi-Cal in California). For this sample, we selected facilities representing a range of geographical areas and occupancy rates. To accomplish this, we sorted the NHs geographically using zip codes, and divided the list into five roughly equal clusters, from which we drew 10–11 NHs per cluster. Within each cluster, we drew a purposeful subsample of both “small” and “large” NHs because our previous research found that occupancy rate was positively associated with the number of Yelp reviews a facility received (Johari et al., 2017). To do this, we used the mean number of occupied beds reported for the full NH sample—88 occupied beds—to define a large NH (≥ 88 beds) and a small NH (<88 beds). We determined that 60% of the full sample comprised large NHs and 40% comprised small NHs. In keeping with this NH distribution, we sorted each geographical cluster of NHs into large and small NHs based on the occupancy rate each NH reported to OSHPD and then randomly selected six large NHs and four to five small NHs from each cluster. Thus, our final study sample of 51 NHs included 30 large NHs (60%) and 21 small NHs (40%). For each of these NHs, we also retrieved from OSHPD the NH’s ownership status. Analysis We used grounded theory to identify topics and categories in the NH reviews (Strauss & Corbin, 1998). Rather than start with a list of preidentified topics, we allowed codes to emerge from the reviews. Two teams, each with two trained research assistants (C. Kellogg and Y. Zhu; K. Johari and K. Vazquez), coded the Yelp reviews for the 51 NHs in our sample. We used open coding to identify initial codes. Using a constant comparison approach, individual codes identified by each coding team member were compared and discussed after completion of coding for each geographical cluster of 10–11 NHs. Next, both teams met to compare, discuss, and reconcile their lists of identified codes. If there was consensus to add new codes, then both teams, as needed, returned to previously analyzed reviews to recode for the new code. Each team met internally to compare individual NH review codes and reconcile discrepancies in coding. Discrepancies were discussed until 100% consensus was reached. Although saturation was reached after coding reviews for approximately 20% of the NH sample, the teams continued coding reviews for all 51 NHs because we wanted to identify not only those codes most frequently mentioned, but also those seldom mentioned. After coding was completed the team met to reconcile codes and conduct axial coding to identify categories among the individual codes using inductive reasoning (Strauss & Corbin, 1998). We then determined the frequency of each code and category. Results NH Sample and Yelp Reviews Of our sample of 51 NHs, most (92%) were for-profit organizations, in keeping with state and national trends. The average number of occupied NH beds for large facilities (n = >88) was 115.5 (range = 89–185; median = 98). The average number of occupied NH beds for small facilities (n = < 88) was 57.7 (range = 34–87; median = 55). We evaluated a total of 264 NH Yelp reviews. The average number of Yelp reviews per NH was 5.2 (range = 1–15; median = 4; mode = 1). The average of the 51 overall Yelp ratings for the sample was three stars (range = 1–5; median = 3; mode = 1). The average of the 264 individual Yelp ratings was 3.2 stars (median = 3; mode = 5). As shown in Figure 1, 82% of all individual ratings were either one star (37%) or five stars (45%). Figure 1. View largeDownload slide Distribution of individual Yelp star ratings for nursing homes (N = 264). Figure 1. View largeDownload slide Distribution of individual Yelp star ratings for nursing homes (N = 264). Yelp Codes and Overarching Categories Our team identified 24 codes across the Yelp reviews, which we further grouped under five overarching categories. Table 1 shows each code within its associated category, along with a definition, review example, and frequency of its mention in Yelp reviews. Table 1. Categories and Topics Identified in Yelp Reviews of Nursing Homes Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Note: Total number of times any topic was mentioned 608. View Large Table 1. Categories and Topics Identified in Yelp Reviews of Nursing Homes Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Note: Total number of times any topic was mentioned 608. View Large Category: Quality of Staff Care and Staffing This category, describing the quality of services that NH staff members provide, includes six related codes, including, most frequently, staff attitudes, responsiveness, and professionalism. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness, making these the most frequently appearing codes in our study. These comments often captured emotional opinions expressed either positively, as in the first example below, or negatively, as in the second example: “I would give 5 stars to the Rehab therapists. They are an amazing group of caring individuals… The team of therapists are more than amazing. Caring, ingenious, and effective. I was so lucky to have found them… I hope to never need their services again, but if I did, I’d select (facility name) again...Oh, and the view and patio area are to die for. Nothing like doing some physical therapy while looking over Hollywood and the hills (quotation identifier: AF7).” “This place is the worst place for anyone to recover or be at. My father was treated like crap here very, very unprofessional staff when transport(ing) him to his dialysis his socks had holes in them from being dragged on the ground…I’M WARNING YOU DON’T LET YOUR LOVED ONE STAY HERE ONE NIGHT AT ALL!!!!!!!! This place DOES NOT deserve a star but I have to select one for this to post, ZERO STARS TO THE GROUND!! (AJ1).” Category: Physical Facility and Setting Yelp reviewers also expressed views about NHs’ physical environment. The most frequently identified codes were cleanliness (appearing in 25% of all reviews), aesthetics (13.64%), and meals (13.64%). Consider these sample comments: “…- The place is super clean. We have tried other rehab centers and they smell awful from all the soiled diapers… The outside grounds are so beautiful. Dad enjoyed sitting near the fountain in the afternoon…(AU4).” “…The place doesn’t smell like a dirty diaper (if you’ve been into other retirement homes, you know what I am talking about), the staff are friendly and attentive, there are numerous activities that occur daily for the residents, and from what I hear...the food is actually very good. If it is quality that you are looking for, look no further than GG...