Nursing homes play a critical role in our nation's healthcare system. Today, nearly 1.3 million Americans reside in over 15,000 certified nursing homes across the county. In the wake of the COVID-19 pandemic, there has been a heightened focus on improving nursing home care quality. As facility administrators, it's crucial to understand quality standards, as this knowledge can directly impact quality ratings, admissions, and overall resident well-being.

In this blog, we’ll explore the systems used to measure and quantify facility quality and provide specific strategies for how to improve quality ratings in nursing homes.

The Five-Star Quality Rating System

The Five-Star Quality Rating System, developed by the Centers for Medicare & Medicaid Services (CMS), is the gold standard for assessing and comparing the quality of care provided by nursing homes in the United States.

While it continues to guide individuals and professionals in making informed decisions, this system has also become a strategic asset for facility stakeholders. Insurance companies and healthcare organizations scrutinize quality ratings to determine network affiliations, partnerships, and patient referrals. Similarly, government agencies use this system to allocate funding and set facility reimbursement rates.

Staying informed about changes and enhancements to the system methodology is paramount in ensuring your facility remains competitive, adapts to evolving standards, and maintains its position as a trusted partner in long-term care services.

The Five-Star Quality Rating System Methodology

A nursing home’s Overall Quality rating is calculated based on its ratings for Health Inspections, Quality Measures (QMs), and Staffing. Each domain and the overall rating are scaled from 1 to 5 stars, with higher ratings signifying superior quality.

State Health Inspection Measures

Health inspection ratings are calculated based on points assigned to the results of surveys over the past three years. The number, scope, and severity of health deficiencies determine point allocations. Lower health inspection survey scores result in a better 5-star rating. Health inspection ratings are updated monthly to incorporate new survey data.

Quality Measures

Quality measures encompass various indicators of resident well-being, including physical and clinical conditions. Ratings are calculated based on 10 Quality Measures (QMs), including seven long-stay (chronic care) QMs and three short-stay (post-acute care) QMs. Points are assigned to each QM to calculate a total QM score.

Staffing Measures

The staffing domain evaluates nursing homes based on staffing levels, including registered nurses, licensed practical nurses, and certified nursing assistants, to determine the adequacy of care provided to residents. These ratings do not include clerical, administrative, and housekeeping staffing hours.

CMS Resources

CMS is committed to continuously improving the Five-Star Quality Rating program. Rating methodologies and quality measures are frequently updated to reflect the latest healthcare practices and standards advancements.

Recent updates, including the Care Compare online portal launch, have enhanced the transparency and accessibility of quality data. In September 2023, CMS also announced changes to Staffing and Quality Measures criteria.

You can download the Five-Star Quality Rating System Technical Users Guide here for more detailed descriptions of each rating domain, the methods used to calculate them, and the most recent revisions to rating criteria.

How Quality Ratings Impact Facility Success

Quality ratings have far-reaching implications for nursing facilities, affecting patient satisfaction and safety, financial stability, and staffing.

Resident Safety and Satisfaction

The safety and satisfaction of residents are of utmost importance in care facilities. Facilities with high-quality ratings often have lower patient falls, infections, and medication error rates. Implementing innovative safety measures, such as remote fall mitigation solutions, can help facilities prioritize patient safety and reduce adverse events that lower quality scores during assessments.

Staff Retention

Retaining high-quality staff plays a crucial role in achieving higher quality ratings. High turnover rates can disrupt continuity and quality of care, ultimately impacting resident satisfaction and safety. A stable workforce is better equipped to provide top-notch care, resulting in improved care outcomes and enhanced quality ratings.

Resident Enrollment

High CMS star ratings are instrumental in boosting referrals and attracting prospective residents. Consistent enrollment ensures a stable income stream, enabling the facility to cover operational costs, invest in staff training, improve cost efficiencies, and implement cutting-edge technology that improves patient outcomes.

Public Perception and Reputation

Recent improvements to Care Compare, Medicare’s official quality comparison website, have made quality ratings more accessible. The rating your facility receives can impact public perception, potentially shaping a reputation that can either bolster or hinder the growth and success of your care network.

Lower Costs, Higher Reimbursement Rates

When a facility consistently delivers superior care quality, it translates into fewer costly incidents such as falls, medical errors, or complications. Additionally, Medicare and Medicaid offer value-based payments to facilities that consistently demonstrate excellent care quality.

