Why You Should Not Rely on Medicare’s Nursing Home Ratings

Are you looking for a nursing home for your loved one? If so, we probably don’t need to tell you how daunting the task can be. From ensuring that the facility you’re considering can meet your family member’s specific needs to finding a well-staffed nursing home that can provide a safe and welcoming environment, you have many considerations to make.

One tool for families searching for nursing home facilities is Medicare’s Nursing Home Compare, through which individuals can see the ratings of specific nursing homes and compare their offerings to other facilities in the region. While this tool is helpful in that it provides access to the most recent inspection report and other information, Medicare ratings should not be relied on as the sole decision-maker when selecting a facility. Read on to learn why you cannot trust the ratings and why you should not be afraid to take on a highly rated facility that abuses your loved one.

About Medicare’s Nursing Home Ratings

Initially introduced in 2008 and revamped in 2019, the Centers for Medicare & Medicaid Services bases its rating system on a five-star scale in three different categories. One-star ratings indicate that the facility is much below average in that specific category, while a five-star rating indicates that the facility is much above average.

The three categories that receive star ratings include:

• Health inspections: Medicare bases its star ratings on the outcome of the facility’s three most recent annual health inspections as well as investigations against any complaints that were made against the facility during that time.
• Staffing: This category considers the number of hours that specific staff members—such as registered nurses, certified nursing assistants, or physical therapists— provide care to each resident. Facilities in which residents have more severe needs generally need more staff.
• Quality measures: Quality measures evaluated several categories, including the number of residents requiring hospitalization, the number of residents with new or worsening bedsores, how many residents receive antipsychotic medication, how many staff physically restrained, how many have received pneumonia or flu vaccines, and more.

Problems With the Rating System

Recently, the New York Times published a lengthy article about the problems with relying on Medicare’s star system to find a quality nursing home for your loved one.

Based on extensive analysis of the data provided through the federal Nursing Home Compare website and years of warnings from experts that the ratings were actually providing a means for nursing homes to game the system, some highlights of the New York Times’ findings include:

• The federal government, through its Medicare/Medicaid certification of nursing homes in the U.S., provides monetary incentives to facilities based on star ratings. Facilities with five-star ratings receive $2,000 in profits per bed, while those with three or four stars have a price tag per bed of $1,000 per bed.
• Much of the information that facilities self-report to Medicare—such as staffing levels—is wrong. Often, this information makes the nursing home facility look safer or cleaner than it really is.
• Nursing homes manipulate the information, such as including employees who are on vacation as staff available to provide care to residents, understating the number of residents taking antipsychotic medication, and not reporting all accidents and worsening health problems that residents have experienced.
• Nursing homes with five-star ratings for their quality of care tend to have more deficiencies in their in-person inspections. Unfortunately, the federal government rarely audits the data that is provided to them by the facilities. Some issues discovered through analysis of these highly-rated facilities include residents with bedsores so severe that bones were exposed.
• Data suggests that nursing homes appear to receive advance notification of “surprise” inspections and that, while inspectors routinely find incidences of abuse and neglect at five-star facilities, those discoveries rarely result in a reduction of ratings. About 70 percent of nursing homes increased their staffing by about 8 percent on the days that the inspections occurred. More than 800 nursing homes had the highest staffing levels on the day of their inspection than they had on the same day of the week any other time of the year. In 2017, a state health inspector in Florida pleaded guilty to accepting half a million dollars in bribes to provide advance notification of surprise inspections to nursing homes.
• Out of 3,500 five-star rated nursing homes that the Times analyzed, 2,400 were cited for problems with either infection control or abuse.
• In a two-year timeframe, the federal government wrote up 5,700 nursing homes—more than one out of every three nursing homes in the country—for misreporting resident data, including 800 highly rated facilities.
• Roughly half of the nursing homes in the U.S. are underreporting issues that point to neglect in the facility, such as residents who experience falls or bed sores. Nursing homes did not report to the federal government about 40 percent of incidences in which a resident required hospitalization for the injuries they sustained in a fall.
• When self-reporting staffing levels, thousands of nursing homes—including more than 450 with four- or five-star ratings—derived at least half of their staffing hours through administrators who are not directly involved in resident care.
• At one five-star rated home, a resident was raped by a nursing assistant. However, the incident was categorized on the inspection report as a “category F” violation, which is a low-level problem that caused potential but not actual harm. Forty other five-star facilities the Times analyzed also had sexual abuse violations that were categorized as minor incidents that did not place residents at risk of actual harm.
• The first known case of Covid at a U.S. nursing facility occurred at a five-star rated facility that had been found deficient in pre-pandemic inspection reports of failing to consistently implement an effective infection control program.