(AA13).” Category: Clinical Care Quality Yelp reviewers infrequently referred to the quality of health care provided. Reviewers tended to report only general health-related information. They might, for instance, report that a loved one’s health condition improved or worsened with the care provided (15.15%), but detailed clinical information—for example, about dementia care, pain management, or depression treatment—was rarely provided. Worth noting is that, even when some clinical care topics emerged (e.g., pressure sores and incontinence), reviewers tended to emphasize the quality of staff care, not details about the care process. One reviewer, for instance, wrote: “This is an amazing facility--from wound care (pressure ulcers) to physical and occupational therapy. The staff, especially the Director of Nursing and the physician in charge, as well as the entire PT staff and nurses, have helped my elderly friend regain her physical and emotional strength. They care so deeply for all of their patients. The degree of caring and compassion is so impressive…(AJ1).” Category: Resident Safety/Security We identified three codes related to resident safety: falls, abuse, and theft. Although these codes were infrequently identified, they may attract consumer attention when they appear due to their potentially serious consequences and sensitive nature. For example: “My father had several falls since his stay at [NH facility] which is unacceptable. I do understand things occur, however repeat incident is unacceptable. I feel the staffing-to-ratio-of-patient is in great need of change to provide better care. It stands to reason that a convalescent (home) would give patient care when the family is not around…(N2).” “…So I went outside with my partner in her wheelchair and he [staff nurse] came out and started dancing around the wheelchair and telling us that he’s considered the clown there. I cannot believe this man is an RN. I have two nurses in my family including my sister who teaches nursing not to mention I’m retired from the legal field that I’m pretty sure he’s setting himself up and his employer for of sexual harassment lawsuit and possibly elder abuse (T3).” Category: Financial Issues A final code, insurance/cost/payment, was identified in 31 reviews (11.74%). Often these comments concerned whether Medicare or Medicaid would cover a loved one’s NH stay, as in this excerpt: “[my mother was]…Discharged because Physical Therapy determined they couldn’t justify keeping her any longer because…she can walk 400’ & Medicare wouldn’t pay for more time (AQ13),” A few reviewers reported that the resident’s insurance coverage influenced living quarters, as in this comment: “Medi-Cal patients are stacked three to a room. Tight quarters. Medicare or private insurance patients are in double rooms (AQ4).” Discussion This study identified common codes and categories in NH Yelp reviews as a strategy for pinpointing the factors consumers consider when evaluating NH quality. The most frequently mentioned topics in the reviews concerned staff responsiveness, caring, and professionalism, as well as the facility’s cleanliness, aesthetics, and meals. Comments under these categories painted a picture of what daily life in the NH is like. Numerous reviewers posted emotional comments, expressing either very negative or very positive opinions of the facility. Our results are consistent with those from other NH studies. Shugarman and Brown found that NH consumers often rely on their own observations of how staff treat or interact with residents when choosing NHs (Shugarman & Brown, 2007). Similarly, Gaudet Hefele et al. found that consumers want information about how the staff treats residents and about the physical facility, including its location and cleanliness (Hefele et al., 2016) Worth noting is that these NH aspects are not evaluated in most other NH rating systems. NHC, the nation’s oldest NH rating system, for instance, does not report quality measures pertaining to staff attitudes or the NH’s physical setting. Rather, NHC focuses its reports on measures of staffing levels (i.e., the amount of staff time per resident per day) and clinical processes and outcomes (i.e., prevalence of urinary tract infections or restraint use) (Centers for Medicare & Medicaid Services, n.d.). Yelp reviewers mentioned these topics, but not frequently, a result in keeping with findings reported in other NH research. In focus groups of NH consumers, Shugarman and Brown found that participants infrequently mentioned concerns about “the clinical, more technical factors that influence quality of care (Shugarman & Brown, 2007, p. v)” This finding—that consumers evaluate different aspects of NH care than NHC assesses—may help explain why recent studies have found discrepancies between consumers’ NH ratings and those reported on NHC. A recent study, for instance, found that Yelp ratings for NHs in California were significantly lower than the overall NHC rating for these NHs (Johari et al., 2017). Similarly, the U.S. General Accounting Office (GAO) found that NHs with higher overall star ratings did not have higher resident satisfaction scores or fewer complaints (U.S. GAO, 2016). Another study found a high level of inconsistency between NHC overall star ratings and consumer satisfaction scores (Williams, Straker, & Applebaum, 2016). Strikingly, we found no consumer guides on choosing a NH that pointed decision-makers to online NH reviews. These guides may overlook the value of online review sites. Online reviews, for instance, directly capture the voices of residents and family members, precisely the kind of information NHs and their consumers need to hear and may want to act on, if resident-directed care is to be achieved. Additionally, NH consumers have expressly requested access to these types of reviews (Konetzka & Perraillon, 2016). Another added value is that consumer reviews are often rich in detail, conveying pertinent information not available on other rating sites. Their story-telling quality may draw in consumers, making it more likely that consumers will consult these sites and give careful thought to the NH information put forth. Concerns about the legitimacy and usefulness of consumer review sites may help explain why many NH consumer guides do not refer to these sites. These concerns include the sites’ lack of a random sample of consumers, lack of reviews for all NHs, and potentially false reviews, (Gaudet Hefele, Li, Campbell, Barooah, & Wang, 2018). There also are concerns that online ratings can be difficult to interpret, especially if, as in this study, individual rating are highly polarized (i.e., mostly 1s and 5s). Additionally, it can be unclear to consumers whether a review pertains to rehabilitative care or long-term care. Notwithstanding these limitations, consumers in recent surveys report trusting online review sites, even while they believe some reviews are fake (studies suggest an estimated 14% to 40% of online reviews are faked) (Guynn, J. & Chang, A., 2013; Neilsen, 2012; YouGov. n.d.; Seligson, 2013). These findings likely stem from consumers’ trust in their own ability to filter out exaggerated or unreliable reviews (Loria, 2016). Additionally, Yelp uses its own software as well as alerts from readers to spot and remove