Can Medicare's Nursing Home Ratings Help You Find Quality Care?
Key takeaways:
Medicare grades nursing homes on a scale from 1 to 5 stars so you can easily compare them. The government compiles data from many sources for the ratings.
To make the most of Medicare’s star ratings, it’s important to know how the data is collected and how the ratings are calculated.
Star ratings are only a jumping-off point. You’ll still want to do your own research to fill in any gaps.
Table of contents
The U.S. Department of Health and Human Services predicts that almost 7 in 10 people over age 65 will need some type of long-term care. When the time comes, many of those older adults and their families will turn to the Centers for Medicare & Medicaid Services (CMS) website Care Compare to find out more about local nursing homes and long-term care hospitals.
On that site, CMS rates nursing homes on the quality of their care using a scale from 1 star (low) to 5 stars (high).
But the star rating system doesn’t tell the whole story. In fact, the ratings have come under intense scrutiny in the wake of the COVID-19 pandemic, when nursing homes saw some of the highest contagion and fatality rates from the disease. That’s one reason the CMS has added some new measures to its ratings.
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Read on for a closer look at the star ratings and the recent updates. Understanding the scores on Care Compare can be a big help in finding high-quality care for yourself or your loved ones.
What is the CMS star rating system used for?
People use Care Compare and its star rating system to learn which nursing homes in their area provide the best care. During the pandemic, when onsite visits were often impossible, the site and its rating system took on added importance as a guide for choosing care facilities.
At the same time, the star rating system makes nursing home facilities accountable for the quality of their care. The rating assessments help facilities pinpoint where they need to improve.
What are CMS star ratings based on?
In 2008, the CMS put together the star rating system using decades’ worth of complex nursing home data. Since then, CMS has judged performance in three distinct categories:
Health inspection data
Staffing levels
Patient care quality measures
Based on those categories, CMS then gives each facility an overall rating. So, in total, each nursing home gets four separate star ratings — one overall, and one for each of the three categories.
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Health inspection results
Star ratings in this category represent the results of the three most recent state health inspections. The inspections typically happen every year.
Inspections assess whether a facility meets federal standards for care. Among the aspects considered by inspectors are:
Living environment
Resident rights
Staff and resident interaction
Medication management
Quality of life
Nursing home administration
Food services
Infection control and prevention
Inspectors examine resident medical records and interview residents, relatives, and administrators. The inspectors ask how the problems affected residents and how long it took to remedy them.
The CMS then calculates its star rating for this category based on the inspection reports.
Staffing ratio
Federal regulations require nursing homes to employ enough nurses to “safely care” for residents. A nursing home’s star rating in this category indicates how many staff hours are available per resident.
For this assessment, the CMS uses payroll data to count the number of staffers on each shift, including:
Registered nurses
Licensed practical nurses
Licensed vocational nurses
Nurses’ aides
In 2022, the CMS added additional measurements regarding worker turnover and weekend staffing to this category.
Quality of care measures
CMS uses 15 different quality measures to rate the quality of care for nursing homes.
It examines 6 factors to score temporary resident facilities, where people stay for fewer than 100 days. Usually, short-term residents are there for some type of rehabilitative care after an accident or emergency.
For long-term facilities, where people stay for more than 100 days, the CMS considers 9 factors. Long-term residents are there to deal with chronic and debilitating ailments.
Many facilities offer both types of care.
Quality measures include four quarters’ worth of data on the number of patients who:
Are hospitalized
Visit the ER
Are treated with antipsychotic drugs
Suffer from pressure sores
Experienced one or more falls
Get urinary tract infections
Improved their mobility
Overall star rating
To assign a nursing home’s overall star rating, CMS combines results and data from these three quality measures. The scoring process starts with the in-person health inspection results and then adds points for staffing and quality of care.
What are the recent changes to CMS star ratings?
CMS added two new measurements to its staffing ratio category in 2022: weekend staffing levels and staff turnover.
The move came after CMS research showed higher staff turnover is associated with lower quality of care. CMS studies also revealed that more robust staffing — especially on weekends — can improve the quality of care.
In addition to the existing data on nurse hours per resident per day, the new staffing star ratings reflect:
Total nurse staffing hours per resident per day on weekends
Total nurse staff turnover in a given year
Total RN turnover in a given year
Administrator turnover in a given year
In July 2022, the CMS began using the new measurements to calculate nursing homes’ staffing scores. The change caused a dramatic shift. More than 1 in 4 providers with overall 5-star ratings saw those ratings decline from June to July.
