5 Star Analysis - Nursing Home

Nursing Home Five Star Analysis

Extract Date: June 1, 2023

Overall 5 Star Rating:

Previous Month:

3 Months Prior:

Follow the sections below to see how your current rating is calculated and 2 scenarios that could possibly change your overall 5 star rating. View Overall 5 Star Trend

Growing Importance of Nursing Home Ratings

Receiving a better than average 5-star rating has never been more important to nursing homes.

These ratings are increasingly used by consumers, regulators, insurers and other payers, and provider networks to select which facilities they will consider having relationships with. Nursing homes may not even be able to obtain sufficient referrals or receive Medicare and Medicaid funding in the future if they do not have at least a 3-star rating.

Health Inspection 5 Star Rating:

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3 Months Prior:

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The health inspection rating is based on the number, scope, and severity of deficiencies identified during the 3 or 2 most recent annual inspection surveys and 36 months of complaint investigations and focused infection control surveys. More than one revisit will have a negative impact on the score for a survey cycle. The total score from each survey cycle is weighted so that the more recent survey cycles have more impact on the overall total score as compared to the older survey cycle. View Health Inspection 5 Star Trend

Inspection Cycle	1	2	3
Health Survey Date	2021-11-04	2020-01-30	2018-10-11
Count of Health Deficiencies
Freedom from Abuse, Neglect, and Exploitation	0	0	0
Quality of Life and Care	4	0	1
Resident Assessment and Care Planning	0	0	1
Nursing and Physician Services	0	0	0
Resident Rights	3	1	2
Nutrition and Dietary	0	1	0
Pharmacy Service	0	1	1
Environmental	0	0	0
Administration	0	0	0
Infection Control	0	0	1
Standard Inspection
Number of Standard Inspection Health Deficiencies	7	3	6
Scope of most Severe Standard Inspection Health Deficiency	Few	Some	Many
Severity of most Severe Standard Inspection Health Deficiency	Minimal harm or potential for actual harm	Minimal harm or potential for actual harm	Minimal harm or potential for actual harm
Complaint Inspection
Number of Complaint Inspection Health Deficiencies	0	0	0
Scope of most Severe Complaint Inspection Health Deficiency
Severity of most Severe Complaint Inspection Health Deficiency
Infection Control Inspection
Number of Infection Control Inspection Health Deficiencies	0	0	0
Scope of most Severe Infection Control Inspection Health Deficiency
Severity of most Severe Infection Control Inspection Health Deficiency
Total Number of Health Deficiencies	7	3	6
Health Deficiency Score	28	16	36
Number of Health Revisits	1	1	1
Health Revisit Score	0	0	0
Total Health Score	28	16	36
Survey Weighting	1/2	1/3	1/6
Weighted Total Health Score	14	5	6
Total Weighted Health Survey Score	25 View Cut Points
Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your inspection ratings to your peers.

Staffing 5 Star Rating:

Previous Month: only updated quarterly

3 Months Prior:

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View Staffing 5 Star Trend

Staffing Measure	Rate	Points	Interpretation	Bottom Cut Point	Top Cut Point
Adjusted RN Hours Per Day View Trend	2.214	100	Full points are currently being attained for this measure, but decreasing this rate by -41.4% or by approximately -0.916 could result in losing 10 points.	1.298	Or Higher
Adjusted Weekend Total Nurse Hours Per Day View Trend	4.997	50	Full points are currently being attained for this measure, but decreasing this rate by -13.4% or by approximately -0.669 could result in losing 5 points.	4.328	24
Adjusted Total Nurse Hours Per Day View Trend	5.503	100	Full points are currently being attained for this measure, but decreasing this rate by -10% or by approximately -0.549 could result in losing 10 points.	4.954	Or Higher
Administrator Turnover Count View Trend	0	30	Potential To Lose Points Although full points are currently being attained for this measure, increasing the count by 1 would result in losing 5 points.	0	0
Total Nurse Turnover Percentage View Trend	35.9	45	Decreasing the rate for this measure by 4.1% or by approximately 1.483 could result in gaining 5 points.	34.417	40.594
RN Turnover Percentage View Trend	38.2	40	Increasing the rate for this measure by 3.7% or by approximately 1.423 could result in losing 5 points.	33.109	39.623
Note: The staffing measures and points in this table have been rounded to either one, two, or three decimal places due to space constraints. However, the full value has been used to calculate facility scores and rankings. To view the full staffing cut point tables, click here .

Total Points	Unscaled	Maximum	Available	Scaling Factor	Re-Scaled
Current	365	380	380	1	365
Gain	365				365
Lose	360				360
Gain and lose	360				360

Staffing Stars

Interpretation

This facility currently has a 5 star staffing rating of 5.
The value of 'Administrator Turnover Count' is close to a cut point and has the potential to result in losing 5 points.
Although the scores are close to a cut point, there is a possibility that the change in cut point groups could result in the staffing rating remaining constant.

Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your staffing to your peers.

