Nursing Home Star Ratings Explained
How CMS builds the Five-Star health inspection, staffing, and quality ratings, how the abuse icon caps them, and what the stars miss.
The Five-Star Quality Rating System is how CMS summarizes nursing home quality on Medicare.gov Care Compare. It began in December 2008. Every Medicare- or Medicaid-certified home gets an overall rating of one to five stars and separate ratings for three areas. This guide explains how each rating is built, based on the July 2026 edition of the CMS Technical Users' Guide, and what the stars can and can't tell you.
Health inspection rating
The health inspection rating is based on the home's two most recent standard inspections, plus complaint inspections and focused infection control surveys from the past three years. CMS switched from three standard inspections to two in July 2025. Each citation earns points based on its scope and severity letter (A through L). More serious and more widespread problems earn more points, and citations involving substandard quality of care earn extra points. Points are also added when a home needs more than one revisit to show it fixed its problems.
Recent findings count more. The most recent standard inspection gets three-quarters of the weight and the one before it gets one-quarter. Complaint and infection control findings from the past 12 months get more weight than those from 13 to 36 months ago.
Homes are then ranked within their own state, because inspection practices vary from state to state. In each state, the best 10% get five stars, the worst 20% get one star, and the middle 70% are split about evenly among two, three, and four stars. That means a home's health inspection stars show how it compares with other homes in the same state, not a national standard.
Staffing rating
The staffing rating uses six measures drawn from payroll data that homes submit each quarter through CMS's Payroll-Based Journal system:
- Total nursing hours per resident per day (registered nurses, licensed practical/vocational nurses, and nurse aides)
- Registered nurse (RN) hours per resident per day
- Total nursing hours per resident per day on weekends
- Total nursing staff turnover
- RN turnover
- The number of administrators who left
Staffing hours are adjusted for how sick and dependent residents are ("case-mix"), so a home caring for sicker residents is expected to staff more. A home automatically gets one star for staffing if it fails to submit data, reports four or more days in a quarter with no RN hours, or fails a CMS staffing data audit.
Quality measures rating
The quality measures (QM) rating uses 15 measures, nine for long-stay residents and six for short-stay residents, drawn from resident assessments (the Minimum Data Set) and Medicare claims. Examples include the share of residents with pressure ulcers, falls with major injury, antipsychotic medication use, hospitalizations and emergency visits, and, for short-stay residents, successful return home. Some measures are risk-adjusted. Most homes also get separate long-stay and short-stay QM ratings. CMS periodically raises the point thresholds for these stars as scores improve nationwide, and it did so most recently in July 2026. So a home can lose a star even though its own results stayed the same.
How the overall rating is calculated
The overall rating is not an average. CMS builds it in three steps:
- Start with the health inspection rating.
- Add one star if the staffing rating is five stars. Subtract one if it is one star.
- Add one star if the quality measures rating is five stars. Subtract one if it is one star.
The overall rating can't go above five stars or below one. If the health inspection rating is one star, staffing and quality can raise the overall rating by at most one star. Because of this, the health inspection rating matters most, and the other two can move the overall rating up or down by at most two stars. A home with only one standard inspection so far, such as a newly opened home, gets no ratings in any area.
The abuse icon
Care Compare shows a red hand icon for homes that meet either of two tests:
- They were cited for abuse at the level where residents were actually harmed (G or higher) on the most recent standard inspection or on a complaint or infection control survey within the past 12 months.
- They were cited for abuse at the level of potential harm (D or higher) in both the most recent period and the period before it.
Abuse here covers citations under F-tags F600 (abuse and neglect), F602 (misappropriation of resident property), and F603 (involuntary seclusion). A home with the icon has its health inspection rating capped at two stars. As a result, its overall rating can be no higher than four stars. The icon and the cap come off at the first monthly update after the home no longer meets the criteria.
Special Focus Facilities
Homes currently in CMS's Special Focus Facility program, which is for homes with a long history of serious problems, receive no star ratings at all. Care Compare shows a yellow warning sign instead.
Limitations to keep in mind
- State-relative scoring. Health inspection stars compare homes within a state, so a four-star home in one state can't be compared directly with a four-star home in another.
- Data lag. Staffing and quality data are updated quarterly and cover past periods. Inspection findings can be more than a year old.
- Self-reported data. Quality measures based on assessments rely on information the home reports, although CMS audits some of it.
- Averages hide details. A home's overall stars may not reflect the unit, shift, or type of care your family member needs.
- Not all measures count. Some quality measures and all fire safety findings appear on Care Compare but don't count toward the stars.
The best use of the stars is to build a shortlist. Then read the inspection reports, look at the individual staffing numbers, and visit in person. Details on the methodology are on CMS's Five-Star Quality Rating System page. This guide is general information, not medical or legal advice.