Five-star quality rating

How we calculate ratings

We create the overall 5-star rating for nursing homes based on 3 parts: 1) Health inspections 2) Quality measures (QMs) and 3) Staffing. Star ratings for each part and the overall rating range from 1 star to 5 stars, with more stars indicating better quality.

We assign the overall 5-star rating in these steps:

Step 1: Start with the health inspections rating.

Step 2: Add 1 star if the staffing rating is 4 or 5 stars and greater than the health inspections rating. Subtract 1 star if the staffing rating is 1 star.

Step 3: Add 1 star if the quality measures rating is 5 stars; subtract 1 star if the quality measures rating is 1 star.

Step 4: If the health inspections rating is 1 star, then the overall rating cannot be upgraded by more than 1 star based on the staffing and quality measure ratings.

Step 5: If a nursing home is a special focus facility, the maximum overall rating is 3 stars.

We briefly describe each of the 3 parts below:

1. Health inspections rating:
   We base health inspection ratings on the 3 most recent comprehensive (annual) inspections, and inspections due to complaints in the last 3 years. We place more emphasis on recent inspections.
2. Quality measures (QM) rating:
   We combine the values on 16 QMs (a subset of the 24 QMs listed on Nursing Home Compare) to create the QM rating. QMs are derived from clinical data reported by the nursing home.
3. Staffing rating:
   We base the staffing rating on 2 measures: 1) Registered Nurse (RN) hours per resident per day; and 2) total staffing hours per resident per day. Total staffing includes: RNs; Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs); and Certified Nurse Aids (CNAs). Staffing data are submitted by the facility and are adjusted for the needs of the nursing home residents.

What information can I get about staffing?

These types of staff are included in the nursing home staffing information that is collected by CMS:

• Registered Nurse (RN)
• Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN)
• Certified Nursing Assistant (CNA)
• Physicial Therapists (PT)

Each nursing home reports its staffing hours to its state survey agency. These staffing hours are from a two-week period just before the state inspection. Staffing data reported on Nursing Home Compare come from the states.

The staffing hours are reported by the nursing home into a measure that shows the number of staff hours per resident per day. Staffing hours are reported by nursing homes and displayed as the number of staff hours per resident per day.

Staffing hours per resident per day is the total number of hours worked divided by the total number of residents. It doesn't necessarily show the number of nursing staff present at any given time, or reflect the amount of care given to any one resident.

Why is this important?

Federal law requires all nursing homes to provide enough staff to adequately care for residents. However, there's no current federal standard for the best nursing home staffing levels.

The nursing home must have at least one RN for at least 8 straight hours a day, 7 days a week, and either an RN or LPN/LVN on duty 24 hours per day. Certain states may have additional staffing requirements. CNAs provide care to nursing home residents 24 hours per day, 7 days a week. The amount of physical therapy service hours depends on the needs of the resident.

Some nursing homes might require more nursing staff due to the conditions of their residents, and other factors like whether the nursing home has special care units.

An important caution: These staffing numbers are based on information reported by the nursing home. They represent staffing levels for a two-week period prior to the time of the state inspection. CMS checks the data for unusual reporting issues, like obvious data entry error, and asks states to follow up with nursing homes in those cases. However, there's currently no system to fully verify the accuracy of the staffing data that nursing homes report. Because of this limitation and because staffing levels may have changed since the last inspection, you should be cautious when interpreting the data.

Staffing education and training requirements (Note: each state may have its own specific requirements.)

Registered nurses and licensed practical and vocational nurses

By law, registered nurses (RNs) must assess nursing home residents' needs. RNs and licensed practical and vocational nurses (LPNs/LVNs) work together to plan care, implement care and treatment, and evaluate residents' outcomes. Nurses must be licensed in the state. RNs have between 2 and 6 years of education. LPNs/LVNs generally have 1 year of training.

Certified nursing assistants

Certified nursing assistants (CNAs) work under the direction of a licensed nurse to assist residents with activities of daily living, like eating, bathing, grooming, dressing, transferring, and toileting. All full time CNAs must have completed a competency evaluation program or nurse assistant training within 4 months of their permanent employment. They must also pursue continuing education each year.

Physical therapists

Physical therapists (PTs) help residents improve their movement and manage their pain. PTs test muscle strength, the amount of flexibility in joints, and the residents’ ability to walk or move. PTs often work with other providers, like doctors, nurses, and occupational therapists (OTs) to create individualized therapy plans to address and restore the resident’s physical function and well-being. All states license PTs.

What information can I get about quality measures?

Quality data

Nursing homes regularly collect assessment information on all their residents using a form called the Minimum Data Set. The information collected includes the residents' health, physical functioning, mental status, and general well-being. Nursing homes self-report this information to Medicare.

Quality measures

Medicare uses some of the assessment information to measure the quality of certain aspects of nursing home care, like whether residents have gotten their flu shots, are in pain, or are losing weight. These measures of care are called "quality measures." Medicare posts each nursing home's scores for these quality measures on Nursing Home Compare. By comparing scores, you can evaluate how nursing homes may differ from one another.

You can use the quality measures to:

• choose a nursing home for yourself or others
• find out about the care at nursing homes where you or family members already live
• gather information to talk to nursing home staff about the quality of care

Nursing homes can use the quality measures to review and improve the quality of the care they give to residents.

Things to keep in mind

The quality measures on Nursing Home Compare:

• Aren't benchmarks, thresholds, guidelines, or standards of care, and aren't appropriate for use in a lawsuit.
• Are based on care given to all the residents in a nursing home, not to individual residents.

Most of these quality measures reflect residents' conditions during the 7 days before the assessment was done. Therefore, the quality measures may not represent the residents' clinical conditions during the entire time period between assessments.

Inspection results

What happens after a nursing home inspection?

If an inspection team finds that a nursing home doesn't meet a specific standard, it issues a deficiency citation. The federal government may impose penalties on nursing homes for serious deficiencies or for deficiencies that the nursing home fails to correct for a long period of time. For example, Medicare may assess a fine, deny payment to the nursing home, assign a temporary manager, or install a state monitor.

State governments may also impose penalties on nursing homes. These aren't listed on Nursing Home Compare. Information about them may be available on state websites.

The complete nursing home inspection

States record all the information they find during an inspection in a detailed report (form HCFA-2567). When the state finds a deficiency, it records the specific reasons for the deficiency. Medicare attempts to ensure all the states report their findings in a consistent and timely way.

Each nursing home that provides services to people with Medicare or Medicaid is required to make the results of its last full inspection available at the nursing home for the public to review. Nursing Home Compare shows all reports from the last year.

What inspection results mean

These inspections assess whether the nursing home meets certain "minimum" standards. If a nursing home has no deficiencies, it means that it met the minimum standards at the time of the inspection. Inspections don't identify nursing homes that give outstanding care.

While reading these reports, keep in mind that the quality of a nursing home may get much better or much worse in a short period of time. These changes can occur when a nursing home's administrator or ownership changes, or when a nursing home's finances suddenly change.