Thousands of nursing homes face lower Five-Star ratings

Jul 31, 2022 | Five Star Staffing Ratings

News Digest: Implications of an expanded Staffing Five Star rating model

First announced in January, 2022, the Staffing Five Star rating for skilled nursing facilities was updated with additional measures and a new, more complex calculation.  The new rating grew from two, to six measures, and includes three staffing level measures and three turnover measures.

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.

With these new measures, the impact on Five Star ratings for nursing homes was felt broadly across the country.


CMS Revises Methodology for Calculating Staffing Five Star

  • Weekend staffing levels and staff turnover will now be factored into the calculation of nursing home ratings.
  • The new rating is based on six new measures, which include staffing levels (per resident/per day) and the rate of turnover over the course of a year.

Effective with the July 2022 refresh, the Centers for Medicare & Medicaid Services (CMS) is revising the methodology for calculating the staffing star rating.

These measures, which have been posted on the CMS website for more than a decade, are used to calculate each nursing home’s star rating for the staffing section of the Nursing Home Five-Star Quality Rating System.


July, Analysis |. by Jasmyne Ray |. “CMS Revises Methodology for Calculating Staffing Star Rating.HealthLeaders Media,


Thousands of nursing homes face lower Five-Star ratings with changes to staffing stars

New Five-Star scoring metrics could penalize an estimated 10% to 16% of providers who have relied on staffing strengths to drive their overall ratings.

The Centers for Medicare & Medicaid Services on Thursday published new guidance for calculating staffing stars in the public-facing rating system. It incorporates total nurse staffing on weekends; annual RN and total nurse turnover; and administrator turnover.

The guidance also tightens up which facilities can get an extra star for above-average staffing. Instead of awarding an additional star for facilities with a 4-star staffing rating, CMS will now reserve that privilege for facilities with 5-star staffing ratings only.


Marselas, Kimberly. “Thousands of Nursing Homes Face Lower Five-Star Ratings with Changes to Staffing Stars.” McKnight’s Long-Term Care News, 11 July 2022,


Five-Star shifts have added pressure to staffing urgency — it’s time for a new approach

Skilled nursing facilities were among the hardest hit during the COVID-19 pandemic by nurse staffing shortages, impacting patient care and staff satisfaction.

As skilled nursing facilities work to hire more nurses in the wake of COVID-19-related staffing shortages, the Centers for Medicare & Medicaid Services’ recent changes to its Five-Star Quality Rating System are putting additional pressure on HR and nursing leaders. The updated guidelines now include measures for staff turnover (including RNs, licensed practical nurses, nurse aids and administration) and weekend staffing levels.

Reducing the time to hire will greatly improve staffing star ratings. Thankfully, hiring processes are evolving to create new ways to bring in staff faster. Innovative new technologies and meeting nurse applicants where they are during the application process will allow SNFs to reduce hiring costs, improve retention, optimize their ratings and contribute to the financial viability of their facilities.


Maufer, Kevin. “Five-Star Shifts Have Added Pressure to Staffing Urgency — It’s Time for a New Approach.” McKnight’s Long-Term Care News, Nov. 2022,


Ensuring Accuracy of Staffing Ratings in Nursing Home Care Compare

The Nursing Home Care Compare quarterly refresh on July 27 incorporated new staffing measures into ratings on the Five Star Quality Rating System. The six new measures, first publicly reported beginning in January 2022, include total nurse staffing, nurse staffing on weekends, Registered Nurse (RN) staffing, total nurse staffing turnover, RN turnover, and administrator turnover. These measures were calculated in the staffing domain rating, which impacts the overall star rating. More information on these measures is available in the Five Star Quality Rating System Technical Users Guide.

To ensure accurate staffing data, the Centers for Medicare and Medicaid Services (CMS) strongly encourages providers to double-check data submissions through the use of 5 key reports in the Certification and Survey Provider Enhanced Reporting (CASPER) system.


Eyigor, Jodi. “Ensuring Accuracy of Staffing Ratings in Nursing Home Care Compare.” LeadingAge, 5 Aug. 2022,


1 in 3 nursing homes fall in staffing under new CMS Five-Star rating system

The Centers for Medicare & Medicaid Services officially unveiled its updated Five-Star rating system on Wednesday, and it revealed that thousands of nursing homes’ ratings had dropped. The new system takes weekend staffing levels and turnover rates into play for the first time.

An analysis by consulting and analytics firm Formation Healthcare found that more than a quarter of providers (3,783) nationally declined in overall 5-star rating from June to July, with 419 losing 2 or more stars.

