Posted by: Katie May

When I think of the Nursing Home Compare Five Star Quality Rating System, I can’t help but picture an impeccably dressed Ed McMahon on stage with a young Britney Spears or Adam Sandler competing for a coveted perfect score of four stars to beat the Challenger! While Star Search, produced from 1983-1995, brought us many rising stars, some — like Justin Timberlake — didn’t win. When utilizing the Five-Star Quality Rating System, it is important to keep in mind that some fivestar facilities may not be the right place for your loved one, while lower-rated facilities might end up at the top of your chart.

Recently the Centers for Medicare and Medicaid Services (CMS) expanded Medicare’s widely-used Five Star Quality Rating System for Nursing Homes, known as Nursing Home Compare. Implemented five years ago, this tool has been heavily criticized due to the self-reporting nature of the system. Nursing Home Compare is a consumer-based rating system that attempts to assist family members through the difficult decisions that must be made when placing a loved one in a Skilled Nursing Facility (SNF).

The changes to the Five Star System, taking effect in January of 2015, are aimed to address these self-reporting concerns. For example, when a SNF reports staffing levels, CMS will have the ability to compare the numbers reported to the SNF’s payroll records to ensure accuracy. Staffing of facilities is of major importance to prospective patients as it directly impacts the care patients receive. If facility staffing is thin, this likely results in longer wait times when the resident rings his or her call button. This time lapse then leads to an impatient patient attempting to ambulate or toilet without necessary assistance or supervision. This action results in falls which can lead to injury and hospitalizations. Staffing also impacts the quality of care in many other ways, such as providing more skilled individuals to notice a change in a patient and can adjust the care plan accordingly.

An auditing program will also be implemented to verify the Quality Measure rating based on information collected about each patient. This will include the gathering of data such as whether or not the patient is bedridden or requires a wheelchair, how many patients are developing bedsores, or have lost and/or gained weight. This data will then be analyzed when awarding the facility’s star rating. Whether patients in a given facility get healthier or maintain their current level of care needs –as opposed to declining in health –is valuable information to be included into the rating determination.

Perhaps the most interesting update to the star rating system will be the inclusion of the percentage of residents receiving antipsychotic medications. These medications are often administered to “difficult” patients and inappropriately used to sedate them to decrease challenging behaviors. However, with our population living longer and mental illness rates on the rise, this is a difficult measure to balance.

The Chicago End of Life Coalition reported that Greg Crist, spokesman for a lobbying group representing for-profit nursing homes, stated, “We’ve seen improvements in quality across the board. Some questioned that a few weeks ago. Yet this push for greater accuracy should help reassure patients and families those improvements are both real and making a difference in improving lives.”

It will be very interesting to watch this improved collection of data and how it affects the star ratings of facilities. When the program was initially implemented, 36% of SNFs received a four- or five- star rating. By 2013, that percentage reached 65% of facilities. While I believe this update to the rating system will provide consumers with an improved tool to compare facilities, the most important research when placing a loved one in a SNF remains the same: PERSONAL OBSERVERATION. There are good facilities, decent facilities, and bad facilities. I do not believe the Five Star Rating System is a tool to rely on, even with these updates.

Consider the following five tips when visiting a facility:

  1. Look Around and Observe. Does the facility look and smell clean? Are the residents appropriately dressed and groomed? Watch the staff interact with the patients and observe their mannerisms. Are they respectful, pleasant, and patient or annoyed, harsh, and rushed?
  2. Interview Everyone. Ask the difficult questions. What is the staffing ratio? What type of training do you invest in for staff? What screening is completed during hiring? What is the turnover rate at all levels of the facility? Ask other family members present how their experiences have been. Speak with the other patients and ask them the same.
  3. Have any contract reviewed by an Elder Law Attorney. Be aware of what you and your loved one are contractually agreeing to. Often, these contracts contain terms that are not in your best interest and may bind you financially or restrict your legal rights should an injury occur.
  4. Be Involved in Care Plan Determinations. How are medical needs handled? Who is involved in the care planning process? Are the Medical Director and Facility Administrator easily accessible? What types of activities are planned? What types of licensing and education do the Admission staff, Activities staff, and Social Services staff possess?
  5. A Patient Advocate is imperative. Whether the advocate is a family member or licensed professional, having someone active in the care of your loved one is just as critical in a Five-Star facility as it is in a Two-Star facility. Communication and flow of information is essential to proper diagnosis, medication management, and quality of care. A licensed Geriatric Care Manager (GCM) has the expertise and knowledge to ensure your loved one receives the best possible care. Healthcare providers are human. Mistakes are easy to make in a busy, fast-paced environment, so having this skilled oversight is invaluable.

If you would like to obtain data on a facility near you, you can find a link to Nursing Home Compare at
Some of the additional resources found on the CMS website include a Nursing Home checklist and a Guide to Choosing a Nursing Home.