CMS Five-Star Ratings Explained
CMS rates nursing homes one to five stars on inspections, staffing, and quality. Learn what each star rating measures and where it falls short.
Category: ratings-inspections · Updated 2026
CMS Five-Star Quality Ratings are the most widely used shorthand for nursing home quality in the United States. The rating appears on each facility's page on Medicare Care Compare. It is a composite score built from three separate domains: health inspections, staffing, and quality measures. Each domain gets its own star rating, and CMS then combines them into an overall rating.
The ratings are useful, but they are not a complete picture of a facility. Knowing what each domain measures, and what it does not, helps you read the numbers like a tool rather than a verdict.
The three domains behind the overall rating
CMS calculates each of these separately, then derives the overall star rating:
- Health inspections come from on-site surveys by state survey agencies acting on behalf of CMS, plus complaint investigations.
- Staffing comes from payroll-based reporting of nurse staffing hours and turnover.
- Quality measures come from clinical assessment data reported by the facility.
According to the CMS Five-Star Technical Users' Guide, the health inspection domain carries the most weight in the overall rating, and the other two domains can adjust the overall score. Read the current technical guide at CMS Five-Star Quality Rating System for the exact formula, which CMS updates over time.
What the health inspection star measures
The inspection rating reflects how well a facility met federal requirements during its most recent standard surveys and any complaint surveys. CMS weights recent inspection cycles more heavily than older ones. State surveyors cite deficiencies on a scope-and-severity grid, and the most serious findings, called immediate jeopardy, carry heavy weight.
A facility's inspection rating is a snapshot of compliance, not a measure of day-to-day kindness or culture. See How to Read a Nursing Home Inspection Report for the details behind the score.
What the staffing star measures
The staffing domain uses Payroll-Based Journal (PBJ) data, which facilities report daily. CMS looks at adjusted nurse staffing hours per resident per day and at staff turnover. Higher staffing generally supports better outcomes, and turnover can signal instability even when hours look adequate. Our guide CMS Staffing Ratings Explained breaks this down further.
What the quality measure star measures
The quality measure (QM) rating comes from the Minimum Data Set (MDS), the clinical assessment tool facilities complete for each resident. CMS uses a set of short-stay and long-stay measures that cover things like falls with major injury, pressure ulcers, and antipsychotic medication use. Because the data is self-reported and then risk-adjusted, it reflects reported care processes and outcomes. See CMS Quality Measures Explained.
How to use the ratings well
Treat the star ratings as a screening tool, not a final answer:
- Compare facilities within the same state or region, since inspection practices can differ by state.
- Look at all three domain ratings, not just the overall star.
- Open the facility's inspection results and read the actual deficiencies.
- Combine the data with a visit, a tour, and conversations with staff and families.
- Check the date of the data, since 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 cautions
Ratings change when a new survey lands or when staffing data updates, so a facility can move several stars in a year. Small facilities and those serving a high share of Medicaid residents can be penalized by resource differences that the formula does not capture. CMS states that the ratings are not a measure of whether a facility is the right fit for a particular person. Use them alongside, not instead of, your own evaluation.
Sources: CMS Five-Star Quality Rating System; Medicare Care Compare; CMS Provider Data Catalog.
Related guides
- How to Read a Nursing Home Inspection Report
- CMS Staffing Ratings for Nursing Homes Explained
- CMS Quality Measures for Nursing Homes Explained
- Spotting Red Flags in CMS Nursing Home Data
- Special Focus Facilities: What the CMS Program Means
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. Processing date: 2026-10-05.
Important disclosures
Informational only, not medical advice. This directory publishes public data and general information. It does not provide medical advice, diagnosis, or treatment recommendations, and it is not a substitute for consulting a qualified health care professional or Medicare.
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