5 Star Analysis - Nursing Home

Nursing Home Five Star Analysis

Extract Date: January 1, 2016

 

Overall 5 Star Rating:
Previous Month:
3 Months Prior:
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Follow the sections below to see how your current rating is calculated and 2 scenarios that could possibly change your overall 5 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 number, scope and severity of deficiencies identified during the three most recent annual inspection surveys and from the most recent 36 months of complaint investigations. 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 cycles.

Inspection Cycle123
Health Survey Date2015-07-222014-07-032013-07-12
Count of Health Deficiencies
     Standard
          Immediate Jeopardy000
          Severe000
          Substandard QOC000
          Administration000
          Environmental000
          Mistreatment000
          Nutrition and Dietary001
          Pharmacy Service100
          Quality of Care001
          Resident Assessment000
          Resident Rights000
          Number of Standard Health Deficiencies102
          Scope and Severity of most Severe Standard Health DeficiencyDNONEF
     Complaints
          Number of Complaint Health Deficiencies100
          Scope and Severity of most Severe Complaint Health DeficiencyDNONENONE
Total Number of Health Deficiencies202
Health Deficiency Score8020
Number of Health Revisits100
Health Revisit Score000
Total Health Score8020
Survey Weighting1/21/31/6
Weighted Total Health Score403
Total Weighted Health Survey Score 7 View Cut Points
Use Quality Metrics to compare your adjusted deficiencies to your peers (login required using your MyLeadingAge username and password).
Staffing 5 Star Rating:
Previous Month:
3 Months Prior:
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2The 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.

Total nurse staff hours (RN, LPN, & CNA) <-- Lower Higher --> RN hours <-- Higher Lower --> 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 5.33484 0.68266 Current Gain Lose Remain RN Hours Total Nurse Staff Hours
Interpretation
  • This facility currently has a 5 star staffing rating of 4.
  • 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.

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 to compare your adjusted staff hours to your peers (login required using your MyLeadingAge username and password).

View Cut Points
Quality Measure 5 Star Rating:
Previous Month: only updated quarterly
3 Months Prior:
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Quality Measure Rate Points Better Worse Interpretation Bottom Cut Point Top Cut Point
High Risk Pressure Ulcers (long-stay) 0 100 0 0 2.7 Full points are currently being attained for this QM, but increasing this rate by approximately 2.66 percentage points could result in losing 20 points. 0 2.66
Catheter (long-stay) 0 100 0 0 1 Full points are currently being attained for this QM, but increasing this rate by approximately 1.042 percentage points could result in losing 20 points. 0 1.042
Physical Restraints (long-stay) 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
Injurious Falls (long-stay) 8.974 20 9 5 100 Decreasing this QM rate by 44.3% or by approximately 3.974 percentage points could result in gaining 20 points. 5 100
Moderate to Severe Pain (long-stay) 18.122 20 18.1 12.5 100 Decreasing this QM rate by 30.8% or by approximately 5.588 percentage points could result in gaining 20 points. 12.535 100
Antipsychotic Medications (long-stay) 8.974 80 9 8.1 14.3 Decreasing this QM rate by 9.9% or by approximately 0.886 percentage points could result in gaining 20 points. 8.088 14.286
New or Worsening Pressure Ulcers (short-stay) 0.217 75 0.2 0 0.7 Decreasing this QM rate by 100% or by approximately 0.217 percentage points could result in gaining 25 points. 0 0.674
Urinary Tract Infection (long-stay) 7.792 40 7.8 6.1 9 Increasing this QM rate by 15.3% or by approximately 1.19 percentage points could result in losing 20 points. 6.084 8.982
Activities of Daily Living (long-stay) 14.474 60 14.5 12.2 15.5 Increasing this QM rate by 7.2% or by approximately 1.037 percentage points could result in losing 20 points. 12.195 15.51
Antipsychotic Medications (short-stay) 2.166 60 2.2 1.4 2.3 Increasing this QM rate by 7.9% or by approximately 0.17 percentage points could result in losing 20 points. 1.351 2.336
Moderate to Severe Pain (short-stay) 7.187 100 7.2 0 8.3 Potential To Lose Points
Full points are currently being attained for this QM, but increasing this rate by 15.9% or by approximately 1.146 percentage points could result in losing 20 points. 		0 8.333
Note: The QM rates in this table have been rounded to either 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 755 3 Months Prior: 715
Gain 755
Lose 695
Gain and lose 695
1 2 3 4 5 Current Gain points Lose points Gain and lose points

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

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 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
Use Quality Metrics to compare your 5 Star Ratings to your peers (login required using your MyLeadingAge username and password).

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