Five Stars for Poor Service: How the Nursing Home Rating System Was Compromised

An influential star-rating system designed to assess the quality of nursing homes is not as reliable as patients and families might have hoped. Established by the federal government, the system under question is intended to rate nursing homes on a scale of 1 to 5, with 5 being the best.

A recent report in The New York Times reveals how the data that elderly care homes provide to oversight agencies are often inflated, misleading, or even fabricated in order to prop up their ratings. In fact, many nursing homes appear to be gaming the system, which is managed by the U.S. Centers for Medicare & Medicaid Services (CMS).

Worse yet, the pandemic only seems to have worsened a trend that already existed, with profit-motivated homes hiding the various shortcomings and missteps that helped spread deadly infections among patients.

The news has come as a shock to thousands of families who have relied on the rating system to find long-term homes for loved ones who are in need of care.

In all, the report advances a concern many families have unfortunately feared for some time: that the general state of our country’s nursing homes is sub-standard and woefully inadequate.

While the pandemic has shed light on the sorry state of the country’s elderly care service — leading some states to reverse laws that had given nursing homes legal immunity — such a change shouldn’t have to depend on something as devastating as a global pandemic.

How Nursing Homes Are Failing Patients

The Times report shows how the CMS rating system is so fraught with data manipulation as to render it virtually useless. Here are some of the ways in which the system and the nursing homes that are subject to it have been compromised:

  • Manipulating or fabricating data: To make homes appear cleaner and safer than they actually are, many facilities understate accidents and health problems, underreport medication regimens, and inflate staff numbers so as to improve staff-to-patient ratios.
  • Inconsistent ratings: Five-star nursing homes are not only as likely to flunk in-person inspections as lower quality homes, but also as likely to experience COVID-19 infections that lead to death.
  • Little oversight: Nursing homes’ self-reported data is rarely audited by the Centers for Medicare & Medicaid Services (CMS).
  • Advanced warning: Many homes seem to know in advance about what are supposed to be surprise inspections from health officials.
  • Lack of consequence: Despite the identification of patterns of abuse or negligent care, inspections often do not result in lower ratings for highly rated homes.

One shocking datapoint from the Times investigation shows that as much as 68% of 5-star-rated homes in the country have been cited for patient abuse, an infection violation, or both.

It Goes Both Ways

The true extent of the problem does not lie solely on the backs of the nursing home industry, roughly 70% of which is composed of for-profit companies.

The CMS itself has been far too lenient in its ratings system, which has resulted in many substandard homes enjoying higher ratings than they actually deserve. The government has also failed to audit or inspect homes with repeat violations or suspect self-reported data.

According to the Times report, inspectors cited nearly 65% of all homes inspected between 2017 and 2019 for not following basic safety and sanitation precautions, yet none of those homes received lower ratings.

To the extent that data submitted from nursing homes to the government is wrong or misleading, which it often is, nursing homes have been allowed to operate with high ratings while administering low-quality care. In some cases, an improved rating did not correspond with improved care.

All this under-reporting, inflating, and manipulation of data made these same nursing homes utterly ill-prepared for the COVID-19 pandemic.

The COVID Difference

According to the CMS, over 130,000 nursing home residents have died from COVID-19 in the U.S., a truly staggering figure next to the overall tally of roughly 565,000. But, according to the New York Times, residents of 5-star-rated homes were about as likely to die of COVID as those in lower-ranked homes.

The Times investigated the mortality rates between highly rated and low-rated facilities, and found insignificant differences. In all, the death rate at 5-star homes was only half a percentage point lower than that of lower-ranked homes.

Eight other studies have shown that high ratings were not associated with improved outcomes related to the pandemic.

A Reckoning to Come?

The wider nursing home industry may be on the verge of a reckoning, having been buoyed by years of legal and regulatory shielding.

Earlier this month, the state of California sued its largest chain of nursing home facilities, Brookdale Senior Living, charging the company with manipulating the CMS 5-star-rating system. Specifically, the lawsuit claims, Brookdale inflated the number of hours that staff members were working.

The company allegedly evicted or transferred some patients illegally so as to make room for new patients with deeper pockets, often without much notice or time to prepare.

Meanwhile, another chain of senior living homes is seeking to resolve a lawsuit alleging similar misconduct and manipulation. Aegis Senior Communities LLC asked a federal judge in March to approve a settlement stemming from allegations that it misled patients and prospective customers about its staffing levels while violating elder abuse statutes.

These revelations, as well as a slow tide of other stories detailing abuse and negligence at many homes throughout the country, has invited scrutiny from lawmakers.

Once immunized from lawsuits, nursing homes in some states will soon be open to criminal and civil liability.

In New York last month, legislators passed a repeal of a law that effectively shielded nursing home executives from being held responsible for deaths stemming from the pandemic. Recently it was revealed that the administration of New York Governor Andrew Cuomo had been undercounting COVID-related nursing home deaths in the state.

A similar act was recently passed in Connecticut in February, where Governor Ned Lamont signed an executive order detailing plans to end legal immunity for nursing homes and other healthcare facilities in the state.

Nearly 30 other states granted similar immunities at the beginning of the pandemic, but with much of the worst behind us, families are beginning to question that decision.

As the media, lawmakers, patients, and families take a closer look at the state of the nursing home industry, most are concluding that some changes are in order. For many families, particularly the hundreds of thousands who have suffered losses due to COVID-19, that change can’t come soon enough.

Sokolove Law Team

Contributing Authors

The Sokolove Law Content Team is made up of writers, editors, and journalists. We work with case managers and attorneys to keep site information up to date and accurate. Our site has a wealth of resources available for victims of wrongdoing and their families.

Last modified: April 12, 2021

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