Physical inspections, staffing and quality outcomes measures
There’s now a basis for comparing the quality of nursing facilities that goes beyond just local reputation. Medicare rates nursing facilities, including those attached to a CCRC, with a 1-5 star rating system (in ½ star increments). Nursing facilities are graded on three areas and also receive a combined score. (It’s a Consumer Reports like rating system.)

You can see the results for all facilities in a city or ZIP code or for a particular facility through this Medicare link (Medicare Ratings) .

medicare ratings uses a series of stars

Medicare ratings for nursing facilities uses a star rating system.

  • Health Inspections. Nursing facilities are periodically inspected as a condition of receiving Medicare reimbursements and are inspected in response to complaints. The rating looks back three years at both types of inspections, considers the severity of any deficiencies or errors cited, the number of deficiencies and how long or how many re-inspections it takes to get right with the standards. A 5-star rating means mistakes are minor and few and quickly redressed. Only 10% of facilities in any state are 5-star rated. The bottom 20% are 1-stars. The other three categories equally distribute the remaining facilities with about 23.3% in each of the 2, 3 and 4-star categories.
  • Staffing.  Nursing facilities track skilled staff patient ratios both generally and for registered nurses (RNs). RNs are required for some patient care tasks so their presence in adequate numbers is important. Licensed Practical Nurses (LPNs) and Nurse Aides fill other roles. Ratings consider, 1) RN hours per resident day, and 2) RN + LPN + nurse aide hours per resident day. Clerical and housekeeping staff are not measured or rated by Medicare, but can and do matter to both residents and other staff. There is also a so-called risk adjustment or case-mix adjustment performed. That is, facilities with high need residents require more staff to get the same rating. The staffing requirements are stringent so that expected standard is high. The median or average falls in the 3-star range. Less than 30% of all facilities are 5-star rated. These can roughly be read as 3-stars are average, 4-stars above average and 5-stars are substantially above average.
  • Quality. Medicare ratings track 18 different quality measures (QMs) for nursing facilities but current ratings only include 11 of the QMs, 8 long-stay measures and 3 short-stay measures. Generally the measures discourage use of restraints or antipsychotic drugs to manage patients and encourage effective pain management. Frequency of urinary tract infections, bed sores and patient falls are other QM indicators of inadequate care. The top 25% of nursing homes by QMs are 5-star. The bottom 15% are 1-star. The remaining three categories contain 20% of the total distribution.

Note that the distribution for 5-stars is not the same category-to-category.

  • Overall. The overall rating starts with and heavily weights the health inspection. A bad inspection record limits how well a facility can do even with excellent staffing and strong quality measures.

Special Focus Facilities. Medicare has a list of facilities with a long history of serious quality deficiencies or problems. These so-called Special Focus Facilities are targeted for improvement with added both regulatory focus and assistance. However, if you’re shopping for care you don’t want to choose a Special Focus Facility (SFF) nursing facility for yourself or your loved one if it can be avoided. The current list to avoid is here at this link.

One flaw with the Medicare Star Rating system is that it is difficult to compare facilities across state lines as rankings are relative to other facilities within the same state. We’ll examine how to use the raw data if you are considering facilities in different states in an upcoming post.

Sources. Summarized from two federal government sources (Medicare Ratings): (short version) (long version, 25 page users guide)

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