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Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State

About 1.3 million people receive care each day in over 15,500 nursing homes in the United States that are certified by either Medicaid or Medicare or both. The federal government requires nursing homes to meet minimum standards as a condition of Medicare and Medicaid payment. Over the years, serious concerns have been raised about the quality of nursing home care and the adequacy of oversight and enforcement.1 Nursing home provisions in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) were enacted to help address these concerns. Nonetheless, reports of quality problems in nursing homes persist, such as low staffing levels, new pressure ulcers (bedsores), and documented fire hazards.2 These are serious issues given the frailty and vulnerability of nursing home residents.

In 2008, the Centers for Medicare and Medicaid Services (CMS) launched the Five-Star Quality Rating System on its Nursing Home Compare website to provide summary information to help consumers choose a nursing home in their area. CMS recently modified the methodology of these ratings, began posting more information about nursing home deficiencies from state health inspections, and is planning future steps to increase the star ratings’ reliability, as required by certain provisions in The Affordable Care Act (ACA) and the Improving Medicare Post-Acute Care Transformation Act (IMPACT). This issue brief presents national and state-level analysis of nursing homes quality scores based on these five-star ratings and discusses relevant policy considerations.

Key Findings

  • More than one-third of nursing homes certified by Medicare or Medicaid have relatively low overall star ratings of 1 or 2 stars, accounting for 39 percent of all nursing home residents. Conversely, 45 percent of nursing homes have overall ratings of 4 or 5 stars, accounting for 41 percent of all nursing home residents.
  • For-profit nursing homes, which are more prevalent, tend to have lower star ratings than non-profit nursing homes. Smaller nursing homes (with fewer beds) tend to have higher star ratings than larger nursing homes.
  • Ratings tend to be higher for measures that are self-reported (quality measures and staffing levels) than for measures derived from state health inspections.
  • In 11 states, at least 40 percent of nursing homes in the state have relatively low ratings (1 or 2 stars). In 22 states and the District of Columbia, at least 50 percent of the nursing homes in the state have relatively high overall ratings (4 or 5 stars).
  • States that have higher proportions of low-income seniors tend to have lower-rated nursing homes.
Issue Brief

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.