Nursing Homes & Long-Term Care

CMS Five-Star Nursing Home Ratings Explained

NHQC Editorial Team · Last updated April 14, 2026

The Three Star Domains

Health Inspections — three most recent state surveys weighted most recent.
Staffing — RN and total nurse staffing hours per resident per day, case-mix adjusted.
Quality Measures — 15 MDS-based measures: falls, pressure ulcers, antipsychotic use, hospitalizations.

How the Overall Rating Is Calculated

CMS starts with the Health Inspection rating, adds one star if Staffing is 4–5, subtracts one if Staffing is 1, adds one for a 5-star Quality rating, subtracts one for a 1-star Quality rating. Max Overall is 5, minimum is 1.

Disclaimer: This content is for educational purposes only and is not medical, legal, or financial advice. NHQualityCampaign.org is not affiliated with or endorsed by the U.S. government or the federal Medicare program.

Frequently Asked Questions

How often are ratings updated?+

Monthly on Medicare.gov, using rolling inspection and PBJ staffing data.

Can facilities game the system?+

Quality Measures rely on facility-reported MDS data, which has audit risk. Staffing data comes from Payroll-Based Journal submissions and is audited against payroll records.

Do stars predict resident outcomes?+

Yes — multiple peer-reviewed studies show 5-star facilities have lower hospitalization and mortality than 1-star facilities after risk adjustment.

What's an abuse icon?+

A red hand icon appears next to facilities cited for abuse, neglect, or exploitation in recent surveys — a major red flag.