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Quality Measure 5 Star Rating:

Previous Month: only updated quarterly

3 Months Prior:

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Long Stay Quality Measure 5 Star Rating:

Short Stay Quality Measure 5 Star Rating:

View Quality Measure 5 Star Trend

Quality Measure	Rate	Points	Interpretation	Bottom Cut Point	Top Cut Point
Higher Rate is Better
Functional Improvement (short-stay) View Trend	66.85	75	Increasing this QM rate by 0.8% or by approximately 0.52 percentage points could result in gaining 15 points.	64.28	67.37
Successful community discharge (short-stay) View Trend	48.45	60	Increasing this QM rate by 1.5% or by approximately 0.71 percentage points could result in gaining 15 points.	46.09	49.16
Lower Rate is Better
New or Worsening Pressure Ulcers (short-stay) View Trend	0	100	Potential To Lose Points Although full points are currently being attained for this QM, having a single person flag for this QM would result in losing 20 points.	0	0
Number of hospitalizations per 1,000 resident days (long-stay) View Trend	1.863	60	Potential To Gain Points Decreasing this QM rate by 0% or by approximately 0.001 percentage points could result in gaining 15 points.	1.862	2.064
Injurious Falls (long-stay) View Trend	5.405	20	Potential To Gain Points Decreasing this QM rate by 4.7% or by approximately 0.255 percentage points could result in gaining 20 points.	5.15	100
Urinary Tract Infection (long-stay) View Trend	5.046	20	Potential To Gain Points Decreasing this QM rate by 10.2% or by approximately 0.516 percentage points could result in gaining 20 points.	4.53	100
Number of outpatient emergency department (ED) visits per 1,000 resident days (long-stay) View Trend	0.353	135	Potential To Gain Points Decreasing this QM rate by 1.7% or by approximately 0.006 percentage points could result in gaining 15 points.	0.347	0.497
ED Visits (short-stay) View Trend	14.783	30	Potential To Gain Points Decreasing this QM rate by 0.8% or by approximately 0.123 percentage points could result in gaining 15 points.	14.66	17.59
Mobility Decline (long-stay) View Trend	41.582	15	Decreasing this QM rate by 33.9% or by approximately 14.102 percentage points could result in gaining 15 points.	27.48	100
Antipsychotic Medications (long-stay) View Trend	8.182	120	Decreasing this QM rate by 8.3% or by approximately 0.682 percentage points could result in gaining 15 points.	7.5	9.6
Catheter (long-stay) View Trend	2.677	40	Decreasing this QM rate by 18.6% or by approximately 0.497 percentage points could result in gaining 20 points.	2.18	3.56
Hospital readmission (short-stay) View Trend	28.9	30	Increasing this QM rate by 4.9% or by approximately 1.42 percentage points could result in losing 15 points.	27.44	30.32
High Risk Pressure Ulcers (long-stay) View Trend	2.105	100	Full points are currently being attained for this QM, but increasing this rate by 79.1% or by approximately 1.665 percentage points could result in losing 20 points.	0	3.77
Antipsychotic Medications (short-stay) View Trend	0.855	80	Potential To Lose Points Increasing this QM rate by 12.3% or by approximately 0.105 percentage points could result in losing 20 points.	0.01	0.96
ADL Decline (long-stay) View Trend	6.63	150	Potential To Lose Points Full points are currently being attained for this QM, but increasing this rate by 8.4% or by approximately 0.56 percentage points could result in losing 15 points.	0	7.19
Note: The QM rates and points in this table have been rounded to either one, two, or three decimal places due to space constraints. However, the full QM value has been used to calculate facility scores and rankings. To view the full QM cut point tables, click here.

Total Points	Overall	Long-Stay	Short-Stay
Current	1199	660	539
Gain	1291	730	561
Lose	1127	645	482
Gain and lose	1218	715	503

Overall

Long-Stay

Short-Stay

Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your QMs to your peers or to see how your QMs are trending.

View Cut Points

Overall 5 Star Rating:

Previous Month:

3 Months Prior:

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Follow the steps below to see how your current rating is calculated and 2 scenarios could possibly change your overall 5 star rating.

Step	Instruction	Current	Likely to Gain	Likely to Lose
1	Start with the health inspection rating.	4	4	4
2	Add one star to the Step 1 result if the staffing rating is five stars; subtract one star if the staffing rating is one star. The overall rating cannot be more than five stars or less than one star.	+ 1	+ 1	+ 1
3	Add one star to the Step 2 result if quality measure rating is five stars; subtract one star if quality measure rating is one star. The overall rating cannot be more than five stars or less than one star.	+ 0	+ 0	+ 0
Note	If the health inspection rating is one star, then the overall quality rating cannot be upgraded by more than one star based on the staffing and quality measure ratings.	- 0	- 0	- 0
Final Overall Star Rating		5	5	5
Use Quality Metrics (login required using your MyLeadingAge username and password) and the Nursing Home Trend Report to compare your 5 Star Ratings to your peers.