Changes Coming to Your Five-Star Quality Rating

2021 has arrived after a long and challenging year for post-acute/ long-term care providers. While the Centers for Medicare & Medicaid Services (CMS) made multiple adjustments to survey and certification activities in 2020, in December the Agency made an important announcement – changes to the Five-Star Quality Rating were coming with the new year.

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Most significantly, starting on January 27, 2021, with the January refresh of Care Compare (FKA Nursing Home Compare), nursing home Health Inspection Ratings will be unfrozen. There are several important details to recognize about your Health Inspection rating.

Updates to the Health Inspection Rating

  • Surveys conducted after March 3, 2020 will now be included in your Health Inspection rating
  • Citations from Focused Infection Control Surveys will be included in the rating calculation (in a similar manner to how complaint citations are weighted)

This means that Health Inspection domain ratings are now based on the number, scope and severity of deficiencies identified during:

  • The three most recent annual inspection surveys (cycles)
  • Substantiated findings from the most recent 36 months of complaint investigations and Focused Infection Control Surveys.

Deficiencies from Focused Infection Control Surveys

Citations from Focused Infection Control Surveys are weighted with the following methodology:

  • If 2+ Infection Control inspections cite the same deficiencies within a 15-day period, all of the citations are included.
    • If one or more of these deficiencies was also cited on a recertification survey and/or a complaint investigation within the same 15-day window, only the Infection Control citations are included.

Facilities with Abuse Icon

Facilities who currently have the abuse icon on their Nursing Home Compare profiles may see this change based on the incorporation of more recent survey data. If a facility no longer meets the abuse icon criteria, its Health Inspection rating will no longer be capped at two stars. The abuse icon will be listed for facilities with the following:

  • Harm-level abuse citation in most recent survey cycle (S/S: G or higher) – A facility that been cited for abuse at a Scope/Severity of Actual Harm or higher on the most recent standard survey, complaint investigation or Focused Infection Control Survey within the past 12 months will have the Abuse icon on its Care Compare profile.
  • Repeat abuse citations – Facilities that have been cited for abuse at a Scope/Severity of D or higher on the most recent standard survey or on a complaint or on a Focused Infection Control Survey within the past 12 months and on the previous standard survey or complaint survey in the prior 12 months will have the Abuse on their Care Compare profile.

Missing Recertification Survey Data

Since routine survey activity was delayed for much of 2020, there may be instances where facilities do not have all three cycles’ of data. In that case, the following will occur:

  • If a facility is missing one cycle’s recertification data, the most recent survey cycle receives a 60% weight and the prior cycle receives a 40% rating.
  • If there is only data available from one recertification survey, Care Compare will display “Not Available” for the facility.

FYI – Also note that citations given under F731 Waiver- Licensed Nurses 24Hr/Day and RN Coverage and F884 Reporting – National Health Safety Network are not included in the calculation.

Special Focus Facilities

The Special Focus Facility (SFF) Program will also be updated and any facility designated as an SFF will not have rating data assigned in any domain. Facilities designated as SFFs also have an indicator on their Nursing Home Compare profile, and some providers may see this change as well with the January refresh. In 2017, CMS updated the methodology for selecting SFFs to “harmonize” the with the Health Inspection domain, and for the most part, the SFF list (along with the candidate list) has been updated monthly with the rest of the provider data. Seema Verma further explained the methodology in 2019, inferring that the best way to stay off the candidate list is to achieve good survey outcomes because more points = greater likelihood of being added to the SFF candidate list.

Is Your Organization Ready for Survey?

Your organization’s performance on surveys in 2020 is about to be factored into your Health Inspection rating, and it is time to look forward and think about how to have a successful survey in 2021. There have been several revisions made to the Long-Term Care Survey Process (LTCSP) and the associated survey resources since November 2020, including the incorporation of the stand-alone Focused Infection Control Survey into the LTCSP. Does that mean the days of these focused surveys are over? The answer is no,  not for the foreseeable future. This means that skilled nursing facilities need to not only continue to have a good handle on Infection Control, but prepare for a broader look at what has been going on in your building over the past year in every department.

Although CMS had announced in August 2020 that it was resuming routine inspections for all providers, the return to business as usual for State Survey Agencies has varied by State due to whether the necessary resources have been available (i.e. PPE and survey staff). There is a significant backlog of complaints that have not been investigated, as well as many recertification surveys that are overdue in addition to all the facilities that are currently in their usual survey window. Expect to see open complaints being brought into your recertification survey as surveyors try to close the gap.


To review the entire set of changes to the Five-Star Quality Rating System, view the January 2021 Design for Care Compare Nursing Home Five-Star Quality Rating System Technical Users’ Guide.


Does your organization need help preparing for survey? CMS Compliance Group can help. Contact us to learn about our on-site and off-site/remote Mock Surveys and Quality Reviews. Our interdisciplinary team of nurses, social workers, dietitians and Life Safety/facilities consultants can help you identify potentially problematic areas and implement corrective actions to improve your quality and avoid survey deficiencies.

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