CMS: Hundreds More Buildings Could Receive One-Star Staffing Ratings Under New Rules

Apr 30, 2019 | Five Star Staffing Ratings

News Digest: CMS Makes Five Star Ratings Harder

In a new QSO letter from CMS, they announced a change to the Five Star Rating tiers and a new one star penalty.  The change in the Five Star staffing tiers is designed to incentivize improved nursing home staffing levels and increase the weight (value of) registered nurse staffing hours.

CMS also lowered the penalty threshold to automatically get a One Star ratings to four days of missing RN hours. Previously facilities that reported seven or more days in a quarter with no RN onsite were automatically assigned one-star for their staffing rating domain.


CMS to Crack Down on Staffing, Separate Short- and Long-Term Stays in SNF Star Rating Overhaul

The Centers for Medicare & Medicaid Services (CMS) on Tuesday announced stricter standards for its consumer-facing nursing home ratings, including a lower threshold for staffing penalties and new separate ratings for short-term and long-term stays.

Starting April 24, CMS will automatically hand out one-star staffing ratings to buildings that have four or more days in a quarter with no registered nurse on site, down from the current seven-day standard.

“Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes,” the agency said in a Tuesday statement announcing the new rules for the Five-Star Quality Rating System.


Spanko, Alex. “CMS to Crack Down on Staffing, Separate Short- and Long-Term Stays in SNF Star Rating Overhaul.” Skilled Nursing News, 5 Mar. 2019,


CMS makes changes to nursing home star ratings

The CMS will update the star ratings on Nursing Home Compare in April with several changes including new ratings for health inspection performance and stricter criteria for staffing level ratings.

The changes to the ratings, which will likely go live in mid-April, are part of an ongoing effort by the CMS “to improve the accuracy and value of the information found on the site,” the agency said Tuesday in a release. The CMS has made modified the ratings several times over the years, including most recently replacing the collection of staffing data from a self-reported process to the Payroll-Based Journal system, which is said to be more accurate because it requires nursing homes to submit their payroll information every quarter.


Modern Healthcare. “CMS Makes Changes to Nursing Home Star Ratings.” Modern Healthcare, 5 Mar. 2019,


Nursing homes subject to one star rating if they go more than four days without an RN onsite

The Centers for Medicare and Medicaid Services is updating the nursing home compare and the five-star quality rating system by dropping the threshold for RN staffing from seven to four days, adding a measure for hospitalizations among long-stay residents and lifting the freeze on health inspections.

The changes go into effect in April.

Currently, facilities that report seven or more days in a quarter without a registered nurse onsite are assigned a one-star staffing rating. Starting next month, it will only take four days to trigger the automatic downgrade to one-star.


Morse, Susan. “Nursing Homes Subject to One Star Rating If They Go More than Four Days without an RN Onsite.” Healthcare Finance News, 8 Mar. 2019,


CMS: Hundreds More Buildings Could Receive One-Star Staffing Ratings Under New Rules

The Centers for Medicare & Medicaid Services (CMS) announced March 5 that it would overhaul its star ratings system, cracking down on staffing in particular. The agency will automatically give one-star staffing ratings to nursing facilities that have four or more days per quarter with no registered nurse (RN) on site, down from the current threshold of seven or more.

“Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes,” CMS said in a statement announcing the new rules. “CMS found that as staffing levels increase, quality increases.”

Though staffing problems are well documented in the SNF world, they likely aren’t the cause of the problems CMS is trying to address, Don Feige, the founder and former owner of SNF-focused software firm ezPBJ, told Skilled Nursing News.


Flynn, Maggie. “CMS: Hundreds More Buildings Could Receive One-Star Staffing Ratings Under New Rules.” Skilled Nursing News, 12 Mar. 2019,


CMS moves the goalposts for Staffing Five-Star ratings

Many facilities will lose a Staffing star due to CMS’ increased emphasis on RNs in Staffing Five-Star ratings.

In its March letter to State Survey Agency Directors and related updates to the Five-Star Users Guide, CMS announced a series of changes to Nursing Home Compare and Five-Star ratings, including:

  • Changes to the Staffing Five-Star (read below)
  • The end of the November 2017 freeze on Health Inspection ratings
  • Changes to Quality Measures including new short-stay and long-stay measures


“CMS Moves the Goalposts for Staffing Five-Star Ratings.” SimpleLTC, 18 Apr. 2019,


PBJ Priorities Avoid Top Errors & Identify Effects on Star Ratings & PDPM

RECORDED WEBINAR: The Payroll-Based Journal system (PBJ) is evolving and in a notification to state survey agencies, CMS identified the need for additional oversight. While timely reporting is critical for program compliance, PBJ data is used to calculate staffing star ratings and can trigger a CMS audit.

This training will help leaders better review data for potential errors and staffing issues. The presenters also will share strategies for collecting the necessary support data for submission, navigating an audit and potential changes to the process in 2019.


