Hawaii has a higher percentage of top-rated nursing homes than any other state in the country, according to a newly revised rating system by the federal government that includes tougher standards for evaluating long-term care facilities.

Eighteen of Hawaii’s 46 nursing homes, or 39 percent, received five stars, the highest score under the Centers for Medicare and Medicaid Services system.

That percentage was higher than the rates for the 49 other states and second only to Washington, D.C.’s 53 percent, according to an analysis of the numbers by the Hono­lulu Star-Advertiser. Ten of Washington’s 19 nursing homes received five stars, a coveted rating by facility operators.

The federal government’s switch to tougher standards resulted in about a third of the nation’s nursing homes getting lower scores, including some that lost their five-star marks, according to USA Today. But that didn’t seem to be the case here.

John McDermott, Hawaii’s long-term care ombudsman, said the new numbers reflect the high quality of care generally found in the local industry.

"Hawaii has a lot to be proud of," he said.

Hawaii led the nation in several key performance categories, according to the federal data, released last week and posted on the Nursing Home Compare website.

For instance, among the 50 states, Hawaii had the lowest percentages of short- and long-stay residents who were getting antipsychotic medications. Only 0.9 percent of short-stay residents had recently received an antipsychotic, while 9.9 percent of long-stay ones were given such medications, according to the data.

The powerful medication can pose high risks for older people. A low usage rate is considered good.

Regulators added that category and others to its revised list of evaluation criteria, all designed to improve the overall assessments.

Based on the new evaluations, Hawaii also led the nation with the lowest percentage, 2.9 percent, of high-risk, long-stay residents with pressure ulcers, or bedsores. The presence of such injuries generally is a red flag, particularly if an institution has an unusually high rate of such cases.

Hawaii scored among the top states in several other categories, including having one of the lowest percentages of long-stay residents who experienced one or more falls resulting in major injury and one of the lowest rates of short-stay residents who reported moderate to severe pain.

George Greene, president and chief executive of the Healthcare Association of Hawaii, a trade group that includes nursing homes among its members, noted that the new ratings add to the top marks given in prior reports by the federal agency, U.S. News & World Reports and others.

"This is yet another confirmation that Hawaii’s long-term care facilities are top of the nation," Greene said in emailed comments to the Star-Advertiser. "Hawaii residents have incredibly good choices for care."

Green cautioned consumers to keep in mind that the changes to the rating system essentially mean all institutions have been "downgraded" to fit into the new system and that CMS advised against comparing the current numbers to previous ones.

"It’s like changing the grading curve," he said, alluding to institutions with lower scores. "This does not mean that there has been a drop in quality."

According to the federal data, Hawaii had only one nursing home, Nuu­anu Hale, that received a 1-star rating, the lowest possible.

That represents just 2 percent of Hawaii’s facilities — the lowest percentage among the 50 states, according to the Star-Advertiser analysis.

Gayle Lau, Nuuanu Hale administrator, said in a written statement that her facility previously had a 2-star rating, which included 5 stars for a "quality measures" subcategory.

The current rating includes 4 stars for quality measures, she noted, linking the new numbers to the "rebasing" of the rating system.

"Other nursing homes across the nation have experienced similar changes," Lau wrote. "The quality of care received by our residents remains the same. Nuu­anu Hale has and continues to strive to provide the highest quality of care since 1975."

While lauding Hawaii’s numbers, some analysts say they must be considered in the context of past concerns raised by federal regulators regarding the state’s inspections of nursing homes.

The federal agency previously has voiced concerns about Hawaii’s tendency at times to rate deficiencies inappropriately and to not perform inspections on a timely basis. Budget cuts were partly to blame.

But state inspectors failing to properly evaluate deficient care and being too soft on nursing homes also were cited as factors, helping explain why Hawaii nursing homes historically have been sanctioned at among the lowest rates in the country.

"That’s been a longtime concern," said Cullen Haya­shida, a University of Hawaii gerontologist. "They (inspectors) tend to be a little bit more lenient."

A spokesman for CMS declined comment.

According to the new numbers, Hawaii ranked 12th among the states for the lowest percentage of facilities hit with penalties. Six of the 46 nursing homes in Hawaii, or 13 percent, received penalties in 2013 and 2014.

The more recent cases from last year included:

» Kula Hospital on Maui, hit with a $10,255 fine and three-day payment denial.

» Hale Ho‘ola Hama­kua in Hono­kaa, a $2,500 fine.

» Life Care Center of Hilo in Hilo, a $2,500 fine.

Hayashida said Hawaii’s high overall ratings likely can be attributed in part to relatives and friends visiting nursing home residents on a frequent basis, with their presence helping to keep the pressure on staff to provide good care.

He also cited greater competition from community-based care homes, which have taken in more residents needing nursing-home-level care.

"You get pressure (from competition), you’re going to respond," Haya­shida said.

AT THE TOP Among the 50 states, Hawaii had the highest percentage of nursing homes with a top federal rating of five stars. STATE Hawaii 39% Delaware 33% Vermont 32% California 32% New Hampshire 32% Rhode Island 31% Idaho 31% Colorado 30% Connecticut 29% Nebraska 29% Wisconsin 28% Alaska 28% Michigan 28% Arizona 27% New Jersey 27% Massachusetts 26% North Dakota 26% Minnesota 26% Maryland 26% Washington 26% Nevada 25% Iowa 25% Utah 23% Florida 23% Kansas 22% Montana 22% South Carolina 22% Missouri 22% Alabama 22% Maine 21% Indiana 21% Oregon 21% Mississippi 21% Illinois 21% New York 21% Arkansas 20% South Dakota 20% New Mexico 20% Virginia 19% Pennsylvania 19% Wyoming 18% North Carolina 18% Tennessee 18% Ohio 17% Kentucky 16% Georgia 15% Oklahoma 12% Texas 12% West Virginia 10% Louisiana 10% Source: Centers for Medicare and Medicaid Services, Star-Advertiser