5 Star Analysis - Nursing Home

Nursing Home Five Star Analysis

Extract Date: April 1, 2018

Calvert County Nursing Ctr., Prince Frederick, MD  

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

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Health Inspection 5 Star Rating:
Previous Month:
3 Months Prior:

The health inspection rating is based on the number, scope, and severity of deficiencies identified during the 2 most recent annual inspection surveys that occured prior to 11/28/2017 and from complaint investigations during that same time period. 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 cycle have more impact on the overall total score as compared to the older survey cycle. If there is a survey after 11/28/2017, the information will be listed below (i.e., cycle 0) but is not used for the health inspection rating at this time. View Health Inspection 5 Star Trend

Inspection Cycle12
Health Survey Date2017-01-062015-10-08
Count of Health Deficiencies
     Standard
          Freedom from Abuse, Neglect, and Exploitation 0 0
          Quality of Life and Care 1 0
          Resident Assessment and Care Planning 0 0
          Nursing and Physician Services 0 0
          Resident Rights11
          Nutrition and Dietary00
          Pharmacy Service01
          Environmental30
          Administration10
          Number of Standard Health Deficiencies62
          Scope of most Severe Standard Health DeficiencySomeSome
          Severity of most Severe Standard Health DeficiencyActual harmMinimal harm or potential for actual harm
     Complaints
          Number of Complaint Health Deficiencies110
          Scope of most Severe Complaint Health DeficiencySome
          Severity of most Severe Complaint Health DeficiencyActual harm
Total Number of Health Deficiencies112
Health Deficiency Score4012
Number of Health Revisits11
Health Revisit Score00
Total Health Score4012
Survey Weighting3/52/5
Weighted Total Health Score245
Total Weighted Health Survey Score 29 View Cut Points
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Staffing 5 Star Rating:
Previous Month:
3 Months Prior:

The number in the box where the blue (i.e. adjusted RN hours) and red (i.e. adjusted total nurse staff hours) lines intersect represents the numbers of stars this facility receives for staffing. The columns going from left to right represents the number of stars for total nurse staff hours. The rows going from top to bottom represent the number of stars for RN hours. View Staffing 5 Star Trend

Total nurse staff hours (RN, LPN, & CNA) <-- Lower Higher --> RN hours <-- Higher Lower --> 4.20318 0.89625 Current Gain Lose Remain RN Hours Total Nurse Staff Hours 1 1 2 2 3 1 2 3 3 3 2 3 3 4 4 2 3 4 4 4 3 3 4 4 5
Interpretation
  • This facility currently has a 5 star staffing rating of 4.
  • The adjusted total nurse staff hours is close to a cut point.
  • The adjusted RN hours is close to a cut point.
  • Due to being close to a cut point, there is potential to gain 1 star for the staffing rating.
  • 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.

To see how a change in your resident mix or reported hours could change your staffing rating, use the Staffing Scenario Worksheet

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

View Cut Points
Quality Measure 5 Star Rating:
Previous Month: only updated quarterly
3 Months Prior:
View Quality Measure 5 Star Trend
Quality Measure Rate Points Better Worse Interpretation Bottom Cut Point Top Cut Point
Higher Rate is Better
Successful community discharge (short-stay)
View Trend
52.716 40 52.7 47.7 54.9 Increasing this QM rate by 4.2% or by approximately 2.19 percentage points could result in gaining 20 points. 47.668 54.906
Functional Improvement (short-stay)
View Trend
67.102 60 67.1 62.9 71 Increasing this QM rate by 5.8% or by approximately 3.865 percentage points could result in gaining 20 points. 62.862 70.967
Lower Rate is Better
Physical Restraints (long-stay)
View Trend
0 100 0 0 0 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 40 points.
0 0
ED Visits (short-stay)
View Trend
17.7 20 17.7 15.5 100 Decreasing this QM rate by 12.3% or by approximately 2.171 percentage points could result in gaining 20 points. 15.529 100
Hospital readmission (short-stay)
View Trend
28.744 20 28.7 25.7 100 Decreasing this QM rate by 10.6% or by approximately 3.055 percentage points could result in gaining 20 points. 25.689 100
Urinary Tract Infection (long-stay)
View Trend
2.1 80 2.1 1.9 3.4 Decreasing this QM rate by 11.8% or by approximately 0.248 percentage points could result in gaining 20 points. 1.852 3.424
Moderate to Severe Pain (short-stay)
View Trend
8.833 80 8.8 7.4 13.2 Decreasing this QM rate by 16.7% or by approximately 1.474 percentage points could result in gaining 20 points. 7.359 13.23
Antipsychotic Medications (short-stay)
View Trend
1.286 60 1.3 1 1.9 Decreasing this QM rate by 22.3% or by approximately 0.286 percentage points could result in gaining 20 points. 1 1.913
Catheter (long-stay)
View Trend
2.537 60 2.5 2.1 3.2 Decreasing this QM rate by 17.5% or by approximately 0.443 percentage points could result in gaining 20 points. 2.094 3.178
Mobility Decline (long-stay)
View Trend
22.438 40 22.4 19.3 24.9 Increasing this QM rate by 11% or by approximately 2.468 percentage points could result in losing 20 points. 19.333 24.906
New or Worsening Pressure Ulcers (short-stay)
View Trend
1.181 50 1.2 0.7 1.6 Increasing this QM rate by 32.6% or by approximately 0.385 percentage points could result in losing 25 points. 0.693 1.566
Moderate to Severe Pain (long-stay)
View Trend
12.077 40 12.1 8.3 13.1 Increasing this QM rate by 8.3% or by approximately 1.004 percentage points could result in losing 20 points. 8.311 13.081
ADL Decline (long-stay)
View Trend
20.118 40 20.1 16.8 20.8 Increasing this QM rate by 3.4% or by approximately 0.676 percentage points could result in losing 20 points. 16.779 20.794
Antipsychotic Medications (long-stay)
View Trend
11.842 80 11.8 6.8 12.7 Increasing this QM rate by 7.3% or by approximately 0.863 percentage points could result in losing 20 points. 6.843 12.705
Injurious Falls (long-stay)
View Trend
2.308 80 2.3 1.3 2.4 Potential To Lose Points
Increasing this QM rate by 4.2% or by approximately 0.096 percentage points could result in losing 20 points.
1.316 2.404
High Risk Pressure Ulcers (long-stay)
View Trend
8.442 40 8.4 6.2 8.6 Potential To Lose Points
Increasing this QM rate by 2.3% or by approximately 0.192 percentage points could result in losing 20 points.
6.182 8.633
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 Current 890 3 Months Prior: 805
Gain 890
Lose 810
Gain and lose 810
1 2 3 4 5 Current Gain points Lose points Gain and lose points

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
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Overall 5 Star Rating:
Previous Month:
3 Months Prior:
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 five-star rating. 4 4 4
2 Add one star to the Step 1 result if staffing rating is four or five stars and greater than the health inspection rating; subtract one star if staffing is one star. The overall rating cannot be more than five stars or less than one star. + 0 + 1 + 0
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
4 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
5 If the nursing home is a Special Focus Facility (SFF) that has not graduated, the maximum overall quality rating is three stars. This facilty is not a special focus facility. NA NA NA
Final Overall Star Rating 4 5 4
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