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Should You Rely on the Government Star Rating When Choosing a Nursing Home?

Posted on May 16, 2016

Finding quality care in a nursing home is a very serious issue, especially when you are looking for a home for a loved one. Most nursing home residents are particularly vulnerable and reports of abuse, neglect and substandard care have become commonplace.

In order to help families find a safe place for their loved ones and to encourage nursing homes to provide better care (in theory, nothing promotes compliance quite like the government airing your dirty laundry), the Centers for Medicare & Medicaid Services (CMS) began publicly reporting nursing home reports in 1998 and and started giving nursing homes ‘star ratings’ in 2008.

So the question must be asked: Should you rely on the government nursing home ratings when choosing a nursing home? We wanted to dig into this further, so together we worked with data analysis and data visualization company 1point21interactive in order to do a more in depth analysis of the data.

Overall Ratings for Nursing Homes in PA and What you Need to Know

The rating system is meant to be a gauge of overall nursing home and care quality, with one star being the lowest score and five stars the highest. The overall score for each facility is based on their performance over three measures:

  1. Health Inspections
  2. Staffing Ratios
  3. Quality Measures (Q.M.).

The map above shows the distribution government ratings for nursing homes in Pennsylvania according to the data on the medicare.gov website. Click on any point on the map to see the name of the nursing home and the rating. 

Distribution of Overall Ratings

As the images below show, we can see the distribution of nursing home ratings in the state is fairly evenly distributed.

pa-nursing-home-ratings2

Is the Overall Star Rating a Good Measure of Quality of Care?

While the star rating system is user friendly, it has been widely criticized for several reasons; ranging from it’s heavy reliance on self reporting data to facilities inflating staffing numbers to raise scores.

Additionally, the overall rating is heavily weighed on the outcome of the Health Inspection measure.  Therefore, it is entirely possible for a facility to have a high overall score – a 4 or 5 star rating – while scoring very poorly in one of the other two categories.

This is especially apparent – and alarming – in the Quality Measure category.  In Pennsylvania alone, we identified 49 nursing homes with an overall rating of 4 or 5 stars that were given a 1 or 2 star score in the Quality Measure Category – nearly 20 percent of all homes that earned a 4 or 5 star rating. This issue isn’t unique to Pennsylvania, we found facilities fitting this same description in every state – a total of 1127 facilities as seen in this map below.

Nursing homes that received a high rating while receiving a low quality measure score

What are Quality Measures?

We spoke with a 20 year veteran of the skilled nursing industry (a physical therapist who preferred anonymity),  “While Health Inspection information is incredibly important, the categories found in the Q.M. score are a very good measure of the overall level of care a facility is providing.”

So, what exactly are the quality measures?

The Q.M. score is based on 11 (eight long-stay measures and three short-stay measures) of the 18 quality measures (QMs) criteria from the Minimum Data Set on the Nursing Home Compare website. Each measure is given equal weight, but is adjusted for prevalence in each home.

Long-Stay Residents:

  • Percent of residents whose need for help with activities of daily living (ADL) has increased – This covers late-loss ADLs which include bed mobility, transfer, eating and toileting. It reflects worsening performance on two late-loss ADLs by one functioning level or one ADL by two or more functioning levels.
  • Percent of high risk residents with pressure ulcers (sores) – This concerns Stage II-IV pressure ulcers.
  • Percent of residents who have/had a catheter inserted and left in their bladder – Reports those who had an indwelling catheter in the last seven days.
  • Percent of residents who were physically restrained – Concerns residents restrained on a daily basis, which can affect ADL. Rules stipulate that restraints should be removed for 10 minutes every two hours to allow for exercise. During sleeping hours, the patient’s position should be changed based on their needs.
  • Percent of residents with a urinary tract infection – Covers those who have had a UTI in the past 30 days.
  • Percent of residents who self-report moderate to severe pain – Patients who have reported frequent moderate to severe pain within the last five days.
  • Percent of residents experiencing one or more falls with major injury – This reports those have fallen within the past calendar year or target period.
  • Percent of residents who received an antipsychotic medication – Those who received this medication within the target period.

Short-stay residents:

  • Percent of residents with pressure ulcers (sores) that are new or worsened – Patients with new Stage II-IV sores.
  • Percent of residents who self-report moderate to severe pain – This concerns all reports of any frequency.
  • Percent of residents who newly received an antipsychotic medication – Patients who received medication during the target period but not on their initial assessment.

These measures are important because they have significant health and safety implications.  High instances of pressure ulcers can indicate that patients are being neglected. Nursing homes can help prevent or treat pressure ulcers by frequently changing the resident’s position, proper nutrition, and using soft padding to reduce pressure on the skin.

