The Five-Star Quality Rating System for Nursing Homes: How the Ratings Work
Summary
- Every nursing home gets a rating from 1 to 5 stars, built from three domains: health inspections, staffing and quality measures.
- The health inspection rating is the base. Staffing and quality measures can move it up or down by one star each.
- Health inspections are rated relative to other facilities in the same state. Staffing and quality measures use national scales.
- Facilities with an abuse citation can reach 4 stars at most. Facilities in the Special Focus Facility program get no stars at all.
What is the Five-Star Quality Rating System?
The Five-Star Quality Rating System is a tool that helps consumers, families and caregivers to compare and choose nursing homes. It was created by the Centers for Medicare and Medicaid Services (CMS) in December 2008 when they also started their Care Compare website.
According to the official user guide, each facility gets an overall rating from 1 to 5 stars, plus one rating per domain:
| Domain | What it measures | Data source |
|---|---|---|
| Health inspections | Deficiencies found in state surveys | State survey results |
| Staffing | Nurse hours per resident and staff turnover | Payroll-Based Journal (PBJ) and MDS census |
| Quality measures (QMs) | Resident outcomes such as falls, hospitalizations and pressure ulcers | MDS assessments and Medicare claims |
Two groups of facilities get no stars:
- Facilities with only one standard survey have too little data, so Care Compare shows "Not Available" for all domains.
- Special Focus Facilities show a yellow warning sign instead.
How does the health inspection rating work?
The health inspection rating is based on the two most recent standard surveys, plus the last 36 months of complaint investigations and focused infection control surveys. Since July 2025, the third most recent standard survey is displayed on Care Compare but no longer scored.
Step 1: Points per deficiency
Each deficiency gets points based on scope (isolated, pattern, widespread) and severity. A lower total is better.
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J: 50 | K: 100 | L: 150 |
| Actual harm | G: 20 | H: 35 | I: 45 |
| Potential for more than minimal harm | D: 4 | E: 8 | F: 16 |
| Potential for minimal harm | A: 0 | B: 0 | C: 0 |
Step 2: Revisits
If a facility needs repeat revisits to prove it fixed its deficiencies, it gets additional points. The first revisit costs nothing. The second adds 50% of the survey score, the third 70% and the fourth 85%.
Step 3: Weighting by recency
Recent results count more:
- Standard surveys: the most recent counts 3/4, the second most recent 1/4.
- Complaint and infection control surveys: findings from the last 12 months count 3/4, findings from months 13 to 36 count 1/4.
Complaint citations within 15 days of a standard survey are counted only once, using the higher scope and severity.
Step 4: Ranking within the state
CMS ranks facilities against others in the same state, because survey practices and state licensing rules differ.
| Facility's position in its state | Health inspection rating |
|---|---|
| Best 10% (lowest scores) | 5 stars |
| Next 23.33% | 4 stars |
| Next 23.33% | 3 stars |
| Next 23.33% | 2 stars |
| Worst 20% | 1 star |
CMS recalibrates the cut points every month. A facility's rating only changes when its own score changes, for example through:
- a new survey
- a new complaint citation
- a second or later revisit
- a resolved dispute
- an old complaint citation aging into the lower-weighted period
When does a nursing home get the abuse icon?
A facility gets the abuse icon if it has a harm-level abuse citation (G or higher) on its latest standard survey or in the past 12 months of complaint and infection control surveys. It also gets the icon for repeat abuse citations at D level or higher across two consecutive survey cycles. The health inspection rating is then capped at 2 stars, which limits the overall rating to 4 stars. The cap lifts at the first monthly refresh after the facility no longer meets the criteria.
To prepare for the surveys behind this rating, see how to stay CMS survey-ready. Which citations show up most often: the 10 most common CMS deficiencies in US nursing homes.
How does the staffing rating work?
The staffing rating rests on six measures. Hours come from the Payroll-Based Journal, which facilities submit quarterly. The resident census comes from MDS assessments.
| Measure | Max points |
|---|---|
| Case-mix adjusted total nurse hours per resident day | 100 |
| Case-mix adjusted RN hours per resident day | 100 |
| Case-mix adjusted total nurse hours on weekends | 50 |
| Total nurse turnover | 50 |
| RN turnover | 50 |
| Administrator departures | 30 |
| Total | 380 |
Staffing hours are adjusted for case mix using PDPM nursing groups, so a facility with sicker residents is not penalized for needing more hours. For the three hours measures, facilities are sorted into national deciles. A facility needs at least 1.202 adjusted RN hours per resident day to hit the top decile (100 points).
