Choosing a Facility
Nursing Home Star Ratings: How CMS Scores Every Home
How Do CMS Nursing Home Star Ratings Work?
Nursing home ratings on Medicare's Care Compare run from 1 to 5 stars and come from CMS's Five-Star Quality Rating System, which rates every certified home on health inspections, staffing and quality measures, then combines them into an overall rating. The inspection rating carries the most weight and compares homes within the same state. In August 2026 data, CMS rated 2,981 of 14,690 nursing homes 5 stars overall.
When you search Medicare’s Care Compare, the first thing you see for each nursing home is a row of stars. Those stars are a summary of a lot of federal data, and knowing how they’re built tells you which ones to trust most for your parent and what questions to ask about the rest.
How Nursing Home Ratings Work
Every nursing home that takes Medicare or Medicaid gets four ratings from CMS, each from 1 to 5 stars:
- Health inspections: what state inspectors found on site.
- Staffing: how many nursing hours each resident gets, and how often staff leave.
- Quality measures: how residents fare on things like falls, pressure ulcers, antipsychotic use and hospital visits.
- Overall: a combination of the three.
CMS describes 5 stars as much above average and 1 star as much below average. The ratings are spread fairly evenly across the country. In August 2026 data:
| Overall rating | Nursing homes |
|---|---|
| 5 stars | 2,981 |
| 4 stars | 2,785 |
| 3 stars | 2,820 |
| 2 stars | 2,962 |
| 1 star | 3,015 |
The national average was 2.98 stars. That even spread is by design, so a rating tells you where a home stands against others more than it certifies a fixed level of quality.
How CMS Builds the Overall Rating
The overall rating isn’t an average. CMS builds it in three steps, in this order:
- Start with the health inspection rating.
- Adjust for staffing. Add one star if the staffing rating is 5 stars. Subtract one if it is 1 star.
- Adjust for quality measures. Add one star if the quality measure rating is 5 stars. Subtract one if it is 1 star.
The result can’t go above 5 or below 1. One more rule: if the inspection rating is 1 star, the home can climb no more than one star overall, however good its staffing and quality data look. CMS explains that a 1-star inspection reflects a serious, recent finding from inspectors who were in the building, and the other ratings shouldn’t outweigh it.
So a 4-star overall rating can mean very different things. One home might have 4 inspection stars and average everything else. Another might have 3 inspection stars and 5-star staffing. Open the home’s profile and look at all three.
The Health Inspection Rating
This is the backbone of the system. CMS scores the two most recent standard inspections, plus complaint investigations and infection control inspections from the past three years. The most recent standard inspection counts for three-quarters of the score and the one before it for one-quarter.
Each citation earns points based on how serious and how widespread the problem was. A minor isolated issue with potential for minimal harm earns nothing. A citation where residents were harmed earns 20 to 50 points. An immediate jeopardy citation, where residents faced serious injury, harm or death, earns 50 to 150 points, and more when it counts as substandard quality of care. Homes that need repeated follow-up visits to prove a fix get extra points: 50%, 70% or 85% of their inspection score for a second, third or fourth revisit.
Then CMS ranks homes within each state. The top 10% get 5 stars, the bottom 20% get 1 star, and the middle 70% split evenly across 2, 3 and 4 stars, about 23.33% each. CMS does this because inspection practices vary from state to state. It also means you should compare inspection stars only between homes in the same state. In August 2026 data, 4,953 homes had 4 or 5 stars for inspections.
The inspection reports guide shows you how to read the citations behind the score.
The Staffing Rating
The staffing rating comes from payroll records. Every quarter, nursing homes submit staffing hours to CMS’s Payroll-Based Journal system, including agency and contract staff, based on auditable payroll data. CMS adjusts the hours for how sick the residents are, so a home caring for residents with heavier needs is expected to staff more.
Six measures add up to a maximum of 380 points:
| Measure | Maximum points |
|---|---|
| Total nurse hours per resident per day | 100 |
| Registered nurse hours per resident per day | 100 |
| Total nurse hours on weekends | 50 |
| Nursing staff turnover | 50 |
| Registered nurse turnover | 50 |
| Administrator departures | 30 |
A home needs 320 points or more for 5 stars and gets 1 star below 155. A home that reports no registered nurse hours on a day with residents, or fails a CMS staffing audit, gets 1 star for staffing.
