How to Check Nursing Home Violations the Star Ratings Miss

Harm-level citations by current overall star rating

The share falls as the current overall rating rises, but it does not reach zero. The denominator is the 14,568 facilities with a current overall rating in the selected provenance period.

Sub-rating averages describe different cohorts

These are descriptive means, not a prediction test. The G+ cohorts are defined by at least one qualifying citation in the study window.

Top 100 high-star facilities by G+ citation count

The ranking uses G+ citation count descending, then current overall rating descending, then CCN ascending. A row is a CMS record, not a recommendation or an assessment of current conditions. Names and locations come from the latest production deficiency row for each CCN.

High-star facilities with G+ citations by state

These are absolute counts and are not normalized for the number of nursing homes in each state. The table shows the first 20 rows; the JSON download contains the complete production vector.

A literal three-year window, not three inspection cycles

The maximum processing date in production is 2026-04-01. The SQL subtracts three years from that anchor and filters survey_date from 2023-04-01 through 2026-04-01. Consequently, 2023 and 2026 are partial calendar years in the table below.

Sensitivity only: the full inspection-cycle file spans 2017-03-23 to 2026-03-18. It yields 1,790 high-star facilities with G+ (30.69%). That result is not the study headline and is not described as a three-year finding.

Methodology and integrity checks

The canonical SQL selects the latest claim-bearing CMS Nursing Home Provider Information period, pivots four unsuperseded CCN-keyed rating metrics, aggregates G-L deficiency citations inside the literal survey-date window, and joins on CCN. PostgreSQL performs every count and ranking inside a read-only transaction; no client-side row count is used.

• 14,700 facilities in the rating-source universe; 14,568 with an overall rating and 132 without one.
• 418,148 deficiency rows across 14,635 CCNs in the production file.
• 19,732 of 20,431 windowed G+ citations joined to a currently rated CCN.
• 0 duplicate CCN/metric groups and 0 out-of-range overall ratings in the selected period.
• Informal-dispute sensitivity: 1,452 of 5,832 (24.9%).

See the broader Fonteum methodology, or download the exact production SQL.

Limitations

• The join pairs current May 2026 ratings with citations surveyed over three years; it does not reconstruct the rating that existed on each survey date.
• A citation is a survey finding, not a unique resident event. Multiple citations can belong to one facility or survey.
• The analysis is descriptive. It does not establish that a rating caused, prevented, or predicted a citation.
• Facility names and locations are taken from each CCN's latest production deficiency row and can change over time.
• State counts are not adjusted for facility count, bed count, resident days, inspection frequency, or survey-agency practice.
• Ratings, citations, and dispute status can change after the observation date.

Frequently asked questions

What does a severity-G nursing-home deficiency mean?

CMS uses an A-to-L scope-and-severity scale. G, H, and I indicate actual harm that is not immediate jeopardy; J, K, and L indicate immediate jeopardy. This study groups G through L as G+.

How many four- and five-star nursing homes had a G+ citation?

1,464 of 5,832 currently rated four- and five-star facilities had at least one G+ citation between 2023-04-01 and 2026-04-01. That is 25.1%.

Is the study window the same as the full CMS deficiency file?

No. The headline uses survey dates from 2023-04-01 through 2026-04-01, a literal three-year interval anchored to the file's maximum processing date. The full file spans 2017-03-23 through 2026-03-18 and is shown only as a sensitivity check, not as a three-year result.

What happens when citations under informal dispute resolution are excluded?

1,452 high-star facilities still had at least one G+ citation not marked as under informal dispute resolution, or 24.9% of the high-star cohort.

Does a high CMS star rating guarantee that no harm-level citation exists?

No. In this joined snapshot, 18.62% of five-star facilities and 32.15% of four-star facilities had at least one G+ citation in the study window. The rating and deficiency files measure related but different aspects of facility performance.

Sources, downloads, and citation

Rating source: CMS Care Compare — Nursing Home Provider Information (4pq5-n9py), released 2026-05-01, retrieved 2026-06-10. Deficiency source: CMS Care Compare — Nursing Home Health Deficiencies (r5ix-sfxw), queried from current production and observed 2026-07-17.

Suggested citation: Fonteum LLC. “How to Check Nursing Home Violations the Star Ratings Miss.” Updated 2026-07-17. 1,464 of 5,832 high-star facilities (25.1%) had at least one CMS G+ citation in the 2023-04-01–2026-04-01 survey window.