Investigative Report Questions Five-Star Rating System for Nursing Homes

How reliable are the ratings given nursing homes under the five-star rating system that the federal government recently instituted? Not very, according to an investigative report by the Massachusetts magazine Commonwealth.

In an in-depth discussion of the rating system, the report highlights numerous instances in which facilities received above-average overall ratings despite being cited for serious deficiencies in care, some of which resulted in serious injuries of residents.

The rating system, which was launched in December 2008 by the federal Centers for Medicare and Medicaid Services (CMS), gives nursing homes a rating of between one and five stars. A five-star designation means the facility ranks "much above average" compared to other facilities in its state, while a one-star designation means that a facility ranks "much below average" in the state. The rankings, which are updated monthly, are based on a nursing home's performance in three areas: quality measures, nurse staffing levels and health inspection reports.

The problem, according to the report, is that the rating scheme uses a quota system to rank facilities. Nursing homes that rank in the top 10 percent in health inspections in each state receive five-star ratings in that rating category, while facilities in the bottom 20 percent receive one-star ratings. This "grading on a curve" approach means that homes with serious deficiencies can still score high as long as their inspection records are better than most other homes in their state, while in another state a home with few problems could nevertheless receive a mediocre or poor rating.

Adding to the confusion is that the star ratings are heavily weighted by the health inspections, which are conducted by state surveyors and, according to the report, "vary considerably in scope and depth from state to state." The report points out that Massachusetts inspectors give nursing homes relatively few deficiency citations, resulting in "grade inflation" where the top 10 percent of homes would not necessarily be as outstanding as the top facilities in another state.

Disturbed by these issues, last year the attorneys general of 30 states sent a letter to CMS asking it to suspend and revise the rating system.

Nursing home consumer advocates appear conflicted about the rating system: on the one hand, they see it as a useful tool for consumers, but on the other they concede that it includes some four- and five-star homes that have been cited for negligence that resulted in deaths or injuries of patients.

According to the Commonwealth report, Edward F. Mortimer, technical director of the Survey and Certification Group for CMS, "says the star ratings should be only the starting point in the search for a nursing home, and he urged consumers to dig deeper into the information provided on the website and to visit homes in person."

Despite problems with the ratings of individual facilities, one overall trend that has emerged from the rating system is the general superiority of non-profit nursing homes compared with for-profit homes, the report points out.

To read the Commonwealth magazine report, "Misdiagnosis," click here.