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Medicare Quality Data
Explanation of Ratings Provided by Medicare

Medicare Quality Ratings
Medicare Quality Ratings

In our Nursing Home directory we display various data on inspections, complaints and quality ratings from Medicare's Quality Rating data.

We display this publicly available data to assist you in reviewing and researching nursing homes in a given area.

Below we go into detail about which data sources we use to obtain and compile the Medicare data, as well as how we interpret this data and display it along with our list of nursing homes.

Five Star Ratings

The ratings provide are the Five-Star Quality Ratings provided by the Medicare. The nursing home ratings are taken from three sources of data:

Data TypeData SourceData Frequency
1.Health and Fire Inspections Trained inspectors Annually, plus more frequently for poor performance
2.Staffing Nursing homes Annually
3.Quality Measures Nursing homes Averaged Quarterly

Medicare provides a star rating, from 1-5, for each of the 3 sources of data. Data from these three data sources are combined to calculate the overall rating of the nursing home.

The Medicare Five-Star Quality Rating System is based on ongoing efforts from the Omnibus Reconciliation Act of 1987 (OBRA '87), a nursing home reform law, and recent campaigns such as the Advancing Excellence in America's Nursing Homes, which is a coalition of consumers, health care providers, and nursing home professionals.

Calculating the Overall Rating

Besides the formula listed below, it is important to know that the health inspection ratings include inspections for the past 3 years. However, more emphasis is given to more recent inspections. Also, though many staffing metrics are reported by Medicare, only the RN and total staffing hours per resident per day are used for calculating the 5 star rating.

  1. Start with the Health Inspections Rating.
  2. Add 1 star if the Staffing rating is 4 or 5 stars and greater than the Health Inspections Rating. Subtract 1 star if the Staffing rating is 1 star.
  3. Add 1 star if the Quality Measures rating is 5 stars; subtract 1 star if the Quality Measures rating is 1 star.
  4. If the Health Inspections rating is 1 star, then the Overall rating cannot be upgraded by more than 1 star based on the Staffing and Quality Measure ratings.
  5. If a nursing home is a Special Focus Facility, the maximum Overall rating is 3 stars.

Health and Fire Inspections, Annual Inspection Problems, and Complaints

Sources for Deficiencies

Trained inspectors perform the inspections about once a year, and in poorly performing nursing homes, more often. Fire safety specialists inspect nursing homes to determine if they meet the Life Safety Code standards set by the National Fire Protection Association (NFPA).

When the inspection teams find that a nursing home doesn't meet specific standards, deficiency citations are issued. The state inspection teams record specific reasons for deficiencies found in their inspection reports. Every nursing home that provides services to Medicare or Medicaid residents is required to make their last full inspection report public. Medicare only shows some of the information in the inspection details. The inspection reports and inspection problems can give you an insight into the standards a specific nursing home failed to meet.

Deficiencies are Common

Certified nursing homes are required to meet over 180 regulatory standards that are designed to protect residents which cover many topics including medication management, protecting residents from abuse and neglect, and food storage and preparation. With such a large number of standards, it is common for nursing homes to receive some deficiencies. Facilities average more than 3 deficiencies per month.

Scale of Deficiencies

Medicare uses a matrix that compares the severity of the deficiency and the number of residents that are potentially affected to determine the scale of a deficiency. This matrix determines a rating for a deficiency from A to L.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

Because some deficiencies are much more severe than others, has color coded each deficiency so that potential residents can more easily find the deficiencies that are more serious. While Medicare determines the scale of the deficiency, the color coding has been given separately by

Severe Deficiencies

Deficiencies that are coded as orange or red within the grid denote deficiencies which indicate substandard quality of care if the standard of care which is not met is from the following Federal regulations:

  • 42 CFR 483.13 Resident behavior and facility practices
  • 42 CFR 483.15 Quality of life
  • 42 CFR 483.25 Quality of care

For any regulation, any deficiency in the top row of the grid is regarded as immediate jeopardy. Immediate jeopardy is a situation in which the nursing home's non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. For such deficiencies, an enforcement action is enacted that requires the home take immediate steps to remove the deficiency. If the nursing home does not comply within the time period determined by Medicare, it is terminated from the Medicare program within 23 days of the end date of the inspection.

Long Term Care Minimum Data Set for Each Resident

The Minimum Data Set (MDS) includes health information, physical functioning, general well-being, and mental status assessment information on residents. This information is collected for all residents by nursing home staff - regardless of whether their payment method includes Medicare. The MDS assessment forms are completed for residents on admission and periodically during their stay.

The data collected from a resident's MDS allows Medicare to group each resident according to an individual's Resource Utilization Group (RUG-III). An individual's RUG determines both the amount the nursing home will receive each day from Medicare Part A to pay for the stay as well as the staffing level expected for the resident.


Evaluating a Nursing Home Based on Staffing Levels

It is common for the amount of staffing needed by a nursing home to vary based on the level of care needs of its residents. For instance, a nursing home with many residents that require a great deal of care is expected to have more staff per resident. For this reason, it is often not beneficial to directly compare the number of staff ours from one facility to the next.

To overcome this obstacle, Medicare has introduced expected and adjusted staffing hour metrics. The expected number of hours for a resident is determined by his or her Resource Utilization Group (ie. the quality of care needed as determined by the individuals Minimum Data Set assessment). Medicare then use the number of hours reported vs. the hours expected to create an adjusted number of hours per resident that should be comparable among different facilities. The formula is given below.

Hoursadjusted = Hoursreported / Hoursexpected * Adjustment Factor

The adjustment factor varies over time but includes state and/or national averages of hours per resident.

It is also important to note that the number of staffing hours per resident are averages. The averages do not necessarily show the number of staff present at any time or reflect the specific amount of care given to an individual resident. It is important to ask each potential nursing home the amount of staff available at night and that the staff can handle your specific needs.

Sources of Staffing Data

Medicare receives nursing home staffing data from each state. The state survey agency receives staffing hours from each nursing home. The Centers for Medicare and Medicaid Services then converts these staffing hours into a measure of staff hours per resident per day, which are reported by type of staff and in total for all combined staff.

It is very important to note that the staffing data is reported only once per year and reflect a staffing over only a 2 week period.

These types of staff are included for each facility on our site and are labeled as Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA). The staffing hours per resident per day is the average hours worked divided by the total count of residents.

Quality Measures for Long and Short Stay Residents

As mentioned above, each resident undergoes the Minimum Data Set (MDS) assessment forms to evaluate the resident upon admission and again periodically throughout their stay. Part of the data collected during these assessments includes information about the health of the resident and the care received. For instance, data is collected on whether the resident has received vaccines, experienced a fall, and/or reported moderate to severe pain.

From the MDS data, Medicare takes the averages of residents that have been active in the nursing home in the past 150 days to generate an MDS Frequency Report. The 150 day time period allows for 93 days between quarterly assessments, 14 days for MDS completion, 14 days for submission of MDS data to Medicare, and approximately 1 month grace period for late assessments.

Please understand the quality information provided is based on care given to all residents, not individuals. In addition, the datasets are not benchmarks, thresholds, guidelines, or standards of care. However, the data from the MDS Frequency reports is one more piece of information that can be used to assist you in your nursing home research process.

Carol Marak
Carol Marak

After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.