fake reviews. It also should be noted that NHC ratings have periodically been criticized as untrustworthy (Han, Yaraghi, & Gopal, 2016; (Johari et al., 2017)). In recent years, some studies have reported evidence that NHs have systematically gamed data to inflate their NHC ratings (Abt Associates Inc., 2014; Edelman, 2016; Han et al., 2016; Thomas, 2014). In 2016, the NHC rating system was reformed to prevent this abuse by weighting the independently collected measure of survey deficiencies most heavily and requiring NHs to electronically submit payroll and other auditable data for the staffing measure. The efficacy of these reforms has not been rigorously evaluated. At least one analysis has found evidence of continued data manipulation (Edelman, 2016). Still, some studies report a positive relationship between NHC ratings and NH care quality (Castle & Ferguson, 2010). These mixed findings for both rating systems underscore the conclusion that all rating systems have inherent weaknesses. Consequently, it seems reasonable to recommend that consumers consult diverse systems, if possible, rather than rely on just one. Limitations This is a qualitative study and, as such, has limitations that include a limited ability to test for statistical significance of results. The small sample size and inclusion of only California NHs limits the study’s generalizability. Conclusion Online consumer reviews are familiar to almost everyone these days. We either write these reviews, read them, or both. Only recently, however, have researchers begun to examine these reviews with an eye toward learning what health care consumers have to say about the services they receive. In this study, the major codes addressed in consumers’ Yelp reviews of NHs were staff treatment of residents and the physical environment in which residents live. Topics, such as clinical care areas, addressed by NHC and similar rating sites seem of less concern. We therefore recommend that NH consumers consult both types of rating systems because they provide complementary information. Seeking diverse assessment information also may mitigate the impact on decision making of each system’s inherent weaknesses. We also recommend that patient advocates point NH consumers to both qualitative and quantitative rating systems. Doing so will empower consumers to make more informed NH decisions. Acknowledgment We want to thank Precious Toni Jackson and Krystle Irvine for help with data collection. Conflict of Interest None reported. References Abt Associates Inc . ( 2014 ). Nursing Home Compare Five-Star Quality Rating System: Year Five Report [Public Version] . Abt Associates . Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/NHC-Year-Five-Report.pdf American College of Physicians . ( n.d .). Plan, Do, Study, Act (PDSA) Resources | Quality Improvement | ACP . Retrieved January 3, 2018, from https://www.acponline.org/practice-resources/quality-improvement/pdsa-resources Arrington , M . ( 2008 ). Yelp Throws Down On CitySearch . Retrieved January 2, 2018, from http://social.techcrunch.com/2008/11/19/yelp-throws-down-on-citysearch/ Castle , N. G. , & Ferguson , J. C . ( 2010 ). What is nursing home quality and how is it measured ? The Gerontologist , 50 , 426 – 442 . doi: 10.1093/geront/gnq052 Google Scholar CrossRef Search ADS PubMed Centers for Medicare & Medicaid Services . ( n.d .). Medicare Nursing Home Compare Overview . Retrieved August 15, 2017, from https://www.medicare.gov/NursingHomeCompare/About/howcannhchelp.html. Edelman , T . ( 2016 ). Don’t be Fooled by the Federal Nursing Home Five-Star Quality Rating System . Retrieved June 6, 2017, from http://www.medicareadvocacy.org/dont-be-fooled-by-the-federal-nursing-home-five-star-quality-rating-system/. Findlay , S. D . ( 2016 ). Consumers’ interest in provider ratings grows, and improved report cards and other steps could accelerate their use . Health Affairs (Project Hope) , 35 , 688 – 696 . doi: 10.1377/hlthaff.2015.1654 Google Scholar CrossRef Search ADS PubMed Gaudet Hefele , J. , Li , Y. , Campbell , L. , Barooah , A. , & Wang , J . ( 2018 ). Nursing home Facebook reviews: Who has them, and how do they relate to other measures of quality and experience ? BMJ Quality & Safety , 27 , 130 – 139 . doi: 10.1136/bmjqs-2017-006492 Google Scholar CrossRef Search ADS PubMed Grabowski , D. C. , & Town , R. J . ( 2011 ). Does information matter? Competition, quality, and the impact of nursing home report cards . Health Services Research , 46 , 1698 – 1719 . doi: 10.1111/j.1475-6773.2011.01298.x Google Scholar CrossRef Search ADS PubMed Grol , R. , Bosch , M. , Hulscher , M. , Eccles , M. , & Wensing , M . ( 2007 ). Planning and Studying Improvement in Patient Care: The use of Theoretical Perspectives . Retrieved January 2, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690312/. doi:10.1111/j.1468-0009.2007.00478.x Guynn , J. , & Chang , A . ( 2013 ). Yelp reviews: Can You Trust Them? Some Firms Game the System - Latimes . Retrieved December 17, 2015, from http://articles.latimes.com/2012/jul/04/business/la-fi-yelp-reviews-20120704. Han , X. , Yaraghi , N. , & Gopal , R . ( 2016 ). Five-star ratings for sub-par service: Evidence of inflation in nursing home ratings (Brookings Institution Reports) . Washington : Brookings Institution Press . Hefele , J. G. , Acevedo , A. , Nsiah-Jefferson , L. , Bishop , C. , Abbas , Y. , Damien , E. , & Ramos , C . ( 2016 ). Choosing a nursing home: What do consumers want to know, and do preferences vary across race/ethnicity ? Health Services Research , 51 Suppl 2 , 1167 – 1187 . doi: 10.1111/1475-6773.12457 Google Scholar CrossRef Search ADS PubMed Johari , K. , Kellogg , C. , Vazquez , K. , Irvine , K. , Rahman , A. , & Enguidanos , S . ( 2017 ). Ratings game: An analysis of nursing home compare and yelp ratings . BMJ Quality & Safety . doi: 10.1136/bmjqs-2017–007301 Konetzka , R. T. , & Perraillon , M. C . ( 2016 ). Use of nursing home compare website appears limited by lack of awareness and initial mistrust of the data . Health Affairs (Project Hope) , 35 , 706 – 713 . doi: 10.1377/hlthaff.2015.1377 Google Scholar CrossRef Search ADS PubMed Loria , G . ( 2016 ). How Patients use Online Reviews . Retrieved June 6, 2017, from http://www.softwareadvice.com/resources/how-patients-use-online-reviews/. Neilsen . ( 2012 ). Newswire | Consumer Trust in Online, Social and Mobile Advertising Grows . Nielsen . Retrieved December 18, 2015, from http://www.nielsen.com/us/en/insights/news/2012/consumer-trust-in-online-social-and-mobile-advertising-grows.html. Ramnarace , C . ( 2012 ). Choosing A Good Nursing Home - 10 Tips For Picking A Nursing Home, War ... Retrieved January 2, 2018, from http://www.aarp.org/home-garden/housing/info-03-2012/safe-nursing-home-questions-to-ask.html. Seligson , S . ( 2013 ). Yelp Reviews: Can You Trust Them? BU Today , Boston University . Retrieved December 17, 2015, from