Medicare Nursing Home Ratings: A Brief Guide

Essentially, the Five-Star Quality Rating System rates nursing homes — and other care types — on a scale of one to five stars. One-star ratings indicate nursing homes that are below average in quality, while five stars are for nursing homes considered well above average. However, it’s also important to understand how rankings are evaluated and determined.

The FSQRS combines data and ratings from three categories: staffing, health inspections, and quality of resident care. Each of these areas has their own metrics for assigning separate ratings. These three ratings are then combined, with the health inspection rating as the base metric, to determine an overall star rating.^[01]

Staffing rating

Medicare rates the quality of staffing in a nursing home by evaluating six characteristics that can help identify potential issues, such as whether or not residents will receive enough one-on-one care.

When rating the staffing in a nursing home, Medicare evaluates:

• Total nursing hours provided per resident per day. This includes care provided by registered nurses (RNs), licensed practical nurse (LPNs), and nurse aides.
• The staffing levels of RNs alone (also in hours per resident per day) for a better understanding of staff availability for more advanced care and medical assistance.
• Total nurse staffing on the weekends.
• Total nursing staff turnover — specifically RNs, LPNS, and aides who left the job over a 12-month period.
• Total RN turnover over a 12-month period.
• Total administrator turnover over a 12-month period.^[02]

Understanding staffing hours and turnover rates can point to potential burnout among caregivers and management issues. It’s an essential metric to look at since consistent care is both a safety and comfort issue. Turnover of familiar staff can cause a feeling of loss in your parent, as well as concerns about their continued care.

Health inspection rating

Any nursing home that participates in Medicare and/or Medicaid programs must undergo comprehensive health inspections to maintain their certification. These inspections happen on average once a year and rarely take place more than 15 months apart. They cover a wide range of quality assessments, including health-based ones such as skin care, medication management, environment, and food. The FSQRS for health inspections is based off of the three most recent recertification surveys, any complaints that have been processed during that three-year period, and any deficiencies that involved infections.^[02]

It’s important to note that health inspections vary by state, as each state has different regulations. Medicare compares facilities within each state — rather than on a national level — because of these state-level differences. Facilities scoring in the top 10% by state for health inspections receive five stars, while facilities in the lowest 20% receive only one star.^[03]

Quality of resident care rating

The resident care rating evaluates short-term and long-term residents. Long-term residents are evaluated for any improvement or decline in their ability to live independently, including their ability to move around the facility or perform activities of daily living (ADLs). Their health is also evaluated: Medicare checks for bedsores, whether antipsychotic medications have been administered, or if emergency intervention has been needed. While all of these are good regulations to have in place, some can cause issues when potentially beneficial and needed medications are not administered in order to avoid lowering star ratings.^[02]

For residents who have short stays, such as during rehabilitation periods after a surgery, the metrics are slightly different and often focus on improvement. These measures include percentage of patients who improved their ability to move independently, rehospitalizations or emergency medical treatment, pressure ulcers, and whether antipsychotics had to be administered for the first time to a resident.^[02]

All of these data points can paint a picture about how residents are treated and how the nursing home provides health care to them.

Is a nursing home the right fit?

Once scores are calculated for the areas above, the overall rating is then determined using a set scoring system. The scoring begins by using the health inspection. For example, if this is four stars, then the base rating is four stars.

A star is then added if the staffing rating is five stars, or a star is removed if the staffing rating is one star. In this example, if the staff rating was one star, then the overall rating would fall to three stars.

Finally, an additional star is added if the quality rating is five stars or removed if the quality rating is one star. For this example, if the quality rating was five stars, then the overall rating would be brought back to four stars. ^[02]

Note that if the health inspection scores a single star, the facility cannot receive a rating any higher than two stars, since the health inspection is conducted by certified surveyors and a one-star health inspection represents serious recent deficiencies.^[02]

With any ranking system, there are always potential issues. Unfortunately, the Five-Star Quality Rating System rankings often rely on information submitted by the nursing homes themselves, which can result in misleading numbers or issues being hidden from CMS. If accidents or resident health issues are unreported, for example, then they won’t affect the measures used in rankings.

CMS has recently updated the way they rank staffing with the addition of the weekend staffing and turnover data in the hopes of having more transparency throughout the process.^[04]

While star ratings can be helpful in narrowing down choices, they should never be solely relied on when deciding where a loved one will stay. Always read reviews by residents and their families, talk to people you trust about any potential care providers, and visit nursing homes in person before making any care or housing decisions for your loved one.

To view nursing home star ratings, you can go to the Care Compare website under the Medicare.gov umbrella of sites. Here you can type in the ZIP code where you’re looking for care and see the rankings of all Medicare-certified nursing homes near that location. Once you have this, you can filter for specific ratings under each measure: health inspections, staffing, and quality of care. You can also select up to three nursing homes and compare them. This will bring up not only their star ratings to compare but also other useful information, such as their distance from the desired location and their number of Medicare-certified beds.

Nursing homes questions? Get expert help

In addition to checking a nursing home’s rating under the Five-Star Quality Rating System, you can also read reviews and descriptions for facilities online. NursingHomes.com is a helpful nursing home listing site with photos, descriptions, reviews, and contact information for over 15,000 facilities across the country.

When you find nursing homes in your area, it’s important to have checklists ready before you visit the facility to ensure that important standards of care are being met. Medicare and the American Health Care Association both have online checklists that include important questions to ask and aspects to check for yourself when touring of nursing home.

Along with questions regarding your loved one’s specific care needs, here are some other questions to consider:

• What actions does a nursing home take to prevent abuse?
• Is there good lighting throughout the facility?
• Do residents seem well groomed and comfortable?
• What types of foods are served, and are special diets accommodated?
• Is it easy to report any issues?

Having the answers to these and other important questions will help you better compare facilities and navigate the complex choices behind choosing a nursing home. The FSQRS can often provide a solid starting point for your search, but other factors should be considered as well.

Nursing homes are usually best for people who need considerable assistance with their activities of daily living and/or daily medical care. While finding a quality nursing home facility is essential for a loved one who needs skilled nursing care, it’s also important to know what type of care is actually required

In some cases where a loved one doesn’t need skilled nursing care, lower levels of care may be a better fit. With both assisted living and in-home care, a loved one can maintain their independence while receiving assistance when needed.