The Five-Star Quality Rating system for nursing facilities (NF) was created to help consumers and families more easily compare nursing homes and identify high and low performing facilities.   Facilities are given a Five-Star rating in 3 areas – Health Inspections, Staffing and Quality Measures – which are then combined to calculate an Overall rating.  It is increasingly important for NFs to monitor Five-Star ratings as it could negatively impact operations including census and managed care contracting.


The program has undergone many changes since its inception in 2008 partially in response to widespread criticism.  In April 2019, CMS made major changes to the staffing, health inspection and quality measure components of the Five-Star rating system causing many facilities to lose stars as illustrated in the chart below.



187 Ohio facilities (19.4%) have 5 stars compared to 20.6% nationwide.

The distribution of stars in the overall star rating is show in the chart below. Ohio’s distribution of stars mostly parallels the nationwide distribution, though Ohio has a slightly larger percentage of one-star facilities.



 Health inspection ratings unfrozen with half of all facilities seeing ratings changes.

In November 2017, CMS implemented a new inspection process and, due to differing standards and processes between facilities, froze the health inspection star rating for nursing homes. As of April 2019, CMS began utilizing the health inspection star rating again and returned to the pre-freeze weighting with ratings based on three cycles of standard inspections and any complaint surveys from those same cycles. They will also be suppressing the star ratings for Special Focus Facilities (SFFs), which are those nursing homes with a history of serious quality issues that are included in a special program designed to help improve their quality of care.

With the unfreezing of the health inspection component, approximately one-quarter of all facilities nationally and statewide have seen a decrease in star ratings (24% nationally and 26% in Ohio), while a similar number of facilities nationally (25) and statewide (26%) have seen an increase in star ratings.



 Downgrade to 1 staffing star if 4 days in quarter without RN (previously 7 days) has big impact on staffing stars.

In April 2019, CMS made significant changes to the staffing component. In an attempt to incentivize improved staffing levels they established new thresholds for determining ratings with the most significant threshold being registered nurse staffing. Previously, facilities reporting seven or more days in a quarter without an RN onsite were automatically downgraded to one-star for the staffing component however the new changes set the threshold at four days instead of seven. As a result of these changes, 1,638 facilities nationwide (11%) and 129 facilities in Ohio (13%), were downgraded to one-star, compared to only 8% nationally and 11% in Ohio prior to the changes.

Overall, approximately one-third of all facilities both at the national and state levels have seen a decrease in staffing stars. Amidst the numerous changes, though, it can be noted that the staffing star ratings were the most stable of all the components with greatest percentage of facilities that had no change in rating, with over 50% remaining unchanged both nationally and statewide.



Can you identify opportunities and risks to your Five-Star quality measure rating?

CMS also revised the thresholds for quality measure (QM) ratings and is now weighting and scoring the individual QMs differently. While each facility will continue to receive an overall quality measure rating, it will now be based equally on short-stay and long-stay ratings. CMS also will continually increase the quality measure thresholds, at a rate of 50% the average rate of improvement in scores every six month, matching their expectation that nursing facilities will continue to make quality improvements over time.  With the changes to the calculations, 48% of facilities nationally and 50% of facilities in Ohio saw a decrease in the QM star rating, while only 8% nationwide and 14% in Ohio saw an increase in the QM star rating.

Quality Measure five-star ratings are recalculated on a quarterly basis. Sometimes a small change can cause you to gain or lose a quality measure star if you are close to a cut-off point. If you identify these opportunities or risks, you can focus your quality improvement efforts in these areas.   Contact your HW Healthcare Advisor if you would like to know more.

Paula Z. Reape, CPA, LNHA