CMS Five-Star Rating System for Nursing Homes: Complete Guide
By David Chen, MHA, Healthcare Policy Analyst · 2026-03-22 · 8 min read
The Five-Star rating system drives consumer choice and regulatory attention. Understanding how it works helps you manage your facility's public profile and compliance priorities.
How the Five-Star System Works
CMS's Five-Star Quality Rating System provides nursing homes with an overall rating of 1 to 5 stars, where 5 stars represents the highest quality and 1 star indicates much below average quality. Published on Medicare's Care Compare website, these ratings significantly influence consumer decisions and regulatory scrutiny.
The overall rating is a composite of three independent domain ratings:
1. Health Inspection Rating — Based on deficiency citations from the three most recent surveys
2. Staffing Rating — Based on nurse staffing levels from Payroll-Based Journal data
3. Quality Measures Rating — Based on clinical quality indicators from MDS assessments
The health inspection rating carries the most weight in determining the overall star rating. A facility with a 1-star health inspection rating cannot receive an overall rating higher than 3 stars, regardless of staffing and quality measure performance. This makes survey outcomes the single most important factor in your public rating.
Health Inspection Rating Deep Dive
The health inspection component is calculated using a points-based system that considers deficiency citations from the three most recent standard surveys plus complaint investigations from the past three years.
Each deficiency earns points based on its scope and severity:
- Isolated, no actual harm (D): 4 points
- Pattern, no actual harm (E): 8 points
- Widespread, no actual harm (F): 16 points
- Isolated, actual harm (G): 20 points
- Pattern, actual harm (H): 35 points
- Widespread, actual harm (I): 45 points
- Immediate Jeopardy (J-L): 50-150 points
These points are weighted — the most recent survey counts more than older surveys. Complaint survey deficiencies are also added with specific weighting. The total score is then compared to other facilities in the same state to determine the star rating, since survey practices vary by state.
You can explore your facility's deficiency history and compare it to state averages using our SNF Scorecard and State Benchmark tools.
Staffing Rating Methodology
The staffing rating uses data from the Payroll-Based Journal (PBJ) system, which requires facilities to report actual staffing hours based on payroll records. The rating considers both total nurse staffing and RN staffing separately.
CMS evaluates two primary metrics:
- Total nursing hours per resident per day (RN + LPN/LVN + CNA hours)
- RN hours per resident per day
Staffing is adjusted for case mix — facilities with higher-acuity residents are expected to have more staff. The adjustment uses Resource Utilization Group (RUG) scores derived from MDS assessments.
A facility must meet minimum thresholds for both total nursing and RN staffing to receive higher star ratings. Even with excellent total staffing, insufficient RN hours alone can lower the rating. Weekend staffing levels are now reported separately and may factor into future rating calculations.
CMS has proposed minimum staffing requirements that would set mandatory staffing floors. Check our Regulatory Updates page for the latest on staffing rule changes.
Quality Measures Rating
The quality measures (QM) component uses standardized clinical indicators derived from MDS assessment data and Medicare claims. These measures evaluate actual care outcomes across the resident population.
Current QMs used in the rating include:
- Percentage of long-stay residents with pressure ulcers
- Percentage of residents receiving antipsychotic medications
- Rate of falls with major injury
- Percentage of residents with UTIs
- Percentage of residents who self-report moderate to severe pain
- Percentage of residents with new or worsening physical restraints
- Emergency department visits per 1,000 long-stay resident days
Each facility's QM scores are compared nationally (not by state like health inspections). The rating reflects performance across all measures combined. Facilities can monitor their QM performance through the CASPER system and use the data to drive QAPI improvement projects.
How to Improve Your Star Rating
Improving your Five-Star rating requires a strategic approach across all three domains:
Health Inspections (most impactful):
- Maintain survey readiness year-round through mock surveys and CEP audits
- Focus on preventing the most commonly cited F-Tags (F0689, F0880, F0684)
- Write strong POCs that demonstrate genuine corrective action — use our free POC Generator
- Track your facility's citation history to identify patterns with our SNF Scorecard
Staffing:
- Ensure accurate PBJ reporting — underreporting penalizes you
- Maintain consistent RN coverage, especially on weekends
- Cross-train staff to cover gaps
- Use agency staff strategically and report all hours
Quality Measures:
- Monitor QM trends monthly through your QAPI committee
- Implement evidence-based protocols for high-impact measures (fall prevention, infection control)
- Ensure accurate and timely MDS coding — inaccurate coding misrepresents your quality
- Target your lowest-performing measures for improvement initiatives
Remember: the overall rating algorithm gives extra weight to health inspections. Improving survey outcomes is the fastest path to a better star rating.
Frequently Asked Questions
How often are Five-Star ratings updated?
Health inspection ratings update when new survey results are available. Staffing ratings update quarterly with new PBJ data. Quality measure ratings update quarterly. Overall ratings are recalculated whenever any component changes.
Can a nursing home have different star ratings for different domains?
Yes, it's common. A facility might have 4 stars for staffing but 2 stars for health inspections. The overall rating is a weighted composite, with health inspections having the greatest influence.
How long do survey deficiencies affect the star rating?
Deficiencies from the three most recent standard surveys factor into the rating, which typically covers approximately 3 years. Complaint investigation deficiencies from the same period are also included.
What percentage of nursing homes receive 5 stars?
CMS uses a relative distribution, so approximately 20% of facilities in each state receive each rating level. However, states with overall better compliance still award 5 stars to their top 20%, so a 5-star facility in one state might have more deficiencies than a 5-star in another.