In August 2026 data, 5,245 homes had 4 or 5 staffing stars. The median home reported 3.68 total nurse hours per resident per day, 0.58 of them from registered nurses, and a nursing staff turnover rate of 44.9%. The staffing guide explains what those numbers mean on the floor.
5 Stars Overall: Nursing Homes by State
CMS Care Compare lists 2,981 nursing homes in this group (5 stars overall) across 52 states and territories, data from August 2026. Pick a state for its nursing homes, cities and senior care rules.
The Quality Measure Rating
The quality rating draws on 15 measures from resident assessments and Medicare claims, covering the four most recent quarters.
- Nine long-stay measures for residents who have lived in the home more than 100 days, including falls with major injury, pressure ulcers, urinary tract infections, catheter use, antipsychotic use, loss of mobility, increased need for help with daily activities, and hospital and emergency room visits.
- Six short-stay measures for rehab patients, including whether they regain function by discharge, new or worsened pressure ulcers, rehospitalization and successful return home.
For long-stay residents, the national medians for the 2025Q2-2026Q1 period were 13.37% receiving an antipsychotic, 2.85% with a fall causing major injury, 4.17% with pressure ulcers and 12.65% needing more help with daily activities over time. In August 2026 data, 8,309 homes had 4 or 5 quality stars, more than in any other domain.
Quality measures depend partly on what homes report about their own residents, so CMS audits them. Since January 2026, the antipsychotic measure also draws on Medicare and Medicaid claims, and homes found miscoding schizophrenia, a diagnosis excluded from that measure, have their quality rating dropped to 1 star for six months. The antipsychotics guide covers why that measure matters.
If your parent needs short-term rehab, look at the short-stay results. For a long-term move, the long-stay results matter more.
Icons That Cap or Replace the Stars
Some homes carry an icon that changes how the stars should be read:
- Abuse icon. CMS found abuse that harmed a resident, or repeat abuse citations. The inspection rating is capped at 2 stars and the overall rating at 4. In August 2026 data, 1,426 homes had it.
- Special Focus Facility. A home with a long history of serious problems gets a yellow warning sign instead of any stars. The state inspects it at least every six months until it has two consecutive standard inspections with 12 or fewer lower-level citations. In August 2026 data, 525 homes were in the program.
- Trophy. From the September 2026 refresh, high-performing homes with fewer citations and higher staffing show a trophy next to their stars.
- No rating. A home with only one standard inspection is too new for CMS to rate.
The abuse warning signs guide explains what to do if you’re worried about a home your parent already lives in.
How Often Ratings Change
Stars aren’t fixed. Inspection results can change a rating any month, when a new inspection, complaint investigation or revisit is posted, or when an older complaint citation ages and counts for less. Staffing ratings update each quarter. Quality measures update quarterly too, usually in January, April, July and October.
Check the rating again just before you decide, and ask the home about any recent change.
Questions to Ask a Home About Its Stars
A rating is a starting point for a conversation with the administrator or director of nursing. Good homes expect these questions and answer them plainly.
| If you see | Ask |
|---|---|
| A low inspection rating | Which citations drove it, were residents harmed, and what changed afterward? Has the home corrected every deficiency? |
| A recent drop in stars | Was there a new inspection, a complaint investigation or a staffing change this quarter? |
| A low staffing rating | How many residents does each nurse aide care for on days, evenings and nights? How much of the staff comes from agencies? |
| High turnover | How many directors of nursing and administrators has the home had in the past two years? |
| A strong overall rating but weak quality measures | What is the home doing about falls, pressure ulcers or antipsychotic use, whichever is weakest? |
| An abuse icon | What happened, who was involved, and what did the home change in hiring, training or supervision? |
Write down the answers next to the numbers. When you compare two homes later, the way each one answered can matter as much as the stars.
