How to Land a Perfect Five-Star Rating

Tom Jegou

Every day, thousands of Americans struggle with how to best care for a loved one. Although they may realize skilled nursing facilities are better equipped to care for their loved one, they're not  sure how to find the one that will provide high quality care. 

Families often turn to the Nursing Home Compare database and use the Five-Star Quality Rating System to review facilities. The Centers for Medicare and Medicaid (CMS) publishes Five-Star Quality ratings on the Nursing Home Compare website for each nursing home that participates in Medicare or Medicaid.

In addition to the overall Five-Star Rating, the database provides metrics on health inspections, staffing and quality, all of which influences consumer decisions. Therefore, understanding how to navigate the rating process and keeping your facility in top shape is critical to your future success.

Learn about the system behind Five-Star Ratings  

The rating system awards each facility with a Five-Star Quality Rating that ranges from one to five stars based on its performance in three key measures. CMS rates each measure individually and then calculates the overall Five-Star Rating. Nursing homes earning five stars are considered above average quality and those receiving one star are considered below average. 

Potential residents and families aren’t the only ones judging you by your Five-Star Rating. Medical professionals use ratings to determine which facilities to recommend. Meanwhile financial institutions use Five-Star Ratings to assess a facility’s risk and make lending decisions. To learn more about their impact, read The Growing Influence of Five-Star Quality Ratings in LTPAC.

Even potential employees review Five-Star Ratings. Applicants are using the ratings to determine if the facility would be a good place to work. As the nursing shortage continues to loom across the industry, attracting and retaining nurses is more important now than ever. Job candidates could consider a poor rating a red flag and may believe it reflects substandard working conditions or understaffing. A good rating lets applicants know your facility is both safe and sanitary.

Depending on your rating, the Nursing Home Compare database can serve as a beacon to prospective residents, lenders, and applicants — or a warning flag. While it’s in everyone’s best interest to aim for the former, achieving and maintaining a perfect Five-Star Rating can pose a significant challenge for any skilled nursing facility.

Here are a few tips to help you to land a perfect Five-Star Rating and a boost to your reputation. 

Learn how Five-Star Ratings are calculated  

The CMS bases a facility’s Five-Star Rating on three measures: Inspections, Staffing, & Quality. Fulfilling all the requirements doesn’t guarantee you will achieve or keep a top rating since your facility is also measured against other ones, similar to being graded on a curve. According to Leading Age, CMS awards about 10 percent of nursing homes a full five stars and 20 percent one star. The remaining 70 percent are presented two, three, and four stars in equal proportions. 

Inspection: An onsite health inspection kicks off the rating process. CMS sets the initial rating based on this inspection and requires facilities self-report quality and staffing measures.

Staffing: Facilities must follow Payroll-Based Journal guidelines to report staffing history. Five-Star Ratings can change every quarter based on submitted Payroll-Based Journal reports, audits, and inspections. CMS enforces strict requirements for the amount of nursing care residents should receive, providing one staffing rating for registered nurses and another for the total nursing staff. 

Five-star staffing ratings are assigned to facilities who earn a Five-Star Quality Rating in both RN coverage and total staffing or a five-star staffing rating in RN coverage and a four-star rating in total staffing. To learn more about CMS requirements, watch the SmartLinx webinar: Perspective on PBJ — Hear It from CMS and Other Experts.

Quality:  Facilities must follow CMS guidelines for quality and self-report their efforts. Quality measures are based on resident assessment data collected at specified intervals during the residents’ stay. These measures review each resident’s conditions, abilities, preferences and life care desires. Categories include the amount of successful discharges, self-reported pain, and the mental health of residents. Although the quality measure has the least impact on your overall Five-Star Rating, it's still factors into the consumer decision-making process.

Maintain a clean, safe, and healthy environment

This first aspect of the Five-Star Rating system may seem obvious. But keep in mind Health and Safety Inspections set the stage for your Five-Star Rating and can carry the largest impact on your overall score. This category encompasses a wide range of measures—and objectives—ranging from preventing mistreatment to the potential number of resident falls, to keeping the facility sanitary, and identifying deficiencies in fire safety. The rating is influenced by inspections conducted over the last three years. Scoring poorly now can harm your facility’s Five-Star Rating for years to come. Finally,  standard surveys and complaint surveys also influence this rating. You must continually maintain your facility to keep your score high.

