Five Star Technical Users' Guides

Dive into the detailed measures and methods used to calculate nursing home Five Star Ratings

How to Use the Five Star QRS 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.

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Last updated September 2023

Archives of Five Star Technical User Guides

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.

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.

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.

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.