Nursing Home Quality Measures: What Families Need to Know About the Five-Star Rating System

The Five-Star Quality Rating System from the Centers for Medicare & Medicaid Services (CMS) is the most widely used tool for comparing nursing homes in the United States. It is also one of the most misunderstood. Families see a number, assume it tells the whole story, and sometimes choose a facility based on stars alone. That is a mistake.

Stars are a starting point. What matters is what you find when you look behind them. This guide walks you through how the rating system works, where it falls short, and exactly how to use it alongside raw inspection data to make a confident decision.

A note on timing: CMS periodically updates the Five-Star methodology, including changes to staffing measures and weighting. The information below reflects the system as of mid-2026. Before making any decisions, verify the current methodology on the CMS Five-Star Quality Rating System technical documentation page. If the weights or measures have shifted since this article was published, the underlying principles of how to dig into the data still apply.

How the Five-Star Rating System Works

CMS assigns every Medicare- and Medicaid-certified nursing home a rating from 1 (much below average) to 5 (much above average). That overall rating is built from three separate domain scores:

• Health inspections (roughly 50% of the overall rating)
• Staffing (roughly 20%)
• Quality measures (roughly 15%)

Additional adjustments can lower the overall score. A facility with very low registered nurse (RN) hours, for example, may be penalized regardless of how its other domains perform.

Ratings are updated quarterly. The health inspection component draws from the most recent three years of state surveys, with more recent surveys weighted more heavily. That means a bad survey from two years ago still counts, but a bad survey from six months ago counts more.

Here is the critical thing to understand: a single severe finding can override everything else. A facility that receives an "immediate jeopardy" citation (meaning a resident was in danger of serious harm or death) can drop to a 1-star health inspection rating, and that alone can drag the overall rating down to 1 star, even if staffing and quality measures look fine.

Decoding Health Inspection Ratings

The health inspection domain is the heaviest piece of the overall rating, and it deserves the most attention.

State survey agencies conduct annual inspections and respond to complaints throughout the year. During each inspection, surveyors document "deficiencies," which are violations of federal standards. Each deficiency is classified along two axes:

• Scope: isolated (affecting one or a few residents), pattern (affecting multiple residents), or widespread
• Severity: ranging from "potential for minimal harm" up through "actual harm" and "immediate jeopardy"

The combination of scope and severity determines how much each deficiency weighs against the facility. Here is where the nuance matters more than the count.

What Good Looks Like vs. What Bad Looks Like

Consider two hypothetical facilities:

• Facility A has two deficiencies on its most recent survey, both classified as isolated and at the "no actual harm, potential for minimal harm" level. This facility is likely to hold a 4- or 5-star health inspection rating.
• Facility B has just one deficiency, but it is classified as widespread and at the "immediate jeopardy" level. That single deficiency can push the facility to a 1-star health inspection rating.

Counting deficiencies alone tells you very little. You need to read the severity.

You can view full inspection reports on Medicare's Care Compare under the "Health Inspections" tab. When you open a report, look for:

1. The total number of deficiencies
2. Whether any are at the "actual harm" or "immediate jeopardy" level
3. Whether the same type of deficiency (falls, infection control, medication errors) appears across multiple consecutive surveys

Repeat deficiencies are a serious red flag. They suggest the facility either cannot or will not fix a known problem.

Watch the Dates

Inspection reports can lag behind reality. Depending on where a facility falls in the survey cycle, the most recent posted report could be up to 15 months old. A lot can change in that time. If the most recent survey on Care Compare is more than a year old, call your state survey agency directly and ask whether any new surveys or complaint investigations have been completed. The date of the last survey is listed on the facility's Care Compare page.

Staffing Ratings: More Than Just Numbers

The staffing domain measures two things: RN hours per resident per day and total nursing staff hours (RN + LPN + CNA) per resident per day.

As a national benchmark, total nursing hours average approximately 3.9 hours per resident per day, according to CMS data. Facilities below about 3.0 total hours typically receive a 1-star staffing rating. RN hours are weighted separately and carry special significance. CMS considers facilities with fewer than roughly 0.3 RN hours per resident per day to be understaffed, and that triggers a penalty that can lower the overall star rating.

But national averages can be misleading. Some states, such as New York and California, have higher minimum staffing requirements than the federal floor. A facility that looks adequate by national standards might actually fall below your state's median. On Care Compare, you can filter staffing data by state to see how a facility compares locally. Always compare against your state's numbers, not just the national average.

For a deeper look at what staffing ratios mean in practice and what questions to ask during a tour, see our companion guide: How to Evaluate Nursing Home Staffing Ratios and What They Mean for Your Loved One's Care.

One more thing about staffing data: it is self-reported by facilities through the Payroll-Based Journal system. CMS audits these reports, but not continuously. Ask the administrator during your visit for the current staffing schedule, and compare what you see on the floor to what the data says.

