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Star Ratings

5 Star Staffing Ratings

We’re getting a lot of inquiries about 5 star ratings. It’s understandable because of the changes coming in April. One question we’re getting asked is “What would it take to improve my staffing rating?” or “How can I get another star?”

In this post we’re going to take a look at that, using the new staffing cut points and the latest data from the nursing home compare data. If you are unfamiliar with how those work or the April update, check out this post.

As our example, let’s assume you own a nursing home and your star ratings look like this:

Category Rating
RN Staffing

Note: This is an actual facility I have chosen as an illustration. I have no affiliation with this building which I will keep anonymous. The data is real.

As you can see, overall this facility is 3 stars. It received one bonus star due to excellent quality metrics but did not get an extra star from staffing. (4 overall staffing stars would give another bonus star in this case.) So a natural question would be: How many more nurses would it take to generate that bonus star and get this building to 4 overall stars? (We’re ignoring the elephant in the room regarding survey scores.)

The Details

To answer our question we need to know a few things. First off we need to know that stars are assigned based on adjusted hours using the following table:

Cut Points as of April 2019 (click to enlarge)

Next we need to know is where we stand. Our example facility has a adjusted RN hours of 0.574 and overall adjusted nursing hours of 3.467. Looking that up in the table, you can see we have 3 RN stars and 2 total nursing which nets 3 stars for staffing.

Now we need to understand how adjusted hours are calculated.

CodeCogsEqn (1).png

Adjusted hours are simply scaled by the national average hours and the expected hours. (More on both of those later.)

Looking back at the table, there are several ways we can get 4 overall stars. We can keep RN stars at 3 and get overall nursing hours way up. We could run RN hours way up and keep overall nursing hours the same, or even lower. Or we could shoot for 4 RN stars and 4 total nursing stars. That seems like the logical choice: we’ll have more margin when any type of nursing hours fluctuate. (Keep in mind that case-mix hours are moving as well.)

So we now have an objective: raise the adjusted RN hours to ≥ 0.724 AND raise the overall adjusted nursing hours to ≥ 4.038.

Let’s add some additional requirements:

  • Aide, LPN and RN hours should at least meet or exceed the case-mix hours. (These used to be called expected hours so you can see why we’d like to get as close to those as possible.)

  • Minimize the cost. Cost is the reason there aren’t more nurses in facilities anyway so we might as well optimize to get the maximum 5 star rating we can get for our dollar.

For our example facility I am assuming that the hourly costs per nurse type are as follows. Keep in mind that the exact numbers don’t matter much, just the relationship. (Aide hours cost less than LPN hours which cost less than RN hours.)

NurseHourly Rate

The Disclosure

To solve this problem I am going to use a technique called linear programming. I’m not going through all the details here because that’s not the point of this post.

The Results

NurseOriginal HoursOptimized HoursFTE ChangeDaily

You can see in an attempt to minimize the expense, the optimization reduced the number of LPNs and increased CNAs, because under the star rating system, LPNs and CNAs are the same. (Obviously that’s not true in the facility, just the star ratings.)

Okay, at first glance you’re probably thinking: “$2,408.74 per day?!” The short answer is “yes”. It costs a lot to increase staffing. It’s also the future with PDPM. Check out this article.

Why so much?

One thing I said I would come back to is the “case-mix hours”. Remember this equation?

CodeCogsEqn (1).png

The case-mix hours in the denominator represent the acuity of the patients in your facility. In fact, those hours are useful to compare one facility to any other in the country. You can’t know exactly what RUGs were billed but you can be sure that higher case-mix hours mean more nursing hours are expected. (Acuity, in this case, is based on the STRIVE Study which maps nursing hours to the RUGS IV 66 grouper. It’s actually pretty interesting and a little controversial. Maybe that’s a topic for another time.)

Case-mix hours or “expected” number of total nursing hours per day for all skilled nursing facilities

Case-mix hours or “expected” number of total nursing hours per day for all skilled nursing facilities

This is a histogram of the expected overall nursing hours for every facility in the US. Notice the tight distribution.

One thing I didn’t share earlier about our example facility is the overall case-mix hours are 4.12158. Take a moment to find 4.12 on that histogram. Our example facility is in the 99th percentile for case-mix, or expected hours. (That means our example facility has higher acuity that 99.1% of the facilities in the US.)

If you refer to the equation from earlier, you can see that higher case-mix hours lower your adjusted hours, meaning you need more hours for a given star rating if you have higher average acuity. This is important. Read the part in bold again. Acuity is a moving target and changes each time new star ratings are released, but if your building has a tendency to trend higher, you’ll pay for it in either a lower star rating or higher labor costs.

