Top Tips for Maintaining Solid Nursing Home Star Ratings Amid MDS Changes, CMS’ Bid to Track More Quality Measures

Meticulous documentation is the name of the game for nursing home operators looking to keep up with Minimum Data Set (MDS) changes and maintaining a good rating in the Five-Star Quality Rating System. This is especially because inaccurate or insufficient data could affect a facility for at least a year in the future.

Leaders in the nursing home space emphasized the importance of following state-specific coding guidelines for MDS, while also monitoring changes to the Quality Reporting Program (QRP) thresholds, as the Centers for Medicare & Medicaid Services (CMS) will track added quality measures.

While there aren’t as many upcoming MDS changes to note this year, operators should pay attention to new diagnosis codes. And, running weekly and 6-month assessment reports can help operators monitor quality measures and what data CMS is pulling for Five-Star, said Amy Greer, director of quality initiative at Zimmet Healthcare Services Group.

The penalties are substantial if Payroll-Based Journal (PBJ) data isn’t submitted on time as well, with facilities facing an 18-month star reduction if this data isn’t submitted correctly and on time, said Greer.

Alicia Cantinieri, managing director of clinical reimbursement and regulatory compliance for Zimmet, reviewed changes to the MDS within the 2025 Skilled Nursing Facility Proposed Payment Rule, and called attention to the fact the CMS is starting to call for data on quality measures set to take effect in 2027 – those focused on social determinants of health and discharge planning, specifically.

Cantinieri and Greer kicked off Zimmet’s conference last week, diving into MDS documentation insights, updates and best practices, among other topics.

Coding in Section GG, which had the most meaningful section update to the MDS announced a couple years ago, should be supported with documentation to support coding chosen in the new system, they said. Data entered needs to be consistent with clinical assessment documentation in the resident’s medical record – auditors and surveyors will be looking for this.

Retaining a good quality measure score

Facilities must continue to audit their MDS assessments for accuracy so there are no surprises with star ratings in January, experts said.

Meanwhile, with CMS expanding what goes into the overall quality score, operators should prepare for potential impacts of these added items and discuss with residents, families, hospitals, third-party lenders and the community.

Moreover, activities of daily living (ADLs) should be closely monitored to maintain the star rating. This includes comparing the loss of ADLs over time with previous assessments, and ensuring the accuracy of documentation, according to experts.

If a decline in ADLs is observed, experts advise facilities to document any additional therapy provided, and note whether staff encourages ADL independence or makes referrals to physical therapy, occupational therapy or restorative nursing. There should also be documentation of appropriate adaptive equipment provided.

Facilities should be examining and documenting other root causes of ADL decline too, Cantinieri and Greer said. If there’s existing pain, depression or refusal of treatment, this should be noted as well.

For residents with pressure ulcers, identifying those residents that could develop one while also reviewing policy and procedure is also a must. In other words, facilities should monitor how staff notifies the team of new wounds or skin issues.

“If the policy isn’t followed, [know] what in the policy isn’t working? Why do residents keep getting pressure ulcers? How does the staff know to alert someone else? These are all things you should be thinking of because ultimately this all impacts your quality measures,” said Greer.

Preventative measures like toileting schedules, rounding, and getting down to root cause analysis were also mentioned as ways to improve or maintain a high star rating, they advised.

Highlights of the SNF proposed rule

In terms of proposed changes to the MDS within the 2025 SNF Proposed Payment Rule, some primary diagnoses for the PDPM ICD-10 were removed, since policy makers at CMS believed these conditions were typically treated outside of a skilled nursing stay, said Cantinieri. These diagnoses were mostly related to metabolic management and insulin resistance.

The silver lining in this change is that it’s small compared to numerous proposed changes from the previous year.

“We will not be able to use those as a primary diagnosis on our MDS. But the good news is, that’s the change they proposed. Last year, we had pages and pages. This year we do not,” she said.

Another change in the proposed rule – revisiting a list of non-therapy ancillary (NTA) comorbidities, several of which are asthma-related as well as COPD and chronic lung disease. These make up a lot of resident Part A stays, Cantinieri said. CMS has asked for comments on its methodology, assigning points to each comorbidity based on patient population and care practices over time.

Points are added up to determine whether a service is more costly or requires extensive services.

Some Standardized Patient Assessment Data Elements (SPADE) items will be starting in fiscal year 2027, according to the rule, with data being collected starting on Oct. 1 2025. These are linked to quality measures in the SNF Quality QRP under social determinants of health, and questions will need to be asked surrounding a resident’s living situation, food scarcity, and if utilities have been shut off at their home. In other words, questions about discharge planning.

Another update with the QRP in the proposed rule requires staff to ask about a resident’s overall vaccination status, pain management and depression. CMS issued another request for information for the vaccination composite, Cantinieri said, and a quality measure about patient satisfaction.

Randomly selected facilities will be required to provide MDS data on select quality measures three years prior to its planned implementation. For those measures due to be implemented in 2027, it’s taking place now, she said.

These requests for MDS data from facilities is similar to an audit request, with operators having 45 days to submit documentation needed. CMS would reduce the facility’s Medicare market basket percentage by 2%. Letters for these requests just went out at the beginning of the month, Cantinieri said.