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 Five Star – 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.   

CMS updates the Technical Users' Guide several times a year. The staffing Five Star ratings and calculations using PBJ data change regularly.  Listed below, you can review key changes and the Technical Users' Guide in use at each Guide update.

2018-2019: Figuring out what works

CMS used the first several years of PBJ data collection to both perfect the systemic reporting of PBJ data, as well as refine its Staffing Five Star rating system. From a goal of ensuring accurate and auditable staffing data, CMS modified the methods for resident Census calculation (and Hours per Resident Day measures) and implemented One Star penalties for blatant violations of nurse staffing requirements.

2020: Temporary COVID changes

The COVID pandemic greatly impacted the Five Star rating system for skilled nursing facilities. PBJ data collection was paused temporarily. Some one star penalties were temporarily halted so that SNF's could be given an opportunity to fix problems that happened right before the pandemic started. And finally, formulas had to be adjusted to account for the data gaps.

2021-Present: Tightening rules in response to critiques

Researchers, the media and the Office of the Inspector General quickly began exploring PBJ data and analyzing staffing trends – including staffing changes during the COVID pandemic. Various studies and media stories appeared to trigger additional CMS changes to the staffing Five Star calculations and new measures to indicate staffing quality.

Notably CMS continued to tweak its use of Turnover measures, and continued to update case-mix thresholds to manage distribution of ratings across the 5 star levels.

View the current Technical Users Guide on CMS.gov

To learn how to calculate a staffing Five Star rating, take our course in the PBJ Academy for a step-by-step calculation tutorial.

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