http://www.bu.edu/today/2013/yelp-reviews-can-you-trust-them/. Shugarman , L. , & Brown , J . ( 2007 ). Nursing Home Selection: How Do Consumers Choose? Volume I: Findings from Focus Groups of Consumers and Information Intermediaries | RAND . Retrieved August 16, 2017, from https://www.rand.org/pubs/working_papers/WR457z1.html. Stoppelman , J . ( 2015 ). Yelp’s Consumer Protection Initiative: ProPublica Partnership Brings Medical Info to Yelp . Retrieved January 2, 2018, from https://www.yelpblog.com/2015/08/yelps-consumer-protection-initiative-propublica-partnership-brings-medical-info-to-yelp. Strauss , A. , & Corbin , J . ( 1998 ). Basics of qualitative research - techniques and procedures for developing grounded theory ( 2nd ed.). London : Sage Publications . Thomas , K . ( 2014 ). Medicare star ratings allow nursing homes to game the system . The New York Times . Retrieved March 23, 2018, from https://nyti.ms/2kekpDL U.S. Dept. of Health and Human Services . ( 2017 ). Paving the Way for Patient-Centered State Innovation | HHS.gov . Retrieved January 2, 2018, from https://www.hhs.gov/healthcare/empowering-patients/providing-relief-right-now-for-patients/paving-the-way-for-patient-centered-state-innovation/index.html. U.S. GAO . ( 2016 ). Consumers Could Benefit from Improvements to the Nursing Home Compare Website and Five-Star Quality Rating System . Retrieved from http://www.gao.gov/assets/690/681138.pdf. Williams , A. , Straker , J. K. , & Applebaum , R . ( 2016 ). The nursing home five star rating: How does it compare to resident and family views of care ? The Gerontologist , 56 , 234 – 242 . doi: 10.1093/geront/gnu043 Google Scholar CrossRef Search ADS PubMed Yelp . ( 2015 ). Factsheet | Yelp . Retrieved December 18, 2015, from https://www.yelp.com/factsheet. YouGov . ( n.d .). Americans Rely On Online Reviews Despite Not Trusting Them . Retrieved January 29, 2018, from http:////today.yougov.com/news/2014/11/24/americans-rely-online-reviews-despite-not-trusting/. © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Gerontologist Oxford University Press

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Abstract

Abstract Background Although patient-centered care is an expressed value of our healthcare system, no studies have examined what consumers say in online reviews about nursing homes (NHs). Insight into themes addressed in these reviews could inform improvement efforts that promote patient-centered NH care. Research Design and Methods We analyzed nursing home (NH) Yelp reviews. From a list of all NHs in California, we drew a purposeful sample of 51 NHs, selecting facilities representing a range of geographical areas and occupancy rates. Two research teams analyzed the reviews using grounded theory to identify codes and tracked how frequently each code was mentioned. Results We evaluated 264 reviews, identifying 24 codes, grouped under five categories: quality of staff care and staffing; physical facility and setting; resident safety and security; clinical care quality; and financial issues. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness. Yelp reviewers also often posted about NHs’ physical environment. Infrequently mentioned were the quality of health care provided and concerns about resident safety and security. Discussion and Implications Our results are consistent with those from related studies. Yelp reviewers focus on NH aspects that are not evaluated in most other NH rating systems. The federal Nursing Home Compare website, for instance, does not report measures of staff attitudes or the NH’s physical setting. Rather, it reports measures of staffing levels and clinical processes and outcomes. We recommend that NH consumers consult both types of rating systems because they provide complementary information. Assessment of condition, Quality of care, Quality of life, Qualitative analysis, Satisfaction Every year more than a million older adults enter nursing homes (NHs), yet there is limited information about how they choose a facility or what they think about the facility after their stay (Shugarman & Brown, 2007). When decision-makers search Google for help with finding a good NH—a commonly reported strategy—they often are directed to NH checklists and lists of questions to ask NH staff (Findlay, 2016; Konetzka & Perraillon, 2016; Shugarman & Brown, 2007). Some of these guides point consumers to websites that compare NHs (Ramnarace, 2012). The oldest of these is the Center for Medicare and Medicaid Services’ (CMS’) Nursing Home Compare (NHC) site (Centers for Medicare & Medicaid Services, n.d.) CMS and Statewide NH Rating Sites Launched in 1998, NHC is a web-based report card that publicly rates the quality of virtually every NH in the nation based on measures of care quality, staffing sufficiency, and survey deficiencies. The purpose of the site is to provide standardized care quality information to help consumers make informed decisions when selecting a NH. Following CMS’s lead, 19 states now publish their own NH report cards online (Castle & Ferguson, 2010). Despite these sites’ years of operation, recent studies have found that many consumers are unaware of NHC, and relatively few visit the statewide NH rating sites (Findlay, 2016; Konetzka & Perraillon, 2016; Shugarman & Brown, 2007). Consistent with these reports, research has shown that public reporting of standardized NH quality measures has had minimal influence on consumers’ decision making (Grabowski & Town, 2011). Consumer Review Websites More recently, use of online consumer review websites for businesses has increased. One of the most popular sites, Yelp.com, now has more than 80 million unique desktop visitors each month, up 33% from 60 million monthly visitors in 2012 (Yelp, 2015). The cumulative number of health care-related Yelp reviews also has increased, jumping from 160,000 in 2008 to 7.26 million in 2016 (Arrington, 2008). Growth in health care-related reviews is expected to continue as Yelp focuses on this aspect of its business. In August, 2015, Yelp partnered with ProPublica, an investigative journalism agency, to incorporate health care information into Yelp business pages, including CMS-culled statistics for all NHs reviewed on Yelp (Stoppelman, 2015). According to the CEO of Yelp, this change is meant to empower consumers by giving them “even more information... when they are in the midst of the most critical life decisions, like…which nursing home will provide the best care for aging parents (Stoppelman, 2015).” Lack of Knowledge of Consumer Perspectives on NHs Although patient-centered, family-oriented care is now an expressed value of our health care system (U.S. Dept. of Health and Human Services, 2017), our literature search found only one study that examined what consumers say in online reviews about hospitals and no study that did so for NHs. Thus, there is a dearth of research on the consumer perspective of important aspects of NHs. Insight into topics and categories