Understanding CMS Star Ratings for Nursing Homes
When researching nursing homes, the CMS 5-star rating system is usually the first quality indicator families encounter. Maintained by the Centers for Medicare and Medicaid Services, this rating system assigns every Medicare-certified nursing home a score from 1 to 5 stars across multiple quality dimensions. Understanding how these ratings work, what they actually measure, and where they fall short will help you use them as a starting point for evaluation rather than a final verdict.
What Is the CMS 5-Star Rating System?
The CMS 5-star quality rating system was launched in 2008 to help consumers compare nursing homes more easily. It applies to all nursing homes that participate in Medicare or Medicaid programs, which includes the vast majority of facilities in the United States.
Each nursing home receives four separate ratings:
- Overall rating (1-5 stars)
- Health inspection rating (1-5 stars)
- Staffing rating (1-5 stars)
- Quality measures rating (1-5 stars)
The overall rating is a weighted combination of the three component ratings, with health inspections carrying the most weight.
How Is the Health Inspection Rating Calculated?
The health inspection rating is based on the three most recent annual standard inspections plus any complaint investigations conducted over the past three years. Each inspection identifies deficiencies, which are instances where the facility failed to meet one or more federal requirements.
What Inspectors Evaluate
State survey teams conduct unannounced inspections that typically last several days. They review:
- Resident care practices, including medication administration, wound care, and infection control
- Resident rights, including privacy, dignity, and freedom from abuse
- Quality of life, including food, activities, and the living environment
- Environmental safety, including fire protection, emergency procedures, and physical accessibility
- Administrative practices, including staff training and record-keeping
How Deficiencies Are Scored
Each deficiency is scored based on two factors:
- Scope: Was the deficiency isolated (affected one or a few residents), a pattern (multiple residents), or widespread (throughout the facility)?
- Severity: Did the deficiency pose no actual harm but potential for harm, cause actual harm to a resident, or create immediate jeopardy to a resident’s health or safety?
The combination of scope and severity determines a point value. More severe and widespread deficiencies receive higher point values. The facility’s total deficiency score is then compared to all other facilities in the state to determine the star rating.
State-Level Comparison
Health inspection ratings are assigned relative to other facilities within the same state, not nationally. This means a 5-star facility in one state might have a similar inspection record to a 4-star facility in a state with stricter survey practices. The top 10% of facilities in each state receive 5 stars, and the bottom 20% receive 1 star.
| Rating | Approximate Percentile (within state) |
|---|---|
| 5 stars | Top 10% |
| 4 stars | Next 23% |
| 3 stars | Next 27% |
| 2 stars | Next 20% |
| 1 star | Bottom 20% |
How Is the Staffing Rating Calculated?
The staffing rating measures the number of nursing staff hours provided per resident per day. CMS uses data from the Payroll-Based Journal (PBJ), which requires facilities to submit staffing information based on actual payroll records rather than self-reported estimates.
What Is Measured
CMS evaluates two staffing metrics:
- Total nursing hours per resident per day: Includes RN, LPN, and CNA hours combined
- RN hours per resident per day: Measured separately because RNs provide the highest level of clinical oversight
Both metrics are adjusted for the acuity (medical complexity) of the facility’s resident population. A facility caring for sicker, more complex residents is expected to have higher staffing levels.
Staffing Rating Thresholds
The specific thresholds vary by case mix, but generally:
| Rating | Interpretation |
|---|---|
| 5 stars | Staffing levels well above average for the facility’s case mix |
| 4 stars | Above average staffing |
| 3 stars | Average staffing for the case mix |
| 2 stars | Below average staffing |
| 1 star | Significantly below average staffing |
Weekend Staffing Adjustment
In recent updates, CMS has incorporated weekend staffing data into the rating. This is important because some facilities reduce staffing dramatically on weekends, which affects care quality during those periods. Facilities with large disparities between weekday and weekend staffing may see their ratings adjusted downward.
How Is the Quality Measures Rating Calculated?
Quality measures (QMs) are clinical indicators derived from data that nursing homes report through the Minimum Data Set (MDS), a standardized assessment tool used for every resident.
