Last week Medicare’s Nursing Home Compare website ( launched a five-star rating system for all nursing homes nationwide. Accordig to CMS, individual nursing homes will receive one to five stars in three categories — quality measures, nurse staffing and health inspections — as well as an overall rating. It will be the first time the Centers for Medicare & Medicaid Services (CMS) has used such a rating system. According to CMS the five-star rating system provides a new, simple, easy-to-understand approach to making what might be the hardest decision ever — putting a loved one in a nursing home.

I’ve taken a look at some information about this and want to share it with you. I will review the site more and we can discuss it more later. This has been such a busy month, and sometimes I get home so exhausted from surveys – I don’t get to writing like I should!

So the information, which has been sent to me by what I believe is a firm helping CMS to get the word out, is in the form of an adobe powerpoint slide presentation. The presentation explains that all nursing homes that are Medicare & Medicaid Certified (16,000 in the nation – and counting!) will receive a 1 to 5 star rating (I imagine it is something similar to rating systems used in many other avenues of life.)  The five star rating summarizes specific information for each nursing home. These areas are: 1. An Overall rating, 2. Health Inspections, 3. Quality Measures, and 4. Staffing.

For the health inspections, the star rating takes into account the 3 most recent annual inspections, with the most recent having the most weight, and all complaint investigations for the last three years. The rating considers the number and the Severity and Scope of the deficiencies, with the more serious ones lowering the star rating. If you remember, in July, we discussed Severity & Scope.

CMS selected 10 Quality Measures (we have not yet discussed this, but I will address that in a future post), which are basically what they sound like, measures of the quality of care in a facility. CMS selected the 10 measures with the highest reliability ans uses the three most recent quarters of data to help determine the star rating. I do want to point out that the quality measure data is dependent on the nursing home providing accurate data. The 10 that CMS selected to assist in determining the star rating for nursing homes are: ADL (Activities of Daily Living) change, Mobility change, High Risk Pressure Ulcers, Long Term Catheters, Physical Restraints, Urinary Tract Infections, Pain (for both Long Stay and Short stay), Delirium, and Short Stay Pressure Ulcers.

For staffing data, the star rating takes into account the number of hours of care on average provided to each resdient each day, the nursing staff (meaning RNs, LVN/LPNs and CNAs). CMS has adjusted these to account for differences in the level of care resident of different nursing homes may need.

5 Stars = Much above average, 4 Stars = Above Average, 3 Stars = Average, 2 Stars = Below Average, and 1 star = Much Below Average.

For the Overall rating it appears the calculation of the number of stars is in steps and Step 1 starts with the health inspection rating. Step 2 takes into account the staffing, and they add 1 star for a 4 or 5 star staffing and subtract a star for 1 star rating. The 3rd step adds 1 star for 5 Star Quality Measures and subtracts a star for 1 star Quality Measures.

So it appears each item has its own stars and then an over all star system is also determined.

I’ll take some more time to help you understand the system, and if you have any questions you’d like me to ask, feel free. The group who sent me the information stated I could talk to a CMS spokesperson if there were questions. Although this information is mostly for consumers, I can see an Nursing Home and Hospital Surveyor taking a look at this information during their offsite preparation for a survey.


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The staging system is one way of summarizing certain characteristics of pressure ulcers, including the extent of tissue damage. The best definitions for the stages of pressure ulcers are from the National Pressure Ulcer Advisory Panel. You will find much more information about Pressure Ulcers at their website. Nursing home and hospital surveyors will use this staging system as they look at pressure sores during a survey.

Stage I is a change in normal intact skin. The change can be seen and is a result of pressure on the skin. Some of the changed signs are: skin temperature (warmth or coolness); tissue consistency (firm or boggy); Sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. Many times Stage I pressure ulcers may be difficult to identify because they are not readily visible and they present with greater variability. Advanced technology (not commonly available in nursing homes) has shown that a Stage I pressure ulcer may have minimal to substantial tissue damage in layers beneath the skin’s surface, even when there is no visible surface penetration. The Stage I will generally persist even after the pressure on the area has been removed for 30-45 minutes.