By prioritizing quality and safety, your care network can navigate the challenges and opportunities these ratings present, ultimately delivering the highest level of care to the individuals you serve.

Strategies to Improve Low Quality Ratings

In this section, we’ll explore several strategies that facilities can implement to improve quality ratings and enhance the overall quality of care.

Prioritize Staff Training and Retention

Satisfied, well-trained staff are the cornerstone of any highly-rated nursing facility. If your facility needs to perform better in staffing, consider implementing staff training initiatives to address skill deficiencies. Training initiatives can cover topics such as infection control and prevention, mental illness education, or fall prevention. Upskilling staff can improve working practices and attitudes towards resident safety and care quality and can also be associated with significant reductions in avoidable accidents and hospitalizations.

Similarly, if staff turnover is a frequent challenge, communicate with your nursing leadership to address staffing pain points. Work together to implement strategies and solutions to reduce burnout and strengthen workforce morale. These strategies include offering competitive compensation, providing professional development opportunities, and fostering a more supportive work environment.

Conduct Quarterly Internal Compliance Audits

During your facility’s health inspection, surveyors review your compliance with health regulations and standards. These inspections play a critical role in your overall quality rating. To better prepare for these inspections, instruct your leadership teams to perform quarterly internal audits. This internal audit should aim to identify and address any areas of non-compliance.

These audits can include assessments of:

• Infection control measures, including the proper use of personal protective equipment (PPE) and hand hygiene protocols
• Medication management processes, ensuring the accuracy and compliance with medication administration guidelines
• Environmental safety standards, such as fire safety measures, emergency preparedness, and resident safety protocols

Optimize Resident Safety and Care Quality

Each of the 10 Quality Measures (QMs) evaluated by CMS aims to measure and quantify a facility's success in delivering effective, safe, equitable, and timely care to residents. To improve individual QM scores and your facility's overall quality rating, prioritize initiatives focusing on resident safety and care delivery.

Start by evaluating facility performance for each of the 10 QM scores – pinpointing your highest and lowest-performing QMs. Then, meet with your leadership teams to identify top areas for improvement, implementing small-scale changes to boost QM scores during your next assessment.

These strategies can include:

• Conducting a thorough assessment of resident care plans, ensuring that every plan is personalized and up-to-date
• Implementing technology solutions, such as AI-assisted fall prevention, to reduce the number of accidents and associated hospitalizations
• Establishing a more structured bladder management program, including regular toileting schedules and tailored interventions for high UTI-risk residents
• Implementing comprehensive resident engagement programs that promote social interaction and mental stimulation

Success Stories

Only 10% of nursing homes nationwide are awarded a 5-star rating by CMS. Below are examples of three facilities that have recently received this distinction.

• All three Lee Health Skilled Nursing Facilities in Fort Myers, FL, were awarded a five-star rating by CMS in 2023. They’ve earned these prestigious distinctions by consistently delivering exceptional patient outcomes, maintaining optimal staffing levels, and prioritizing the quality of care for both short-term and long-term residents within their three facilities. U.S. News & World Report also recognized these facilities as “The Best Nursing Homes” in the country for a second year.
• Pine Crest Nursing Home in Merrill, WI, earned a five-star rating from CMS for delivering exceptional care and fostering a warm, nurturing environment for its residents. With a nearly 70-year history in Lincoln County, Pine Crest provides comprehensive services, including skilled nursing care, memory care, rehabilitation therapy, and engaging social activities, making it an invaluable resource for this rural community.
• Arbor Ridge Rehabilitation & Healthcare Center in Wayne, NJ, has earned a five-star overall rating from CMS, signifying its commitment to delivering superior care and maintaining low hospital readmission rates. The facility is undergoing a substantial renovation to enhance its services and offer more specialized care, including a dedicated Korean cultural program.

The CMS Five-Star Quality Rating System undeniably plays a crucial role in determining the success of nursing home facilities. Implementing strategies such as staff training and enhanced resident safety measures not only impacts your facility's rating but also the overall well-being of residents. To discover how OK2StandUP’s remote fall mitigation solutions can positively impact the health and safety of your residents, click here.

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