Medicare employs a five-star quality rating system for nursing homes throughout the United States. Nursing homes that receive a five-star rating are supposed to be the best in the nation – only about one-fifth of the more than 15,000 nursing homes in the United States have received a five-star rating. Medicare awards stars based on three criteria: health inspections, staffing, and quality measures.
The Medicare nursing home rating system can be manipulated by the owners and management of nursing homes because two of the three criteria – staffing levels and quality measures – are self-reported by the nursing homes to Medicare. Medicare generally accepts as true, without verification, the information reported to them from nursing homes regarding their staffing levels and their quality measures. If the reported information in these two categories is misrepresented, wrong, or fraudulent, nursing homes may receive higher ratings (more stars) than they would otherwise be entitled had the true and accurate information been provided. Because so many families look to and rely on the published Medicare nursing home star ratings when looking for and choosing a nursing home for a loved one, they may be deceived to the detriment of their loved one when basing their choice of nursing homes on unreliable Medicare star ratings.
For-profit nursing homes, many of which are owned and operated by large corporate chains, attempt to maximize their billings and profits by maximizing the number of patients in their facilities – the more residents they have (who are attracted by the higher Medicare star ratings), the more money they receive, which is reflected in their balance sheets and reported to their shareholders. Not only are residents and their families deceived by falsely reported information to Medicare, but the investors of the nursing homes are also deceived about the quality of their investment. Lenders also look to the Medicare star-rating of nursing homes when evaluating whether to loan money to the owners, and under what terms.
With so much at stake when Medicare determines how many stars a nursing home receives, nursing home owners and managers have learned how to game the system: while 37% of nursing homes achieved four-star or five-star ratings when Medicare first began the star-rating system in 2009, by 2013, almost one-half of nursing homes had been awarded the top two star-ratings. Nearly two-thirds of the more than 50 nursing homes that are on the federal watch list for quality issues are rated four or five stars by Medicare for the self-reported criteria: staff levels and quality measures. Yet more than 95% of the nursing homes on the federal watch list received only one or two stars for health inspections, which are independently conducted by the states in which the nursing homes are located.
Staffing Level Stars
Nursing homes have an incentive to misrepresent their self-reported staffing levels to Medicare: they receive an extra star for their overall rating if their staffing level rating is four or five stars. Only 39% of nursing homes received an extra star for staffing levels in 2009, yet by 2013, 52% of nursing homes received the extra star for receiving four or five stars for their staffing levels. Nursing homes can manipulate their self-reported staffing levels by adding staff shortly before their annual inspections – they know in advance when the annual inspection will occur. After the inspection period, the additional staff often disappear.
Quality Measures Stars
Nursing homes have an incentive to misrepresent their self-reported quality measures to Medicare: they receive an additional star for their overall rating if their quality measures is five stars. The percentage of nursing homes that have received five-star ratings for quality measures has increased from 11% in 2009 to 29% in 2013. Nursing homes can manipulate their quality measures data, which are based on matters such as the number of residents who have serious falls or who develop pressure ulcers (and the seriousness of the bedsores), by down-playing the severity of such injuries in their residents’ records (e.g., documenting a Stage III pressure ulcer as a Stage I pressure ulcer).
The New York Times recently reported on a nursing home located in California that Medicare had awarded five stars. Despite its highest rating from Medicare, the nursing home was fined the highest fine possible ($100,000) by California in 2013, for the death of a resident in 2006 due to an overdose of a blood thinner. This same highest-rated nursing home was subject to at least 102 consumer complaints between 2009 and 2013, which is much higher than the state average. It is reported that many of the nursing home residents live three in a room, there is a shortage of quality staff, and there is often a scarcity of basic supplies, such as washcloths.
If you or a loved one suffered injuries (or worse) while a resident of a nursing home in the United States, you should promptly consult with a nursing home claim lawyer in your state who may investigate your nursing home claim for you and represent you in a nursing home negligence, nursing home abuse, or nursing home neglect case, if appropriate.
Click here to visit our website or telephone us toll-free at 800-295-3959 to be connected with nursing home lawyers in your state who may assist you.
Turn to us when you don’t know where to turn.