Nursing home star ratings, explained

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By Nursing Homes In Each State · Published October 31, 2026 · Last updated October 31, 2026

The four ratings

You'll see these on Medicare's Care Compare site and on every nursing home page on this site. They come from CMS's Five-Star Quality Rating System, which CMS updates monthly.

How the overall star is built

CMS's Technical Users' Guide (September 2026) describes three steps:

1. Start with the health inspection rating.
2. Staffing: add one star if the staffing rating is 5 stars; subtract one star if it is 1 star.
3. Quality measures: add one star if the quality measure rating is 5 stars; subtract one star if it is 1 star.

The result can't go above 5 or below 1. Two limits apply on top of that. If a home's health inspection rating is 1 star, staffing and quality measures can raise its overall rating by no more than one star. And homes that are current participants in CMS's Special Focus Facility program get no star ratings at all; Care Compare shows a warning sign instead.

This is why two homes with the same overall star can look very different underneath. A 3-star home might have average results everywhere, or a 2-star inspection record lifted by strong staffing. Always look at the three component ratings, not just the overall.

Inspection stars are graded on a curve, by state

Health inspection ratings compare homes with other homes in the same state, not against a national standard. CMS gives the top 10% of homes in each state 5 stars, the bottom 20% 1 star, and splits the middle 70% about evenly across 2, 3 and 4 stars. CMS recalibrates the cut points each month so the share in each band stays roughly steady.

Two consequences follow. A 3-star inspection rating in one state isn't directly comparable with a 3-star rating in another, because inspection practices differ between states. And because it's a ranking, a fixed share of homes in every state will always get 1 star for inspections.

Recent inspections count more. CMS weights the most recent standard inspection at three-quarters and the one before it at one-quarter. Complaint and infection-control findings from the last 12 months also count three times as much as those from 13 to 36 months ago.

CMS caps the health inspection rating at 2 stars for homes that show its abuse icon. Because of the way the overall rating is built, CMS says the highest overall rating such a home can reach is 4 stars.

What goes into the staffing star

The staffing rating uses payroll-based staffing data that homes submit to CMS, adjusted for how much care residents need (CMS calls this case-mix adjustment). It combines six measures into a points score:

• Total nurse staffing hours per resident per day (RNs, licensed practical nurses and nurse aides)
• Registered nurse hours per resident per day
• Total nurse staffing hours per resident per day on weekends
• Total nursing staff turnover over a year
• Registered nurse turnover over a year
• Number of administrators who left in a year

For context, the median certified nursing home in CMS's data reports 3.72 of total nurse staffing per resident per day, including 0.59 of registered nurse time. These are the reported hours CMS publishes, October 2026, before the case-mix adjustment used for the star.

What the quality measure star covers

The quality measure rating is based on 15 measures: 9 for long-stay residents (people who live in the home) and 6 for short-stay residents (usually people in rehab after a hospital stay). Long-stay measures include falls with major injury, pressure ulcers, urinary tract infections, antipsychotic use, and hospital and emergency visits. Short-stay measures include improvement in function, new or worsened pressure ulcers, rehospitalization and successful return home.

CMS also publishes separate long-stay and short-stay quality ratings. If you're choosing a place for rehab, the short-stay rating is the more relevant one; for a long-term move, look at the long-stay rating. Some measures come from assessments the homes themselves report, and others from Medicare claims.

Unlike the inspection rating, the overall rating isn't forced into fixed shares, so the spread above reflects how the three components combine across the country. You can see the same breakdown for one state on any state page below.

What the stars don't tell you

• They look backward. Inspections can be a year or more old, and a change of owner, administrator or director of nursing may not show up yet.
• Some data is self-reported. Staffing hours and many quality measures come from the homes. CMS audits them, but they aren't direct observations.
• They don't measure everything families care about: how kind the staff are, the food, activities, cleanliness, or how well a home handles dementia care.
• Small differences don't mean much. A 3-star and a 4-star home can be close on the underlying scores.

Use the stars to build a shortlist, then dig deeper: read each home's inspection findings, check whether CMS lists it as a Special Focus Facility or shows its abuse icon, compare staffing with the state median, and visit at different times of day. Our guide to skilled nursing facilities explains the staffing roles behind the numbers, and you can compare up to four homes side by side.

More guides

• How to check a nursing home's violations and inspection reports

  Where to find a home's inspection citations and full CMS-2567 reports, how to read the A to L severity letters, and what to look for.

• What is a skilled nursing facility?

  What "skilled nursing facility" means, how it differs from a nursing home and rehab, who works there, and how CMS rates them.

• Does Medicare pay for nursing home care?

  What Medicare covers in a nursing home in 2026, the 3-day hospital rule, what you pay on days 21 to 100, and where Medicaid comes in.

Last updated October 31, 2026. Figures about nursing homes on this page come from the CMS Provider Data Catalog, October 2026, and update when CMS releases new data. Rules and dollar amounts are from the government sources listed above and can change; check them before you rely on them. Not medical, legal or financial advice. Nursing Homes In Each State is independent and not affiliated with CMS or Medicare. About the data · Report an error.