Five Star Quality Rating System with Public Reporting

2020 marks 13 years of the Five Star Quality Rating System with public reporting on the CMS Nursing Home Compare website. Since 2008, the rating system and website have evolved with updates in 2012, 2015, 2018 and during this past year. With the April 2019 update, nearly 40% of nursing homes experienced a decline in overall star rating. The abuse icon, removal of pain quality measures and modified quality measure thresholds were implemented in October 2019. Despite these moving targets, there are several proactive action steps that can be taken to strengthen fundamental systems that are the foundation of Five Star Quality.

Key Ways to Driving 5-Star Rating Improvements in 2020:

1.  Establish a robust Survey Preparedness and Management plan

  • Step 1 of the overall 5-star rating begins with the health inspection rating. If the Health Inspection rating is one star, then the Overall Quality rating cannot be upgraded by more than one star based on the Staffing and Quality Measure ratings.
  • The methodology for the health inspection rating is based on outcomes from state health inspections with the number, scope, and severity of deficiencies identified during the three most recent annual inspection surveys, as well as substantiated findings from the most recent 36 months of complaint investigations.
  • Effective policies and procedures and regular quality monitoring are important. Good places to start monitoring efforts are: care plan implementation, medication pass, resident interviews & care competency observations. Formal review processes including mock survey may identify potential risk areas and opportunities for improvement to systems, procedures and processes of care. 

2.  Master Staffing and Labor Management

  • Providers with a staffing rating of 4 or 5 stars that is greater than the health inspection rating can add one star to the overall rating. One star is subtracted if the staffing rating is one star.
  • Ratings on the staffing domain are based on two measures: 1) Registered nurse (RN) hours per resident per day; and 2) total nurse staffing (the sum of RN, licensed practical nurse (LPN), and nurse aide) hours per resident per day.
  • Because of the strong emphasis on RN staffing, providers with four or more quarterly occurrences of less than eight hours of RN coverage will automatically get one star in staffing, and subsequently, lose a star overall in their Five Star Quality Rating.
  • Payroll-based Journal (PBJ) data are submitted quarterly and are due 45 days after the end of each reporting period. Only data submitted and accepted by the deadline are used by CMS for staffing calculations and in the Five-Star Rating System. Providers should ensure facility PBJ reporting systems are accurate by reviewing the CASPER 1702S Staffing Summary Report & CASPER 1704S_Daily MDS Census Summary Report to confirm data used for the staffing calculation is accurate. 

3.  Understand Resident Quality Measures (QMs)

  • Providers with a QM 5 star rating are rewarded with one star added to the overall rating. Providers will subtract one star if the QM rating is one star.
  • Ratings for the quality measures are based on performance in nine long-stay measures and six short-stay measures collected from Minimum Data Set (MDS) and Medicare claims data to describe the quality of care provided in nursing homes. Methods used to calculate quality measures can be found here.
  • Long-stay measures include 1) need for help with activities of daily living has increased, 2) ability to move independently worsened, 3) high-risk residents with pressure ulcers, 4) catheter inserted and left in their bladder, 5) urinary tract infection, 6) one or more falls with major injury, 7) antipsychotic medications, 8) number of hospitalizations, and 9) number of outpatient emergency department visits.
  • Short-stay measures include 1) improvement in function, 2) new or worsened pressure ulcers, 3) antipsychotic medications, 4) re-hospitalizations after a nursing home admission; 5) outpatient emergency department visits; and 6) rate successful return to home and community.
  • Starting in April 2020, every six months the QM thresholds will increase by 50% of the average rate of improvement in QM scores.
  • To drive QM performance, establish a process for reviewing QM data on a monthly basis to ensure plans are in place to identify system level issues and specific resident’s triggering for each QM area. Establish a performance improvement plan (PIP) to reduce the likelihood of triggers for the QM on subsequent assessments.

4.  Track and Trend Your Data

  • Monitor and routinely assess QMs through use of Certification and Survey Provider Enhanced Reports (CASPER).
  • Incorporate QM systems review into facility processes.
  • Review monthly Provider Preview in CASPER for feedback on PBJ submissions. Consider also running CASPER reports (1700D Employee Report, 1702D Individual Daily Staffing Report, and/or 1702S Staffing Summary Report) prior to submission before the quarterly deadline to ensure accuracy.

5.  Establish Specific Facility Goals with Timeframes and Assigned Tasks

  • Identify facility-specific risk areas based on data collection and monitoring activities.
  • Incorporate Performance Improvement Projects (PIPs) into the facility QAPI program.


Proactive Medical Review specializes in assisting facilities with Five-Star Rating Improvement plans. Contact us today for more information regarding our proven Five-Star Improvement partnerships. Click here for Proactive Toolkits and Training to drive your 5 Star improvement plan.

Resources –

  1. Five-Star Quality Rating System Technical User’s Guide (October 2019)
  2. MDS 3.0 Quality Measures User’s Manual (v12.1) (October 2019)



This 10-part webinar series will focus on advancing results in the three domains of the CMS 5-Star Quality Rating System: Health Inspections, Staffing, and Quality Measures. Click here to learn more and access registration info.

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Blog by Stacy Baker, OTR/L, CHC, RAC-CT, Director of Audit Services, Proactive Medical Review

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