What CMS Nursing Home Star Ratings Mean

Hospice & Senior Care Finder · Published October 27, 2026

Every nursing home that takes part in Medicare or Medicaid gets a CMS star rating from 1 to 5. Three stars means average quality, five means much above average, and one means much below average. CMS built the system so families can compare homes and spot what to ask about. The stars are a good place to start, but they're easy to over-read. The overall star leans mostly on inspections, inspection stars are graded against other homes in the same state, and CMS itself says not to choose on stars alone.

Below is how the rating is put together, and what our analysis of CMS data as of September 1, 2026 shows across all 14,690 nursing homes in the CMS file.

Four ratings, not one

Each home gets one overall rating plus three separate ones: health inspections, staffing, and quality measures. The overall star is what most people see first. The other three tell you where it came from.

Health inspections

Standard inspections are unannounced and happen about once a year on average. The inspection rating counts the number, scope and severity of the problems (deficiencies) cited in the two most recent standard inspections, plus findings from the last 36 months of complaint investigations and focused infection-control inspections. The latest standard inspection carries three quarters of the weight and the one before it carries a quarter.

Since the July 2025 refresh, CMS uses two standard inspections instead of three. Care Compare still shows the third one, but it no longer counts toward the stars.

Staffing

The staffing rating uses six measures, taken from payroll data that homes submit to CMS every quarter through the Payroll-Based Journal. Three are nurse staffing levels in hours per resident per day, adjusted for how much care the residents need (CMS calls this case-mix adjustment). One of those three covers weekends only. The other three measure turnover among nursing staff, registered nurses, and administrators.

A home that misses the deadline to submit staffing data, or reports four or more days in a quarter with no registered nurse hours, gets one staffing star for that quarter. The nurse hours on our listings are the reported figures, before case-mix adjustment, so they won't line up exactly with the staffing star.

Quality measures

The quality rating is built from 15 measures, nine for long-stay residents and six for short-stay residents, drawn from resident assessments and claims data. Medicare describes them as things like whether residents got their flu shots, were hospitalized, were injured in a fall, or are getting antipsychotic drugs. Care Compare shows more quality measures than these 15, and the extra ones don't affect the stars.

How the overall star is calculated

The overall rating starts with the health inspection rating. If the staffing rating is five stars, add one star; if it's one star, take one away. Then do the same with the quality measure rating. The result can't go below 1 or above 5.

Two limits apply. A home with a one-star inspection rating can gain no more than one star from the other two. And a home with the abuse icon has its inspection rating capped at two stars, so its overall rating can't go above four.

CMS doesn't use fixed weights, but it calls the inspection rating the most important part. Staffing and quality can move the result up or down by two stars at most. In practice, the overall star is mostly the inspection star.

Take a home with three inspection stars, five staffing stars and one quality star. Staffing lifts it to four, quality drops it back to three. Its overall rating is three, the same as a home that scored three on everything. That's why it pays to open the separate ratings.

Inspection stars are graded within each state

Inspection stars aren't measured against one national standard. CMS ranks each home against the other homes in its state. The top 10 percent get five stars, the bottom 20 percent get one, and the middle 70 percent are split evenly across two, three and four stars. The cut points are recalculated every month, but a home keeps its inspection rating until its own inspection score changes.

You can see that design in the national numbers. In our analysis, each overall star level holds between 19% and 20.7% of rated homes. So a star works more like a ranking than a pass mark. On inspections, a one-star home is in the bottom fifth of its own state. That doesn't tell you how it compares with a home across the state line, where the curve is drawn from different homes.

The ratings don't all update on the same schedule. Care Compare refreshes monthly. Staffing ratings are posted quarterly, and quality measure ratings are usually updated in January, April, July and October.

What the numbers look like at each star level

We grouped all 14,565 rated homes by their overall CMS star and took the median (the middle value) of what CMS reports for each group. This is our analysis of CMS data as of September 1, 2026.

Homes with more stars tend to report more nurse hours per resident, lower staff turnover, fewer deficiencies at their latest standard inspection, and fewer fines. In the CMS file, 77.9% of one-star homes had at least one fine, against 13.7% of five-star homes. The median five-star home reported 4.12 nurse hours per resident per day; the median one-star home reported 3.41.

Some of this pattern is built in. Staffing levels and turnover feed the staffing rating, and deficiencies feed the inspection rating, so the stars and these figures move together partly by design. These are also group medians. Plenty of homes sit far from the middle of their band, so look at the figures for the home you're actually considering.

Icons and labels that change the picture

The abuse icon marks a home with a harm-level abuse citation in its most recent inspection cycle, or with repeated abuse citations. In Medicare's words, the home "has been cited for issues related to abuse." The icon caps the inspection rating at two stars. The icon and the cap come off at the first monthly refresh after the home no longer meets the criteria. In our analysis, 1,429 homes (9.7%) carried the icon.

A Special Focus Facility is a home with a history of serious quality issues. Instead of stars, Care Compare shows a yellow warning sign, with "Not Available" in place of each separate rating. These homes are inspected at least once every six months, face more penalties, and can lose the ability to be paid by Medicare or Medicaid. A home leaves the program after two standard inspections in a row with 12 or fewer deficiencies at scope and severity level E or lower.

CMS also publishes a list of SFF candidates: homes that qualify to be selected. There are five candidates for each open slot, with at least 5 and no more than 30 per state. Our data had 87 current Special Focus Facilities and 440 candidates, and our listings show either status. CMS warns that its SFF list should be read with caution because the data can lag, and checked against the ombudsman's office, the state survey agency, or other sources.

Homes with only one standard inspection, usually because they're new, get no ratings and show "Not Available". In the CMS file we analyzed, 125 homes had no overall rating; current Special Focus Facilities are among them.

Starting with the September 2026 refresh, high-performing homes get a trophy icon in addition to the 5-star rating. CMS says these homes have fewer citations, higher staffing levels and other quality indicators.

What the stars can't tell you

CMS is direct about the limits: "No rating system can address all of the important considerations that go into a decision about which nursing home may be best for a particular person." It asks families to use the ratings together with a visit to the home and with local sources such as advocacy groups and the State Ombudsman program. Medicare puts it more simply: star ratings aren't a substitute for visiting.

So read the four ratings separately, check how old the latest inspection is, and look at the actual staffing and penalty figures. Then go and see the place. Our guide on how to choose a nursing home walks through those steps, and our methodology page explains what each listing shows.