“PBJ Priorities Avoid Top Errors and Identify Effects on Star Ratings & PDPM.” BKD CPAs and Advisors, 12 Apr. 2019,


CMS using data to better monitor nursing home performance

The Centers for Medicare and Medicaid Services is warning nursing homes that it wants to see better care and outcomes and is using data to track progress.

“Every nursing home resident deserves to retain their basic human dignity and to be treated with respect at all times,” CMS administer Seema Verma cautions. “Just as we’re unleashing innovative strategies and technologies in other areas of CMS, we’re continuously looking for ways to improve our approach to nursing home safety and quality.”


“CMS Using Data to Better Monitor Nursing Home Performance.” Health Data Management, 16 Apr. 2019,


CMS Launches 'Compreshensive Review' of Nursing Homes Regulation

The Centers for Medicare & Medicaid Services has launched a review of regulations and processes governing safety and quality of care in the nation’s nursing homes, Administrator Seema Verma said.

“While we support and promote the private sector’s critical role in our healthcare system, CMS’ duty to monitor the safety of the nation’s hospitals, nursing homes, and other providers, is a unique governmental task which lies at the core of government’s role in healthcare,” Verma said in a media release.

“I have directed my team at CMS to undertake a comprehensive review of our regulations, guidelines, internal structure, and processes related to safety and quality in nursing homes,” she said.


HealthLeaders. “CMS Launches ‘Comprehensive Review’ of Nursing Homes Regulation.” HealthLeaders Media, 16 Apr. 2019,


CMS Brings Changes to Nursing Home Compare and Five-Star Ratings in April 2019

On April 11, 2019, CMS announced updates to Nursing Home Compare and the Five-Star Quality Rating System. The Nursing Home Compare website contains data, including quality measures and staffing information, for more than 15,000 nursing homes around the country. The star rating provides a “snapshot” of the quality of each nursing home.

CMS is making changes to the quality component on Nursing Home Compare that would improve identifying differences in quality among nursing homes, raise expectations for quality, and incentivize continuous quality improvement. This article provides a brief overview of these changes.

The Nursing Home Compare website and Five-Star Quality Rating System were created in 1998 to help consumers and their families find a nursing home and to encourage nursing homes to achieve higher quality through public reporting of nursing home performance


“CMS Brings Changes to Nursing Home Compare and Five-Star Ratings in April 2019.” Baker Donelson, 19 Apr. 2019,


Nursing homes experience a lack of … nurses

The federal government accelerated its crackdown on nursing homes that go days without a registered nurse by downgrading the rankings of a tenth of the nation’s homes on Medicare’s consumer website, new records show.

In its update in April to Nursing Home Compare, the Centers for Medicare & Medicaid Services gave its lowest star rating for staffing — one star on its five-star scale — to 1,638 homes.


Jordan Rau & Elizabeth Lucas / Kaiser Health News. “Nursing Homes Experience a Lack of … Nurses.” Considerable, 6 May 2019,


Nursing Homes' Star Ratings Significantly Impacted by New CMS Updates

The Centers for Medicare and Medicaid Services has updated the Five-Star Quality Rating System, causing significant movement in nursing home domain ratings.

While some nursing homes may have missed the announcement about Centers for Medicare and Medicaid Services (CMS) updating the Five-Star Quality Rating System methodology beginning April 1, it would be difficult to ignore it now. With the recent release of CMS’ Nursing Home Compare quarterly data, the full impact of these updates can now be assessed.

Since the changes have taken effect, we have analyzed swings within specific domains as nursing home ratings rise and drop based on the new criteria. By highlighting some of these swings, we can better evaluate the cumulative impact of CMS’ updates.


“Nursing Homes’ Star Ratings Significantly Impacted by New CMS Updates.” CliftonLarsonAllen, 14 May 2019,


PBJ questions, answered

Payroll-based journal (PBJ) has released data that mainstream media is picking up…The following are some of those expert answers to some questions members asked that I thought I’d share with you.

If a facility is penalized for an erroneous PBJ, for how long would their star rating be reduced before it can be updated again?  We want to be mindful that PBJ data is only submitted on a quarterly basis. So if your facility has been penalized and your star rating has been effected, that rating is going to stay in place for a whole quarter.

Hurlburt, Amanda. “PBJ Questions, Answered.” The Post-Acute Advisor, 10 May 2019. No longer available.


How Skilled Nursing Facilities Can Win Under the New Five-Star System

The federal government hit skilled nursing facilities with a flurry of changes to its quality rating system earlier this year, but by diving into their own data, SNFs can pinpoint how to do better — while making the best use of their limited resources.

Some key steps include scrutinizing a facility’s Certification and Survey Provider Enhanced Reporting (CASPER) reports, keeping track of payroll-based journal (PBJ) data, and identifying education opportunities for staff.


Flynn, Maggie. “How Skilled Nursing Facilities Can Win Under the New Five-Star System.” Skilled Nursing News, 13 June 2019,

Related CMS and PBJ Resources

To learn more about the details, policies and information in these articles, please review these CMS and PBJ publications.

Cms qso memorandum for pbj
QSO Memo 19-08-NH
Five star care compare technical users guide
Technical Users' Guide

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