Imagine walking into a nursing home with a giant red mark on its front door. You would see it as an unmistakable sign that something has gone wrong. That’s essentially what the abuse icon on Nursing Home Compare communicates.

Just as Hester Prynne’s scarlet letter branded her in the eyes of society, the icon publicly signals a facility’s wrongdoing. But how fair is the system that applies this modern-day brand of shame?

Launched in 2019 as part of the Centers for Medicare & Medicaid Services’ transparency initiative, the abuse icon was meant to be a consumer protection measure, helping families steer clear of potential danger. The intention is understandable — no one wants their loved one in an unsafe environment.

However, in practice, the icon’s impact is far more complex. It raises tough questions about fairness, consistency, and whether it truly helps or simply stigmatizes facilities indefinitely.

The significant geographic variation in the abuse icon

At first glance, the abuse icon might seem like an objective measure of quality, but a closer look at national data tells a different story. The national average of flagged facilities sits at 9.85%, but some states see significantly higher — or lower — rates.

For example, Illinois (29.16%) and Wyoming (28.57%) lead the pack, with nearly a third of facilities branded. Contrast that with Minnesota (2.06%) and New Hampshire (1.35%), where the abuse icon is practically nonexistent.

What explains this stark contrast, and what is the implied guidance to consumers? Move?

It seems clear that two major factors influence the numbers: survey practices and survey timing.

First, each state interprets CMS regulations differently, leading to variations in citations. In addition, some survey teams are stricter than others, making the icon more common in certain regions. I have seen abundant inconsistencies among facility findings on CMS Form 2567, the official document used to record deficiencies found during surveys of healthcare facilities, with over assignment but also under assignment of scope and severity.

Second, facilities aren’t all surveyed with the same frequency, which affects how long it takes until a facility with an abuse icon has a chance to clear it. Specifically, the icon is removed if a facility does not receive an abuse-level citation for one survey cycle (if the citation was issued during a standard survey). Facilities with a recent citation for actual harm (Scope/Severity Level G or higher) retain the icon for a year after the citation, or for two years if there were repeat abuse citations at lower severity levels (D or higher).

In states with longer standard survey intervals, the icon will linger longer even if a facility has taken corrective actions.

These disparities make one thing clear: The abuse icon doesn’t necessarily measure risk the same way across the country. Instead, it may reveal more about regulatory inconsistencies than actual differences in care quality.

More like a permanent tattoo than disappearing ink

The abuse icon was intended as a warning, not a life sentence. Yet, for many facilities, it feels like an inescapable mark that erodes trust and deters admissions long after issues have been addressed. Unlike a stain that can be scrubbed away, this designation functions more like a tattoo.

Much like Hester Prynne’s infamous “A,” the abuse icon can define a facility indefinitely, overshadowing efforts to improve. This raises a key concern in the Five-Star system. Nursing homes that receive the icon have their health inspection rating capped at a maximum of two stars.

These are not minor concerns; they impact the lives of residents, staff, and families making care decisions. Transparency is essential, but fairness matters too. Without giving facilities a path to redemption, the abuse icon risks being less about accountability and more about branding a facility with an indelible mark, regardless of its current performance.

A system designed to protect residents must also be just. While the abuse icon serves a purpose, it should not function as an irreversible brand of shame. It’s time for a more balanced approach — one that provides transparency while allowing facilities the opportunity to demonstrate meaningful change.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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