The Centers for Medicare & Medicaid Services (CMS) uses its Five-Star Quality Rating System to assess and rate nursing homes, making this information publicly available to assist consumers in choosing facilities. The overall rating is a cumulative score based on performance in three primary categories: health inspections, staffing, and quality measures. These ratings are displayed on the Medicare Care Compare website.
The Three Key Domains of the CMS Rating System
The overall star rating is derived from a weighted combination of separate star ratings for each of the three key domains.
1. Health Inspections Rating
This is typically the most significant factor, accounting for 60–70% of the overall score. The rating is determined by findings from state surveys, including annual inspections, complaint investigations, and infection control reviews. Deficiencies found during these inspections are assigned points based on their scope and severity, with more recent findings having a greater impact. Facilities are rated relative to others in their state to account for variations in state survey practices.
2. Staffing Rating
Contributing 15–20% to the overall score, this rating assesses the amount of direct care staff time residents receive. Data is submitted by facilities and adjusted for resident acuity. Key metrics include RN and total nurse staffing hours per resident per day, as well as staff turnover rates. Failure to submit data or consistent lack of an on-site RN can result in a one-star staffing rating.
3. Quality Measures (QM) Rating
Making up 15–25% of the total score, the QM rating focuses on resident health outcomes using data from the Minimum Data Set (MDS) and Medicare claims. Measures cover both short- and long-stay residents and include factors like pressure ulcers, weight loss, falls with injury, use of antipsychotic medications, and vaccination rates. Performance is compared to national benchmarks, with facilities grouped into quintiles.
The Overall Rating Calculation
The overall rating calculation begins with the health inspection rating. Adjustments are then made based on the staffing and quality measures ratings. A significantly higher staffing rating (4 or 5 stars and greater than the health inspection rating) or a five-star QM rating can add a star to the overall score, while a one-star rating in either category can result in a deduction. If the health inspection rating is one star, the overall rating cannot increase by more than one star. Special Focus Facilities, identified for consistently poor care, are capped at a three-star overall rating.
Comparing Rating Components
| Feature | Health Inspections | Staffing | Quality Measures (QM) |
|---|---|---|---|
| Data Source | State surveys (annual, complaint, infection control) | Facility-reported Payroll-Based Journal (PBJ) data | Facility-reported Minimum Data Set (MDS) and Medicare claims data |
| Rating Basis | Number and severity of deficiencies; weighted by recentness. | Case-mix adjusted hours per resident day and staff turnover rates. | Resident health outcomes and clinical performance. |
| Comparison Group | Ranked relative to facilities within the state. | Compared to national averages and benchmarks. | Ranked relative to national distribution. |
| Recent Weighting | Heaviest on most recent survey results. | Based on the previous three months for staffing levels. | Uses data from the last four available quarters. |
| Maximum Rating Impact | Starting point for overall rating. | Can add or subtract one overall star. | Can add or subtract one overall star. |
Conclusion
The CMS Five-Star Quality Rating System provides a valuable framework for assessing nursing home quality by evaluating health inspections, staffing, and quality measures. This system offers a standardized way to compare facilities. However, CMS emphasizes that these ratings should be used as one part of a comprehensive evaluation process. Prospective residents and their families should also conduct facility visits, speak with staff and residents, and consult resources like the long-term care ombudsman program to make an informed decision. CMS continues to refine the system to promote ongoing quality improvement in nursing home care.
Learn more from official sources
For the most current information on individual nursing homes, visit the official Medicare Care Compare website.
