CMS Star Rating Process, with Wide State Variation, Sparks Trouble for Consumers and Nursing Homes

Hundreds of nursing homes continue to maintain or display high star ratings despite Immediate Jeopardy incidents in the previous three years, and this can create headaches for both nursing homes and consumers alike.

According to a Scripps News analysis released Wednesday, which takes in to account government data from February 2024 of more than 14,000 nursing homes, there may be a lag of several months before the citations and corrections get filtered into the calculation for the star ratings, in turn misleading consumers.

But sector experts, who spoke to Skilled Nursing News, said that it’s common to see the lag because of the way the system is set up – and it can cause legal and financial problems for nursing homes as well.


Due to the process in place, there’s a six-month gap between when a facility submits data to the Centers for Medicare & Medicaid Services (CMS) and when it’s integrated into the star ratings. The gap pertains to submission of Minimum Data Set (MDS) and payroll-based (PBJ) data to CMS, experts said.

“So there’s the concept of an expected delay in when a facility is filling out data on the minimum data set, and the PBJ files and they’re submitting them on schedule to CMS … No one’s late, no delays, but by design there’s six months between when a facility is submitting data to when it’s reflected in the star ratings,” said Steven Littlehale, chief innovation officer at Zimmet Healthcare Services Group.

CMS created the Five-Star Quality Rating System to help consumers compare nursing homes. The overall star rating is calculated from state health inspection surveys, staffing levels reported at the time of the survey, and finally on 15 quality measures. Ten of these measures are from the MDS, while five are from Medicare claims data.


Incidents of noncompliance with federal health and safety standards that put residents at risk of injury and even death, are deemed Immediate Jeopardy (IJ).

When a nursing home receives an Immediate Jeopardy citation, it can take corrective action and come into compliance, but the process takes its due course.

In the meantime, citations for Immediate Jeopardy are publicly displayed on the Nursing Home Care Compare website, but they are not included in a facility’s star rating until the dispute is complete.

The Scripps News story cites the case of Touchmark on South Hill – a facility near Spokane, Washington – for which the Immediate Jeopardy wasn’t reflected in the ratings for a very long time, in turn misleading consumers. The facility continued to maintain an overall top rating of 5 stars for nearly seven months following a resident’s death. Eventually, the nursing home’s overall rating did drop to its current 3-star rating.

At least 247 nursing homes in the Scripps News analysis had 4-star or 5-star ratings despite also being found to have had at least one Immediate Jeopardy incident in the previous three years.

Also, the Scripps investigation found that the Immediate Jeopardy was removed within months of the death of a resident.

For example in Pennsylvania, an elderly woman froze to death outside her nursing home in 2021 after staff failed to notice she was missing. Despite a finding of Immediate Jeopardy, the facility continued to maintain a 5-star rating for more than a year following the incident before dipping to 4 stars for three months and then returning to 5, the Scripps News investigation states.

Meanwhile, in Minnesota, a facility maintained a 5-star rating for more than a year after a resident slipped out of the facility in 2021, purchased a knife and killed himself. The facility then dropped to a 4-star rating for several months before returning to 5.

Wide state-level variation on star rating calculation

Moreover, the method by which the federal government assigns ratings to nursing homes varies by state, Scripps News states.

“Even with the same health inspection findings, a nursing home that has a 5-star rating in one state could be rated much lower in a different part of the country. That’s because a nursing home’s health inspection rating — the baseline for its overall rating — is assigned based on how its inspection findings compare to other nursing homes in the same state,” the story states.

There were 397 nursing homes with 4- and 5-star ratings that could have had just 1 star if they were rated against a different state’s homes, the analysis found.

While some of the factors used in calculating a facility’s rating, namely staffing and quality, are determined using national thresholds, the health inspection scores that contribute to an overall federal star rating are based on comparisons to other facilities in the same state, Julie Brookhart, a spokesperson for CMS told Scripps News.

“This is due to variations between states,” she said. “When someone is looking for a nursing home, they are typically looking for one in a particular state … So, using the in-state comparison provides more relevant information about the local conditions for consumers.”

Star ratings may not reflect every individual incident that occurs, Brookhart conceded. “They are a summary of many different data elements to reflect a general level of quality on a scale of 1 to 5.”

Brookhart also said that only 1% of nursing homes with high ratings had an Immediate Jeopardy on their most recent inspection cycle.

“It is likely that these … facilities had an isolated issue leading to the [Immediate Jeopardy] but did not have many other citations that could indicate systemic issues,” Brookhart said. “We recommend individuals contact the nursing home they are considering and talk to the administrator, director of nursing or medical director, and inquire about the type of care they provide and ask questions that are important to them,” Brookhart said.

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