Choosing a nursing home is one of the most important decisions families and caregivers make. To support informed choices, the Centers for Medicare & Medicaid Services (CMS) developed the Five-Star Quality Rating System—a trusted tool used nationwide to evaluate nursing home quality, staffing levels, and resident outcomes.
If you’ve ever searched for “how nursing homes are rated,” “what CMS star ratings mean,” or “how to improve nursing home quality measures,” this guide breaks it all down in a clear, practical way.
The CMS Five-Star Rating System evaluates nursing homes across three core domains:
1. Health Inspections
The foundation of a facility’s overall rating. State surveyors assess compliance with federal regulations through routine inspections and complaint investigations—making this a critical driver of nursing home compliance and regulatory performance.
2. Staffing Levels
Measures total nursing hours per resident, including Registered Nurse (RN) staffing. These metrics are adjusted based on resident acuity, helping reflect adequate staffing in nursing homes—a key factor in quality care.
3. Quality Measures (QM)
Quality Measures evaluate clinical outcomes and resident care quality, including:
Together, these domains provide a standardized, data-driven view of nursing home performance used by families, providers, and healthcare organizations alike.
The CMS star rating follows a structured three-step methodology:
Step 1: Start with the Health Inspection Rating
This serves as the base score and carries the most weight in determining overall performance.
Step 2: Adjust for Staffing
Step 3: Adjust for Quality Measures
Important: If a facility receives a 1-star health inspection rating, the overall rating cannot increase by more than one star—regardless of staffing or quality performance.
Example 1: Nursing Home ABC
Overall Rating: 2 stars
In this case, mid-range staffing and quality scores do not impact the base rating.
Example 2: Nursing Home DEF
Overall Rating: 5 stars
Strong performance in quality measures elevates the facility to a top-tier rating.
The Quality Measure domain uses a points-based system to evaluate performance across multiple indicators—an essential component of nursing home quality improvement efforts.
Decile-Based Scoring (15–150 points)
Used for many CMS measures:
Top performers earn up to 150 points, while lower-performing facilities receive fewer points.
Quintile-Based Scoring (20–100 points)
Used for select measures:
A facility’s total QM score determines its Quality Measure star rating, directly impacting the overall CMS rating.
Some measures—such as falls with major injury or use of restraints—often result in zero reported cases across many facilities.
To maintain fairness, CMS applies exception scoring:
This approach ensures:
Not all nursing homes serve the same populations. CMS accounts for this by adjusting scoring based on resident type:
This ensures facilities are evaluated fairly based on the care they actually provide.
Short-stay Quality Measures are multiplied by a factor of 1.150/800 to align with long-stay scoring potential.
Without this adjustment:
This methodology supports equitable benchmarking across nursing homes, regardless of patient mix.
For example, a facility with:
In CMS scoring models:
The CMS Five-Star Rating System does more than rank nursing homes—it provides a roadmap for continuous quality improvement in long-term care.
By understanding how ratings are calculated, facilities can:
Ultimately, tools like CMS Quality Measures and Five-Star Ratings empower providers to deliver higher-quality, patient-centered care—while helping families make confident, informed decisions.