Turnover counts a nurse as gone after a gap of 90 days without any worked hours. Only staff with at least 120 hours in the baseline period are included, so occasional shift cover does not distort the number. Administrators score 30 points with no departure, 25 with one and 10 with two or more.
The total score maps to stars as follows:
| Stars | Points |
|---|---|
| 1 | below 155 |
| 2 | 155 to 204 |
| 3 | 205 to 254 |
| 4 | 255 to 319 |
| 5 | 320 to 380 |
Three situations override the score and produce 1 star:
- No staffing data submitted by the deadline.
- Four or more days with residents in the building but no RN hours.
- A failed or ignored PBJ audit (1 star for three months).
Facilities with implausible data, such as zero total hours or more than 12 hours per resident day, get no reported staffing levels.
How does the quality measure rating work?
CMS uses 15 quality measures:
- 9 for long-stay residents (more than 100 days) and 6 for short-stay residents.
- Ten come from MDS assessments, five from Medicare claims.
The rating uses the four most recent quarters of data. The return-to-home measure uses two years.
The 15 measures by type:
| Stay type | MDS-based | Claims-based |
|---|---|---|
| Long-stay | Need for help with daily activities increased, ability to walk worsened, pressure ulcers, catheter, urinary tract infection, falls with major injury, antipsychotic medication | Hospitalizations per 1,000 resident days, outpatient ED visits per 1,000 resident days |
| Short-stay | Discharge function score, new or worsened pressure ulcers, new antipsychotic medication | Re-hospitalization within 30 days, outpatient ED visits, successful return to home and community |
Measures are not weighted equally. Nine measures score between 15 and 150 points in deciles. The other six score between 20 and 100 points in quintiles.
CMS then sums the points into a long-stay score (155 to 1,150), an adjusted short-stay score (144 to 1,150) and an overall score (299 to 2,300). Stars follow fixed point thresholds. CMS raises them every six months by half of the average score improvement. These are the overall thresholds as of July 2026:
| Stars | Overall QM points |
|---|---|
| 1 | 299 to 927 |
| 2 | 928 to 1,120 |
| 3 | 1,121 to 1,299 |
| 4 | 1,300 to 1,493 |
| 5 | 1,494 to 2,300 |
Facilities also get separate long-stay and short-stay QM ratings. Measures with fewer than 20 eligible assessments are filled in with the state average for scoring, but those values are not published.
Three 2026 changes matter here:
- January 2026: the long-stay antipsychotic measure was respecified to include Medicare and Medicaid claims data.
- April 2026: all residents with a schizophrenia history are now excluded from that measure.
- July 2026: the rating thresholds went up.
Who gets the CMS rating trophy icon?
The trophy icon marks nursing homes that qualify for the Risk-Based Survey (RBS), a shortened version of the standard inspection. CMS began showing it on Care Compare on October 8, 2026. It sits next to the star rating and flags quality indicators beyond the stars, such as a history of fewer citations and higher staffing. CMS estimates that about 12% of nursing homes qualify (1,560 of 14,682 facilities, based on June 2026 data).
How is the overall rating calculated?
The overall rating is calculated in four steps:
- Start with the health inspection rating.
- Add one star if staffing has 5 stars. Subtract one star if staffing has 1 star.
- Add one star if the QM rating has 5 stars. Subtract one star if it has 1 star.
- Keep the result between 1 and 5.
One exception: if the health inspection rating is 1 star, staffing and QMs can add at most one star in total.
Some examples:
| Health inspection | Staffing | QM | Overall |
|---|---|---|---|
| 3 | 5 | 5 | 5 |
| 4 | 5 | 3 | 5 |
| 3 | 5 | 1 | 3 |
| 2 | 1 | 1 | 1 |
| 1 | 5 | 5 | 2 |
A facility can move up or down by at most two stars from its health inspection rating. Ratings update on different schedules: health inspections monthly, staffing and QMs quarterly.
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