How much higher? In this case, if our example facility were in the 50th percentile for acuity instead of the 99th, it would become a 5 star staffing facility immediately. In fact they could actually have fewer RNs and LPNs on average (with slightly more CNAs) and still be five stars for staffing. The bottom line is that if this facility were in the 50th percentile, they could potentially save $3,016.93 per day in labor! That’s a $5,425.67 daily difference from our optimized plan to get 4 stars.

Taken further, if this facility were in the 1st percentile instead of the 99th, the potential labor savings would be $5,371.08 per day or $1.96M annually.

While you can’t just change acuity, do keep in mind the effect it is having on your star rating.

Final Thoughts

One more thing I didn’t mention is your adjusted hours are also affected by the national average numbers. That means that if the national averages were to rise for some reason, like say, PDPM, then your adjusted hours would go up without you making any changes. Don’t say CMS never gave you anything.

Contact us today if you would like to analyze your staffing star ratings.

Staffing Star Ratings - April 2019 Update

CMS has released an update to the 5 star rating system that’s included in Nursing Home Compare. In this post we’re going to look at changes in the staffing portion of the update. We’ve covered staffing and star ratings in the past, here , here and comprehensively here. So here we go again.

According to CMS in the announcement for this new change:

In recognition of the importance of RN staffing, the method by which the RN staffing rating and the total nurse staffing rating are combined to generate the overall staffing rating is changing to provide more emphasis on RN staffing.

To accomplish this, CMS has increased the requirements (or cut points in their language) to achieve RN stars. (If you are not familiar with the way staffing stars work, refer to this post.)

The chart below shows the current and new cut points. On average, the requirements are increasing by 20% for RN hours.

RN Star Cut Points

RN Star Cut Points

The cut points for overall nursing hours are changing as well. These changes are essentially small tweaks to the current numbers. The cut point to get to 2 stars actually went down slightly. The overall nursing hours required to reach 5 on the overall nurse staffing rating (not overall staffing rating) is going up 3.8%.

Overall nursing hours cut points.

Overall nursing hours cut points.

CMS also changed the way RN and overall nursing hours are mapped to your staffing star. (This is the one that can cause you to get a bonus overall star if you reach 4 or 5 staffing stars.)

click to enlarge

I’ve highlighted some changes here. Green stars are new and red stars have been taken away. You can see the emphasis on RN hours clearly here.


Overall this change brings higher resolution to the five star system. As we’ve covered in the past, nearly 30% of skilled nursing facilities have 5 overall stars and more than 50% are either 4 or 5 overall stars. The system is skewed high, which doesn’t drive improvement. While getting RN hours in the skilled nursing setting is very challenging, especially in certain areas of the country, adjusting the star rating system in this way will help to highlight those problems and drive improvements, especially as more facilities lose the 4th staffing star. The only downside to this change is timing: with PDPM coming in October, there is precious little time to implement changes.

Using the latest data from CMS, we can visualize the change in staffing star ratings. The animation below shows both the current and April 2019 limits on a graph. Each blue dot represents a skilled nursing facility in the US. (I’m not sure if this will show up for blog subscribers. If you don’t see it, click the link to view the actual posting.)


This graph is arranged like the star table above. The RN rating is on the left and increases as it goes down. The overall nursing rating is on the bottom and increases as it goes to the right. You can see quite a few homes get downgraded as the limits change.

Staffing Star Distribution Shifting

This change shifts the staffing star distribution much closer to normal. See below.

Current Staffing Star Distribution (click to enlarge)

April 2019 Staffing Star Update (click to enlarge)

Impact on Overall Star Rating

While the staffing star is an important part of the star rating, it is especially important to those facilities with 4 staffing stars and less than 5 stars on the state survey. The loss of the 4th star will lower the overall star rating. Using the CMS data to calculate staffing star ratings before and after, there are 1750 facilities (11.9%) that we estimate will lose an overall star due to this change. (Note: There are also some significant changes to the quality measures portion of the star rating. This analysis ignores quality measures.)

More importantly, (for some at least) we estimate that 245 facilities (1.7%) will go from 3 overall stars to 2, which in some markets will negatively impact Part A admissions.

How close is your facility to losing a staffing star? An Overall star? You don’t have much time to react, but you can plan for the future and make improvements. Let’s talk it over! Contact us today! Let Broad River Rehab help!

How Many RNs Does it Take to...

How Many RNs Does it Take to...

How many RNs does it take to change your star rating? That's the topic of today's post. (You thought this was going to be a joke about registered nurses and light bulbs, didn't you?)

RN staffing hours have a huge effect on your star rating. Specifically the staffing score is about two thirds RN hours. The goal of this post is to help you understand how nursing hours effect your staffing star rating and how many hours it would take your facility to move from your current star rating to any other rating.

The staffing star rating is hardest bonus star to achieve. (Check out my previous post about the different ways facilities get star ratings.) In fact, you can get the staffing bonus star with either a 4 or 5 star staffing rating and it's still less frequently awarded than the QM bonus star which can only be achieved with a 5 star QM rating.

