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The Centers for Medicare & Medicaid Services (CMS) identifies 88 nursing facilities nationwide that are among the most poorly performing facilities in the country. CMS calls these facilities, generally two per state, Special Focus Facilities (SFFs). SFFs have a special icon on the federal website Nursing Home Compare that identifies their SFF status. At present, CMS does not report any quality ratings for these facilities. CMS also identifies, monthly, an additional 400+ facilities that meet the Special Focus criteria status – the “candidate list.”

The Center for Medicare Advocacy looked at the 21 nursing facilities that CMS reported in May 2019 had “graduated” from the SFF Program.[1] We found that, in the year before they “graduated,” six of the 21 SFFs were cited with one or more harm or immediate jeopardy deficiencies, the two highest categories of noncompliance in the federal regulatory system that are applied to less than 5% of all deficiencies.

On October 31, 2019, the Center again looked at the May 2019 graduates in order to determine how they were rated on Nursing Home Compare five months after they graduated. The most troubling finding was that 5 of the 19 we could find on Nursing Home Compare – more than a quarter – were on the October 23, 2019 candidate list of SFFs. In other words, they had rejoined the ranks of the worst-performing facilities in the country. Moreover, the recent graduates continued to rate poorly on the CMS website, particularly in their ratings for health inspections and overall ratings. The graduates performed “best” only on the largely self-reported quality measure domain, once again underscoring how meaningless this quality measure domain is.

Star Ratings of the 19 May 2019 Graduates from SFF Program, as of October 31, 2019

Star ratings Overall rating Health survey rating Staffing rating Quality domain rating
1 star 7 facilities 10 facilities  4 facilities
(including 2 w/icon)
2 stars 8 facilities   7 facilities 10 facilities 5 facilities
3 stars 3 facilities   1 facility  4 facilities 5 facilities
4 stars 0   0  1 facility 5 facilities
5 stars 1 facility   1 facility 0 4 facilities

Fifteen of the 19 graduates had overall ratings of “much below average” (one star) or “below average” (two stars).

The 19 graduates performed most poorly on their health survey ratings; 17 were rated “much below average” (one star) or “below average” (two stars). Two of these facilities boosted their overall rating by one star because of their five-star rating on the quality measure domain.

Conclusion and Recommendations

The SFF program is not achieving its goal of addressing the worst-performing nursing facilities and bringing them into sustained compliance with Requirements of Participation. We reiterate, and strengthen, our recommendations from June 2019 on ways to revise graduation policies so that a facility is not removed from SFF status until the following have been achieved:

    • The facility has not been cited with a harm-level or immediate jeopardy deficiency for 18 months;
    • The facility has not been cited with four or more no-harm deficiencies for 18 months;
    • The facility has not had an abuse icon for 18 months;
    • The facility has not had more than two complaint surveys conducted for 18 months; and
  • The facility has staffing levels of at least four stars for 18 months.

As we noted in June, facilities that have been selected for the SFF program because of a multi-year history of providing extremely poor care should not graduate until they have fully returned to compliance and demonstrated their sustained compliance for 18 months.  To allow facilities to graduate when they were recently cited with significant deficiencies, had multiple complaint surveys, or had inadequate staffing levels invites the recidivism that The New York Times documented in July 2017.[2]

November 7, 2019 – T. Edelman


[1] CMA, “Special Report – “Graduates From the Special Focus Facility Program Provider Poor Care” (Jun. 20, 2019),
[2] Jordan Rau, “Poor Patient Care at Many Nursing Homes Despite Stricter Oversight,” The New York Times (Jul. 5, 2017),

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