CMS' ubiquitous star rating system for nursing homes—which originally aimed to simplify "reams of information" about nursing homes' quality and safety into "objective, government-blessed metrics"—provides "a badly distorted picture of the quality of care at the nation's nursing homes," according to a New York Times investigation.

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About the CMS star rating system for nursing homes

In 2008, lawmakers created a new nursing home rating system that aimed to streamline information about resident safety, staffing, and "dozens of other metrics" into a star rating system with a high score of five stars and a low score of one star. 

The overall star rating for each nursing home is based on three components: a grade from in-person inspections, which accounts for the majority of the ranking, plus two other ratings—staffing and care quality—that are determined largely by self-reported data. The staffing score is based on how many hours staff spend with residents, while the care quality score is based on 15 care-based metrics, such as residents' medications and wounds.

Once calculated, the overall star rating—as well the individual scores for in-person inspections, staffing, and care quality—are posted to CMS' Care Compare website.

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According to the Times, the system when rolled out drew praise from senior-care groups, who said it provided an easily comprehensible snapshot of nursing homes. However, within months of the system's launch, members of a Medicare advisory board warned federal officials that—in an industry with razor-thin margins—the system incentivized nursing homes to misreport their metrics.

As a precaution, board members and former regulators called for more auditing of self-reported data—but audits remained rare, according to the Times.

For its part, CMS in a statement said that the star-rating system is "intended to serve as one tool" for people to select nursing homes, and that "[o]verall scores should be considered in light of a potential resident's unique care needs." An agency spokesperson added that HHS "takes reports of fraud seriously," and that "CMS deploys enforcement and accountability measures swiftly if fraud is detected."

About the NYT investigation

To assess the reliability of the star-ranking system, the Times established a database to examine "millions of payroll records" to quantify how much hands-on care nursing homes give residents; evaluated 373,000 state inspection reports; and reviewed financial statements that more than 10,000 nursing homes filed with the government.

According to the Times, this analysis depended in large part on nursing homes' self-reported data from January 2020, which was submitted before the novel coronavirus pandemic temporarily altered how data is submitted, as well as payroll and cost report data from 2019. To assess how star ratings changed over time, the Times examined quarterly ratings and metrics through 2015.

In addition, the Times gained access to ratings information typically not made public from academics who, via research agreements with CMS, had access to such data.

Key findings

Among other findings, the Times investigation found:

• A significant amount of the data submitted to CMS is incorrect

Not only is "much" of the information submitted to CMS incorrect, the Times reports, but that incorrect information often makes nursing homes seem "cleaner and safer" than they are.

For instance, the Times reports that the rating system requires facilities to report the prescription medication they administer to residents and penalizes nursing homes that overuse certain medications. However—based on court documents and interviews with administrators, nurses, and federal officials—nursing homes "for years have underreported the number of residents" using opioid and antipsychotic medication.

As an example, the Times cites the experience of one nursing home resident, Eunice Hill, at a five-star facility in South Carolina, where medical records indicate that Hill was given a strong antipsychotic on her first day, as well as anti-anxiety medication each day for a week. However, the organization in the data it filed with CMS indicated that it didn't give Hill any antipsychotic medication, and only administered anti-anxiety medication once.  Ultimately, Hill died in January 2018, after being rushed to the hospital with kidney failure and severe dehydration in late December 2017.

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In addition, facilities frequently don't report accidents and health problems among residents, the Times reported, citing several studies as part of its investigation. For instance, the Times cited a paper last year from Integra Med Analytics, which compared hospital admissions data with nursing homes self-reported CMS data and found that 50% of nursing homes underreported potentially fatal bed sores by at least 50%, as well as a study from the University of Chicago that found between 2011 and 2015, nursing homes did not report to CMS 40% of residents who had to be hospitalized following falls.

Despite this misreporting, audits remain relatively rare, the Times reports. Between 2017 and 2019, health inspectors wrote up an estimated 5,700 nursing homes—accounting for more than 33% of all nursing homes in the country—for misreported data on residents' wellbeing, including nearly 800 homes with high overall scores. But even when such misreporting was discovered, the Times reports, federal auditors didn't more closely review all the data that those homes had submitted to CMS.

• The star ratings system can result in misleading reports on staff levels

Another issue the Times citing in its investigation was imprecisely reported staffing levels, which could mislead consumers about how much time staff is able to spend with each patient or resident.

Specifically, CMS as of 2018 requires facilities to submit payroll records detailing the daily hours logged by staff. However, CMS permits facilities to include in the total reported number of staff hours on Care Compare both the hours of staff who work directly with patients and the hours of administrative staff, who do not see patients—without any breakdown between the two.

