The Five Star Technical Users' Guide

The Technical Users’ Guide describes the methods and measures to compute an Overall Five Star rating as well as three sub-components of the overall rating:

• Health Inspections – Based on weighted outcomes from state health inspections findings of the number, scope, and severity of deficiencies from the three most recent annual onsite surveys, plus findings from complaint investigations and infection control surveys in the prior 36 months
• Staffing – Based on six staffing levels and turnover measures. Nurse staffing levels are measured in hours per resident per day and derived from quarterly Payroll-Based Journal reports and MDS derived resident census. Staffing level measures are case-mix adjusted.  Turnover measures use six consecutive quarters of PBJ data for nursing staff and administrators.
• Quality Measures – Based on facility performance on nine long-stay and six short-stay measures reported on the MDS and claims for resident care.

CMS frequently state there is considerable evidence of a relationship between nursing home staffing levels and resident outcomes. PBJ staffing hours are used to calculate the rating for staffing based on these six measures:

1. Case-mix adjusted total nursing hours per resident day (registered nurse (RN) + licensed practical
   nurse (LPN) + nurse aide hours) for a quarter averaged across all days (weekdays and weekends)
2. Case-mix adjusted RN hours per resident day for a quarter, averaged across all days (weekdays
   and weekends)
3. Case-mix adjusted total nursing hours per resident day (RN + LPN + nurse aide hours) for a
   quarter averaged across all weekend days (Saturdays and Sundays)
4. The percentage of nursing staff that left the nursing home over a twelve-month period.
5. The percentage of RNs that left the nursing home over a twelve-month period.
6. The number of administrators that left the nursing home over a twelve-month period.

In addition to staffing hours, these measures include the resident census - which is calculated by CMS using MDS assessments of residents.

Case mix adjustments are a way for CMS to factor in differences in the complexity of care between nursing homes. CMS uses patient reported data to calculate and adjust staffing measures according to the formulas described in the Technical Users' Guide.

In December 2008, the Centers for Medicare & Medicaid Services (CMS) published Five Star ratings for skilled nursing facilities (SNFs) on its Nursing Home Compare public reporting site.

CMS included a set of quality ratings for each nursing home that participates in Medicare or Medicaid. The ratings take the form of “star” ratings for each nursing home. CMS' goal with this rating system is to provide residents and their families an easy way to evaluate nursing home quality and make meaningful distinctions between high and low performing nursing homes.

CMS regularly updates and changes the measures used for this purpose and consumers can view numerous individual measures as well as a collective average in three areas: Health Inspections, Staffing and Quality Measures.  An Overall Five Star Rating is a weighted average of all the individual measures.   

Take a course in the PBJ Academy for a practical hands-on understanding of the PBJ manual in real-life.

Browse our Five Star Users Guide archive to view prior versions of the PBJ manual and see how it changed over time.

Read our History of the Five Star Users Guide for a quick summary of the last 10 years.