The Worst Nursing Homes, List, Rankings and Data

What Makes a Skilled Nursing Facility One of the Worst Nursing Homes, How to Use Our Database of the Worst Nursing Homes

Every month we rank all of the skilled nursing facilities in the United States. The rankings for nursing homes are based on extensive metrics that are provided by The Centers for Medicare & Medicaid (“CMS”). The metrics include the CMS 5-Star Rating System which rates skilled nursing facilities using a rating system of five stars, where one star is the lowest and five stars is the highest rating. The rating system also rates nursing homes across five different dimensions including overall rating, health inspection rating, quality measures rating, overall staffing rating, and RN staffing rating (RN is an acronym for Registered Nurses).

In addition to the 5-Star Rating System, CMS provides numerical metrics that summarize:

• Health Inspection Data. CMS provides four numerical metrics related to the most recent health inspection surveys. These values, also known as “cycle scores”, are a distillation of detailed surveys conducted by a team of inspectors over a multi-day period. A score of each of the three most recent periods is provided along with a weighted score which is a combination of the three periods weighted towards the more recent periods. CMS estimates that more than 400,000 data points are used to calculate the four health inspection scores.
• Nursing Hour Statistics. Using multiple reporting methods, CMS calculates the amount of time that the nursing staff spends with residents. This is measured across multiple dimensions, one each for three different levels of nursings, including Registered Nurses (“RNs”), Licensed Practical Nurses (“LPNs”) and Certified Nursing Assistants (“CNAs”), plus one metric that totals all contributions. These metrics are expressed in hours per resident per day. CMS also provides state-level and national averages for the metrics to allow for additional comparisons.
• Abuse Flag. Abuse is always a concern in skilled nursing facilities. To highlight the issue, CMS has extracted this feature as its own flag. Facilities with an actual abuse event or where the potential for abuse has been shown for the past two years are flagged. The Health Inspection Score is capped at 2-stars for nursing homes that have been flagged for abuse.

Skilled nursing facilities that are new and do have at least two surveys completed are not rated by CMS. These facilities may have health inspection scores which can be used to evaluate the facility.

While this may seem like a lot of information,it has some drawbacks. The most significant problem is that when CMS calculates its 5-Star Rating, it does so based in part on state-level rather than national level data. Specifically, the health inspection star rating, which is the basis for the overall rating, is based on how a skilled nursing facility performs within the state not nationally. The top 10 percent of nursing homes with the lowest weighted health inspection score are given a 5-star rating. What qualifies for this cut varies from state to state (take a look at this cut-rate analysis by state).

What has also become problematic is that the frequency of nursing home inspections has declined since the beginning of the Covid pandemic. Inspections should be performed at least once every 12 months. CMS admits that in "rare cases" this could slip to 15 months, but our analysis suggests that the lag time between inspections is longer. This report shows that the lap time is now just under 500 days (or more than 16 months). There are also now hundreds of skilled nursing homes that have not been inspected in more than 24 months. This list shows the skilled nursing homes with the longest period since being inspected. According to the CMS data these homes have not been inspected since 2018!

The rating system is also biased against new nursing homes. An overall rating is not awarded until a nursing home has gone through two annual inspections meaning that at least two years and likely more time passes before we can use the 5-Star system with a nursing home.

While the cut-points for the health inspection ratings may change from month to month, the rating for a given skilled nursing facility is held constant until there is a change in the weighted health inspection score for that nursing home.

The CMS 5-Star Rating Quality Rating System for Nursing Homes

CMS has put a lot of effort into creating its 5-Star Quality Rating System expressly to provide a quick way for residents and family members to easily understand what is a very complicated review process. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and worst performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.

The rating system has five separate ratings including:

• Overall rating
• Health Inspection rating
• Staff rating
• RN Staffing rating
• Quality Measures rating

Nursing homes are rated from 1-star to 5-stars with 1-star being the worst rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS.

Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :

1. Begin with the Health Inspection Rating
2. Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
3. Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
4. Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
5. Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.

Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)

Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.

Components of the 5-Star Quality Rating System

CMS builds its 5-Star Quality Rating System using analysis from three domains (if you thought there were going to five domains then you've taken this idea of symmetry too far!):

• health inspections surveys,
• analysis of staffing hours per resident, and
• multiple quality measures that are based on analysis of outcomes derived from Medicare claims data.

Health Inspection Scores

The first and most important domain iis the Health Inspection Score (previously known as the Cycle Score). Health Inspection Scores factor in the number, scope and severity of deficiencies identified during annual on-site health inspections. The scores also factor in data from complaint investigations, infection control surveys, and accounting for number and timing revisits that are required to confirm that deficiencies have been corrected. Nearly 400,000 data points are used to compute the Health Inspection Scores.

CMS states that it conducts annual health inspections of all of the over 15,000 skilled nursing facilities. Only rarely does the period for an annual inspection exceed 15 months. (This has changed dramatically since the beginning of the Covid pandemic. CMS is very far behind at this point.)

The inspections are unannounced, take place over multiple days, and involve a team of healthcare professionals. During the inspection period, the team evaluates:

• Residents rights
• Quality of life for residents
• Medication Management
• Skin Care
• Resident Assistance
• Nursing Home Administration
• Overall Environment, and
• Kitchen and Food Services

In general a home is assessed points for any deficiencies that are discovered. Lower scores are therefore better. The worst nursing homes will have high Health Inspection Scores.