As an example of how this system can affect overall star ratings, the Times cited a nursing home in Florida, which in early 2019 had a two-star rating for its staffing. However, in the second half of 2019, the facility reported a dramatic increase in nursing hours—supplied entirely by the addition of administrative nursing staff—and by January 2020, the facility had a five-star rating, the Times reports.

For his part, Alexander Kusmierz, executive director of the facility, said, "The administrative nursing staff at Sun Terrace work very closely with the direct care staff in a collaborative team approach to ensure the facility provides the best possible care for each and every resident." However, Kusmierz added that in light of the Times' questions, the facility would audit the staffing data it supplied to CMS to "continue to make certain that the information provided is thorough and accurate."

• Data indicates that some nursing homes learn of "surprise" inspections in advance

According to the Times, nursing home inspections—which form the basis of the overall star ratings—can, in theory, occur at any time, without any warning. However, the Times investigation found that in 2019, about 70% of nursing homes boosted their staffing levels by an average of 25 staff hours on inspection days, when compared with typical staffing levels for that day of the week. In fact, at more than 800 nursing homes, inspectors reviewed the facilities during what ended up being the facilities' best-staffed day of the year.

According to the Times, the odds of such circumstances happening by chance are "virtually zero," indicating that some nursing homes can anticipate when their inspections will occur. And at least in some cases, the Times reports, this results from corruption; an inspector in Florida in 2017 and the head of Oklahoma's health department in 2002 separately pled guilty to charges of accepting bribes in exchange for letting homes know when they would be inspected.

• Issues identified during in-person inspections rarely affect overall star ratings

According to the Times, despite the weight CMS allots in-person inspections in its overall star rating, "the exams do little to penalize homes with serious problems"—particularly among nursing homes with five stars for care quality, which are nearly as likely to fail these inspections as they are to ace them.

In fact, according to the Times, inspectors over a three-year period spotted at least one issue involving potential patient abuse—such as staff acting violently toward residents, or failure to look into injuries—among nearly 1,200 homes with overall five-star ratings.

As an example, Times cites several instances in which homes with five star ratings were able to maintain their overall scores even after officials during in-person inspections identified serious quality and safety issues, such as when the wound of one resident at a nursing home in Minnesota became infected with maggots and when the ventilators of residents at a facility in New Jersey weren't changed for more than a month.

In another instance, federal officials categorized the rape of a resident by a staff member at a nursing home in San Diego as a "category F" violation, which designates a lower-level issue that causes "potential, not actual, harm"—and enabled that facility to hold on to its five-star rating. In fact, according to the Times, inspectors determined that incidents of sexual abuse in at least 40 other facilities with five-star ratings did not comprise actual harm or put residents in "immediate jeopardy."

• Little correlation between star ratings and how facilities fared amid Covid-19

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According to the Times, the pandemic hit nursing homes harder than other part of the industry, with nearly one in every 10 nursing home residents dying from Covid-19—and it also suggested that the star-ratings system does little to spotlight which organizations excel at infection prevention and control.

Ultimately, the Times' investigation found the Covid-19 fatality rate at five-star facilities was just half a percentage point lower than at facilities with lower ratings—and in fact, the fatality rate was slightly lower at two-star facilities than at four-star facilities, the Times reports.

According to the Times, better predictors of how nursing homes would fare amid the pandemic were the infection rate of the surrounding community and the race of a nursing homes' residents.

California files suit against nursing home

In related news, California Attorney General Xavier Becerra (D) and several other state prosecutors on Monday filed a lawsuit against Brookdale Senior Living, the nation's largest chain of senior living communities, alleging that the organization had submitted incorrect information to CMS so as to manipulate the agency's star rating system, the Times reports.

In the lawsuit, filed in California's Superior Court, prosecutors claimed that the organization misrepresented its staffing levels, particularly the hours worked by RNs, and incorrectly discharged and transferred residents to make room for residents who would generate a greater profit. According to the Times, the lawsuit seeks civil penalties—which under California law, in this case, could total $5,000 per violation since seniors and individuals with disabilities are involved—and an injunction against future instances of illegal conduct.

In response to the allegations, Brookdale said it was disappointed by the lawsuit and "categorically den(ies) that Brookdale engaged in intentional or fraudulent conduct."

A spokesperson added, "We are disappointed in the allegations against the skilled nursing industry. Publicizing unproven allegations is reckless and undermines the public's confidence in a service necessary to the care of elderly individuals, especially during the Covid-19 pandemic. Brookdale is dedicated to providing quality care to our residents and patients, and we take our mission of enriching the lives of those we serve seriously," a spokesperson said (Silver-Greenberg/Gebeloff, New York Times, 3/13; Silver-Greenberg, New York Times, 3/15; Thompson, Associated Press, 3/15; Christ, Modern Healthcare, 3/15).