Five Star Technical Users' Guides

⭐ Dive into the detailed measures & methods used to calculate nursing homes’ Five Star ratings

How to Use 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.

Since 2008, the Centers for Medicare & Medicaid Services (CMS) has displayed Five Star ratings on its Nursing Home Compare public reporting site. Every nursing home participating in Medicare or Medicaid receive star ratings so that residents and families may easily assess and understand nursing home quality.

The Latest Five Star QRS Technical Users' Guide

Updated January, 2023
Links to current version on

Archives of the Technical User Guides affecting PBJ

CMS regularly updates the Technical Users’ Guide for Design for Care Compare (Nursing Home Five-Star Quality Rating System). These archives capture the time and details of historical changes to the payroll-based journal driven staffing Five Star rating.

Major additions to the staffing Five Star calculation - July 2022

CMS announced a major change to the Five Star calculation for staffing, increasing from from 2 to 6 components to calculate the rating:

  • Case-mix adjusted total nurse levels: HPRD
  • Case-mix adjusted RN levels: HPRD
  • Case-mix adjusted total weekend nurse levels: HPRD
  • Total nurse turnover: % last 12 months
  • RN turnover: % last 12 months
  • Administrator turnover: # who left in last 12 months

In addition, CMS changed the bonus, such that only 5 star staffing levels earns a 1 star increase in the overall five star rating.  Before both 4 and 5 star staffing levels earned the increase.

Open Users’ Guide | Related Posts

NEW weekend and turnover staffing measures - January 2022

CMS announced they will begin posting new staffing measures for every nursing home on Care Compare:

  • Weekend Staffing: Hours of RN and nursing staffing on weekends
  • Staff Turnover: A measure based on the % of nurses and number of administrators who stopped working at the facility over a 12-month period.

This guide also changed the exclusion rules to allow more staffing levels and ratings to be reported.

Open Users’ Guide | Related Posts

Shift to Care Compare & new rating display rules - January 2021

CMS announced the retirement of Nursing Home Compare and launch of a new Care Compare provider Five Star system.

In addition, this Guide suppresses staffing Five Star ratings and displays “Not Available” for facilities not reporting by Nov. 14 or with 4 or more days with no RNs.

Finally, CMS resumes the 1 star downgrade for Feb 14 submissions for facilities with 4 or more days with no RNs.

Open Users’ Guide | Related Posts

Resumes updating ratings on Nursing Home Compare - October 2020

CMS is resuming the updating of PBJ-based Five Star ratings on Nursing Home Compare.

In addition, this Guide suppresses rating for facilities not reporting by August 14 or with 4 or more days with no RNs, but resumes the 1 star downgrade in January 2021 for facilities not reporting to PBJ or having 4 or more days with no RN.

Finally, there is an adjustment to case-mix to concur with the staffing timeframes.

Open Users’ Guide | Related Posts

How Five Star ratings handled in COVID during PBJ waiver - July 2020

CMS held Staffing Five Star ratings constant due to the COVID waiver and because skilled nursing homes were not required to submit PBJ reports for the Jan 1 – Mar 31 quarter.

This Guide also temporarily removed any 1 star downgrades and instead suppressed ratings for facilities unable to improve their ratings due to the lack of new reports in the waiver quarter.

Open Users’ Guide | Related Posts

Temporary Five Star changes due to the COVID pandemic - April 2020

This Guide implemented changes on the display of Five Star ratings on Nursing Home Compare due to the COVID-19 pandemic

No changes were made to the Staffing domain calculations.

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Modified rating thresholds and increased RN emphasis - April 2019

CMS made changes to the staffing rating thresholds – with the staffing level required to receive a 5-star rating set based on the interaction between staffing levels and quality measures.

These changes Increased the importance of RN staffing by changing how the RN and total nurse ratings are combined to create the overall staffing rating.

The Guide also sets the overall and RN staffing ratings to one star for nursing homes that report 4 or more days in the quarter with no RN onsite, and stops suppressing staffing ratings for nursing homes that have 5 or more days with residents and no reported nurse hours.

Open Users’ Guide | Related Posts

More triggers to award a staffing One Star - July 2018

This Guide adds additional reasons why a nursing home may receive a one-star rating for Staffing and RN Staffing levels.

Additionally, the method of estimating the RUG-IV case-mix index – which is used in the calculation of adjusted nurse staffing and adjusted RN staffing – for assigning the star ratings has changed slightly.

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New calculation for Resident Census - May 2018

Provides additional detail on a new calculation of resident census based on MDS submissions.

Residents are counted based on a prior MDS within 12 months of the measured quarter and no identifiable or assumed discharge.

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Start of PBJ-based staffing Five Star ratings - April 2018

In this Guide, CMS first implements a staffing Five Star rating based on PBJ data and replaces the existing staffing measures. The PBJ model includes:

  1. Payroll-based journal (PBJ) staffing hours,
  2. Resident census derived from MDS assessments, and
  3. Case-mix based on RUG-IV’s 66 groups

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Pre-PBJ Staffing Five Star using self-reported hours - February 2018

This is the final Guide for the staffing Five Star rating before PBJ data was used. Data used:

  1. Self-reported staffing hours from the CMS-671 form,
  2. Self-reported Census from the CMS-672 form and
  3. Case-mix adjustments based on RUG-III’s 53 groups

Use as a historical reference to pre-PBJ staffing Five Star ratings.

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More Resources in the PBJ Library

Payroll-Based Journal (PBJ) Policy Manual

Five Star QRS Technical Users’ Guide

CMS QSO Memorandums and Guidance

PBJ Resources for Providers from CMS

Studies and Research Using PBJ Data