CMS Nursing Home Rating and What It Means for SNFs

The Centers for Medicare and Medicaid Services (CMS) created the Five-Star Quality Rating System to help consumers compare nursing home ratings when deciding where to seek services. This system was established in 2008 and has continued with some updates to reflect changes in health care priorities and challenges since then. The CMS Nursing Home rating system gives each facility between one (lowest quality) and five stars (highest quality) to indicate the quality of care provided, safety ratings, and staffing levels there. Half-star ratings are also possible. All information is published on the Care Compare website so consumers can easily access this information.

While this is not the only source of data about nursing home performance or the only factors families need to consider when deciding where to seek care, it’s a database of information that can influence decision making. Factors considered when determining the nursing home’s rating include health inspections, quality measures, and staffing levels.

How are CMS Nursing Home Ratings Determined?

The Care Compare website includes ratings and data on the performance of nursing homes, physicians, hospitals, clinics, home health services, and rehabilitation facilities. It acts as a one-stop-shop for patients and family members trying to decide where to seek care.

Setting a rating for a nursing home is a five-step process, as outlined by the CMS.

1. A health inspection gives the facility a rating between one and five. These ratings are calculated on the nursing home surveys and complaint surveys over the past three years. There is a designated state agency that performs these inspections. They are unannounced and usually take several days to complete. Each state then ranks nursing homes based on these scores. The top 10% of nursing homes in the state receive five stars for their health inspection. The following 23.33% receive a four-, three-, or two-star rating respectively. The bottom 20% of nursing homes will get one star. Health inspections are extensive and include assessments of:
   • Medical records
   • Physical environment
   • Food safety
   • Administration
   • Quality of life
   • Medication management
   • Interactions between the staff and patients
   • Interviews with patients and their families
2. The staff rating is calculated into the overall rating next. This number is determined by the RN hours per resident day and the total staffing hours per resident day. Staffing rating is adjusted based on the number of RNs, LPNs, and nurse aides per RUG-III group. This assessment is compared to other nursing homes as well as the 2001 CMS Staffing Study. If the staffing rating is four or five and also higher than the health inspection rating, an additional star is added to the overall CMS Nursing Home rating for the facility. If the staffing rating is one star, a star is subtracted from the overall rating.
3. Quality measure ratings are calculated and included in the overall rating. There are 15 quality measures that can affect the star rating of a facility when compared to other facilities across the nation:
   • Percentage of patients who need help with activities of daily living
   • Mobility declines
   • Catheter use
   • High-risk patients with pressure injuries
   • Urinary tract infections in the past 30 days
   • Pressure injuries in short-term patients
   • Unplanned hospitalizations (for both long-term and short-term patients)
   • Visits to emergency rooms for treatment (for both long-term and short-term patients)
   • New use of antipsychotic medication and overall percentage of patients on antipsychotic medication
   • Percentage of residents that show improved or declined independence
   • The rate that short-term patients transition back into their homes or communities
   • Falls within the past year

Points are assigned for all 15 measures and then the total is compared to other nursing homes across the country similar to how the health inspection rating is calculated with the top ten percent raking five stars and the bottom 20% raking one star. If the nursing home gets a five-star quality measure rating, the overall score goes up by one. If the nursing home gets a one-star quality measure rating, the overall score goes down by one.

4. If the health inspection score is one star, regardless of the rating in the other categories, the overall score can only be as high as two stars.

5. For a Special Focus Facility that has not graduated, it cannot receive an overall rating higher than three stars. These facilities were identified by CMS as having serious quality issues that need to be addressed by stringent oversight. They have, on average, twice the number of deficiencies as other nursing homes, some of which result in harm to patients and have not been resolved in of the past three annual assessments. In order to graduate from this program, they must demonstrate sustained improvement over the course of several assessment periods.

Considering all of these factors will lead to a final score for each nursing home of between one and five stars. This is the CMS Nursing Home rating that is displayed on the Care Compare page for consumers to consider.

What Do CMS Nursing Home Ratings Mean?

CMS recognizes that these three assessments cannot possibly reflect every data point about a healthcare facility and recommends doing additional research before deciding where to seek care. However, this is a great starting point for patients and their families. The resources included in Care Compare are intended to give patients the opportunity to search for facilities that meet their needs, follow all national guidelines for staffing and patient care, and are committed to regularly updating their training and community outreach.

Facilities are only included in the list once they have been through the evaluation process twice. Prior to that, their Care Compare rating will say “too new to rate.” Additionally, if there are not enough eligible patients to reliably calculate the ranking, it will be reported as “data not available.”

While the CMS nursing home rating will help patients make informed decisions, it will also encourage them to ask additional questions about the type of care provided and the priorities of the facility.

Facilities with higher star ratings experience higher enrollment and fewer cases of disenrollment, particularly among those with complex health care needs. In addition, facilities rated four or five stars are eligible for a 5% bonus for each enrollee in the contract and higher rebate payments.

How are CMS Nursing Home Ratings Updated?

CMS Nursing Home ratings are updated quarterly. Data is pulled from all of the following sources to recalculate the rating:

• State-conducted health inspections
• Complaint investigations
• Infection control inspections
• Recertification annual inspections
• Revisits to ensure compliance issues have been remedied
• Minimum Data Set submissions
• Medicare data and reimbursement
• Staffing levels
• Staffing turnover

The Five-Star Quality Rating uses more than 400,000 records to draw data points and create an evaluation of each facility. Rating thresholds are recalculated monthly to ensure an equal distribution of all levels of star ratings are represented within the state.

How Can Staff Affect the CMS Nursing Home Rating?

Staffing levels and frequency of staff turnover affect the star rating of a nursing home. “Research and experience tell us that staffing levels and staff turnover can substantially affect quality of care and health outcomes for people living in nursing homes,” CMS Administrator Chiquita Brooks-LaSure said. Higher rates of turnover are negatively associated with patient outcomes, so this measure was added to the Five Star rating system in 2022.

In response to this research, CMS recently launched a Nursing Home Staffing Campaign. The goal is to increase the number of nurses working in nursing homes and at state inspection agencies. Incentives including tuition reimbursement for RNs and on-the-job training for new employees to become CNAs are making it easier for new employees to enter as nursing home staff.

It’s also essential that employees are engaged in patient care while at work. CMS nursing home ratings are based on the number of hours of care provided to each patient in the facility. Fully invested staff members spend more time with their patients, pay closer attention to health needs, and respond faster to prevent negative events. A 2001 study on staffing found that sufficient clinical care is 4.1 hours per resident day for all staff and 0.75 hours from RNs.

How Should Patients or Care Givers Consider CMS Nursing Home Ratings?

While the Five Star CMS Nursing Home rating is not the only way to evaluate a nursing home as a potential caregiver, this system is a great way to determine the best facilities in a region. Balance this data with information about the specific services provided in a nursing home, preferences for practitioners the patient may have, and location. All of these factors can also affect the experience patients have in a nursing home.

Those making healthcare decisions about nursing homes should consult with social workers and current healthcare professionals about the needs of the patient and the ability of considered facilities to meet those specific needs. It’s highly recommended that they visit the nursing home to understand the culture prior to making a decision.

CMS Nursing Home Rating and Correcting Facility Data

Because this rating is so important to nursing homes, you want to be sure yours is accurate and up to date. You have the opportunity to review and correct the data prior to publication on the CMS website. The Review and Correct Report is available to administrators within the CMS reporting system. By accessing this information as early as possible, you can catch errors and have them corrected or start making improvements in your facility, training, hiring, or safety. You have 30 days to preview the data and request changes.