Abuse in Nursing Home Facilities

Despite years of indications that the prevalence of abuse and neglect in nursing homes is far higher than reported, research on the topic is limited. However, one study focused on the answers provided on a survey of certified nursing assistants (CNAs) working in long-term care facilities indicated that 81 percent of respondents had witnessed staff members psychologically abusing residents and 40 percent confessed to psychologically abusing residents themselves within the past year.

Yelling or swearing at a resident in anger was the most commonly reported form of psychological abuse, with 70 percent of the CNA participants stating that they had witnessed this behavior from coworkers toward residents.

Other commonly mentioned forms of psychological abuse included:

• Inappropriate isolation of the resident.
• Threatening to hit or throw an object at a resident.
• Denying food privileges.

Physical abuse includes slapping, hitting, punching, or striking a resident, and can also include improper use of physical or chemical restraints, as well as sexual abuse, which involves nonconsensual sexual acts, including unwanted touching, indecent exposure, or rape.

Neglect involves the failure to provide basic needs to the resident. Examples of neglect, as offered by the CNA survey participants include actions such as denying a resident medical, dental, or psychological care; failing to change residents promptly when they have been incontinent; failing to provide the resident with adequate nutrition and hydration; failing to follow the resident’s personal care plan, including provisions for fall prevention or the prevention of bedsores; failing to provide necessary assistance with toileting, eating, and personal hygiene tasks.

Reporting the Abuse

If you have reason to believe that a nursing home is abusing or neglecting your loved one:

• If you believe your loved one is in immediate danger of physical harm or death, call 911 and report your suspicions immediately.
• If the danger is not imminent, report your suspicions as soon as possible to either the police, your local adult protective services department (this is usually an arm of your local Department of Social Services), or to your state’s long-term ombudsman program. If you are unsure as to who you should contact, you can obtain information Monday–Friday, from 9 a.m. to 8 p.m. Eastern Standard Time, from the Eldercare Locator, by calling 1-800-677-1116.
• Call a nursing home lawyer for help with the above steps, and to learn about how you may seek compensation for the damages you or your loved one sustained.

Recovering Damages for Your Loved One

Once you have reported your suspicions to the proper authorities and have ensured your loved one is receiving care for the physical and psychological injuries resulting from the abuse, think about holding the facilities that fail to provide quality care to their residents accountable and obtain compensation for the costs and impacts of the injury.

The process of obtaining compensation for the expenses and quality-of-life impacts that resulted from nursing home abuse and neglect is through a nursing home neglect or abuse lawsuit, or—in cases in which the elder has died from his or her injuries—a wrongful death lawsuit. These are legal claims filed in civil court that seek to prove who is liable (legally responsible) for the injury and show the expenses and impacts that your loved one suffered.

In nursing home abuse and neglect cases, liable parties can include:

• Staff members who failed to provide a standard of care that observes the federal rights conveyed to nursing home residents.
• The facility tasked with ensuring that all staff members are properly qualified and trained for their positions and that it has established and enforced policies to provide adequate care for residents and avoid injury or illness.
• Other medical providers affiliated with the facility or involved in your loved one’s care who failed to provide the standard of care or failed to report known or suspected abuse of the resident.

Damages refers to a payment made in compensation for harm.

Some of the damages that plaintiffs can recover in a nursing home negligence case include:

• All medical expenses incurred in the treatment of nursing home abuse and neglect.
• The cost of relocating your loved one to a different facility that will meet his or her needs.
• Physical and emotional pain and suffering resulting from the abuse.

Hughey Law Firm Stands up to Highly Rated Nursing Homes

Federal nursing home reform laws require nursing home facilities to uphold the rights of nursing home residents that maintains or improves their quality of life, ensures them a dignified existence free of discrimination and abuse, and allows the resident to have as much say as possible in his or her medical care and daily activities.

While nursing homes apparently can fudge the numbers to garner a high rating without being audited by the federal government, they should not provide substandard care to the detriment of the elderly and vulnerable residents they must care for and protect.

Hughey Law Firm aggressively fights for the rights of our elderly clients and their families to obtain the compensation they deserve after suffering an injury due to nursing home abuse or neglect.

Our recent results include:

• $235,000 for a client who was allowed to suffer a fall, resulting in a left scaphoid fracture and lacerations to her head.
• $260,000 for a client who was allowed to go for eight days without nutrition and hydration.
• $340,000 for a client who suffered a complete lack of care that resulted in skin breakdown, a urinary tract infection, dehydration, and ultimately death.

Let our experienced nursing home abuse and neglect attorney explain your legal options and the process of obtaining compensation for you during a free case evaluation. Contact us online or by calling (843) 881-8644.

Nathan Hughey

Nathan Hughey, an attorney and fourth-generation South Carolinian, founded Hughey Law Firm in 2007. Before that, he spent five years defending nursing homes and insurance companies. Leveraging his experience, he now advocates for those injured or wronged by such entities, securing over $220 million in verdicts and settlements.