Skilled Nursing Facility Five Star Rating

It’s All in the Stars…..or IS it?   

In 1998, The Centers for Medicare and Medicaid Services (CMS) implemented a national online site called, “Nursing Home Compare,” for the public to be able to compare skilled nursing facilities (SNFs), based on objective information CMS gathers from every Medicare and Medicaid certified SNF in the country.

The information provided in Nursing Home Compare includes Inspections Results, Staffing Levels, and Quality Measures.

  • Inspection Results – includes nursing home information and inspection deficiencies:
    • The 3 most recent state inspections; and,
    • Any recent complaint investigations.
  • Staffing Levels – provides information about the ratio of staffing hours per resident day.
    • The ratio includes direct care staff who provide hands-on care to residents, such as Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), and Physical Therapists (PTs).

  •  Quality Measures – The measures are determined by CMS, and are data that the SNF must complete on standardized resident assessments.
    • The data measures resident physical and clinical conditions and their abilities over a period of time.
    • The assessments are the basis for SNF payment.
    • The quality measures are compared across SNFs to determine overall quality of care.

In 2008, CMS revised the Nursing Home Compare site to make it more “user friendly” for the public, by implementing a Five Star Rating System. The objective of the Five Star Rating System is for anyone to quickly determine how one SNF rates, in comparison to others.

  • Each SNF is rated on the same 3 categories, Inspection Results, Staffing Levels, and Quality Measures.
  • For each of these categories, CMS assigns a score of 1 – 5 stars, with 1 being the lowest rating and 5 being the highest rating.                          
  • From time-to-time, CMS changes the specific areas it measures within the Quality Measure category.

The overall 5 Star SNF Rating is a weighted average of the stars a SNF receives in each category. The weighted average is calculated the same way for all SNFs:

Inspection Results

  1. The number of stars a SNF receives for its inspection results serves as the base number of stars.
  2. To this, stars are either added or subtracted based on the other two categories.
    • If the Inspection Results rating is 1 star, the overall rating cannot increase more than 1 star for Staffing Levels and Quality Measures.
    • If the SNF is ‘special focus facility’ the maximum overall rating cannot be more than 3 stars. (A special focus facility is one that has more frequent, and more severe regulatory compliance issues.)
    • The total of stars cannot go above 5, or below 1 star.

Staffing Levels

  1. If a SNF receives 4 or 5 stars, and this is greater than the number of stars for the Inspection Results, 1 star is added.
  2. If a SNF receives only 1 star in this category, 1 star is deducted from the base number of stars (Inspecition Results total stars).

 Quality Measures

  1. If a SNF receives 5 stars for its Quality Measures, 1 star is added to the base number of stars.
  2. If a SNF receives 1 star for its Quality Measures, 1 star is subtracted from the base number of stars.
  3. If a SNF receives 2, 3 or 4 stars, no stars are added or subtracted from the base number.
   SNF Five Star Rating Calculation Chart



If you think much of this is confusing, you’re not alone. The same applies for SNFs too. Here’s an example:

XYZ SNF has the following star rating based on the most recent CMS analysis done on XYS’s inspections results, staffing levels, and quality measures:

  1. Inspections Results:     4 stars
  2. Staffing Levels:              2 stars
  3. Quality Measures:        2 stars

Calculating the Overall SNF 5 Star Rating:

  1. Inspection Results is the base:            4 stars
  2. Staffing Levels:                                    No change
    Since Staffing Levels is at 2 stars, no stars are subtracted or added.
  3. Quality Measures:                              No change
    Since Quality Measures is at 2 stars, no stars are added or subtracted
  4. Overal SNF Fives Star Rating is the total stars from above = 4 Star Rating

This seems like an objective way to compare SNFs, since CMS measures the same things for each SNF.

  • This is true if someone is only interested in the overall rating of a SNF, the total number of stars.
  • This is what CMS intended, a “user friendly” way for the public to quickly compare SNFs.
  • But CMS is very clear on the Nursing Home Compare website, that the SNF Five Star Rating should not be the only information a person uses when determining the best SNF for a Loved One.

There are two ways that the SNF Five Star Rating overall rating can be misleading:

  1. The overall rating can overestimate, as well as underestimate the quality of services and treatment provided by a SNF. In just a moment, I’ll use the above example to demonstrate this.

  2. A SNF has the ability to sway an overall rating in its favor. It’s unwise if a SNF chooses to do this, because CMS will discover it and penalize the SNF. Unknowingly, you might choose this SNF for it’s star rating, over another SNF that has fewer stars, but actually provides better quality of care.

Potentially overestimating quality services:

SNF Star Scale: 1 – 5 stars, with 1 being the lowest rating, and 5 being the highest rating.

From the above example:

  • Inspection Rating Results =   4 Stars (Above Average)
  • Staffing Levels =                      2 stars (Below Average)
  • Quality Measures =                2 stars (Below Average)

The overall SNF Five Star Rating = 4 (Above Average)

While the SNF has an above average score for its inspection results, both staffing levels and quality measures are below the national average.

We can’t tell for sure if this SNF is above average compared to other SNFs, until we evaluate it more closely, e.g. tour the facility, read its survey results, etc.

Potentially Underestimating Quality Services

ABC SNF has the following Nursing Home Compare Scores:

  • Inspection Results:                  1 star
  • Staffing Levels:                         3 stars
  • Quality Measures:                   5 stars

Calculating the Overall Five Star Rating:

In this hypothetical case, the SNF quality of services and care may be underestimated by CMS’ score of 2 stars.

  • Perhaps the SNF had a terrible survey, yet made significant changes that won’t be recognized until the next annual survey.
  • Staffinng Levels =       3 stars (Average)
  • Quality Measures =    5 stars (Excellent)

With an overall SNF Five Star Rating of only 2, this SNF may very well be overlooked when someone selects a SNF for a Loved One. Yet, it’s possible that the family missed an opportunity to choose a very good SNF.

These examples demonstrate why CMS doesn’t want the public relying solely on the SNF Five Star Rating to evaluate SNFs.

 Swaying a SNF Five Star Rating

Another way in which a SNF Five Star Rating could be misleasing, is if a SNF, knowingly or unknowingly, manipulates, or sways, the star rating to their benefit. This can be done in two areas, Staffing Levels and Quality Measures.

If a SNF knowingly reports false information to CMS, it will result in penalties that may be so severe that the SNF loses it’s certification to be a provider under the Medicare and Medicaid programs. This can potentially cause a SNF to go out out of business.

When a SNF unknowingly sways the star rating, it’s usually due to a well itentioned employee(s) who wants to do their very best, but who doesn’t have the necessary training, or understanding, on how to properly code resident assessments, or if in billing, how to properly bill for Medicare services.

Most SNF providers contract with an independent company that has the expertise to review Staffing Level documentation, Quality Measure documentation, and billing. These companies conduct periodic audits to ensure that assessments of residents are accurate, and that billing is consistent with the assessment information. SNFs have an opportunity to submit any necessary changes, in a timely manner, in order to remain compliant with the regulations.

Now you know the true meaning behind the SNF Five Star Rating, and why it’s impotant to evaluate SNFs beyond their overall star rating.

So, it’s really NOT in the stars……

only you know what’s important for your Loved One….

And how to help them navigate the Skilled Nursing Facility Five Star Rating!