addressed in online consumer reviews of NHs could inform improvement efforts that promote patient-centered care. They also could guide the development of online resources that empower consumers to make informed decisions. To bridge this gap in knowledge, we analyzed the content of Yelp reviews for a sample of NHs in California. Theoretical Framework for the Study This study is centered on a theoretical framework known as Total Quality Management (TQM), sometimes referred to as Continuous Quality Improvement (CQI). Borrowed from other types of industry (e.g., car manufacturing) and introduced to health care practice in the 1990s, TQM emphasizes “the continuous improvement of (multidisciplinary) processes in health care in order to better meet customers’ needs (Grol, Bosch, Hulscher, Eccles, & Wensing, 2007, p. 117).” Among its basic principles—and one that sets it apart from many other improvement theories—is its focus on patients and caregivers, the consumers of health care services (Grol et al., 2007). The TQM model views consumers as both a target of services and a source of knowledge about how to improve services. TQM uses plan-do-study-act (PDSA) cycles to drive continuous improvement (American College of Physicians, n.d.). The study component of PDSA cycles includes customer feedback, including feedback obtained through consumer reviews such as those posted on Yelp. Through continuous quality improvement cycles, TQM tenets suggest that topics found in NH Yelp reviews can inform improvement efforts that promote patient-centered care. Also in line with TQM principles, Yelp feedback can guide the development of online resources that empower consumers to make informed decisions. With this in mind, our study sought to better understand issues important to NH consumers. Methods We conducted a qualitative study of NH reviews posted on Yelp.com. NH Data and Sample We used data from the California Office of Statewide Health Planning and Development (OSHPD) to identify our NH sample. Long-term care facilities, including skilled nursing facilities, group (or congregate) living facilities, and stand-alone hospices, submit annual utilization reports to OSHPD, which then compiles them into a complete data set. We used the 2014 data set, which provided an initial list of 1092 licensed NHs. Excluded from this list were congregate (or group) living facilities and stand-alone hospices. From this initial NH list, we eliminated facilities without NHC ratings, leaving a total of 991 (90.8%) NHs. Between September and November of 2016, we searched Yelp for each NH on this list of 991 NHs. Each individual who posts a Yelp review rates the NH on a five-point scale (1 = the worst rating; 5 = the best rating). Yelp also reports an overall rating, which represents the average rating across all consumer reviews posted for that NH. The average rating is rounded to the nearest half-point. We collected the overall Yelp rating as well as all the Yelp reviews for each NH and the individual five-star ratings assigned to those reviews. We then drew a purposeful sample of 51 NHs certified by Medicare and/or Medicaid (known as Medi-Cal in California). For this sample, we selected facilities representing a range of geographical areas and occupancy rates. To accomplish this, we sorted the NHs geographically using zip codes, and divided the list into five roughly equal clusters, from which we drew 10–11 NHs per cluster. Within each cluster, we drew a purposeful subsample of both “small” and “large” NHs because our previous research found that occupancy rate was positively associated with the number of Yelp reviews a facility received (Johari et al., 2017). To do this, we used the mean number of occupied beds reported for the full NH sample—88 occupied beds—to define a large NH (≥ 88 beds) and a small NH (<88 beds). We determined that 60% of the full sample comprised large NHs and 40% comprised small NHs. In keeping with this NH distribution, we sorted each geographical cluster of NHs into large and small NHs based on the occupancy rate each NH reported to OSHPD and then randomly selected six large NHs and four to five small NHs from each cluster. Thus, our final study sample of 51 NHs included 30 large NHs (60%) and 21 small NHs (40%). For each of these NHs, we also retrieved from OSHPD the NH’s ownership status. Analysis We used grounded theory to identify topics and categories in the NH reviews (Strauss & Corbin, 1998). Rather than start with a list of preidentified topics, we allowed codes to emerge from the reviews. Two teams, each with two trained research assistants (C. Kellogg and Y. Zhu; K. Johari and K. Vazquez), coded the Yelp reviews for the 51 NHs in our sample. We used open coding to identify initial codes. Using a constant comparison approach, individual codes identified by each coding team member were compared and discussed after completion of coding for each geographical cluster of 10–11 NHs. Next, both teams met to compare, discuss, and reconcile their lists of identified codes. If there was consensus to add new codes, then both teams, as needed, returned to previously analyzed reviews to recode for the new code. Each team met internally to compare individual NH review codes and reconcile discrepancies in coding. Discrepancies were discussed until 100% consensus was reached. Although saturation was reached after coding reviews for approximately 20% of the NH sample, the teams continued coding reviews for all 51 NHs because we wanted to identify not only those codes most frequently mentioned, but also those seldom mentioned. After coding was completed the team met to reconcile codes and conduct axial coding to identify categories among the individual codes using inductive reasoning (Strauss & Corbin, 1998). We then determined the frequency of each code and category. Results NH Sample and Yelp Reviews Of our sample of 51 NHs, most (92%) were for-profit organizations, in keeping with state and national trends. The average number of occupied NH beds for large facilities (n = >88) was 115.5 (range = 89–185; median = 98). The average number of occupied NH beds for small facilities (n = < 88) was 57.7 (range = 34–87; median = 55). We evaluated a total of 264 NH Yelp reviews. The average number of Yelp reviews per NH was 5.2 (range = 1–15; median = 4; mode = 1). The average of the 51 overall Yelp ratings for the sample was three stars (range = 1–5; median = 3; mode = 1). The average of the 264 individual Yelp ratings was 3.2 stars (median = 3; mode = 5). As shown in Figure 1, 82% of all individual ratings were either one star (37%) or five stars (45%). Figure 1. View largeDownload slide Distribution of individual Yelp star ratings for nursing homes (N = 264). Figure 1. View largeDownload slide Distribution of individual Yelp star ratings for nursing homes (N = 264). Yelp Codes and Overarching Categories Our team identified 24 codes across the Yelp reviews, which we further grouped under five overarching categories. Table 1 shows each code within its associated category, along with a definition, review example, and frequency of its mention in Yelp reviews. Table 1. Categories and Topics Identified in Yelp Reviews of Nursing Homes Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Note: Total number of times any topic was mentioned 608. View Large Table 1. Categories and Topics Identified in Yelp Reviews of Nursing Homes Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Category/Code Definition Example Comment (individual identifier for quotation, which refers to a location on an Excel sheet) Number and % of yelp reviews containing the code (number of reviews = 264) Quality of Staff Care and Staffing Attitude/Caring Any reference to staff attitude or caring, can be positive or negative “Mom stayed here for hip replacement. They took really great care of her. The staff was patient and compassionate…” (F3). 