The 5-Star Quality Rating System was created by CMS in 2008. Today, almost 15 years later, we still see confusion and a lack of understanding of the 5-Star domains, how they are calculated, and how the DON can best lead the facility in improving the 5-Star rating. Does your facility employ these strategies to manage Five Star success?

Understanding the 5-Star Quality Rating System

The 3 Domains of the CMS 5-Star Quality Rating System Quality Rating System are: Health Inspections, Staffing, and Quality Measures. For the Health Inspection Domain, CMS calculates the health inspection score based on points assigned to deficiencies identified in each of the three most recent recertification health inspections, as well as on deficiency from the most recent three years of complaint inspections and from focused infection control surveys. The Nursing Home Five-Star Quality Rating System Technical Users’ Guide explains how “points are assigned to individual health deficiencies according to their scope and severity –more serious, widespread deficiencies receive more points, with additional points assigned for substandard quality of care”. The chart below from this guide demonstrates how the points are assigned:



A separate table in the guide outlines how repeat deficiencies are weighted. Each facility is assigned a star rating for Health Inspections as follows:

  1. CMS bases 5-Star quality ratings in the health inspection domain on the relative performance of facilities within a state. This approach helps control for variation among states. CMS determines facility ratings using these criteria:
      • The top 10 percent (with the lowest health inspection weighted scores) in each state receive a health inspection rating of five stars.
      • The middle 70 percent of facilities receive a rating of two, three, or four stars, with an equal number (approximately 23.33 percent) in each rating category.
      • The bottom 20 percent receive a one-star rating.
  1. The rating for staffing is based on six measures. This information comes from the Payroll Based Journal (PBJ) information. The six measures are as follows:
      • Case-mix adjusted total nursing hours per resident day (registered nurse (RN) + licensed practical nurse (LPN) + nurse aide hours) for a quarter averaged across all days (weekdays and weekends)
      • Case-mix adjusted RN hours per resident day for a quarter, averaged across all days (weekdays and weekends)
      • Case-mix adjusted total nursing hours per resident day (RN + LPN + nurse aide hours) for a quarter averaged across all weekend days (Saturdays and Sundays)
          • The percentage of nursing staff that left the nursing home over a twelve-month period.
          • The percentage of RNs that left the nursing home over a twelve-month period.
          • The number of administrators that left the nursing home over a twelve-month period.

The 5-Star Users’ Guide also describes that “a set of quality measures (QMs) was developed from Minimum Data Set (MDS) and Medicare claims data to describe the quality of care provided in nursing homes.” From the MDS, there are 7 Long Stay QMs and 3 Short Stay QMs derived. From claims-based data there are 2 Long Stay Measures and 3 Short Stay Measures. The guide details how the QM domain points are calculated, and includes Table 5 below, which shows the point ranges.



Finally, based on the star ratings for the health inspection domain, the staffing domain and the quality measure domain, CMS assigns the overall 5-Star rating in three steps:

      • Step 1:  Start with the health inspection rating.
      • Step 2:  Add one star to the Step 1 result if the staffing rating is five stars; subtract one star if the staffing rating is one star. The overall rating cannot be more than five stars or less than one star.
      • Step 3:  Add one star to the Step 2 result if the quality measure rating is five stars; subtract one star if the quality measure rating is one star. The overall rating cannot be more than five stars or less than one star.


How well is your team driving Five Star improvement?

Does your facility conduct regular health inspection readiness activities such as a mock survey?

Do staff have regular assignments for completing review of the Casper reports, including the QM, and performing audits of QM areas such as accurate MDS coding of diagnoses and care plan interventions for falls and skin issues?

Are you reviewing your PBJ information for accuracy and looking at your staffing each day to address any concerns related to RN coverage, or decreased C.N.A hours?

Is your QAPI process effective in identifying areas that could be improved before they present as an actual problem?


By understanding the components that make up each domain of the 5-Star rating, and applying a QAPI approach for reviewing and developing improvement plans, the DON and other members of the IDT will be on the way to 5-Star Success! Join Proactive on January 18, 2023 for the first session in the 5-Star Work Plans A-Z series: 5-Star Overview and Health Inspection Domain. This series will guide your team in analyzing your own data to gain the insights and strategies needed to develop a 5-Star Workplan that puts your facility on a path to success.

Also, don’t miss the Mission Possible: SNF Department Head Briefing series beginning January 24th, 2023 which examines the critical roles of individual department heads in survey preparedness, quality care, retention and customer satisfaction, among other objectives. The first session in this series highlights essential responsibilities of the effective DON, including 5-Star rating management.

Contact Proactive for more information on 5-Star consulting services including remote QA review and targeted onsite support.



Cowritten by Stacy Baker, OTR/L, CHC, RAC-CT and Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC


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