Nursing homes shoot for the stars and land among one or two

Over one-third of the 15,500 nursing homes in the U.S. received ratings of just one or two stars on CMS’s Five-star quality rating system, according to an analysis by the Kaiser Family Foundation (KFF). The analysis, which examined the ratings used to score nursing homes based upon deficiencies identified during health inspections, reveals that a significant number of nursing homes—those responsible for 39 percent of the nation’s nursing home residents—are failing in terms of staffing and care quality.


In 2008, CMS modified its Nursing Home Compare website to include a more user-friendly five-star rating system based upon quality ratings for each of the Medicare and Medicaid certified nursing homes. As a result of 2015 changes, the rating system uses three domains—(1) state health inspections; (2) staffing ratios; and (3) quality measures—to rank nursing homes from the lowest in quality (one star) to the highest in quality (five stars). The CMS changes are part of an ongoing effort to increase the star ratings’ reliability, as mandated by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) (P.L. 113-185). One change mandated by the ACA will be the inclusion of “staffing data collected quarterly from electronic systems used for payroll reporting” as an alternative to self-reported data.


The KFF analysis used data from the Nursing Home Compare database February 2015 data release. The study looked at information including a “nursing home’s name, location, size, and number of recorded deficiencies and fines.” The analysis was restricted by the data set to only nursing homes with Medicaid or Medicare participation or both. KFF cautioned that the analysis does not demonstrate the validity or reliability of the CMS data set, but instead, is intended to show variation among states and nursing home characteristics.


In addition to the finding that 36 percent of nursing homes scored just one or two stars on the rating system, the analysis uncovered that 45 percent of nursing homes have an overall rating of four or five stars. Those 45 percent of high scoring nursing homes account for 41 percent of all nursing home residents in the nation. The analysis indicated that high scores may be due in part to self-reporting because scores on self-reported measures tended to outperform scores from state health inspections.

Profit and size

According to KFF, for-profit facilities performed less well than non-profit facilities. For example, one in five for-profit nursing homes received one star, whereas one in ten non-profit nursing homes received a one-star rating. Additionally, 33 percent of non-profit nursing homes received five stars, whereas only 18 percent of for-profit facilities received the highest rating. Smaller facilities also outperformed larger facilities with 39 percent of nursing homes with 60 or fewer beds receiving five stars and just 14 percent of nursing homes with 120 beds or more receiving five stars. KFF hypothesized that the lower scores among larger facilities are likely a result of the lower staffing numbers seen in large nursing homes.

State level

The analysis also found significant variation among states. For example, in 11 states, at least 40 percent of the nursing homes scoed one or two stars. In Texas, 51 percent of nursing homes received either one or two stars. Nine states, including Texas, Louisiana,

Oklahoma, Kentucky, Tennessee, New Mexico, West Virginia, Ohio, and Georgia, had more than 20 percent of nursing homes with one star. On the positive side, in 22 states and the District of Columbia, at least half of the nursing homes scored a four or a five on the star-rating system. Additionally, 66 percent of U.S. counties have a nursing home with a four or five star rating.