5 Star Quality Ratings for Nursing Homes Highly Questionable

By Pamela D. Wilson, CSA, MS, BS/BA

The news recently buzzed about the Five Star Quality Ratings published for skilled nursing facilities. I was excited myself until I looked further into how the ratings were actually calculated.  The ratings are based on three categories of data: health inspections, staffing and quality measures.  Information is available online at Medicare Nursing Home Compare.

The category entitled “Health Inspections” is the ONLY category that provides information derived from trained teams of surveyors. However the category descriptor also mentions that there are “differences in state licensing requirements that affect quality, and in state Medicaid programs that pay for much of the care in nursing homes.” Additionally, inspections don’t identify nursing homes that give outstanding care. While reading these reports, keep in mind that the quality of a nursing home may get much better or much worse in a short period of time. These changes can occur when a nursing home’s administrator or ownership changes or when a nursing home’s finances suddenly change.  I’ve personally experienced this myself when I’ve had clients in certain communities, many of whom I would have previously recommended but would now recommend.

The second category “Staffing”, was based on “the overall number of staff compared to the number of residents and how many of the staff are trained nurses”.  This number was “self-reported” meaning that the rating relies on the integrity of the nursing home providing the information and only over a two week period of time.  Research shows that relying on numbers only is not a realistic measure of quality.

After all how many times have we heard the joke “how many xyz does it take to change a light bulb?   One skilled and efficient person can do the work of several.  On the other hand multiple untrained individuals can cause more harm than good.  More relevant, an article in The Gerontologist related staffing levels and nursing home quality by focusing on staff stability, stating that “highly stable employees are likely to deliver consistent care and have a greater appreciation for care practices.” Staffing quality is not only a numbers game.

Even more interesting is the category entitled “Quality Measures” which reports how well each nursing home performs on ten aspects of care such as dressing eating and preventing skin ulcers.  These quality measures again are “self-reported” by each nursing home rather than collected by an independent agency.

Let me play devil’s advocate.  A small percentage of the 5 star rating is provided by a trained team of surveyors and the remainder nearly 60% is self-reported. I would say that the ratings are more questionable than not especially taking into consideration that the surveys are done during a “snapshot” of time when many nursing homes are on their best behavior and the survey itself mentions quality can change at the drop of a hat. These 5 star quality ratings are no more reliable than 5 star quality ratings for restaurants. The rating all depends on the timing of the experience and the stability of staff providing the service.

So how does one determine what makes a good nursing home?  It’s not easy, especially if you’re a family member trying to make a choice and are held captive by an insurance company that dictates which nursing homes are covered by  insurance.  Timing is usually an issue when choosing a nursing home because hospitals are ready to release a loved one.  Hospital discharge planners may contact communities who have immediate availability rather than knowing about the reputation of care provision.  If possible family members should personally visit nursing homes under consideration and when in doubt, seek expert advice from an advocate familiar with the care levels of nursing homes in the town where you live.

1) Castle, Nicholas G et. al. “Further Examination of the Influence of Caregiver Staffing Levels on Nursing Home Quality,” The Gerontologist, Vol. 48, No. 4, 464-476.

© 2012, 2013 Pamela D. Wilson, All Rights Reserved

Return to Dangers of Ignorance PageReturn to All Category Page