To calculate the total weighted score, more recent standard surveys are weighted more heavily than earlier surveys with the most recent period (rating cycle 1) being assigned a weighting factor of 1/2, the previous period (rating cycle 2) having a weighting factor of 1/3, and the second prior period (rating cycle 3) having a weighting factor of 1/6. The individual weighted scores for each cycle are then summed (after including complaint surveys, focused infection control surveys, and revisit points) to create the total weighted health inspection score for each facility. Complaint or focused infection control surveys that occurred within the most recent 12 months from when the data are uploaded receive a weighting factor of 1/2; those from 13-24 months ago have a weighting factor of 1/3, and those from 25-36 months ago have a weighting factor of 1/6. For facilities missing data for one period, the Health Inspection Score is determined based on the periods for which data are available, using the same relative weights, with the missing (third) survey weight distributed proportionately to the existing two inspections using two survey cycles. Specifically, when there are only two recertification inspections, the most recent survey cycle receives 60 percent weight and the prior cycle receives 40 percent weight.

Facilities with only one standard health inspection are considered to have insufficient data to determine a health inspection rating. For these facilities, no overall quality rating is assigned,

Each of the Health Inspection Scores for the prior three periods plus the Weighted Average Health Inspection Score is available on the detailed skilled nursing home pages.

Staffing Hours Spent Per Resident

Staffing is the second domain that CMS considers. There is considerable evidence that better outcomes for patients are highly correlated with the time the nursing staff spends with the patient. (CMS does adjust these values based on the type of treatment the patient is receiving, as certain treatments require more attention from nursing staff than others.) Staffing ratings are based on the hours per day spent per resident by RNs and the number of hours per day spent per resident by the entire nursing staff (RNs, LPNs, and CNAs). The metrics are based on data accumulated over the past two quarters. CMS calculates these measures using quarterly reporting from nursing homes through the PBJ System (sorry not Peanut Butter and Jelly. It’s Payroll-Based Journal) and other reporting by the nursing homes.

The data on hours is self-reported by the nursing homes, though CMS does audit the data for accuracy. Resident numbers are based on daily census numbers that the nursing homes provide through the MDS (“Minimum Data Set”) reporting. The hours include hours spent by the nursing director, full-time and part time staff and any contract labor. The metrics do not include outside nursing staff contracted by the residents directly.

A rating of 1-star is awarded to nursing homes that fail to report staffing data promptly or if no RN hours are recorded for four or more consecutive days in a quarter when the nursing home has residents.

Each of the staffing metrics is shown on the detail page for the skilled nursing facilities.

Quality Measures for Evaluating Nursing Homes

CMS tracks 15 separate Quality Measures to form the third dimension of its 5-Star Rating System. Long-term skilled nursing patients are assessed using 9 measures while short-term residents are evaluated using 6 measures. Some examples of quality measures are the percentage of residents:

• Whose ability to move independently is worsened
• Whose need for help with daily activities has increased
• With urinary tract infections

According to CMS not all of these quality measures are used when calculating the Quality Measure Star Rating. Some metrics are risk-adjusted using resident level covariants. For example, the catheter risk-adjustment model takes into account whether or not residents had bowel incontinence or pressure sores on the prior assessment. Risk adjustment for the rate of successful return to home and community from a SNF measure uses data derived from Medicare enrollment data and Part A claims.

Metrics use the four most recent quarters data except for the rate of successful return to home which uses a two-year period. This is used to have more data for the calculations. Values for the claims-based measures and the short-stay pressure ulcer/pressure injury measure use full-year data instead of 4 quarters. Calculations need full data on at least 20 residents to be valid. If the home has less than 20 then certain data such as state averages is added. Quality measures are weighted differently with some measures having a maximum score of 150 while other measures have a maximum score of 100. For all measures, points are calculated based on performance relative to the national distribution of the measure. Points are assigned after any needed imputation of individual QM values. Quality measures are typically updated at the beginning of each quarter.

The Worst Nursing Homes in Each State

The table below shows the number of low ranking nursing homes in each state and the number of nursing homes that have been cited for abuse in each state. Click on a state to see the Ten Worst Nursing Homes in Each State.

Find Abuse in Nursing Homes

Starting in 2019, CMS has added a field to the provider level data that identifies nursing homes where abuse is a problem. Nursing homes with document abuse should be avoided. According to CMS the criteria for applying the abuse label are where:

• A harm level abuse has been cited in the more recent survey cycle. This includes facilities where residents are found to be harmed on the most recent standard survey or on a complaint or focused infection control survey in the past twelve months
• Where repeat abuse citations have been issued. This includes facilities where residents have been found to potentially be harmed, no document of actual harm, within the past twelve months months and during the prior twelve month period.
• Health inspection ratings are capped at a maximum of two stars for facilities that are flagged for abuse and their overall rating cannot be more than four stars.

There were 823 facilities that were flagged for abuse in the database effective May 1, 2022. The database contains 15,197 nursing homes, meaning that in 5.4% of the skilled nursing facilities either actual harm has occurred in the past 12 months or the potential for abuse has been noted for the past 24 months!

Of the skilled nursing facilities with an abuse flag, 32 had four-star overall ratings.

Other Interesting Lists About Nursing Homes Compiled by NursingHomeDatabase

• Best Nursing Homes
• Newest Nursing Homes
• Nursing Home Ratings Upgrades
• Nursing Home Ratings Downgrades
• Nursing Home Most recent Inspections
• Nursing Homes with the longest time since being inspected
• CMS Scores Required for Nursing Home Five Star Ratings
• Nursing Homes with the Highest Nursing Time Spent per Patient
• Nursing Homes with the Lowest Nursing Time Spent per Patient