Research Indicates Five-Star Quality Rating System Needs Revision

After examining data from recertification surveys and complaint investigations from 15,499 investigations, a JAMA study found that the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System may be in need of revision.

Consumers use the Five-Star Quality Rating System to make nursing home choices, which incorporates data from both recertification surveys and complaint investigations but is presented as a single rating.

When recertification and ratings are combined, consumers can have a less clear picture of the quality of care provided, researchers concluded.


The JAMA study broke down the health inspection star rating into separate recertification and complaint ratings.

“We found evidence that complaint investigations provide information that varies from information derived from recertification surveys. Specifically, the star ratings based on complaint investigations differed considerably from the overall health inspection star ratings we constructed,” researchers wrote.

Researchers said that an absence of complaints may indicate that consumers are pleased with a nursing home’s care and service but also may indicate that they are unaware of their complaint options, have difficulty reporting complaints, or fear retaliation.


Of the nursing homes studied, researchers found that 19.8% had a 1-star overall health inspection rating, 23.2% had a 2-star rating, 23.2% had a 3-star rating, 23.2% had a 4-star rating, and only 9.8% had a 5-star rating.

“However, overall and complaint-based star ratings were discordant, with a relatively large proportion of nursing homes (25.7%) having no complaint deficiencies and therefore high star ratings,” researchers wrote.

Researchers suggest that CMS develop a complaint-focused quality metric that represents the perspectives of residents, families, and others with quality concerns. Yet the drawbacks would be that for nursing homes with no substantiated complaints it is unclear whether their consumers were pleased with care or just faced barriers to lodging complaints.

Although in 2016 the US Government Accountability Office recommended that CMS evaluate the feasibility of adding consumer satisfaction survey results to the Five-Star system, only Minnesota and Ohio have such mandated surveys. 

The efficacy of the Centers for Medicare & Medicaid Services’ Five-Star Quality Rating System and Care Compare is often called into question. Most recently, CMS announced that it will publicly display survey citations that nursing homes are disputing on Care Compare. The citations will not be included in a facility’s Five-Star rating calculation while under dispute.

“While the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance such as Immediate Jeopardy (IJ) citations,” CMS noted in its announcement.

Even though the citations will not be included in the Five-Star rating while under dispute, industry stakeholders said it will be ‘punitive’ for operators.

“Unfortunately, [the new measures] are meant to be punitive,” GAPS Health CEO Dr. Jerome Wilborn told SNN, in reference to CMS’s new measures to reduce the use of antipsychotics. “And that is because as an industry, we don’t do a great job with the management of antipsychotics.”

Additionally, with the Biden administration’s minimum staffing mandate to be unveiled this spring, CMS proposed that facilities incorporate staffing data into Nursing Home Care Compare and the Five-Star Rating System.

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