How Does Nursing Home Compare Determine Five-Star Rating?


In recent years, hundreds of studies, articles, and reports have been conducted regarding the relationship between nurse staffing levels and quality of care in nursing homes. The results are not surprising; higher staffing levels normally result in higher quality of care. The benefits from higher staffing levels often include: lower mortality rates, lower antibiotic use, improved physical functioning, and decreased levels of pressure ulcers, catheters, and urinary tract infections.  

It should also come as no surprise that Nursing Home Compare has given incredible weight to staffing levels, as it is one of just three major factors used in determining Overall Quality Rating, the other two being health inspections and quality measures. Though, because of the magnitude of this rating, many facilities might be wondering how exactly the rating is calculated and what they can do to increase it.


The Staffing Measure Calculation

The formula used to calculate staffing measures for Nursing Home Compare can seem incredibly complicated, but the type of data used in the facility staff rating should be rather familiar:

  1. Registered Nurse (RN) hours per resident day; and 

  2. Total staffing hours (RN + Licensed Vocational Nurse (LVN) + nursing aide hours) per resident day.

Both of these data sets are derived from CASPER data, and are then case-mix adjusted based on MDS 3.0 assessment distributions by RUG-III group. The formula for the case-mix adjustment utilizes the national average in order to set a baseline:

HOURSadjusted = (HOURSreported / HOURSexpected) X HOURSnatl.avg

In 2012, the numbers represented by “national average” hours were 4.0309 for total nursing staff and 0.7472 for RNs. In the calculation, both categories are given equal weight, which places increased pressure on facilities to manage both staffing categories.


Rating Methodology

It’s important to understand the calculation used for the facility staff rating, as it helps identify where deficiencies might exist. For those facilities looking to attain a four or five-star rating, you will need to fall under one of the following two categories:

  • Four-Star: Facilities must receive at least a three-star rating on both RN and total nurse staffing and must receive a rating of four or five stars on either one of those areas. 

  • Five-Star: Facilities must meet or exceed the five-star level for both RN and total staffing.

To receive a four-star rating, total staffing levels would need to be at least 3.661 with an RN rating of 0.513 – 0.709.2 As you can see, receiving a four or five-star staffing rating is difficult, but not impossible.


Improving Facility Staffing Rating

With the calculation and rating methodology in mind, how does a Facility increase their staffing star-rating? Again, it’s highly beneficial to be mindful of the rating system, including the formula used to calculate facility staff rating. However, the real question is “Does increased staffing alone always lead to increased facility staffing star ratings?” Well, not always.

There’s one central thing to remember: compliance is an attitude first, then a behavior. Ensuring that systems are operational and random compliance checks are being completed will lead to higher quality of life and higher quality of care. And, by increasing those measures, higher quality of financial outcomes will be more easily attainable.

Invest in your staff and residents, and everything else will follow.