“A new quarter of staffing data was released to which CMS applied their new methodology for rating staffing that integrates staffing hours per resident day, nursing staff and administrator turnover, and weekend staffing rates. Considering these changes, 4,850 providers (33%) declined in staffing rating, with 939 losing 2 or more stars,”


Brown, Danielle. “1 in 3 Nursing Homes Fall in Staffing under New CMS Five-Star Rating System.” McKnight’s Long-Term Care News, 28 July 2022,


CMS Officially Adds Weekend Staffing, Turnover to Five-Star Quality Ratings

The Centers for Medicare & Medicaid Services (CMS) on Wednesday launched its enhanced Five-Star Quality Rating System – adding weekend staffing and annual turnover to the mix.

CMS began posting weekend staffing and turnover rates on Medicare’s Care Compare website in January; the agency posted how the staffing data will be weighted against other five-star measures earlier this month.

In addition to existing staffing measures for registered nurses (RNs) and total nurse hours per resident per day, new methodology will incorporate:


Stulick, Amy. “CMS Officially Adds Weekend Staffing, Turnover to Five-Star Quality Ratings.” Skilled Nursing News, 27 July 2022,


Lots to learn with new Five-Star

On a recent flight, I sat next to an attorney whose principal focus was compliance. It turned out that we were both on our way to speak at events in the same popular Florida conference destination. She was not in healthcare, but when she heard that I worked with nursing homes, she made a comment that caught my attention.

“There are often significant compliance issues in highly regulated industries,” she said. Intrigued, I asked her to elaborate.

She went on to share that in such industries, especially ones with low margins, staff must be creative and resourceful to meet regulatory requirements and still achieve business goals.

“It’s the perfect Catch-22,” she said


Littlehale, Steven. “Lots to Learn with New Five-Star.” McKnight’s Long-Term Care News, 22 July 2022,


CMS: Turnover, weekend staffing levels now in Five-Star ratings

Nursing home staff turnover rates and weekend staffing levels are now being incorporated into providers’ Five-Star Ratings.

The Centers for Medicare & Medicaid Services on Thursday announced that Care Compare’s July 2022 refresh includes the revision into the methodology for calculating staffing star ratings. It also is being less generous with star upgrades for some facilities.

CMS first announced in January that it would begin posting facility turnover and weekends staffing data to Care Compare, and that the information would be included into the Five-Star rating system by July.

The new rating is based on six separate staffing measures and assigns points based on how well providers perform on each.


Brown, Danielle. “CMS: Turnover, Weekend Staffing Levels Now in Five-Star Ratings.” McKnight’s Long-Term Care News, 8 July 2022,


CMS Issues Guidance on Five-Star Staffing Measures

Guidance on staffing measures tied to the five-star rating system was released on Thursday – the Centers for Medicare & Medicaid Services (CMS) updated its staffing measures to include three on staffing levels and three on staff turnover.

Total nurse staffing hours per resident per day on weekends, in addition to previously announced nurse turnover within a given year, annual registered nurse turnover and annual number of administrators who left the sector will be incorporated into staffing measures.

The agency specified a maximum of 100 points can be awarded for case-mix adjusted total nurse staffing and RN staffing, 50 points max for weekend statistics, and 50 points each for annual total nurse turnover, RN turnover and administrator turnover, respectively.


Stulick, Amy. “CMS Issues Guidance on Five-Star Staffing Measures.” Skilled Nursing News, 7 July 2022,


Revised CMS PBJ Manual

The Centers for Medicare & Medicaid released an updated Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Long-Term Care Facility Policy Manual. You can access it here.

A summary of the changes are as follows:


“Revised CMS PBJ Manual.” IHCA, 17 June 2022,


‘Counterintuitive to the Goal:’ Impending Five-Star Staffing Measures Don’t Address Ongoing Labor Challenges

Operators and nursing home industry leaders wait with bated breath for the implementation of new staffing measures in its five-star rating system starting in July, a move seen by some as insensitive in light of a historic staffing shortage and soaring agency use.

While facilities have been reporting staffing turnover and weekend staffing data since January, it’s unclear how much weight the Centers for Medicare & Medicaid Services (CMS) will give the new measures compared to other areas like quality and regulatory requirements.

CMS is adding three staffing turnover measures as part of its rating system – the percentage of registered nurses that have left over a year’s time frame; the total number of nurses that have left over the year, including RNs, licensed practical nurses (LPNs) and nursing assistants; and the percentage of administrator turnover.


Stulick, Amy. “‘Counterintuitive to the Goal:’ Impending Five-Star Staffing Measures Don’t Address Ongoing Labor Challenges.” Skilled Nursing News, 5 June 2022,

Related CMS and PBJ Resources

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

Five star care compare technical users guide
Technical Users' Guide
Payroll based journal policy manual
PBJ Policy Manual

Version 2.6

📖 PBJ Policy Manual Library

Cms qso memorandum for pbj
QSO Memo 22-19-NH

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