How is the staffing star rating calculated?

(Feel free to skip this part if you just want to know about your facility.) There are two parts to the staffing rating: RN staffing and overall nursing staffing, which includes RNs. That means a change in RN hours affect both ratings. 

For each of the two ratings we calculate something called adjusted hours which are simply your reported RN hours divided by expected hours and then multiplied by the national average hours. The equation looks like this:


Your expected hours are based on the case-mix of your entire population. A RUG-IV RUG is calculated for everyone. Based on those RUGs we get an expected number of nursing hours. This information comes from the latest STRIVE study. (If you want to see the expected hours per RUG-IV RUG, check out page 20 of this document.)

The national averages are occasionally recalculated but as of this writing are 0.380417 for RNs and 3.228514 for total nursing hours.

Next, use your adjusted hours to look up star ratings from the table below. (This table is from the document I linked above.) 


Lastly, your stars for RN and Total are used to look up your overall staffing score from this table, which is from the same document:


Simple, right?

What about MY facility?

So let's say you have a star rating of 5. How many RN hours could you lose and maintain that star rating? Or let's say you have a 3 star rating and want to know how many hours it would take to get a 4 or even 5 star rating?

Since we know how star ratings are calculated, we can easily figure out how many hours it would take for your specific facility to get any star rating we want. Well almost any star rating. You can see from the table that if you have a very low number of LPN and aide hours, it isn't possible to get 5 stars no matter the number of RN hours you add. Also you can only go so low with RN hours before you don't get a score. You can see the exclusion rules in the document I previously linked. See page 8.


Let's look at a specific example:

To the right is information for Meadow Park Health and Rehabilitation in Vidalia Georgia. (Randomly selected, I have no relationship with this building or anyone affiliated with it and I've never been there.) 

This building received 3 stars for staffing as of this writing. (yellow) They reported 0.611 RN hours per resident per day. (Also yellow)

IF they were to reduce the RN hours from 0.611 to 0.261 (orange) they would score 2 stars. That's a reduction of 57%. Any lower than that and they'd get one star.

They could actually reduce RN hours by 52% and MAINTAIN the 3 star rating they already have. (blue)

What would it take for this facility to get to 4 staffing stars? Not much it turns out. Increasing RN hours by less than 2 percent would have done the trick. (green) What's more interesting is this change from 3 to 4 staffing stars would have given Meadow Park Health a bonus star and turned the facility from 3 overall stars to 4.

A 5 star staffing rating would require an incredible 71% increase in RN hours and not net the facility anything other than a really impressive staffing star rating, and of course the intrinsic benefits of an extra RN around. (red) (The bonus star is for 4 or 5 staffing stars.) 

Now let's look at yours!

I've done the calculations described above for every building that currently has a star rating. Just find your facility on the map and click the marker. (Be patient, the map might be slow to load. There are around 15 thousand SNFs on it.)  I highly recommend opening the map in it's own window to make it easier. (click the tiny frame in the upper right corner of the map.) The map has 9 layers: 1 star, 2 star, 3 star (x3), 4 star (x3) and 5 star. 3 and 4 star are split into 3 layers because of limitations in the mapping tool. After you full-screen the map you can enable/disable layers as you'd like. 

If you have any questions about the mapping, the way I did the calculations, star ratings or anything else, contact me. I'd be happy to help you find your facility and interpret your numbers.








If you really were looking for a nursing joke: How many nurses does it take to screw in a light bulb?


None. They have the nursing students do it.

Star Ratings and PDPM - A Proposal

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Star Ratings and PDPM - A Proposal

UPDATE: As of today (6-25-2018) McKnight's is reporting that CMS is including all PBJ information to the nursing home compare website. I consider this progress!

The current star rating system we use for skilled nursing is not compatible with PDPM. The reason for this is that staffing ratings depend upon expected nursing hours, which are based on the case-mix of your facility. That case-mix is based on RUG-IV RUGs calculated for every resident in your facility. Each RUG has an associated number of expected RN, LPN and Aide hours based on data from the STRIVE studies.

The problem is the STRIVE study is based on RUG-IV RUGs and those RUGs have been significantly modified for PDPM. For example, under PDPM, nursing gets its own RUG. Those RUGs do not include any rehab RUGs and several RUG categories have been combined. PE1 and PD1 are now combined into PDE1. (To see the expected minutes per day from the STRIVE study, see table A1 in the appendix of this document.) We don't know how many nursing hours to expect with a PDE1 because there has never been one.

The most simple solution, without doing another STRIVE study would be to simply average the data from the combined nursing RUGs and use that for the new RUG. This makes sense, is inexpensive to do and won't shake up the star ratings all that much.

