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The Five-Star Quality Rating System:
A Look at Nursing Homes’ Top Concerns

In December 2008, the Centers for Medicare & Medicaid Services (CMS) unveiled its Five-Star Quality Rating System to help consumers, their families, and caregivers compare nursing homes more easily and effectively. The system is intended to help consumers and families identify important questions to ask nursing homes. It is also designed to challenge nursing homes improve their quality of care. Facilities are assigned star ratings from a low of one star to a high of five stars based on three primary areas: health inspection surveys, staffing information, and quality of care measures. The ratings are publicly available on the agency’s Nursing Home Compare Web site at www.medicare.gov. Consumers can also use the site to view specific findings from inspections, find additional details on each home, and read consumer tips.

Of course, such an intricate system does not come without a little controversy and concern. Moreover, what it does come with is a lot of questions; especially from the homes that are being evaluated. With so much discussion and misrepresentations, it’s been hard for many nursing homes to fully understand how the rating system truly works. The remainder of this article will explore some of the top questions and concerns surrounding the system and provide CMS’s stance on these topics—so homes can get past the misconceptions and get down to improving their rating.

Accumulating Concerns from the Nursing Home Industry

Since the program went live in 2008, nursing homes from across the country have voiced concerns and possible flaws about the system. While many of these concerns are indeed valid, the good news is that none of these items appear insurmountable—which is certainly good news for homes looking to improve their scores. Below we’ll take a look at the most pressing issues.

Concern: Quality Conditions Change Constantly, Making the System Inaccurate
Quality and conditions within a nursing home can change at any time. Nursing homes can make dramatic improvements between rating periods, while a highly-rated home could see its quality of care deteriorate, making the system inaccurate.

CMS Response: CMS will update the Five-Star quality rating on a monthly basis. CMS stresses that this provides a timely and accurate reflection of nursing home quality. However, it is important to note that the three underlying data sources are reported and updated on different schedules. The quality measures, for example, are updated quarterly.

Concern: The System Has Forced Distribution
In the first round of quality ratings, about 12 percent of the nation’s nursing homes received a full five star rating while 22 percent scored at the low end with one star. The remaining 66 percent of facilities were distributed fairly evenly among the two, three and four star rankings. Many homes feel that this “bell curve” is permanent and by design.

CMS Response: CMS stresses that the distribution of overall star ratings is not fixed, and that the percentage of nursing homes that have one-star ratings or five-star ratings will change over time. In fact, CMS expects that the distribution will shift towards a higher number of stars over time, as facilities take quality improvement actions to improve their star ratings.

Specifically, a nursing home can take actions to improve its rating through:

  • Improvements in care processes, which will result in having fewer and less serious deficiencies on the survey.
  • By increasing the level of registered nurses, licensed practical nurses, and/or certified nurse aide staff.
  • By concentrating on quality improvement actions in the areas reflected in the quality measures.

CMS reinforces that the overall star rating is based on the number of stars achieved in each of the dimensions. Boundary points are therefore not fixed for the overall ratings, and the distribution is not fixed.

Concern: The System Doesn’t Account for Specialty Care
Many nursing homes say the information, gleaned from homes as well as from state inspection reports, misleads families and patients because it doesn’t give an accurate picture of the amount and kind of care in each facility. Some nursing homes, for example, specialize in caring for residents with more serious health issues, such as wound care. So, if you compare that facility with one populated by healthier residents, it might appear that the second home is deficient in caring for patients with more critical health care needs.

CMS Response: CMS states that if consumers are looking for a specialty-type nursing home, such as one that serves a bariatric population, then they will be comparing nursing homes that serve that population. In essence, they will be comparing two nursing homes that would have the same type of population with similar acuity levels and the potential for similar quality measure results. Note: CMS is not contemplating any changes to the way it reports specialty nursing homes at this time.

There is Opportunity to “Cheat”
Two data sets (the quality measures and the staffing data) incorporated into the rating are self-reported by nursing homes. So this begs the question, “what is stopping homes from cheating on this data?”

CMS Response: CMS states that they use multiple approaches to address potential problems with self-reported data. Some measures have built-in antidotes to cheating. For example, if a nursing home lowered its reporting of the rate at which residents were developing pressure ulcers, it would be paid less than it would otherwise. This tends to counteract any temptation to under-report.

Additional measures have or will be put in place to protect data integrity. They include the following:

  • Audit: some of the self-reported measures are amenable to audit (e.g. the self-reported staffing information that is provided for the period just prior to a survey).
  • Statistics: Statistical edits are in place to spot anomalies and require further investigation before scores are rendered, if it appears that score differences may be due to excessive variation rather than true differences in quality.
  • Quality Control: Over time, CMS hopes to improve the integrity of the major measures. For example, CMS has been conducting a major study of the extent to which staffing levels can be reported in a manner that is tied back to payroll data. A report on this potential improvement was recently completed and is available at:


Parting Thoughts
Whether your home has received a top rating or the lowest score, it’s important to remember that the Five-Star Quality Rating System should not be considered the “be-all and end-all.”  Consumers should always be reminded to not base their decision solely on the ratings. You should always encourage prospective residents and their families to visit your site and to talk to management and staff in person. After all, a home that appears perfect on the Nursing Home Compare site can end up being a completely wrong fit for a resident after an onsite inspection.

Although some legitimate concerns have surfaced, it appears that this rating system is set to stay for the long term. Facilities that get caught up in the possible shortcomings and flaws in the system will only lose precious time that could be put to better use (i.e., improving survey scores and staffing). By getting past the controversy and focusing on the facts, your facility will be much better positioned to achieve top ranking.