The use of antipsychotics has been shown to increase risk of death in patients with dementia, so facilities with significantly higher than average use of them may be putting their residents at risk.

Patients losing too much weight could  mean that the resident isn’t being fed properly, their care isn’t being properly managed, or that the nursing home’s nutrition program is inadequate or poor.

Why Is This Important?

When people see an overall 4 or 5 star rating, they are given the impression that a facility is providing the best possible care. However, for these nursing homes that score poorly in the quality measure area, this may not be the case. In fact, as aforementioned, the low scores may be indicative of practices that put residents at a serious adverse health risk.

Take Harlee Manor for example. This facility has a 5 star overall rating, yet over 18 percent of it’s residents have pressure ulcers (bed sores) – that’s more than three times the national average of 5.8 percent The facilities use of antipsychotics and percentage of patients who lost too much weight were also significantly higher than the national average. 

Similarly, Aristacare at Meadow Springs boasts a 5 star overall rating, but 10 percent of residents have a catheter inserted and left in – again over three times the national average.

The table below shows 36 PA nursing homes who received a 4 or 5 star overall rating yet received only a 1 or a 2 in the QM score. The table below includes 7 of the QM metrics:

  • PU = Pressure ulcers
  • LMTW = Lose too much weight
  • CIL = Catheter inserted and left in bladder
  • UTI = Urinary Tract Infections
  • AM = Antipsychotic medication
  • AMW = Ability to move worsened
  • AHM = Anti-anxiety or hypnotic medication

Generated by wpDataTables

*We identified 13 more but the Medicare website did not provide data for these other nursing homes.

So How Does a facility earn a 5 star overall rating despite being given just a 2 in QMs?

The composite score is taken from each of the three categories to determine an overall score – the home’s ‘star rating’. An average or a median of the three is not applied. The process for awarding points, especially in the aforementioned QMs category, was changed last year. If a facility earns a 1 in the QMs section, their overall score is reduced by one point, so it’s impossible for a facility to earn a 5 overall in this scenario. But even a 4-star facility would be given strong consideration. So only taking one star away in this regard does a disservice to the consumer.

There is a set point total by which the number of stars is awarded in the QM category. The number of points necessary to earn two or more stars was among the changes made to the rating system last year, which increased the threshold for what is considered quality care. However, the QM rating has very little effect on the overall score. If the home is on the Special Focus Facility list, it can only earn a maximum of three stars. If it only gets one star in the health inspection category, then it can only earn two stars overall.

The reason that facilities can earn a 4-star rating overall despite a 1-star QM rating is that the facility starts with five stars, and then is awarded or subtracted points based on how they do in each of the three categories. So say a facility gets five stars on health inspection, five stars on staffing but only one on QM, they will still be given four stars overall, because they were awarded a point for how well they did in the first two categories. A facility cannot be given more than five stars or less than one star. QM data is updated throughout the year every quarter.

Are fines included in a nursing home’s rating?

CMS has two ways to hold nursing homes accountable for poor care or outright negligence: Imposing fines and withholding Medicare payments. However, the fines are based solely off what is found in the health inspections and they do not factor into a home’s star rating. While they aren’t perfect – it’s important to know if the home your loved one was in is getting fined and what they are getting fined for.

The table below displays the fines given to nursing home facilities in the state over the last 3 years.

