Nursing Home Star Ratings Explained: What Medicare's 5-Star System Really Measures
Medicare rates every certified nursing home from 1 to 5 stars. The stars are useful — but only if you know what is underneath them. The rating combines three domains, each with different reliability.
Domain 1: Health Inspections
Based on the last three annual surveys plus recent complaint investigations, weighted by severity and recency. This is the only domain built entirely on independent surveyor findings, and it anchors the overall rating. Scores are relative to other facilities in the same state.
Domain 2: Staffing
RN and total nurse staffing hours per resident day, drawn from auditable payroll (PBJ) data and case-mix adjusted, including weekend staffing and turnover. Research links higher RN hours to better outcomes more strongly than almost any other measure.
Domain 3: Quality Measures
Clinical outcomes — falls with injury, pressure ulcers, rehospitalizations, antipsychotic use — drawn largely from facility-submitted assessments. Useful, but the most gameable domain because most measures are self-reported.
How the Overall Star Is Calculated
- Start with the health inspection star rating.
- Add one star if staffing is 4–5 stars (subtract one if it is 1 star).
- Add one star if quality measures are 5 stars (subtract one if 1 star).
- Apply caps: facilities with recent serious problems — like an abuse citation — have their overall rating capped.
Key insight: treat stars as a filter, not a verdict. When you are down to finalists, skip the summary star and read the actual deficiency history on the facility scorecard: severity letters, repeat citations, and whether problems stayed fixed.