Understanding the CMS Five-Star Ratings
CMS gives nursing homes one to five stars for inspections, staffing, and quality. Here is what each star reflects, and where the ratings fall short.
Updated
This guide is informational and is not medical advice.
Category: ratings-inspections · Updated 2026
The CMS Five-Star Quality Rating is the most commonly used shorthand for nursing home quality in the United States. It shows up on every facility's page at Medicare Care Compare. The score is a composite drawn from three separate domains: health inspections, staffing, and quality measures. Each domain earns its own star rating, and CMS then rolls them into an overall rating.
The ratings are helpful, but they do not tell the whole story about a facility. Understanding what each domain does and does not measure lets you treat the numbers as a tool rather than a verdict.
The three domains that build the overall rating
CMS scores each of these on its own, then calculates the overall star rating:
- Health inspections come from on-site surveys by state survey agencies working for CMS, plus investigations of complaints.
- Staffing comes from payroll-based reporting of nurse staffing hours and turnover.
- Quality measures come from clinical assessment data the facility reports.
Per the CMS Five-Star Technical Users' Guide, the health inspection domain carries the greatest weight in the overall rating, while the other two can nudge the overall score. For the precise formula, which CMS revises over time, read the current technical guide at CMS Five-Star Quality Rating System.
What the health inspection star tracks
The inspection rating shows how well a facility met federal requirements in its most recent standard and complaint surveys. CMS gives recent inspection cycles more weight than older ones. State surveyors cite deficiencies on a scope-and-severity grid, with the gravest findings—immediate jeopardy—counting most heavily.
An inspection rating captures compliance at a single point in time; it is not a gauge of daily kindness or culture. See How to Read a Nursing Home Inspection Report for the story behind the score.
What the staffing star reflects
The staffing domain draws on Payroll-Based Journal (PBJ) data, which facilities submit daily. CMS examines adjusted nurse staffing hours per resident per day along with staff turnover. Better staffing generally supports better outcomes, and high turnover can point to instability even when hours appear adequate. Our guide CMS Staffing Ratings Explained unpacks this further.
What the quality measure star captures
The quality measure (QM) rating is built from the Minimum Data Set (MDS), the clinical assessment tool facilities complete on every resident. CMS applies a set of short-stay and long-stay measures covering items such as falls with major injury, pressure ulcers, and antipsychotic medication use. Because the data is self-reported and then risk-adjusted, it mirrors reported care processes and outcomes. See CMS Quality Measures Explained.
Getting the most from the ratings
Use the star ratings as a screening tool, not a final verdict:
- Compare facilities within the same state or region, since inspection practices differ by state.
- Weigh all three domain ratings, not just the overall star.
- Open the facility's inspection results and read the deficiencies themselves.
- Pair the data with a visit, a tour, and conversations with staff and families.
- Note the date of the data, because ratings refresh on a schedule.
No star rating can tell you whether your family member will be treated with dignity. It can tell you where to look harder.
Limits and things to keep in mind
Ratings shift when a new survey arrives or staffing data updates, so a facility can jump several stars within a year. Small facilities and those serving many Medicaid residents can be penalized by resource gaps the formula does not capture. CMS itself notes that the ratings do not measure whether a facility suits a particular person. Use them alongside—never in place of—your own evaluation.
Sources: CMS Five-Star Quality Rating System; Medicare Care Compare; CMS Provider Data Catalog.
Related guides
- Reading a Nursing Home Inspection Report
- CMS Staffing Ratings for Nursing Homes Explained
- Reading the CMS Nursing Home Quality Measure Rating
- Red Flags to Spot in CMS Nursing Home Data
- Special Focus Facilities: What the CMS Program Involves
Frequently asked questions
Is a five-star nursing home always better than a four-star home?
How often do CMS star ratings change?
Why does a facility have a high overall rating but a low staffing rating?
Are the ratings the same in every state?
Where can I see the data behind a rating?
Data sources
CMS Provider Data Catalog · CMS Care Compare. This guide is informational and is not medical advice. Data as of 2026-10-06.
Required disclosures
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