Last month, The Centers for Medicare and Medicaid Services (CMS) released quality ratings for nursing homes that participate in Medicare and Medicaid. The five star rating system, similar to those used for movies, restaurants and hotels, is intended to make comparisons easier for consumers.

Of approximately 15,800 facilities evaluated, about 12 percent received a 5-star rating designating them “much above average” while 22 percent scored a 1 star rating “much below average”. The remaining 66 percent were fairly evenly distributed among 4 “above average”, 3 “average” and 2 “below average”.

The ratings are based on performance in three areas:

Health inspection surveys. Each year state and federal surveyors conduct on-site, comprehensive assessments of each nursing home’s health care services and compliance with federal/state rules. These surveys are designed to help protect the health and safety of residents, including resident’s rights and general quality of life. Surveyors also conduct about 50,000 complaint investigations each year. Information from the most recent three years of survey findings were used to develop the ratings.

Quality measures. The quality rating system uses 10 key quality measures out of the 19 that can be found on the Nursing Home Compare Web site. Areas examined include the percent of at-risk residents who have pressure ulcers (bed sores) after their first 90 days in the nursing home, the number of residents whose mobility worsened after admission, and whether residents received the proper medical care.

Staffing information. There is strong evidence that low staffing levels can compromise patient care in a nursing home. This measure reports the number of hours of nursing and other staff care per patient per day. It is adjusted to account for the level of illness and services required by each facility’s residents.

CMS Acting Administrator, Kerry Weems, says the goal of the 5-star system is “to provide families a straight forward assessment of nursing home quality”. Although consumers will celebrate the simplicity of the system, critics find it lacking in a number of areas.

  • Many important quality of life issues are not measured by the 5 star method, including cleanliness, atmosphere, ratio of nursing professionals and the ability to visit.
  • Two out of three of the criteria are self reported by the facility and may be inaccurate.
  • Staffing data is based on just a two week period – insufficient to show a pattern of care.
  • Quality and conditions within a nursing home can change at any time with dramatic improvement or deterioration between rating periods.

It must be emphasized that the 5 star rating system is just one criteria for choosing appropriate care. It should be used in conjunction with information from physicians, social workers, the state’s nursing home ombudsman, and the states survey and certification office. In –person visits to facilities are most important in evaluating a nursing home. Visiting more than once, visiting at odd hours and talking with other residents and their families can give insights that cannot be measured by a simple rating system.

The CMS provides a Guide to Choosing a Nursing Home with checklists and tips a family can use in personally evaluating a facility. CMS also provides links to information for community-based alternatives to nursing homes. The 5 star ratings and other information are available at


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