Provider Name Provider City Provider State Provider Zip Code Penalty Date Penalty Type Fine Amount
GOLDEN LIVINGCENTER-LANCASTER LANCASTER PA 17,602 02/08/2014 Fine 543,596
PLEASANT ACRES NURSING AND REHAB CENTER YORK PA 17,402 05/23/2014 Fine 181,054
HARRISON SENIOR LIVING OF CHRISTIANA CHRISTIANA PA 17,509 08/29/2013 Fine 136,712
WHITESTONE CARE CENTER STROUDSBURG PA 18,360 07/23/2015 Fine 123,533
MANORCARE HEALTH SERVICES-KINGSTON KINGSTON PA 18,704 11/07/2014 Fine 114,920
MILFORD HEALTHCARE AND REHABILITATION CENTER MILFORD PA 18,337 08/20/2014 Fine 108,843
MOUNTAIN VIEW, A NURSING AND REHABILITATION CENTE COAL TOWNSHIP PA 17,866 02/27/2015 Fine 77,740
MOUNT CARMEL NURSING AND REHAB MT CARMEL PA 17,851 02/12/2014 Fine 67,763
ASBURY HEALTH CENTER PITTSBURGH PA 15,243 12/23/2014 Fine 65,813
RIVERSIDE REHABILITATION AND NURSING CENTER TAYLOR PA 18,517 04/15/2015 Fine 62,400
RIVERSIDE REHABILITATION AND NURSING CENTER TAYLOR PA 18,517 11/15/2013 Fine 60,645
HIGHLANDS HEALTHCARE AND REHABILITATION CENTER LAPORTE PA 18,626 07/23/2013 Fine 60,255
RIVERSIDE REHABILITATION AND NURSING CENTER TAYLOR PA 18,517 11/07/2014 Fine 55,510
MANORCARE HEALTH SERVICES-MERCY FI YEADON PA 19,050 08/29/2014 Fine 55,088
MEADOWVIEW REHABILITATION AND NURSING CENTER WHITE MARSH PA 19,128 12/09/2014 Fine 52,650
SAUNDERS HOUSE WYNNEWOOD PA 19,096 04/24/2015 Fine 50,700
WILLOWBROOKE COURT-GRANITE MEDIA PA 19,063 01/13/2014 Fine 47,938
PLEASANT VALLEY MANOR, INC STROUDSBURG PA 18,360 08/14/2014 Fine 44,303
ORANGEVILLE HEALTH AND REHABILITATION CENTER ORANGEVILLE PA 17,859 05/08/2014 Fine 41,438
GOLDEN LIVINGCENTER-SCRANTON SCRANTON PA 18,510 07/13/2015 Fine 40,463
LAWSON NURSING HOME, INC. JEFFERSON HILLS PA 15,025 05/08/2015 Fine 39,771
GOLDEN LIVINGCENTER-BLUE RIDGE MOUNTAIN HARRISBURG PA 17,110 06/25/2014 Fine 39,098
WEATHERWOOD HEALTHCARE AND REHABILITATION CENTER WEATHERLY PA 18,255 06/20/2013 Fine 39,000
GOLDEN LIVINGCENTER-LANCASTER LANCASTER PA 17,602 07/26/2013 Fine 33,963
GOLDEN LIVINGCENTER-WEST SHORE CAMP HILL PA 17,011 10/03/2013 Fine 30,843
CONSULATE HEALTH CARE OF CHESWICK CHESWICK PA 15,024 01/22/2015 Fine 29,250
VALLEY VIEW HEALTH & REHABILITATION CENTER ALTOONA PA 16,602 03/25/2015 Fine 28,860
MOUNT CARMEL NURSING AND REHAB MT CARMEL PA 17,851 11/25/2014 Fine 25,968
HOSPITALITY CARE CENTER OF HER HERMITAGE PA 16,148 01/30/2015 Fine 23,920
CHESTER VALLEY REHAB AND NURSING CENTER MALVERN PA 19,355 06/24/2015 Fine 23,660
GOLDEN LIVINGCENTER-MONROEVILLE MONROEVILLE PA 15,146 05/13/2013 Fine 17,518
CONCORDIA AT THE CEDARS MONROEVILLE PA 15,146 05/31/2013 Fine 14,718
WESTMORELAND MANOR GREENSBURG PA 15,601 07/10/2015 Fine 14,138
HARRISON SENIOR LIVING OF CHRISTIANA CHRISTIANA PA 17,509 03/13/2014 Fine 13,390
PEMBROOKE HEALTH AND REHABILITATION CENTER WEST CHESTER PA 19,380 11/03/2014 Fine 13,390
WEATHERWOOD HEALTHCARE AND REHABILITATION CENTER WEATHERLY PA 18,255 07/25/2014 Fine 12,773
BRADFORD COUNTY MANOR TROY PA 16,947 05/03/2013 Fine 12,188
FORBES CENTER FOR REHAB AND HEALTHCARE LLC PITTSBURGH PA 15,206 06/02/2014 Fine 10,000
HCC AT WHITE HORSE VILLAGE NEWTOWN SQUARE PA 19,073 07/23/2013 Fine 9,458
TWIN PINES HEALTH CARE CENTER WEST GROVE PA 19,390 01/08/2014 Fine 8,190
MARWOOD REST HOME, INC PHILADELPHIA PA 19,126 12/04/2015 Fine 6,013
