“Reach for the stars,” they said. Are you shaking your head at that old motivational line? Bet that person wasn’t talking about running a nursing home in the midst of a serious nurse shortage, were they?
Well, they likely weren’t. However, that doesn’t mean you can’t reach for the stars anyway. In fact, you should.
A 2019 study of more than 10,000 nursing homes found that those with a five-star CMS rating earned almost double the profit per bed than those with three or four stars. Nursing homes with even lower ratings generally weren’t profitable at all.
Keep reading for a closer look at the CMS Five-Star Quality Rating System and eight steps you can take to reach higher.
Already have those five stars? Time to reach for the Golden Seal of Approval from the Joint Commission.
What is the CMS five-star quality rating system?
The Centers for Medicare and Medicaid Services (CMS) created the Five-Star Quality Rating System in an effort to help families make informed decisions about the options available for nursing home care.
This rating system applies to any nursing home that participates in Medicare or Medicaid and is not to be confused with the other star rating program, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).
CMS five-star rating methodology
A five-star rating is the highest available and means the facility is performing “much above average.” A one-star rating is the lowest rating a facility can achieve and reflects poor scores across the different rating factors.
The following are the overall rating factors in the separate star ratings for three domains:
- Health inspection: These inspections are conducted annually, with no more than 15 months passing between them.
- Staffing: Data for staffing is reported quarterly to the Payroll-Based Journal (PBJ) system, which helps with data interoperability. There is a firm submission deadline of 45 days after each quarter ends.
- Quality measures: This domain measures three components for nursing home residents. It looks at patient data for long stays (more than 100 days), short stays (less than 100 days), and overall.
In addition to the overall star rating, each of the three domains receives its own star rating.
Related: 8 FAQs about the NPI registry
Best practices for a five-star quality rating
Ready to get that five-star rating? Here are eight steps you can take to increase your scores and bring your facility up in the ratings.
1. Assess your current rating
Check your current rating on the Care Compare search engine on Medicare.gov. This online tool is designed to help patients find and compare care providers in their area, but it can also be used to quickly understand where your facility stands.
Medicare’s Care Compare tool provides at-a-glance information about each healthcare provider’s overall star rating, scores for each component of the overall rating, and in-depth information about staffing and safety inspections.
Familiarize yourself with any deficiencies cited and pay attention to what your facility did well. In order to know what you need to work on, you need to understand the current situation first.
Be sure to provide encouragement by pointing out the good that your facility staff did as well.
2. Track the metrics that CMS uses to score facilities
If you didn’t love data before, it’s time to get up close and personal with it. The following are some of the main metrics the CMS measures for the three domains.
Health inspection
Any deficiencies are measured and weighted according to their severity, which ranges from “immediate jeopardy for resident health or safety” to “no actual harm with potential for minimal harm.”
According to the CMS, the health inspection assesses the following:
- Resident rights
- Resident quality of life
- Medication management services
- Resident skin care
- Resident assessments
- Administration of the nursing home
- Nursing home environment
- Kitchen and food services
It’s important to note that the rating methodology for the health inspection domain uses the three most recent surveys and complaints within the last three years.
Staffing
The CMS takes the staff reporting from the PBJ and uses a “case-mix” formula for its staffing calculations and ratings.
Additional metrics include patient census, resident discharges, resident deaths, and turnover of nursing administrators, registered nurses (RNs), licensed practical/vocational nurses (LPNs/LVNs), and certified nursing assistants (CNAs).
Quality measures
Quality measures (QMs) are weighted differently and can be assigned a maximum of 150 or 100 points.
QMs up to 150 points:
- Long-term stay residents with increasing need for assistance with activities of daily living (ADLs)
- Long-term stay residents whose independent walking ability worsened
- Long-term stay residents on antipsychotic medications
- Long-term stay residents with hospitalizations during a 1,000-day long stay
- Long-term stay residents with emergency department visits during a 1,000-day long stay
- Skilled nursing facility patients who, at discharge, have self-care capabilities at or above expectations
- Short-term stay patients with successful discharge to their homes
- Short-term stay patients who were rehospitalized for inpatient or observation care within 30 days
- Short-term stay patients who had an outpatient emergency department visit within 30 days
QMs up to 100 points:
- Long-term stay residents with pressure ulcers
- Long-term stay residents who received and kept a catheter
- Long-term stay residents with urinary tract infections
- Long-term stay resident falls with “major injury”
- Skilled nursing facility (short-term stay) patients with new or worsened pressure ulcers
- Skilled nursing facility (short-term stay) patients receiving antipsychotic medications after the initial assessment
3. Update your compliance for the health inspection ratings
The data is calculated over a significant period of time, which means consistency is key. Use the data and work with your staff to correct any shortcomings or deficiencies noted in previous inspections and ratings.
Provide staff with training to ensure they understand facility policies and procedures regarding HIPAA guidelines, cybersecurity, and other important federal and state regulations.
4. Optimize your staffing effort
Staffing is a critical part of improving your CMS star score. Here are some strategies to help optimize staffing:
- Use per diem staffing platforms like Nursa to cover unexpected staffing gaps and ensure consistent care hours.
- Track your hours per resident day (HPRD) and validate PBJ data accuracy.
- Focus on reducing staff turnover.
- Cross-train staff to enable an internal float pool.
5. Improve your quality measures
You can work towards improvement of your quality measure ratings by doing the following:
- Focus on highly weighted quality measures: The QMs that can earn up to 150 points provide a significant opportunity for improvement.
- Establish preventative care protocols: It’s not enough to react properly in the nursing home setting. Preventative care strategies are of equal importance.
- Monitor hospital readmission rates: Identify where readmissions were unavoidable and when the resident was discharged too soon.
- Involve residents and families: Residents’ and their families’ satisfaction can be a helpful litmus test for progress toward improvement.
Related: Understanding the resource-based relative value scale for facilities
6. Provide regular training on areas for improvement
It’s not just the data that matters. Staff participation and alignment are important for this goal to succeed. Be sure to give staff the tools for that success by focusing on development and training as follows:
- Conducting effective performance evaluations
- Identifying areas for improvement and tracking progress
- Providing the training necessary to support the changes
7. Conduct regular audits
Check your progress on compliance with routine audits of the data, and maintain open communication with your schedulers and other staff.
Performing regular mock inspections will help you keep corrections on course, observe improvements, and identify areas that need more work.
8. Keep up with CMS guidelines and regulatory changes
For many long-term care and skilled nursing facilities, the CMS federal staffing mandate that was finalized in 2024 impacted staffing strategies. The new mandate supersedes any state or local staffing regulations that fall below the new expectation, which is the following:
- A minimum of 3.48 hours per resident day of total nursing care (.55 HPRD by an RN, 2.45 HPRD by a CNA, and .48 HPRD by an RN, a CNA, or an LPN/LVN)
- Presence of a registered nurse in every nursing facility at all times (24/7)
Your five-star quality rating is within reach
Transitioning a nursing home to a five-star rating will be easier for some of you than for others. Nevertheless, it is a worthwhile investment of time and energy. A higher star rating from CMS will help your facility’s profitability, your nursing staff’s wellbeing, and your residents’ quality of life.
Don’t let the staffing domain pull you down if you’re struggling with nurse vacancies and call outs. Nursa is a healthcare staffing marketplace that helps healthcare facilities solve staffing shortages and meet patient demand. Learn how Nursa can be your partner platform for per diem nurse staffing.
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