Staffing scores dropped for one-third of nursing homes (4,850). Of those, almost 1 in 5 (939) lost 2 or more stars.
How does the CMS collect information for its star ratings?
The CMS calculates the star ratings using a combination of in-person health inspection results and a large amount of self-reported data supplied by nursing homes.
For instance, nursing homes submit payroll data that the CMS uses to calculate staffing hours per resident per day and turnover rates. Nursing homes also self-report quality-of-care measures such as the number of hospitalizations, emergency room visits, falls, pressure sores, and the like. It’s unclear how often the government audits the self-reported data.
Health inspection scores work differently. This rating is based on the past three state health inspections, which usually happen about once a year. Results of the most recent inspection are weighted more heavily than the previous two. Inspectors assess a wide variety of items ranging from medical records to food. They also conduct interviews with residents and staff.
The CMS takes all that information and determines how often and how seriously the nursing home fails to live up to federal standards. When problems are found, health inspectors return. The CMS takes that into account as well.
Also considered in the ratings are any complaint investigations or infection-control inspections from the past 3 years. These were especially important during the pandemic.
Are there flaws in the Medicare rating system?
Yes. The CMS star rating system has come under intense scrutiny, especially during the pandemic. More than 154,450 nursing-home residents have died of COVID. An investigation by The New York Times found that people at five-star facilities were about as likely to die of the disease as those at one-star nursing homes.
In addition, The Times found that some nursing homes inflated their staffing numbers by counting administrators or vacationing staffers. On the quality-of-care measures, The Times also found that falls, bedsores, and other problems were sometimes underreported.
Finally, health inspections — supposed to be unannounced — aren’t often a surprise, according to the Times’ investigation. That means the nursing home might have been tipped off to when an inspection is coming. Managers could staff up and make other adjustments for the duration of the inspector’s audit, skewing the overall picture of the facility.
For that matter, concerns over patient safety and the accuracy of self-reported data have been around since well before the pandemic. Cases of abuse and neglect have been found in five-star-rated nursing homes.
Does the CMS rating system affect the cost of nursing home care?
The CMS star ratings don’t directly affect the cost of nursing homes. To be listed on Care Compare, facilities must accept payment from Medicaid and/or Medicare — meaning they’re contracted to take whatever reimbursement rate the government offers.
Factors that do affect cost include the facility’s location and how many specialized services it provides. Memory care homes, for example, command premium prices.
How do I use the CMS rating system to make the best choice of a nursing home?
Use the CMS star ratings together with other sources of information. The CMS offers a guide to choosing a nursing home and a nursing home checklist to help you think of questions to ask when you visit.
On-site visits are key. Visit each of your preferred facilities several times. To get a good sense of each place, you could:
Drop in at different times of day and night to see what the activity and staffing levels are like outside of visiting hours.
Ask to see residential rooms and other facilities that aren’t part of the common area.
Have a meal with the residents so you can get an idea of food quality, variety and options.
Another source of information: your physician (or your family member’s physician). Ask them for suggestions or input about facilities. Ask friends and family, too.
Always check the reputation of nursing homes you are considering with your local Better Business Bureau, Agency on Aging, and other area advocates for older adults. If appropriate, contact your local Alzheimer’s Association chapter.
Finally, be sure to call your state health department or state licensing agency for information about specific nursing home facilities.
The bottom line
When you’re looking for a care facility, the CMS nursing home star rating system is a good place to start. Understanding how CMS calculates ratings, the recent updates to its scoring system, and the shortcomings of the process can help you get the most out of the information.
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References
Alzheimer's Association. (n.d.). Alzheimer's Association.
Brauner, D., et al. (2018). Does Nursing Home Compare reflect patient safety in nursing homes?. Health Affairs.
Centers for Medicare & Medicaid Services. (2008). CMS issues historic star quality rating system for nursing homes.
Centers for Medicare & Medicaid Services. (2019). Your guide to choosing a nursing home or other long-term services and supports.
Centers for Medicare & Medicaid Services. (2022). COVID-19 nursing home data.
Eldercare Locator. (n.d.). Eldercare locator.
LongTermCare.gov. (2020). How much care will you need?. Administration for Community Living.
Medicare.gov. (n.d.). Find and compare nursing homes, hospitals and other providers near you.
Medicare.gov. (2019). Nursing home checklist.