141 (53.41%) Responsiveness Any reference to responsiveness or the lack thereof; can also be referred to as helpfulness or attentiveness “...In addition, the staff was very professional and responsive as to care. There is a case manager there and a doctor who is on the premises Monday thru Friday for patients and I thought she was very responsive to my concerns and a very good doctor...” (AF2). 79 (29.92%) Professional Reference to staff as professional or unprofessional; also, staff behavior that is inferred to be either professional or not “...I was not disappointed the staff are extremely nice and very professional…(AF3). 25 (9.47%) Number of staff Mention of: understaffed or plenty of staff “... aren’t new but were kept clean and lots of staff were around…(AF9). 12 (4.55%) Bilingual Mention of: staff speaking another language or the lack of bilingual staff “...The fact that my parents and grandmother were able to communicate with the staff in (language) brought ease to both parties. The staff made sure that my grandmother received care and also informed my parents of her improvements. ...” (Y2). 5 (1.89%) Disagreement with staff Any mention of conflict between staff and patient or between staff and family/friend of patient “...We tried to get him into many different places for therapy but were rejected. Mostly because the other facilities couldn’t get the paperwork they needed from (staff), the social worker on site (when she’s there). I thought I got one to accept him but I just found out that (staff)) told them that (patient) wasn’t ready for acute therapy. How dare she say that! She is not a doctor or a therapist. The therapists thought he was ready but they are too afraid of (staff) to put anything in writing...”(AK1). 5 (1.89%) Physical Facility and Setting Cleanliness Whether it’s clean or not “...The facility was clean, well-organized, and well-staffed….” (V5). 66 (25.00%) Aesthetics/Environment Reference to the overall appearance or to the type of environment in the facility “...The facility is very clean and peaceful. They have a homelike atmosphere where the staff members make you feel like family...” (Y7). 36 (13.64%) Meals Any reference to meals or food provided “...Once I was permitted real food following a clear liquid diet and then a pureed diet, the food was really very good!” (AJ3). 36 (13.64%) Smell Presence of smell/odor or lack of it “...go take a look and be sure to hold your nose because that place is FOUL all the way around!!!!!!...” (AI1). 20 (7.58%) Roommate(s) Reference to any presence of a roommate “...I received a phone call from the facility that my dad had a verbal altercation with his roommate and that he was moved. I was assured that it was no big deal and that they had handled it. My dad has Alzheimer’s his roommate did not so that was the first mistake putting someone who had their mind with someone who does not...” (V6). 14 (5.30%) Activities/Amenities Mention of activities/amenities in facility or the absence/insufficiency of them “...Most important, the activities department goes above and beyond to engage patients so that they maintain a psycho social well-being...” (AF6). 13 (4.92%) Parking/Geographic location/Accessibility Reference to parking or lack of parking, to the geographic area the facility is in, or to how accessible or non-accessible the facility is “...Easy convenient access with plenty of parking too” (X2). 9 (3.14%) Clinical Care and Management Patient improvement Mention of patient improvement or worsening “...My mom made a rapid recovery with their good care, including the efforts of their PTs and OTs... In fact, they take immense pride in their work and in seeing patients recover...” (X4). 40 (15.15%) Dementia/Cognition Mention of dementia/Alzheimer’s or impaired cognition; or recovery from them “...He was brought in straight from the hospital after learning he had Stage 4 Cancer, along with the Alzheimer’s and Dementia...” (AO4). 14 (5.30%) Bed/Pressure sores Mention of pressure sores or ulcers “...On May 8, 2011, we went to see my dad, the nurse has not changed him all day and his bed was wet. He had a small bed sore when he went in size of a penny, when he got out it was 18cm 4 inches deep were u can see my dad’s tail bone. This place did not turn my dad ever two hours and did not put any meds on it. Per a 2nd doctor out of state, they didn’t take care of him well...” (X13). 13 (4.92%) Incontinence Any mention of incontinence: Can be urinal or fecal “...I was told from hospice every time they went there my dad was soaking wet and that it was brought to their attention each and every time. I believe that is what caused the open wound that he had near his rectum that to this day will not heal. I’m very disappointed in the way they handled the situation and also very concerned that my dad’s care wasn’t what it should have been...” (V6). 10 (3.79%) Pain Any reference to patient pain or lack of “...She was in pain because they didn’t have her on meds for her severe arthritis which is why she was calling out for help”(AE2). 7 (2.65%) Mobility Any reference to patient’s mobility or lack of it, i.e. staying in bed for extended periods of time “...My Grandmother is not mobile. Because of this, the management decided to put her on the B-side. This area is where the elderly are placed who are more or less already gone and dead…”(AD9). 4 (1.52%) Depression Reference to patient’s depression or recovery from “...This place is pretty depressing, after day 1 my grandparent was depressed. I my grandparent he thinks going to die in here and is far from it...” (AE1). 1 (0.38%) Resident Safety/Security Falls Any mention of falls “...My father had several falls since his stay at (facility name) which is unacceptable, I do understand things occur, however repeat incident is unacceptable... (N2). 13 (4.92%) Abuse Can be financial, physical, sexual, or emotional (intimidation) “Beware of who they employ!!!! They hire DV offenders, welfare fraud offenders. They have a person on their staff who bullies people, post their personal information on public forums, threatens to harm them and threatens vindication for anyone who defends themselves!” (AD3). 