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.

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. The rating reflects the number, seriousness, and recency of those citations over roughly the most recent three inspection cycles. CMS publishes the actual citations behind this rating, reproduced from the inspection record, so you can see what was found rather than only the star count.

Staffing

The staffing rating looks at how much nursing time each resident gets, and it now uses payroll-based data rather than self-reported numbers. It weighs registered nurse hours and total nursing hours per resident per day, and it also accounts for staff turnover. Staffing is closely tied to quality of care, since many problems trace back to not having enough people on the floor. CMS publishes the reported hours and turnover figures alongside the star rating.

Quality measures

The quality-measure rating is built from clinical indicators that homes report and that appear in claims data, covering both long-stay and short-stay residents. Examples include how many residents develop pressure ulcers, how many experience falls with injury, and how many are on certain medications. Because some of this data is reported by the facility itself, it is 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. A few limits are worth keeping in mind. Ratings are relative in part, so some are set against how other homes in the same state perform, which means a rating can shift without a home changing. Some inputs are 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. That is exactly the data we reproduce on each facility page. For the official details of how each rating is calculated, CMS publishes its own Five-Star Quality Rating System documentation.