HANOVER HALL HANOVER PA 17,331 09/08/2014 Fine 5,428
WYNDMOOR HILLS HEALTH CARE & REHAB CENTER WYNDMOOR PA 19,038 07/19/2013 Fine 5,200
CHARLES M. MORRIS NURSING AND PITTSBURGH PA 15,217 08/20/2014 Fine 4,550
MANORCARE HEALTH SERVICES-YORK SOUTH YORK PA 17,402 07/30/2015 Fine 4,550
CHESTER VALLEY REHAB AND NURSING CENTER MALVERN PA 19,355 07/11/2014 Fine 2,800
BAPTIST HOMES OF WESTERN PENNSYLVANIA PITTSBURGH PA 15,234 04/05/2013 Fine 2,600
GOLDEN LIVINGCENTER-LANCASTER LANCASTER PA 17,602 05/29/2013 Fine 2,600
REST HAVEN-YORK YORK PA 17,403 07/31/2013 Fine 2,600
CONSULATE HEALTH CARE OF CHESWICK CHESWICK PA 15,024 03/19/2015 Fine 2,600
HIGHLANDS HEALTHCARE AND REHABILITATION CENTER LAPORTE PA 18,626 05/13/2015 Fine 2,600
DUNMORE HEALTH CARE CENTER DUNMORE PA 18,512 05/27/2015 Fine 2,600
GREENERY SPECIALTY CARE CENTER (OF CANONSBURG) CANONSBURG PA 15,317 06/24/2015 Fine 2,600
HEARTHSIDE REHABILITATION AND NURSING CENTER, THE STATE COLLEGE PA 16,801 08/14/2013 Fine 2,282
HEARTHSIDE REHABILITATION AND NURSING CENTER, THE STATE COLLEGE PA 16,801 08/14/2013 Fine 2,282
PAVILION AT ST LUKE VILLAGE, THE HAZLETON PA 18,201 07/15/2015 Fine 1,950
WILLOWBROOKE COURT-GRANITE MEDIA PA 19,063 09/11/2015 Fine 1,950
HEARTHSIDE REHABILITATION AND NURSING CENTER, THE STATE COLLEGE PA 16,801 03/14/2014 Fine 1,820
COLONIAL MANOR NURSING HOME YORK PA 17,403 10/29/2014 Fine 1,690
PLEASANT ACRES NURSING AND REHAB CENTER YORK PA 17,402 06/25/2015 Fine 1,690
PLEASANT ACRES NURSING AND REHAB CENTER YORK PA 17,402 06/25/2015 Fine 1,690
WESBURY UNITED METHODIST COMMU MEADVILLE PA 16,335 06/26/2014 Fine 1,625
VILLAGE AT LUTHER SQUARE, THE ERIE PA 16,502 03/20/2015 Fine 1,625
ST MARY CENTER FOR REHABILITATION & HEALTHCARE LANSDALE PA 19,446 11/22/2013 Fine 1,105
ST MARY CENTER FOR REHABILITATION & HEALTHCARE LANSDALE PA 19,446 11/22/2013 Fine 1,105
ST FRANCIS CENTER FOR REHABILITATION & HEALTHCARE DARBY PA 19,023 12/05/2013 Fine 1,105
ST FRANCIS CENTER FOR REHABILITATION & HEALTHCARE DARBY PA 19,023 12/05/2013 Fine 1,105
ST MARTHA CENTER FOR REHABILITATION & HEALTHCARE DOWNINGTOWN PA 19,335 12/27/2013 Fine 1,105
ST MARTHA CENTER FOR REHABILITATION & HEALTHCARE DOWNINGTOWN PA 19,335 12/27/2013 Fine 1,105
ST JOHN NEUMANN CTR FOR REHAB & HEALTHCARE PHILADELPHIA PA 19,116 12/27/2013 Fine 1,105
IMMACULATEMARYCENTER FOR REHABILITATION&HEALTHCARE PHILADELPHIA PA 19,136 12/27/2013 Fine 1,105
ST MONICA CENTER FOR REHABILITATION & HEALTHCARE PHILADELPHIA PA 19,148 12/27/2013 Fine 1,105
IMMACULATEMARYCENTER FOR REHABILITATION&HEALTHCARE PHILADELPHIA PA 19,136 12/27/2013 Fine 1,105
ST MONICA CENTER FOR REHABILITATION & HEALTHCARE PHILADELPHIA PA 19,148 12/27/2013 Fine 1,105
ST JOHN NEUMANN CTR FOR REHAB & HEALTHCARE PHILADELPHIA PA 19,116 12/27/2013 Fine 1,105
Generated by wpDataTables

So, should you rely on the government’s star rating when choosing a nursing home for a loved one? No. While a facility’s star rating can be a helpful tool, you should always look deeper and examine several factors. Careful examination of the Quality Measure scores, Medicare fine and payment suspension data, along with personal visits should all be used in order to make the best possible decision for your loved one. 

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