9 (3.41%) Theft Any mention of theft or suspected theft “Theft. See my Tips below and do NOT send your parent or family member any mail, care packages or gifts. They’ll vanish” (V4). 5 (1.89%) Financial Issues Insurance/Cost/Payment Any mention of insurance coverage, costs of facility, or payment to facility “This Alzheimer’s facility is highly discriminatory against Medicare/Medicaid in the intake process…we were dumped for a “cash-paying customer” (W2). 31 (11.74%) Note: Total number of times any topic was mentioned 608. View Large Category: Quality of Staff Care and Staffing This category, describing the quality of services that NH staff members provide, includes six related codes, including, most frequently, staff attitudes, responsiveness, and professionalism. More than half (53.41%) of Yelp reviewers posted comments related to staff attitude and caring and nearly a third (29.2%) posted comments related to staff responsiveness, making these the most frequently appearing codes in our study. These comments often captured emotional opinions expressed either positively, as in the first example below, or negatively, as in the second example: “I would give 5 stars to the Rehab therapists. They are an amazing group of caring individuals… The team of therapists are more than amazing. Caring, ingenious, and effective. I was so lucky to have found them… I hope to never need their services again, but if I did, I’d select (facility name) again...Oh, and the view and patio area are to die for. Nothing like doing some physical therapy while looking over Hollywood and the hills (quotation identifier: AF7).” “This place is the worst place for anyone to recover or be at. My father was treated like crap here very, very unprofessional staff when transport(ing) him to his dialysis his socks had holes in them from being dragged on the ground…I’M WARNING YOU DON’T LET YOUR LOVED ONE STAY HERE ONE NIGHT AT ALL!!!!!!!! This place DOES NOT deserve a star but I have to select one for this to post, ZERO STARS TO THE GROUND!! (AJ1).” Category: Physical Facility and Setting Yelp reviewers also expressed views about NHs’ physical environment. The most frequently identified codes were cleanliness (appearing in 25% of all reviews), aesthetics (13.64%), and meals (13.64%). Consider these sample comments: “…- The place is super clean. We have tried other rehab centers and they smell awful from all the soiled diapers… The outside grounds are so beautiful. Dad enjoyed sitting near the fountain in the afternoon…(AU4).” “…The place doesn’t smell like a dirty diaper (if you’ve been into other retirement homes, you know what I am talking about), the staff are friendly and attentive, there are numerous activities that occur daily for the residents, and from what I hear...the food is actually very good. If it is quality that you are looking for, look no further than GG...(AA13).” Category: Clinical Care Quality Yelp reviewers infrequently referred to the quality of health care provided. Reviewers tended to report only general health-related information. They might, for instance, report that a loved one’s health condition improved or worsened with the care provided (15.15%), but detailed clinical information—for example, about dementia care, pain management, or depression treatment—was rarely provided. Worth noting is that, even when some clinical care topics emerged (e.g., pressure sores and incontinence), reviewers tended to emphasize the quality of staff care, not details about the care process. One reviewer, for instance, wrote: “This is an amazing facility--from wound care (pressure ulcers) to physical and occupational therapy. The staff, especially the Director of Nursing and the physician in charge, as well as the entire PT staff and nurses, have helped my elderly friend regain her physical and emotional strength. They care so deeply for all of their patients. The degree of caring and compassion is so impressive…(AJ1).” Category: Resident Safety/Security We identified three codes related to resident safety: falls, abuse, and theft. Although these codes were infrequently identified, they may attract consumer attention when they appear due to their potentially serious consequences and sensitive nature. For example: “My father had several falls since his stay at [NH facility] which is unacceptable. I do understand things occur, however repeat incident is unacceptable. I feel the staffing-to-ratio-of-patient is in great need of change to provide better care. It stands to reason that a convalescent (home) would give patient care when the family is not around…(N2).” “…So I went outside with my partner in her wheelchair and he [staff nurse] came out and started dancing around the wheelchair and telling us that he’s considered the clown there. I cannot believe this man is an RN. I have two nurses in my family including my sister who teaches nursing not to mention I’m retired from the legal field that I’m pretty sure he’s setting himself up and his employer for of sexual harassment lawsuit and possibly elder abuse (T3).” Category: Financial Issues A final code, insurance/cost/payment, was identified in 31 reviews (11.74%). Often these comments concerned whether Medicare or Medicaid would cover a loved one’s NH stay, as in this excerpt: “[my mother was]…Discharged because Physical Therapy determined they couldn’t justify keeping her any longer because…she can walk 400’ & Medicare wouldn’t pay for more time (AQ13),” A few reviewers reported that the resident’s insurance coverage influenced living quarters, as in this comment: “Medi-Cal patients are stacked three to a room. Tight quarters. Medicare or private insurance patients are in double rooms (AQ4).” Discussion This study identified common codes and categories in NH Yelp reviews as a strategy for pinpointing the factors consumers consider when evaluating NH quality. The most frequently mentioned topics in the reviews concerned staff responsiveness, caring, and professionalism, as well as the facility’s cleanliness, aesthetics, and meals. Comments under these categories painted a picture of what daily life in the NH is like. Numerous reviewers posted emotional comments, expressing either very negative or very positive opinions of the facility. Our results are consistent with those from other NH studies. Shugarman and Brown found that NH consumers often rely on their own observations of how staff treat or interact with residents when choosing NHs (Shugarman & Brown, 2007). Similarly, Gaudet Hefele et al. found that consumers want information about how the staff treats residents and about the physical facility, including its location and cleanliness (Hefele et al., 2016) Worth noting is that these NH aspects are not evaluated in most other NH rating systems. NHC, the nation’s oldest