Schedule up-front for compliant staffing

Staffing represents the second most important factor in calculating your Five-Star Rating. Inadequate staffing creates a myriad of problems. Understaffing can lead to a lower rating and signify noncompliance if your schedules don't support PPD values. Overstaffing contributes to excessive labor costs and unnecessary overtime. Nevertheless, when it comes to the star rating, the most important factor is achieving a perfectly balanced staff-to-patient ratio. When you fall into the sweet spot of staffing, you give your residents the best care possible and earn a great star rating — with the bonus of lowering your overtime costs.

To help you achieve staffing success, consider predictive scheduling. Predictive scheduling proactively defines the appropriate staffing level based on the number of residents, resident acuity, and regulatory demands. It enables you to easily create and modify schedules based on your changing needs and PPD values. Predictive scheduling also lets you determine staffing levels in advance, using data insights to drive decisions. 

Stay on top of regulatory changes

The government routinely updates compliance requirements. Nursing home operators should verify that their software providers continually update their systems and train users on evolving Payroll-Based Journal requirements well before quarterly deadlines.

For example, CMS changed how nursing homes must report meal breaks for employees in 2019. Now all facilities must attribute a 30-minute meal break for each 8-hour shift for every employee and contractor (salaried and hourly) regardless of whether they take the full break or not. The Payroll-Based Journal system must also use payroll records to confirm the validity of their reports and meal breaks. To learn more about this requirement, watch Payroll-Based Journal Meal Break Policy Update.

Set up practices to support auditable and verifiable information

While you may view switching to a new system for your Payroll-Based Journal reporting cumbersome, filling out reports manually or using inefficient systems increase the likelihood of error. Not only can this make audits a nightmare, but such errors can lead to a black mark next to your facility’s name on the Nursing Home Compare tool, right by your Five-Star Rating. In addition, these systems can take an enormous amount of time. CMS has started auditing select facilities in its new program. Widespread audits will likely follow.  Watch a two-minute video to see how one facility reduced mandatory reporting from 60 hours to a few minutes.

Report accurately to prevent score inflation

Creating compliant Payroll-Based Journal reports can be labor-intensive and error-prone. Reporting inaccuracies are sometimes overlooked, which may evoke a sigh of relief in some facilities. However, they pose an unseen risk by artificially inflating your Five-Star Rating and subjecting it to plummet after an audit uncovers these reporting inaccuracies. If you put processes in place to keep your reporting methods in line now, you’ll always have an accurate measure of your facility’s performance.  Read how Greek American Rehabilitation refuted a compliance allegation in moments.

Maintain quality through optimized scheduling

Quality measures comprise the third metric in your facility’s Five-Star Rating. By optimizing your staffing levels, you'll be able to provide the best possible care to your residents through a balanced staff-to-patient ratio. Proper staffing and fair scheduling practices can boost the morale of your staff and improve quality of care. After all, happy staff means happy residents! 

Predict and improve Five-Star Ratings

To maximize your Five-Star Quality Rating, you need to predict your rating early in the quarter and identify issues that will damage your score. Then you can adjust schedules, close gaps, and create back up processes. The right technology can proactively predict your staffing rating and help you improve it long before the deadline.

SmartLinx Five-Star Predictor enables you to evaluate for your staffing rating based on Payroll-Based Journal reporting long before the CMS submission deadline. The tool aggregates hourly staffing data in the Payroll-Based Journal, attendance, and employee scheduling systems and factors in CMS calculation criteria and evolving requirements.

The Five-Star Predictor automatically rates each facility in real-time. You can designate a specific time period to review and predict the corresponding staffing rating. The Predictor will also display warnings when any facility’s staffing is poised to jeopardize your desired rating. The system uses current and historical data to calculate the star rating and identify steps you can take to improving staffing and achieve your desired star rating.

You can:

  • Analyze future schedules.
  • See where and when you’ll  need additional nursing staff.
  • Identify the amount of missed coverage that will cause your rating to drop.

Now that you know exactly what goes into your Five-Star Rating, it’s time to act. By putting in place the right policies and tools, your facility will be on the road to a perfect Five-Star Rating.

Want more information on improving your Five-Star Rating?

Check out the following:


About the Author

Tom Jegou

As Compliance Expert at SmartLinx, Tom Jegou oversees SmartLinx innovations in our payroll and compliance systems. Tom is focused on transforming client needs into leading-edge products. Tom leads cross-functional teams from a product's conception through to its launch. Tom led the design of the 1095-C and Payroll-Based Journal reporting features in the WorkLinx<sup style="font-size: 60%;">TM</sup> suite. Since 1996, Tom has worked with every aspect of Human Capital Management Systems. He has defined, supported, implemented and managed Payroll, Time and Labor and HR systems. Tom is a Certified Payroll Professional through American Payroll Association.

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