How CMS Nursing Home Star Ratings Work

The Centers for Medicare & Medicaid Services (CMS) rates every Medicare- and Medicaid-certified nursing home in the United States on a 1–5 star scale. Here is what those ratings mean and how they are calculated.

The Overall Star Rating

The overall rating is a composite of three separate domain ratings: health inspections, staffing, and quality measures. It is not a simple average — health inspections carry the most weight. The overall rating can never exceed the health inspection rating by more than one star, which prevents facilities with poor inspection records from achieving high overall ratings through strong staffing or quality scores alone.

Health Inspection Rating

This domain is based on findings from standard annual inspections and complaint investigations conducted over the past three years, with more recent surveys weighted more heavily. Surveyors assess whether facilities comply with federal health and safety requirements across many areas including care planning, infection control, nutrition, and residents' rights.

Facilities with a substantiated complaint involving abuse, neglect, or exploitation receive an "abuse icon" and are capped at a maximum health inspection rating of 2 stars, regardless of their inspection score.

Staffing Rating

This domain measures the number of nursing hours provided per resident per day, adjusted for the clinical complexity of the resident population. Staffing data comes from the Payroll-Based Journal (PBJ) system — facilities submit actual payroll records to CMS rather than self-reported estimates. Both total nursing hours and registered nurse (RN) hours are measured and rated separately.

Quality Measure Rating

This domain is based on a set of quality measures derived from residents' clinical assessments (MDS data). Measures cover outcomes such as the percentage of residents who experienced falls with major injury, pressure ulcers, antipsychotic medication use, and improvement in mobility. There are separate measures for long-stay residents (those living in the facility for 100 days or more) and short-stay residents (typically post-acute rehabilitation patients).

Special Focus Facility Programme

CMS operates the Special Focus Facility (SFF) programme for nursing homes with a persistent history of serious deficiencies. SFF facilities receive more frequent inspections — approximately every 6 months rather than annually — and are monitored for improvement. Facilities that fail to graduate from the programme within a set period face termination from Medicare and Medicaid. At any time, approximately 88 facilities are on the active SFF list. Facilities identified as meeting SFF criteria but not yet formally placed on the list are designated "SFF Candidates."

How Often Ratings Are Updated

CMS publishes updated data monthly, typically in the first two days of each month. checknursinghomeratings.com updates its database on the 3rd of each month to ensure the CMS data has been fully published before we import it.