Five-Star Changes: The Bar Has Moved—Has Your Organization?
Insights from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, AAPACN Master Teacher – Director of Reimbursement and Education, Pathway Health
Throughout my years of working with skilled nursing providers across the country, I have seen Five-Star ratings become far more than a number displayed on Care Compare. They influence how consumers and families view an organization, how referral partners evaluate placement options, and how managed care organizations, lenders, boards and other stakeholders assess performance. The July 2026 update is another important reminder that Five-Star is not a static system. CMS increased the thresholds required to achieve each Quality Measure, or QM, star level by one-half of the average improvement in provider QM scores between January 2025 and April 2026. Importantly, the point thresholds for the individual measures did not change; facilities now need a higher combined score to maintain or improve their overall QM rating.
What does this mean at the facility level? A provider may experience a decrease in its QM star rating even when its individual clinical outcomes have remained relatively stable. The organization may not have moved backward, but the national performance bar has moved forward. CMS also indicates that it plans to raise the QM rating thresholds every six months based on 50% of the increase in scores during the applicable period. Leaders should therefore avoid managing only to today’s minimum threshold. Sustainable performance requires an ongoing understanding of each measure, its underlying resident population and the operational practices driving the data.
From my perspective, this change reinforces why MDS accuracy must be viewed as an organization-wide responsibility—not simply an MDS department task. The Five-Star QM domain currently includes 15 measures: nine long-stay and six short-stay measures, with both MDS- and claims-based data contributing to the calculation. MDS information also supports other areas of public reporting, including resident census and case-mix adjustment for staffing measures. When assessments are incomplete, inconsistent with the clinical record or unsupported by interdisciplinary documentation, the impact may extend well beyond reimbursement. It can affect quality measures, staffing calculations, care planning, public reporting and leadership’s ability to make informed decisions.
Accurate data begins with accurate resident assessment, but it must lead to action. Leaders should know which measures are improving, which are declining, which residents are triggering the measures and whether the results reflect an actual clinical concern, a documentation gap or an assessment-coding issue. Five-Star data should be reviewed alongside resident-level reports, clinical outcomes, claims information and facility practices. The goal is not to “chase the stars.” The goal is to create reliable assessment and care systems that accurately reflect each resident’s needs and produce better outcomes. When those systems are strong, the data—and ultimately the Five-Star rating—should follow.
Three Leadership Strategies
- Know your data before it becomes public. Review Five-Star and QM reports routinely, drill down to the resident level and identify trends early. Do not wait for the quarterly Care Compare refresh to discover an issue.
- Validate the complete MDS process. Audit assessment accuracy, supporting documentation, interview practices, interdisciplinary participation, submission processes and correction procedures. A technically correct MDS requires reliable information from nursing, therapy, dietary, social services, providers and other members of the interdisciplinary team.
- Connect quality measures to operations and QAPI. Assign accountability for priority measures, establish measurable improvement goals and monitor whether interventions are producing sustained resident outcomes. Share relevant information with the governing body, leadership team and frontline staff so that Five-Star performance is understood across the organization.
How Pathway Health Can Help
- MDS Baseline Assessment
A comprehensive review of MDS accuracy, supporting documentation, interdisciplinary processes, reimbursement risk and opportunities for operational improvement. - Five-Star Quality Measure Assessment
A focused analysis of the facility’s long-stay and short-stay measures, resident-level triggers, Five-Star positioning, documentation practices and priority opportunities for improvement. - MDS Training
Customized education for MDS professionals, clinical leaders and interdisciplinary team members addressing current requirements, assessment accuracy, documentation expectations and the connection between the MDS, quality measures, reimbursement and resident care. - MDS Mentoring
Ongoing support for new or experienced MDS professionals through individualized coaching, case review, process guidance and assistance in building sustainable assessment systems.
Five-Star expectations will continue to evolve. Organizations that understand their data, validate their MDS processes and respond proactively will be better prepared not only to protect their ratings, but also to demonstrate the quality of care they provide every day.
