New ratings say only modest proportion of nursing homes are high performers

Photo: Josh Rushing via Flickr

Fewer than 20% of nursing homes in the U.S. are considered “best” under a revamped analysis from U.S. News and World Report, which is out with its 2019-20 ratings on Tuesday.

Ratings are provided for homes in every state and nearly 100 major metropolitan areas. California tops the list, with 169 nursing homes receiving a “high performing” rating in short-term rehabilitation and 157 “high performing” homes in long-term care, followed by Pennsylvania and Florida. Hawaii, Alaska and Washington, D.C., have the highest proportion of “best nursing homes,” with at least half of all Medicare or Medicaid-certified nursing facilities in these states receiving a high-performing designation in either short-term rehabilitation or long-term care or both.

Just 2,969 of 15,530 homes evaluated met the publication’s criteria for “high performing” in short-term rehabilitation, long-term care or both. Of those, 2,250 facilities are recognized as “best nursing homes: short-term rehabilitation 2019-20,” and 1,139 facilities are recognized as “best nursing homes: long-term care 2019-2020.” Only 420 nursing homes received both distinctions.

The proportion of high performers was comparable to the publication’s “best hospitals” ratings, according to the Zach Adams, senior health data analyst at U.S. News.

These ratings use the same public data as the Centers for Medicare and Medicaid (CMS) but use different methodologies to determine its ratings than the CMS Five-Star Quality Rating System, so ratings for the same nursing homes may differ, Adams said in a phone interview. “We wanted to build our own rating system, much in the way that we build our own ratings for hospitals.”

His team pulled data going back at least a year from CMS’ archive. The overall ratings are based how well the home performs on all quality of care or all types of care that it offers. Input from nursing home quality experts also was considered.

The measures used for the rating system for nursing homes could use a second look, according to Ruth Katz, SVP Public Policy/Advocacy at Leading Age, a national organization representing nearly 2,000 nonprofit aging service providers around the U.S.

The five-star system compares a nursing home’s performance on quality measures, staffing, and health inspections only against the performance of other nursing homes in the same state. A five-star rating means only that a nursing home is performing much better than other nursing homes within its state, according to the organization.

“This system of rating nursing homes does not give consumers as much information as they need and should have to pick the best nursing home for themselves or their family members,” Katz said in an emailed statement. “It’s time to rethink how we look at nursing home quality and regulatory enforcement. The real aim is quality of life and quality of care. We may not be hitting the mark with our current paradigm.”

Leading Age has long advocated for a revision to the survey system, according to Katz. “We see vast ranges of number of citations and size of penalties across the states. We don’t believe these differences reflect differences in quality as much as in how the survey teams approach their work. Even (CMS) recognized this in its recent guidance on survey agencies.”

U.S. News began using a composite quality measure rating for short-term rehabilitation (less than 100 days) in 2018, which assessed the performance of skilled nursing facilities in post-acute care for surgery, heart attack, stroke, injury or similar conditions. This year, a similar metric for long-term rehabilitation (more than 100 days) was added.


Nursing homes are designated as high-performing, average, or below average in the care they provide to individuals, according to this methodology, which evaluates factors most affecting patient and resident care, safety and outcomes.  Staffing levels and consistency are strongly emphasized. 

Adams and his team analyzed the percent of the time that federal standards for registered nurse staffing were met, but that information could get lost if only looking at the average over a quarter or a year, he said. “So we built on that from the payroll-based journal, which has information on all types of staffing hours at every home in the country, every day.”

Considerable weight also is given to metrics like how often short-term patients successfully return home and how often long-term residents require hospital care. They are among the most important and most reliable quality measures available, according to Adams.

“What is clear from this analysis is that there are many ways to look at what defines quality,” said Katz. “Now is a good time to have a public discourse on the measures that would help us — consumers, providers and policymakers — to determine the definition of quality, to ensure that our loved ones, and one day ourselves, will receive the care that we want and expect.”

The short-term rehabilitation rating took into account 10 measures of facility quality. They incorporate several new measures of quality, including consistency of registered nurse staffing, use of antipsychotic drugs and success in preventing falls. Emergency room visits, ability to return home, rate of substantiated complaints, patient-centered rehabilitation therapy and physical therapy staffing also are included. The long-term care rating includes nine quality measures, including data on staffing, success in preventing ER visits and pneumonia vaccination rates. Other metrics include prevention of pressure ulcers, ability to self-care, rate of substantiated complaints, use of anti-anxiety or hypnotic drugs.

The complete list and a search tool are available here.

“We’ve tried to make it easy and digestible,” Adams said. Not only is it important that useful information is available somewhere, but synthesizing the information and having it presented easily and put in context is equally important. He suggested consumers pay attention to all the criteria since different aspects of quality of care may differ from home to home, and people may find value in different parts of the rating.

Remember that ratings — whether for hospitals, nursing homes, or other institutions — are far from perfect and constantly evolving, as I wrote in this 2016 post. So use caution and ask lots of questions.

Take a look at the nursing homes on the list in your state, and look for answers to these questions:

  • Which facilities are consistently doing things right, according to U.S. News criteria vs CMS ratings?
  • Which homes are just OK, and which are below average?
  • Where do they fall short and why?
  • What are some of the major differences between these ratings and CMS ratings?

You may want to dig into nursing home inspection reports and patient satisfaction surveys for particular homes on the list. Also, talk to families, patients, staff and administrators, as well as independent nursing home quality experts, about whether they agree or disagree with the assessments and why.


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