The Proposal

Here's where I would humbly like to suggest we could improve the star ratings and PDPM at the same time: Let's introduce another star for therapy hours. Along with the RN and total nursing stars, we'd have a therapy star as well. (If you aren't familiar with how the RN and overall nursing stars translate into a staffing star, see table 5 on page 11 of this document. I am NOT suggesting a sixth star.)


There are at least two ways to implement this. The first would be a new STRIVE study, but that would take a long time and cost a lot of money. The second would be to use the same 2017 data that CMS used to create the provider-specific impact file for PDPM and calculate the number of therapy minutes delivered on average. This would be significantly less expensive than another STRIVE study and be good enough to estimate expected average minutes for the new therapy categories.


Why is this a good idea? There are at least two reasons:

  • PDPM pays for therapy but does not require any therapy actually be done. A 5 Star facility could theoretically do no therapy at all. Users of the nursing home compare tool have no way of knowing that if they simply rely on the star rating. Since the entire purpose of the star rating is for simple comparisons, I expect a lot of people don't look much further than the overall rating.
  • CMS seems to want to encourage therapy be done but does not want to provide a financial incentive to do it. A therapy star rating would encourage providers to maintain at least a minimum level of therapy or risk a lower star rating.

Thoughts? Am I too far out of the box? 

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Star Ratings - Some Stats

Star Ratings - Some Stats

Star Ratings

Let's talk about star ratings. I know a lot of people in skilled nursing tell me they don't like star ratings. Most say the star ratings are flawed and can be misleading.

I agree that star ratings aren't perfect, but they aren't designed for skilled nursing insiders; they are designed to help people with limited knowledge compare nursing homes. Regardless of any flaws, the system is simple and intuitive because we're used to star ratings systems for things like hotels and restaurants. 

The system is also effective because most people would have a hard time putting mom or dad into a one-star facility. THAT is the simple beauty of the star rating system. The underlying scoring system can always be tweaked to drive facilities towards goals set by CMS. 

Regardless of how we feel about the star system, it's what we've got. We've got to learn to do the best we can with it. Let's take a look at the current star ratings and see how facilities get 5 stars.

Let's start with some statistics:

  • There are 15647 skilled nursing facilities included in the star rating system. 
  • Nearly 30% have 5 star ratings
  • Only 12% have only 1 star

See table and histogram below. Click the histogram to enlarge.

Stars Count Percent
5 4391 29.4%
4 3381 22.6%
3 2468 16.5%
2 2866 19.2%
1 1839 12.3%

How it works

There are basically 3 components to the star rating system: Health Inspections, Staffing and Quality Measures (QM). (Being a special focus facility also plays a role, but we'll ignore that as a special and hopefully rare case.)

The Health Inspection rating is the main driver for the star rating. If you get a score of 5 on the health inspection and don't score a 1 on either the Staffing or Quality ratings, you get a five star rating. 

If you don't get a 5 on your health inspection rating, you can get bonus stars based on your Staffing and Quality Measure scores. If either your staffing score is a 4 or 5 or your QM is a 5 your get a bonus star for each. You can get a maximum of 5 stars and a minimum or 1 star.

The diagram below shows all the different paths to a star rating. The plus sign after either Staff or Quality means a bonus star and a minus sign means a star was removed. Place your mouse over a path to see the number of facilities. (This data came from the Nursing Home Compare datasets.)

You can see that most facilities that achieve a five-star rating get both the staff and QM bonuses (2455 facilities). A large number of facilities also manage a 5 star rating by only getting the QM bonus star (1058 facilities). Very few facilities manage a 5 star rating without the QM bonus star.

In fact, you are more likely to end up with a 2 or 3 star rating than a 5 star rating if you get the staffing bonus star and not the QM bonus.

Getting a 5 star rating based solely on your health inspection with no help from staffing or QM can be done, but not often. Only 213 facilities managed that. 

The path to one star most often involves negative stars from staff or QM ratings and occasionally from both.

Other Indicators

  • For-Profit homes have lower average star ratings than Non-Profits. The average star rating for a for-profit nursing home is 3.19 versus 3.87 for Non-Profits. The difference wasn't just due to staffing scores either. Health inspections and QM were lower as well.
  • Government run homes score lowest on Quality Measures. The average QM score for a government run home is 3.72 versus 3.93 and 4.10 for For-Profits and Non-Profits respectively.
  • Some states in the southeast have lower average star ratings. (click map to enlarge) One of the drivers for this is staffing. States in the south and along the Appalachians have lower staffing scores. (Click on images to enlarge)
  • For-profit homes owned by individuals score lower on overall star rating when compared to for-profits owned by a corporation. For-profit partnerships and corporations edge out individually owned for-profits in quality ratings.
  • Church related non-profits have slightly higher star ratings than some types of non-profits that are not owned by a corporation.