Senators Release Secret List of Poor Quality Nursing Homes

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At present, only 88 nursing facilities nationwide (0.6% of the nation’s total number of facilities) are identified as Special Focus Facilities (SFFs). The Centers for Medicare & Medicaid Services (CMS) describes SFFs as having “more problems” than other facilities, “more serious problems” than other facilities, and “[a] pattern of serious problems that has persisted over a long period of time” (i.e., the prior three years).[1] Identification as an SFF subjects a facility to additional standard surveys, twice a year instead of once, and, in principle, more stringent enforcement actions[2] (although the Center for Medicare Advocacy has documented the minimal enforcement actually taken against SFFs[3]).

CMS and state survey agencies work collaboratively to select SFFs from a candidate list of approximately 400 facilities. Candidates are indistinguishable from facilities that are selected as SFFs. While the federal website Nursing Home Compare identifies SFFs with an icon and, since April 24, 2019,[4] no longer reports star ratings for these facilities, it does not publicly identify SFF candidates and takes no special action against them.

Concerned about the poor quality care provided by some facilities, as documented in many investigative reports, and about the need for greater transparency and public information, Senators Bob Casey (D, PA) and Pat Toomey (R, PA) wrote CMS Administrator Seema Verma in March 2019, requesting information about the SFF program.  Following her response, they released a report, Families’ and Residents Right to Know: Uncovering Poor Care in America’s Nursing Homes,[5] about the SFF program, documenting examples of serious abuse and neglect in candidate facilities.

The report also demonstrates that information on Nursing Home Compare may be “misleading.”  Candidate facilities may have overall ratings raised from one star to two stars (on a five-point scale) because they reported information that gives them high star ratings in staffing and quality measures. Even more troubling, 48% of candidate facilities have quality measure ratings of three stars or more and 49% of candidate facilities have staffing ratings of three stars or more. The public has no way of knowing how serious these candidate facilities’ deficiencies actually are; on Nursing Home Compare, the candidates may appear average.

The Senators also publicly released the April 2019 list of 400+ candidate facilities (CMS updates the list monthly). For the multistate chains that use a common name with all of their facilities, some observations are possible. Several chains have several candidates in a single state, with one named an SFF. An example is Alerion, with three candidates and one SFF in Indiana, out of 17 facilities. Other chains have candidate faculties in multiple states. Life Care Centers of America, for example, has SFF candidates in five states.


CMS should make each month’s SFF candidate list publicly available, just as it makes available the identity of facilities that are selected as SFFs. CMS should report the information, with an icon, on Nursing Home Compare, the federal website that CMS created for the public to provide information about nursing home quality. In addition, CMS should use the information about corporations providing poor quality care to take meaningful corporate-wide enforcement actions.

June 6, 2019, T. Edelman


[1] CMS, “Special Focus Facility (“SFF”) Initiative,”
[2] Id.
[3] “There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities” (CMA Alert) (Feb. 14, 2019),; “Report: There’s Nothing Special About How CMS Treats Special Focus Nursing Facilities,”
[4] CMS, “April 2019 Improvements to Nursing Home Compare and the Five Star Rating System,” QSO-19-08-NH (Mar. 5, 2019),

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