How to Use Medicare Nursing Home Ratings to Compare Homes
CMS itself warns that no rating can capture everything that matters, such as specialized dementia care or how easy it will be for family to visit. Its own guidance is that a home very close to family may be a better choice than a higher-rated one far away. Use the stars to build and trim a shortlist, then visit.
A practical approach:
- Screen out serious problems first. Note any abuse icon, Special Focus status or 1-star inspection rating, and read the inspection report before you rule a home in.
- Match the domain to the need. For a parent who needs a lot of hands-on care, weigh staffing heavily. For rehab after a hospital stay, look at short-stay quality measures.
- Compare like with like. Compare inspection stars only within a state, and compare homes side by side with the Nursing Home Comparison tool.
- Then visit. The how to choose a nursing home guide has Medicare’s tour checklist.
Ratings don’t change who pays. Medicare covers only short-term skilled stays, while Medicaid, private funds and long-term care insurance pay for long-term care. The guide to paying for a nursing home and the Medicare nursing home guide explain the rules, and the Medicaid eligibility guide covers the 2026 limits.
To see ratings for real homes, search the nursing home finder, open your state page, or browse a large city such as Chicago, San Antonio or Baltimore. Each state also has a list of its top-rated homes, sorted by CMS’s own stars, such as the highest-rated nursing homes in Texas.
Frequently Asked Questions
Who Decides a Nursing Home's Star Rating?
CMS, the federal Centers for Medicare & Medicaid Services, calculates every rating from data it collects: state inspection results, payroll-based staffing reports the home submits each quarter, and resident assessments and Medicare claims. Nursing homes don't rate themselves and can't pay for a higher rating.
Why Does a Nursing Home Show No Star Rating?
Three common reasons. A home with only one standard inspection is too new to rate, so CMS shows no ratings at all. A home in the Special Focus Facility program gets a yellow warning sign instead of stars. And a home whose staffing data fails CMS's checks may get no staffing rating that quarter.
Is a 3-Star Nursing Home Bad?
Not by itself. Three stars is the middle of the scale, and inspection stars are spread so that roughly equal shares of each state's homes land on 2, 3 and 4 stars. Look at what drives the rating: a 3-star home with strong staffing and few serious citations may suit your parent better than a 4-star home farther away.
Can a Nursing Home With an Abuse Citation Still Have 5 Stars?
No. When CMS adds the abuse icon, the home's health inspection rating is capped at 2 stars, and the best overall rating it can reach is 4 stars. The cap lifts at the first monthly refresh after the home no longer meets the abuse icon criteria.
Do Star Ratings Cover Assisted Living?
No. The Five-Star system rates nursing homes that participate in Medicare or Medicaid. Assisted living is licensed by each state, and there is no federal star rating for it. The choosing assisted living guide explains how to check a state license.
What Does the Trophy Icon on Care Compare Mean?
Starting with the September 2026 refresh, CMS marks high-performing nursing homes with a trophy icon in addition to their star rating. CMS says these homes have fewer citations, higher staffing levels and other quality indicators.
More on Choosing a Facility
- Choosing a Nursing HomeRatings, inspections, staffing and the questions to ask on a visit
- Inspection ReportsDeficiencies, scope and severity, fines and where to find reports
- Staffing and TurnoverNurse staffing hours, turnover and the federal staffing data
- Antipsychotic UseThe FDA warning for dementia, CMS's measure and what to ask
- Abuse Warning SignsWarning signs, CMS's abuse icon and who to call
- Residents' RightsFederal residents' rights and the free ombudsman program
This guide explains long-term care in plain language from official sources. It isn't medical, legal or financial advice; a doctor, your state Medicaid agency or an elder law attorney can advise on your situation.
Sources
- CMS: Five-Star Quality Rating System
- CMS: Nursing Home Five-Star Quality Rating System, Technical Users' Guide (September 2026)
- CMS: Special Focus Facility Program with candidates list (September 2026)
- CMS: Staffing Data Submission, Payroll Based Journal
- Medicare.gov: Long-term care
- Medicare.gov: How do I choose a nursing home?
- CMS Provider Data Catalog: Nursing Home Provider Information (August 2026)