Unreliable nursing-home ratings raise disturbing questions - leaving families at a dead end

By Brett Arends

The government's 'star' ratings for nursing homes are misleading, new research finds

How reliable are guides to nursing homes, really?

Right now there are about 1.4 million Americans living in nearly 15,000 nursing homes, and the number is rising as baby boomers get older.

To choose a home, many residents and their families rely on the "star" ratings published by the federal government's Centers for Medicare & Medicaid Services. These are supposed to offer some level of assurance about the quality of the treatment residents should expect. These ratings range from one star to five and are published and updated monthly. All the evidence is that people rely on them, in many cases a great deal, when they decide it's time for someone they love to move into a nursing home.

New research is raising disturbing questions about how reliable these ratings are.

Researchers from Georgetown University, Northwestern University and Texas A&M University found that these star ratings fluctuate so much for individual homes that it is hard to take them at face value. They found that the ratings are based on opaque, black-box style calculations that obscure what is really being measured. They warn that those factors include self-reporting by nursing homes, a flaw pretty much guaranteed to hide abuse. And they add that the actual meaning of these star ratings varies from state to state, because the facilities in each state are effectively graded on a curve.

"General volatility, especially without transparency about its causes, can undermine the credibility and usefulness of the star rating system," report David Hyman, Anton Chorniy, William Sage and Bernard Black. "From any initial date, roughly half of one-star homes gain one or more stars and a similar percentage of five-star homes lose one or more stars within six months. It seems unlikely that actual quality fluctuates this much, or this rapidly."

These fluctuations aren't purely random, either. They reflect not just any actual changes or improvements in nursing-home quality, but also "inspections, and reporting practices," they write. There is evidence many nursing homes hire new staff, pause new admissions and improve patient care before inspections - before reversing these improvements once the inspections are over.

The ratings are also "vulnerable to self-reporting bias," they add. Actually, it's worse than that. Nursing homes are supposed to report, for example, how many times residents had to be taken to hospital emergency departments. This means the nursing homes that are the slowest and most reluctant to call an ambulance actually end up with better ratings.

Researchers found that for-profit nursing homes were more likely to have lower ratings than nonprofits.

The AHCA, the trade association for nursing-home operators, said it shares many of the study's concerns. "Residents and families deserve clear, timely information about a nursing home's performance, but the Five Star Rating System isn't delivering," the group's press office said in a statement. "Public facing data should reflect actual performance and be consistent across facilities to assist consumers in making the most informed decision about their care."

The AHCA blamed underpayment by Medicaid, rather than any profit motive, for the reported poorer performance by for-profit homes.

"Do not rely on the ratings system," says Carole Herman, a veteran campaigner on behalf of abused and neglected nursing-home residents and their families. "The ratings system is not accurate - the information the system takes is from self-reporting from the industry."

Herman, who founded and runs the nonprofit Foundation Aiding the Elderly, says the best way to check out a nursing home for a loved one is by making a personal inspection. "If you don't have a good feeling, walk out," she says.

You may reasonably conclude this is a haphazard system by which to make such important decisions. Maybe the system would be better if more people actually cared.

-Brett Arends

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03-11-26 0945ET