Nursing Home Problems With Staffing Should Affect Federal 5-Star Rating System: Study

New research indicates that adding daily staffing fluctuations to the federal nursing home five-star rating system can potentially move facility scores up or down by one star, depending on staff instability.

The federal five-star rating system for nursing homes, managed by the Centers for Medicare & Medicaid Services (CMS), evaluates nursing home quality based on average staffing levels and staff turnover rates. Facilities are rated on a scale from one to five stars. This ranking system is widely used by families and prospective residents to help them select a suitable care facility.

Critics argue that the current CMS method for measuring nursing home staffing levels, which focuses on the average number of hours worked per resident per day and staff turnover rates, fails to account for fluctuations in staffing throughout the day. This oversight, known as staffing instability, means that daily variations in staffing are not reflected in the averages, potentially giving a misleading picture of the actual staffing situation.

In a study published in the journal Health Affairs Scholar last month, researchers from the University of California, Irvine determined that including staffing instability in CMS’s five-star rating system can change a facility’s rating by as much as one star, either increasing or decreasing it. This change could significantly influence where people decide to seek care.

The research team, led by Dana B. Mukamel, looked at staffing ratings on 13,641 nursing homes from the third quarter of 2023, to help them simulate how including new staffing instability measures might affect them.

Staffing instability measures daily fluctuations in nursing home staffing levels, including when the facility is fully staffed and when it may struggle to cover certain shifts.

The team concluded that accounting for staffing instability could potentially raise or lower 21% or more of nursing homes’ five-star ratings by one star. In fact, the percentage of homes that would gain a star or lose a star was virtually the same, at approximately 11% and 10% respectively.

“In recent years, research has made clear that staffing instability—the daily fluctuations in the adequacy of staff that may be masked when using average staffing levels, whether based on actual averages or newly promulgated standards—is an important aspect of quality that consumers should be made aware of, and providers should seek to improve,” Mukamel concluded.

The team also pointed out that there is no reason CMS could not add staffing instability ratings to its metrics, since it has been updating its star-rating measures for at least two decades.

Nursing Home Staffing Issues

This is not the first time that staffing issues in nursing homes have been addressed in recent years.

New CMS nursing home minimum staffing level standards were passed in April 2024, in an attempt to address long-standing concerns over nursing home staffing shortages, dating back to the COVID-19 pandemic, and its aftermath.

However, three months after CMS put those standards in place, the U.S. Department of Health and Human Services determined that less than one-third of U.S. nursing homes had enough nursing assistants on staff. The researchers concluded that many facilities would need to add up to two additional staff members per shift to meet the new CMS guidelines.

Additional research has shown that insufficient nursing home staffing and frequent turnover can lead to reduced quality of care and could increase patient injury risks.