Quality Measures: What the Data Actually Tells You

The quality measures (QM) star aggregates more than 15 individual clinical indicators drawn from the Minimum Data Set (MDS), a standardized assessment completed for every nursing home resident. These measures cover areas like:

• Pressure ulcers among high-risk residents
• Urinary tract infections
• Use of antipsychotic medications without a diagnosis of psychosis
• Physical restraint use
• Decline in ability to perform daily activities
• Pain management

A high QM star can mask poor performance on individual measures. A facility might earn 4 stars overall on quality measures while still having an antipsychotic use rate well above the national average (which has hovered around 14% to 15% for long-stay residents). That specific measure matters enormously, especially if your loved one has dementia.

On Care Compare, click into the individual quality measures for any facility. Focus on the "long-stay" measures if your family member will be a permanent resident. Compare each percentage to the national and state averages shown on the same page.

Be aware that quality measures are derived from facility-reported MDS data. These assessments are not independently verified on every submission. A facility may, intentionally or not, report data that makes its outcomes look better than they are.

Beyond the Stars: Using Inspection Reports and Complaint Data

Stars summarize. Reports tell the story. Always read the raw data.

Full inspection reports, including the statement of deficiencies and the facility's plan of correction, are available on Care Compare. Read at least the last three years of reports to spot trends.

Complaint investigations are also documented, though they may appear separately from annual surveys. You can access complaint data through your state's survey agency website. Some states make this easy; others do not. If the state website is hard to use or appears outdated, call the agency directly.

The Long-Term Care Ombudsman Program, administered through the Administration for Community Living, is another critical resource. Ombudsmen advocate for nursing home residents and can share facility-specific complaint histories and trends that may not appear in star ratings. Every state has a program, and every county or region has an assigned ombudsman. Call yours.

Red flags in complaint data include: multiple complaints about the same issue (repeated falls, medication errors, inadequate wound care) and clusters of complaints filed shortly after a survey cycle ends, which may suggest problems that surface once surveyors leave.

Red Flags and Limitations of the Rating System

The Five-Star system has real limitations. Knowing them protects you.

Stale data. Stars can reflect surveys that are up to three years old. A facility may have improved dramatically or deteriorated since its last survey. Always check the date.

Gaming. Research has documented that some facilities temporarily increase staffing levels around expected survey periods. A 2019 study published in the Journal of Health Economics by researchers at the University of Chicago found that nursing homes increased staffing on days when state inspectors were present, compared to non-inspection days. CMS introduced the Payroll-Based Journal system partly to address this, but the incentive to present a better picture during surveys persists. This behavior is not universal, but it is well-documented enough to warrant skepticism.

Incomplete risk adjustment. Quality measures are not fully adjusted for the complexity of a facility's resident population. A nursing home that specializes in caring for residents with advanced dementia or complex wound care may show higher rates of pressure ulcers or hospitalizations simply because it takes on harder cases. A facility that avoids admitting high-acuity residents may look better on paper without actually providing better care.

Harmful findings despite decent stars. A 2019 report from the HHS Office of Inspector General found that 42% of nursing homes had been cited for deficiencies that caused actual harm or placed residents in immediate jeopardy, yet many of those facilities still carried 3-star or higher overall ratings. Stars alone do not guarantee safety.

Practical Checklist for Families Evaluating a Nursing Home

Here is a step-by-step process that combines star ratings with the deeper investigation they require.

Step 1: Start with the overall star, then split it apart. Go to Medicare Care Compare and look up the facility. Note the overall star, but immediately click into each of the three domains. A 5-star overall could be driven by a strong health inspection rating while staffing sits at 2 stars.

Step 2: Read the last three health inspection reports. Count the deficiencies, but focus on severity. Flag any "immediate jeopardy" or "actual harm" findings. Flag any deficiency that appears in consecutive surveys.

Step 3: Compare staffing hours to your state's averages. Use the state filter on Care Compare. During your visit, ask the administrator for the current staffing schedule and compare it to what CMS reports.

Step 4: Examine individual quality measures. Look for facilities with pressure ulcer rates below the national average (roughly 6% to 7% for high-risk long-stay residents) and antipsychotic use rates below 15%. If a facility is above these benchmarks, ask why.

Step 5: Visit unannounced at different times. Go on a weekday afternoon. Go on a Saturday evening. Observe how quickly call lights are answered. Notice whether residents are clean and dressed. Pay attention to smells. A faint odor in one room is one thing; a pervasive smell of urine throughout a hallway is another.

Step 6: Contact the Long-Term Care Ombudsman. Ask about pending complaints, patterns, and their general impression of the facility. This is a free service, and ombudsmen are often the most candid source of information you will find.

Putting It All Together

The Five-Star system gives you a place to start. It does not give you a place to stop.

Prioritize health inspection history and current staffing levels over the overall star. A 3-star facility with clean recent surveys, strong staffing, and a responsive administrator may be a far better choice than a 4-star facility with a history of serious deficiencies and high staff turnover.

Use the resources above to build a shortlist. Tour each facility with the checklist in hand. Talk to staff. Talk to residents if they are willing. Talk to families in the parking lot.

No rating system, no matter how well designed, can substitute for what you see, hear, and smell when you walk through a building at 7 p.m. on a Tuesday. Trust the data. Then trust your own eyes.