NH rating system, for instance, does not report quality measures pertaining to staff attitudes or the NH’s physical setting. Rather, NHC focuses its reports on measures of staffing levels (i.e., the amount of staff time per resident per day) and clinical processes and outcomes (i.e., prevalence of urinary tract infections or restraint use) (Centers for Medicare & Medicaid Services, n.d.). Yelp reviewers mentioned these topics, but not frequently, a result in keeping with findings reported in other NH research. In focus groups of NH consumers, Shugarman and Brown found that participants infrequently mentioned concerns about “the clinical, more technical factors that influence quality of care (Shugarman & Brown, 2007, p. v)” This finding—that consumers evaluate different aspects of NH care than NHC assesses—may help explain why recent studies have found discrepancies between consumers’ NH ratings and those reported on NHC. A recent study, for instance, found that Yelp ratings for NHs in California were significantly lower than the overall NHC rating for these NHs (Johari et al., 2017). Similarly, the U.S. General Accounting Office (GAO) found that NHs with higher overall star ratings did not have higher resident satisfaction scores or fewer complaints (U.S. GAO, 2016). Another study found a high level of inconsistency between NHC overall star ratings and consumer satisfaction scores (Williams, Straker, & Applebaum, 2016). Strikingly, we found no consumer guides on choosing a NH that pointed decision-makers to online NH reviews. These guides may overlook the value of online review sites. Online reviews, for instance, directly capture the voices of residents and family members, precisely the kind of information NHs and their consumers need to hear and may want to act on, if resident-directed care is to be achieved. Additionally, NH consumers have expressly requested access to these types of reviews (Konetzka & Perraillon, 2016). Another added value is that consumer reviews are often rich in detail, conveying pertinent information not available on other rating sites. Their story-telling quality may draw in consumers, making it more likely that consumers will consult these sites and give careful thought to the NH information put forth. Concerns about the legitimacy and usefulness of consumer review sites may help explain why many NH consumer guides do not refer to these sites. These concerns include the sites’ lack of a random sample of consumers, lack of reviews for all NHs, and potentially false reviews, (Gaudet Hefele, Li, Campbell, Barooah, & Wang, 2018). There also are concerns that online ratings can be difficult to interpret, especially if, as in this study, individual rating are highly polarized (i.e., mostly 1s and 5s). Additionally, it can be unclear to consumers whether a review pertains to rehabilitative care or long-term care. Notwithstanding these limitations, consumers in recent surveys report trusting online review sites, even while they believe some reviews are fake (studies suggest an estimated 14% to 40% of online reviews are faked) (Guynn, J. & Chang, A., 2013; Neilsen, 2012; YouGov. n.d.; Seligson, 2013). These findings likely stem from consumers’ trust in their own ability to filter out exaggerated or unreliable reviews (Loria, 2016). Additionally, Yelp uses its own software as well as alerts from readers to spot and remove fake reviews. It also should be noted that NHC ratings have periodically been criticized as untrustworthy (Han, Yaraghi, & Gopal, 2016; (Johari et al., 2017)). In recent years, some studies have reported evidence that NHs have systematically gamed data to inflate their NHC ratings (Abt Associates Inc., 2014; Edelman, 2016; Han et al., 2016; Thomas, 2014). In 2016, the NHC rating system was reformed to prevent this abuse by weighting the independently collected measure of survey deficiencies most heavily and requiring NHs to electronically submit payroll and other auditable data for the staffing measure. The efficacy of these reforms has not been rigorously evaluated. At least one analysis has found evidence of continued data manipulation (Edelman, 2016). Still, some studies report a positive relationship between NHC ratings and NH care quality (Castle & Ferguson, 2010). These mixed findings for both rating systems underscore the conclusion that all rating systems have inherent weaknesses. Consequently, it seems reasonable to recommend that consumers consult diverse systems, if possible, rather than rely on just one. Limitations This is a qualitative study and, as such, has limitations that include a limited ability to test for statistical significance of results. The small sample size and inclusion of only California NHs limits the study’s generalizability. Conclusion Online consumer reviews are familiar to almost everyone these days. We either write these reviews, read them, or both. Only recently, however, have researchers begun to examine these reviews with an eye toward learning what health care consumers have to say about the services they receive. In this study, the major codes addressed in consumers’ Yelp reviews of NHs were staff treatment of residents and the physical environment in which residents live. Topics, such as clinical care areas, addressed by NHC and similar rating sites seem of less concern. We therefore recommend that NH consumers consult both types of rating systems because they provide complementary information. Seeking diverse assessment information also may mitigate the impact on decision making of each system’s inherent weaknesses. We also recommend that patient advocates point NH consumers to both qualitative and quantitative rating systems. Doing so will empower consumers to make more informed NH decisions. Acknowledgment We want to thank Precious Toni Jackson and Krystle Irvine for help with data collection. Conflict of Interest None reported. References Abt Associates Inc . ( 2014 ). Nursing Home Compare Five-Star Quality Rating System: Year Five Report [Public Version] . Abt Associates . Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/NHC-Year-Five-Report.pdf American College of Physicians . ( n.d .). Plan, Do, Study, Act (PDSA) Resources | Quality Improvement | ACP . Retrieved January 3, 2018, from https://www.acponline.org/practice-resources/quality-improvement/pdsa-resources Arrington , M . ( 2008 ). Yelp Throws Down On CitySearch . 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Retrieved December 18, 2015, from https://www.yelp.com/factsheet. YouGov . ( n.d .). Americans Rely On Online Reviews Despite Not Trusting Them . Retrieved January 29, 2018, from http:////today.yougov.com/news/2014/11/24/americans-rely-online-reviews-despite-not-trusting/. © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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The GerontologistOxford University Press

Published: Apr 20, 2018

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