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Each month, the Centers for Medicare & Medicaid Services (CMS) identifies nursing facilities that are among the facilities providing the poorest care to their residents, as determined by federal deficiencies cited in the prior three years.   These facilities, called Special Focus Facilities (SFFs), receive special attention from state survey agencies – at least two surveys each year (instead of one) and enhanced enforcement activities.  While SFFs may not necessarily be the very poorest quality facilities in the country, they are, by definition, among the facilities nationwide that provide the poorest quality of care.

The Center for Medicare Advocacy (the Center) staff evaluated SFFs identified by CMS on May 16, 2011.[1]  Specifically, we looked at all facilities that were newly-added to the SFF list (22 facilities), 20% of facilities that had not improved (14 facilities), and 20% of facilities that had improved, but were still identified as SFFs (11 facilities) – a total of 47 of the 144 facilities (33%) that were currently identified as SFFs.  We collected information for each of the 47 SFFs and evaluated the star ratings for health surveys, staffing, and quality measures.

We gathered information from CMS's website Nursing Home Compare, on whichCMS posts information reflecting state survey results as well as staffing levels and quality measures reported by the facilities themselves, and, since 2008, rates facilities on each of these measures, using a Five-Star Rating System.[2]  In the Five-Star Rating System one star is the lowest score and five stars the highest.  For health inspections only (conducted by state surveyors), the top 10% of facilities in a state receive five stars; the bottom 20%, one star; and the middle 70%, two, three, or four stars (23.33% each).  Scoring for staffing and quality measures uses different criteria and is not similarly tiered.[3]

The Center found that SFFs, the overwhelming majority of which (45 of 47 SFFs or 96%) were owned on a for-profit basis, had, as expected by their very definition, low star ratings for health surveys, yet still self-reported high levels of staffing and high quality measures.

Survey Findings

1. Health Inspections

Nursing facilities that participate in the Medicare or Medicaid programs, or both, have an unannounced survey each year.  Surveys are conducted by state survey agencies, usually located in the state department of health, using a survey protocol that has been developed, tested, and validated by the federal government.[4]  Although the Government Accountability Office (GAO) has issued many reports over the past 13 years describing the enforcement system as underciting deficiencies and undercoding the significance (scope and severity) of deficiencies it identifies,[5] the publicly-conducted survey is the only objective, independent evaluation of the quality of care provided by nursing facilities.

As expected, most of the SFFs examined in the study had one star in health inspections.  All 22 newly-added SFFs had one star in health inspections.  One of 47 facilities (2%), a facility that had not shown improvement, had two stars.  One of 47 facilities (2%), a facility that had shown improvement, had three stars.  Charts outlining these results, as well as those discussed below, may be found in the full report at:

2. Staffing

Staffing information reported on Nursing Home Compare reflects data provided by facilities to surveyors at the time of survey.  Facilities complete a CMS form reporting staffing information from the two weeks preceding the survey.  CMS does not audit the self-reported information.  Research has shown that self-reported, unaudited data overstate staffing levels.[6]

All facilities reported staffing levels that led to the assignment of considerably higher star ratings than their health inspection ratings.  Thirty-two of 46 facilities (70%) reported staffing levels that led to star ratings of three or more stars.

More than half (25 of 46 facilities, 54%) reported staffing levels that led to four- and five-star staffing ratings.  Seven of 46 facilities (15%) reported staffing levels that led to three-star staffing ratings.  Only 14 of 46 facilities (30%) reported staffing levels that led to one- and two-star ratings in staffing.  Note: Staffing was not reported for one of the newly-added SFFs.

3. Quality Measures

Quality measures, also self-reported by facilities and unaudited by CMS, reflect resident characteristics and care needs, as identified in the resident assessments.  Federal law requires facilities to conduct comprehensive assessments of each resident's needs annually, using multidisciplinary teams.  Assessments are updated quarterly, with additional assessments conducted whenever a resident experiences a significant change.[7]  Facilities must use these assessments to develop individualized, comprehensive care plans for residents.[8]  Low reported rates of residents with pressure ulcers or restraints, for example, result in higher star ratings.

Star ratings for quality measures for all SFFs were also considerably higher than health survey ratings.  More than half the facilities (27 of 47 facilities, 57%) reported quality measures that led to star ratings of three or above. 

More than a third of the facilities (17 of 47 facilities, 36%) reported quality measures that led to four- and five-star ratings.  Ten of 47 facilities (21%) reported quality measures that led to three-star ratings.  Only 19 of 47 facilities (40%) reported quality measures that led to one- and two-star ratings.

Conclusion and Recommendations

In light of SFFs' over-reporting of their staffing levels and quality measures, the Center for Medicare Advocacy recommends that:

  • Staffing and quality measures not be reported on Nursing Home Compare for any SFFs;
  • No SFF be given more than one star on their composite scores unless and until it graduates from the SFF program;
  • Pain not be used as a quality measure for any facility on Nursing Home Compare.

The nursing home industry has long sought to weaken the federal survey process, pointing to improving scores on quality measures as evidence that care in nursing homes is getting better.  The Center's study shows that SFFs often report high staffing and high quality measures, despite their extremely poor performance on publicly-conducted, objective surveys.  The study did not evaluate whether all other nursing facilities' self-reported staffing levels and quality measures are similarly inconsistent with their survey results.

Nevertheless, the Center for Medicare Advocacy study finds:

  1. Consumers need to evaluate information about facilities critically and carefully, and
  2. Proposals to reduce survey time, based on facilities' self-reported quality measures and staffing levels, are suspect and should be rejected.


[1] The full report is available at:
[2] CMS’s webpage on the Five Star Quality Rating System is available at  The page includes links to the Technical Users Guide, the Technical Expert Panel, State-Level Cut Point Table, Consumer Fact Sheet, and other information.
[3] See explanation at CMS’s Technical Users Guide,
[4] 42 U.S.C. §§1395i-3(g), 1396r(g), Medicare and Medicaid, respectively.
[5] See, e.g., Nursing Homes: Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment. GAO-10-70 (Nov. 2009),
[6] See, e.g., Bita A. Kash, Catherine Hawes, Charles D. Phillips, “Comparing Staffing Levels in the Online Survey Certification and Reporting (OSCAR) System with the Medicaid Cost Report Data: Are Differences Systematic?” The Gerontologist, Vol. 47, No. 4, 480-489 (2007).
[7] 42 U.S.C. §§1395i-3(b)(3)(C), 1396r(b)(3)(C), Medicare and Medicaid, respectively; 42 C.F.R. §483.20.
[8] 42 U.S.C. §§1395i-3(b)(3)(D), 1396r(b)(3)(D), Medicare and Medicaid, respectively.

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