Multiple studies show evidence of a strong correlation between nursing home staffing levels and quality of care.[i] Federal law requires sufficient staffing levels to safely meet the care needs of residents. As facilities deal with significant staffing challenges nationwide, it is critical to understand how staffing levels will impact your 5-Star Rating. Here’s what you need to know…

Understanding the 5-Star Staffing Rating

Since July 2022, CMS bases the Staffing star rating on six separate measures that include nursing staffing levels and turnover levels.[ii] The staffing rating is derived from data submitted each quarter through the Payroll-Based Journal (PBJ) System, along with daily resident census that is based on a daily resident census measure calculated by CMS using MDS assessments. The staffing rating is case-mix adjusted based on the distribution of MDS 3.0 assessments by Resource Utilization Groups, version IV (RUG-IV group).

PBJ staffing data is 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 5-Star Rating System. Similar to the 5-Star Quality Measure rating, points are assigned to each of the six staffing measures based on facility performance. These points are then summed and the total staffing score is compared to staffing rating point thresholds to assign a Staffing Rating of one to five stars. The six staffing measures that impact the 5-Star rating are:

  1. Adjusted Total Nursing Hours per Resident Day (HRD) – includes Registered Nurses, Licensed Practical/Vocational Nurses and Certified Nurse Aides hours Max 100 Points
  2. Adjusted RN Nursing Hours per Resident Day – Includes Director of Nursing, RN with Administrative duties, and direct care RNs. Max 100 Points
  3. Adjusted Total Nursing Hours per Resident Day on the Weekend – Max 50 Points
  4. Total Nursing Turnover – Max 50 Points
  5. RN Turnover – Max 50 Points
  6. Administrator Turnover – Max 30 Points

In order to receive a 5-star staffing rating, you must receive a total of 320-380 points from these six measures.

Also in July 2022, CMS revised the methodology for assigning the overall 5-Star Rating. Prior to July, facilities with a four or five star staffing rating received an additional star added to their overall 5-Star Rating. Now, only facilities with a five-star staffing rating will get an extra star added to their overall rating.

Master Staffing and Labor Management

Consider these strategies:

  • Establish 5-Star staffing PPD goals to achieve 5-star staffing rating and monitor your daily labor on to evaluate needed changes in staffing to meet established goals.
  • With nursing shortages, high rates of turnover, and tight budgets, hiring and retaining the best staff can be difficult. This is a great time to review new employee orientation and mentoring programs, as well as recruitment and retention programs to identify areas of performance improvement opportunity.
  • Establish systems to ensure that accurate PBJ data is submitted by each quarterly deadline. Evaluate the CASPER staffing reports (1700D Employee Report, 1702D Individual Daily Staffing Report, and/or 1702S Staffing Summary Report) prior to the quarterly submission deadline to review your submitted data and ensure accuracy.
  • Review your monthly Provider Preview report in your (CASPER) folder for feedback on your most recent PBJ submission.

It’s not too late to join Proactive LTC Consulting’s 5-Star Workplans webinar series.  Access the 5-Star Staffing Rating webinar on-demand here, and don’t miss upcoming sessions in February on the Quality Measure Domains and Developing a Facility-Specific Work Plan for 5-Star Improvement.

You may also contact Proactive for assistance in achieving 5-Star success through an integrated partnership that incorporates survey readiness, quality improvement and sufficient and competent staffing.


[i] Shin, Juh Hyun. George Washington University. Journal of Gerontological Nursing (Dec. 2012). Nurse Staffing, Quality of Care, and Quality of Life in U.S. Nursing Homes…

 [ii] Care Compare Nursing Home Five-Star Quality Rating Technical Users’ Guide (



Written By: Brandy Hayes, RN, RAC-CT


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