5 Star Analysis - Nursing Home

Nursing Home Five Star Analysis

Extract Date: January 1, 2025

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	2024-02-19	2021-08-04	2019-06-07
Count of Health Deficiencies
Freedom from Abuse, Neglect, and Exploitation	0	0	0
Quality of Life and Care	0	0	1
Resident Assessment and Care Planning	0	0	0
Nursing and Physician Services	0	0	0
Resident Rights	0	0	1
Nutrition and Dietary	0	0	0
Pharmacy Service	0	0	1
Environmental	0	0	0
Administration	0	0	1
Infection Control	0	0	0
Standard Inspection
Number of Standard Inspection Health Deficiencies	0	0	4
Scope of most Severe Standard Inspection Health Deficiency			Some
Severity of most Severe Standard Inspection Health Deficiency			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	0	0	4
Health Deficiency Score	0	0	12
Number of Health Revisits	0	0	1
Health Revisit Score	0	0	0
Total Health Score	0	0	12
Survey Weighting	1/2	1/3	1/6
Weighted Total Health Score	0	0	2
Total Weighted Health Survey Score	2 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 Weekend Total Nurse Hours Per Day View Trend	4.643	50	Potential To Lose Points Full points are currently being attained for this measure, but decreasing this rate by -3.9% or by approximately -0.179 could result in losing 5 points.	4.464	24
Adjusted RN Hours Per Day View Trend	1.358	100	Potential To Lose Points Full points are currently being attained for this measure, but decreasing this rate by -11.5% or by approximately -0.156 could result in losing 10 points.	1.202	Or Higher
Adjusted Total Nurse Hours Per Day View Trend	5.322	100	Potential To Lose Points Full points are currently being attained for this measure, but decreasing this rate by -4.7% or by approximately -0.252 could result in losing 10 points.	5.07	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
RN Turnover Percentage View Trend	30.8	40	Decreasing the rate for this measure by 6.6% or by approximately 2.048 could result in gaining 5 points.	28.752	35.714
Total Nurse Turnover Percentage View Trend	20	50	Full points are currently being attained for this measure, but increasing this rate by 55.6% or by approximately 11.126 could result in losing 5 points.	0	31.126
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	370	380	380	1	370
Gain	370				370
Lose	340				340
Gain and lose	340				340

Staffing Stars

Interpretation

This facility currently has a 5 star staffing rating of 5.
The value of 'Adjusted Weekend Total Nurse Hours Per Day' is close to a cut point and has the potential to result in losing 5 points.
The value of 'Adjusted RN Hours Per Day' is close to a cut point and has the potential to result in losing 10 points.
The value of 'Adjusted Total Nurse Hours Per Day' is close to a cut point and has the potential to result in losing 10 points.
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
D/C Function Score View Trend	47.62	60	Increasing this QM rate by 3.5% or by approximately 1.68 points could result in gaining 15 points.	44.98	49.3
Successful community discharge (short-stay) View Trend	60	135	Potential To Lose Points Decreasing this QM rate by 0.4% or by approximately 0.24 points could result in losing 15 points.	59.76	63.35
Lower Rate is Better
Antipsychotic Medications (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
Antipsychotic Medications (long-stay) View Trend	17.476	45	Potential To Gain Points Decreasing this QM rate by 0% or by approximately 0.006 points could result in gaining 15 points.	17.47	20.39
Urinary Tract Infection (long-stay) View Trend	5	20	Potential To Gain Points Decreasing this QM rate by 9.4% or by approximately 0.47 points could result in gaining 20 points.	4.53	100
Injurious Falls (long-stay) View Trend	5.825	20	Potential To Gain Points Decreasing this QM rate by 11.6% or by approximately 0.675 points could result in gaining 20 points.	5.15	100
ADL Decline (long-stay) View Trend	14.706	90	Potential To Gain Points Decreasing this QM rate by 0.4% or by approximately 0.066 points could result in gaining 15 points.	14.64	17.02
ED Visits (short-stay) View Trend	7.325	105	Decreasing this QM rate by 2.7% or by approximately 0.195 points could result in gaining 15 points.	7.13	8.21
New or Worsening Pressure Ulcers (short-stay) View Trend	4.5	40	Decreasing this QM rate by 12% or by approximately 0.54 points could result in gaining 20 points.	3.96	6.47
Number of hospitalizations per 1,000 resident days (long-stay) View Trend	0.782	135	Decreasing this QM rate by 7.7% or by approximately 0.06 points could result in gaining 15 points.	0.722	0.958
Hospital readmission (short-stay) View Trend	22.689	60	Decreasing this QM rate by 1.8% or by approximately 0.399 points could result in gaining 15 points.	22.29	23.75
Catheter (long-stay) View Trend	0.82	80	Decreasing this QM rate by 37.8% or by approximately 0.31 points could result in gaining 20 points.	0.51	1.26
Ambulation Decline (long-stay) View Trend	10.58	135	Increasing this QM rate by 16.7% or by approximately 1.77 points could result in losing 15 points.	8.31	12.35
Number of outpatient emergency department (ED) visits per 1,000 resident days (long-stay) View Trend	1.642	60	Potential To Lose Points Increasing this QM rate by 0.6% or by approximately 0.011 points could result in losing 15 points.	1.405	1.653
Pressure Ulcers (long-stay) View Trend	2.788	100	Potential To Lose Points Full points are currently being attained for this QM, but increasing this rate by 3.3% or by approximately 0.092 points could result in losing 20 points.	0	2.88
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	1404	685	719
Gain	1474	755	719
Lose	1318	650	668
Gain and lose	1388	720	668

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.	5	5	5
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.	+ 0	+ 0	+ 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
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.