Understanding the CMS Five-Star nursing home rating system

The star ratings for U.S. nursing homes come from the Centers for Medicare & Medicaid Services (CMS). CMS gives every Medicare- and Medicaid-certified nursing home an overall rating from one to five stars, along with three separate ratings that feed into it. Knowing what each one measures makes the number far more useful than a single star count on its own.

Everything on this page describes CMS’s own method, as CMS documents it on the Five-Star Quality Rating System program page and in the Five-Star technical users’ guide (PDF). The per-facility ratings themselves are published in the CMS Provider Information dataset (dataset id 4pq5-n9py), refreshed monthly. The release referenced here is the one CMS dated 2026-08-01.

The overall rating

The overall star rating is a summary. CMS starts with the health inspection rating and then adjusts it up or down based on the staffing and quality-measure ratings. Because it is built from the other three, a home with the same overall rating as another can look quite different once you break it apart, which is why it helps to read all four together rather than stopping at the top number.

Health inspections

This rating is based on the on-site inspections, called surveys, that state agencies carry out for CMS. Inspectors check whether a home meets federal health and safety requirements, and they record any violations as citations, or deficiencies. CMS weights those citations by how serious and how widespread each one was and by how recent the inspection cycle was, across the three most recent cycles it holds. CMS publishes the citations themselves in its Health Deficiencies dataset (dataset id r5ix-sfxw), so you can read what was found rather than only the star count.

Staffing

The staffing rating looks at how much nursing time each resident gets. CMS builds it from Payroll-Based Journal data, which facilities report from their payroll systems, rather than from the self-reported counts the rating used before 2018. It weighs registered nurse hours and total nursing hours per resident per day, adjusted for how much care the residents need, and it also accounts for staff turnover. CMS publishes the reported hours and the turnover figures per facility in Provider Information alongside the star rating.

Quality measures

The quality-measure rating is built from clinical indicators that homes report on resident assessments and that appear in Medicare claims, covering both long-stay and short-stay residents. Examples CMS publishes include the share of long-stay residents with pressure ulcers, the share who experienced a fall with major injury, and the share receiving antipsychotic medication. Because part of this data is reported by the facility itself, CMS treats it as one input among several rather than the whole picture.

What the ratings do not tell you

The star system is a helpful starting point, not a verdict, and CMS documents several limits itself. The health inspection rating is set on a curve within each state, so a home’s rating can move because other homes in that state moved. Part of the quality-measure data is self-reported. The ratings also update on a schedule, so they can lag behind a recent change in a home, for better or worse. And a single number cannot capture how a specific resident’s needs are met day to day.

The most reliable way to use the ratings is to treat them as a map of where to look. Read all four together, then open the underlying record: the actual inspection citations, the staffing hours, and the penalty and ownership history. Those records are published per facility in the CMS datasets linked above and on Medicare Care Compare.