In Stage II part of the skin is lost. The ulcer is superficial and looks like an abrasion, blister, or shallow crater.

In Stage III there is skin loss involving damage to subcutaneous tissue that may extend down to, but not through, underlying tissues covering the muscle. It looks like a deep crater.

A Stage IV has extensive skin loss with destruction and/or tissue necrosis (dead tissue), or damage to muscle, and bone.

Although it may be difficult, it is important that you, as well as the nursing home and hospital surveyors, know about these stages and that you help to monitor your loved one for signs of a pressure ulcer. Prevention is the best thing, but if your loved one develops a pressure ulcer whether in a hospital, nursing home, or at home, check out the information available on the Internet and learn all you can about Pressure Ulcers. Learn what acceptable treatments there are, and then question the staff as to what treatment is being provided to your loved one. Ask questions and be proactive. In addition, report it to the local licensing and certification agency so an investigation can be conducted by a nursing home and hospital surveyor.

Be safe and be informed!


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Some residents have many risk factors for developing pressure ulcers. The nursing home has the responsibility to identify and evaluate these risk factors. They must then develop interventions to address the risk factors so a pressure ulcer does not develop. When you become involved with your loved ones care in a nursing home, you too should be aware of these risk factors, and ensure the staff are aware of any that your loved one has. Some of the risk factors include:

  • Impaired/decreased mobility and decreased functional ability;
  • Medical conditions, such as end stage renal disease, thyroid disease or diabetes mellitus;
  • Drugs such as steroids that may affect wound healing;
  • Impaired blood flow
  • Resident refusal of some aspects of care and treatment;
  • Cognitive impairment;
  • Exposure of skin to urinary and fecal incontinence;
  • Poor nutrition, malnutrition, and hydration deficits; and
  • A history of a healed pressure ulcer and its stage [if known] is important, since areas of healed Stage III or IV pressure ulcers are more likely to have recurrent breakdown.
  • Diabetic Neuropathy
  • An acute illness such as an upper respiratory infection, pneumonia, or congestive heart failure

Not all the risk factors can be modified or changed and some of those that can be changed, such as poor-nutrition, take time to be corrected even when there is immediate identification of the risk and appropriate interventions established. On the other hand, some risk factors can be removed promptly, such as pressure on a site.

A Nursing Home Surveyor will look to see if the nursing home staffs who are responsible for the resident’s care review each risk factor and its potential cause(s). They should identify those risk factors that increase the potential for pressure ulcers. The nursing home staff needs to decide what factor(s) can be modified, stabilized, or removed. Then the staff should determine what protocols need to be implemented for each individual resident.

Be safe and be informed!


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A pressure ulcer can occur wherever circulation to the tissues of the body has been compromised by pressure. The staff in a nursing home must identify the individual resident at risk for developing pressure ulcers. The staff must also identify and evaluate each resident’s risk factors and changes in the resident’s condition. They must identify and evaluate factors that can be removed or modified and they must implement interventions to attempt to stabilize, reduce, or remove underlying risk factors. These interventions are to be individualized to each resident’s needs. The staff must monitor the impact of the interventions that were developed and then change or adjust the interventions if they don’t work and when they need to be modified. The nursing home staff must recognize and evaluate each resident’s risk factors and identify and evaluate all areas at risk of constant pressure.

In order to do this the nursing home should have a complete assessment program for an effective pressure ulcer prevention and treatment program. A comprehensive individual evaluation helps the facility to identify residents at risk of developing pressure ulcers, identify the level and nature of risk(s), and identify the presence of pressure ulcers. The nursing home can then use the information to develop and implement a comprehensive care plan that reflects each resident’s identified needs.

A Nursing Home Surveyor will look for a system or process to assure: assessments and interventions are appropriate, timely, implemented, monitored, and changed as needed. They will look for a process that ensures any change in condition is recognized, evaluated, reported to the doctor or Nurse Practitioner, and that the change is addressed. In addition, the Nursing Home Surveyor will look to see if the quality assessment and assurance committee helps the nursing home in the development and monitoring of processes and ensuring they follow accepted standards of practice.

Be safe and be informed!


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