How Nursing Home Quality is Determined

Medicare and/or Medicaid certified nursing homes are required to undergo health and fire inspections, have nursing staff requirements, and collect and submit information about the health, physical functioning, mental status, and general well-being of residents. In order to simply the findings from each of these required areas, Medicare provides a "Five Star Quality Rating System" for each area, as well as an overall rating. This system is designed to give an overall picture of nursing homes and compare high- and low-performing facilities.


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The overall rating is made up of the following areas:


Health Inspections:

Congress sets certain requirements that must be met by nursing homes to be a part of the Medicare and Medicaid programs. The Centers for Medicare and Medicaid Services (CMS) works alongside state governments to do health inspections, as well as investigate complaints about nursing home care.


Certified nursing homes must meet many standards and regulations that are designed to protect nursing home residents. For example, some of these standards are proper management of medications, providing a safe atmosphere that is free of abuse, and food preparation safety. Inspections take place once a year, but inspectors may visit more often if the nursing home is performing poorly.


Some points to consider:


  • States Variations: There are differences in how states perform inspections.
  • Program Variations: There are differences in state licensing requirements that may affect quality.


TIP: Care should be taken when comparing nursing homes in different states.


Quality Measures:

Nursing homes assess all their residents using a form called the Minimum Data Set (MDS). MDS reports include information on resident health, physical functioning, mental status, and overall general well being. This is a self-reported action and it is collected by Medicare. MDS reports measure the quality "quality measures" of nursing home care, for example, if residents are in pain, losing weight or have gotten their flu shots.


Some points to consider:


  • Data Accuracy: The MDS is self-reported by the nursing home, rather than an independent agency.
  • Small Sample of Measures: Not all aspects of care are measured in these reports.


TIP: When visiting a nursing home prepare questions that are most important to you and ask about them, considering there may be many aspects of care that are not covered by these quality measures.


Nursing Staff:

Federal law requirements state that there must be proper number of nursing staff to adequately provider care for residents. Basic standards require one registered nurse (RN) for at least 8 straight hours a day, seven days a week AND either an (RN) or licensed practical/vocational nurse (LPN/LVN) on duty 24 hours a day.  Some states may have additional requirements on nursing staff levels.  Certified nursing assistants (CNA) provide care to residents 24/7 and are the most likely member of the nursing staff to provide assistance with daily activities.


Staff hours are based on the following nursing types:


  • Registered Nurse (RN)
  • Licensed Practical Nurse (LPN)
  • Licensed Vocational Nurse (LVN)
  • Certified Nursing Assistant (CNA)


These nursing hours are self-reported by nursing homes to its state survey agency. These hours are recorded from the two-week period prior to a state inspection. The measure that is used to obtain a quality rating is "Staffing hours per resident per day", which is the average amount of hours worked divided by the total number of residents.


Some points to consider:


  • Data Accuracy: Staff hours are self-reported by the nursing home, rather than an independent agency.
  • Short Period of Time: Hours are recorded over only a two-week period. This may be far too short a period of time to provide an accurate assessment of staff hours per resident per day.
  • Small Sample of Measures: Not all aspects of care are measured in these reports.


TIP: A general rule is that having more staff work directly with residents provides a better quality of care. On visits to nursing homes ask about their staff levels and their qualifications.