Long-Stay Quality Measures
These apply to residents who live in the facility permanently:
- Percentage of residents with pressure ulcers (stages 2-4)
- Percentage of residents who received antipsychotic medications
- Percentage of residents who experienced falls with major injury
- Percentage of residents with a urinary tract infection
- Percentage of residents who were physically restrained
- Percentage of residents who experienced unplanned weight loss
- Percentage of residents with a catheter left in the bladder
- Percentage of residents whose ability to move independently worsened
Short-Stay Quality Measures
These apply to residents admitted for temporary stays, usually for rehabilitation after hospitalization:
- Percentage of short-stay residents who were rehospitalized
- Percentage who had an outpatient emergency department visit
- Percentage who experienced new or worsening pressure ulcers
- Percentage who showed functional improvement
Each facility’s QM performance is compared nationally, and a composite score determines the star rating.
How Is the Overall Rating Determined?
The overall rating starts with the health inspection rating and is then adjusted based on staffing and quality measures.
The Calculation Process
- Start with the health inspection rating as the base
- Add one star if the staffing rating is 4 or 5 stars AND the RN staffing rating is 4 or 5 stars
- Subtract one star if the staffing rating is 1 star
- Add one star if the quality measures rating is 5 stars
- Subtract one star if the quality measures rating is 1 star
- The overall rating cannot exceed 5 or go below 1
This methodology means that health inspections have the largest influence on the overall rating, which is intentional. CMS considers direct observation of care practices (inspections) to be the most reliable indicator of quality.
Limitations of the CMS Star Rating System
While the star rating system is a valuable tool, it has well-documented limitations that families should understand.
Self-Reported Data
Quality measures and, historically, staffing data are based on information reported by the facilities themselves. Although CMS has moved to payroll-based staffing data (reducing the opportunity for manipulation), quality measures still rely on facility-reported assessments. Some facilities may underreport problems or code resident conditions in ways that improve their scores.
Inspection Variability by State
Because health inspection ratings are compared within each state, standards and enforcement practices vary. A state with more rigorous inspectors will produce lower health inspection ratings across all its facilities compared to a state with less aggressive survey practices.
Snapshots in Time
Inspections happen once per year. A facility that performed well during its last inspection may have experienced staffing changes, leadership turnover, or quality declines in the months since. Conversely, a facility that received a poor rating may have made significant improvements.
Does Not Capture Everything
The star rating system does not measure:
- Resident and family satisfaction
- Quality of food beyond nutritional adequacy
- Activity programming richness and engagement
- Staff attitude and culture (kindness, respect, responsiveness)
- Physical environment quality and aesthetics
- Communication with families
- Specialized care quality such as dementia care programs
These factors matter enormously but are not reflected in the ratings.
Gaming the System
Some facilities have learned to optimize their scores without necessarily improving care. For example, a facility might improve its quality measures rating by changing how it codes resident assessments rather than by improving actual clinical outcomes.
How to Use Star Ratings Wisely
Use Ratings as a Screening Tool
Star ratings are most useful for creating a shortlist of facilities to visit. Filtering out 1-star and 2-star facilities is a reasonable starting point, though there may be exceptions worth investigating.
Look at the Component Ratings Individually
The overall rating can mask important differences. A facility might have a 4-star overall rating but a 1-star staffing rating, which is a significant concern. Always check all three component ratings.
Compare Facilities Within the Same Area
Since health inspection ratings are state-based, comparing two facilities in the same state gives you a meaningful relative comparison. Comparing facilities across states is less reliable.
Check the Trend Over Time
A facility that has improved from 2 stars to 4 stars over two years is on a positive trajectory. A facility that has declined from 5 stars to 3 stars may be experiencing problems. CMS provides historical rating data that allows you to track trends.
Combine Ratings with Other Information
Star ratings should be one input among many. Combine them with:
- Inspection report details for specific findings (see our guide on how to read nursing home inspection reports)
- In-person visits to observe care quality firsthand
- Conversations with families of current residents
- State licensing records for enforcement actions
- Your own observations about staff demeanor, resident wellbeing, and facility cleanliness
Where to Find CMS Star Ratings
CMS star ratings are publicly available on the Medicare.gov Care Compare website. You can also access them directly on CareCompass, where we integrate CMS ratings into each skilled nursing facility profile along with inspection summaries, staffing data, and quality measure breakdowns.
On CareCompass, you can search by location, filter by star rating, and compare multiple facilities side by side. This makes it easy to identify high-quality options in your area and dig deeper into the data that matters most.
Making Ratings Work for Your Family
The CMS star rating system is the best standardized quality measurement tool available for nursing homes, but it is not a substitute for your own judgment. Use ratings to narrow your search, read inspection reports to understand specific issues, and visit the facilities that make your shortlist. The right nursing home is one where the data, your observations, and your instincts all align. Start your research on CareCompass and use our tools to turn complex quality data into clear, actionable insights.
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