Care Compare has carried these stars since 2008. CMS describes five stars as much above average and one star as much below average, compared with other homes on the same measure. The comparison group is not the same for every domain. Health inspection stars are assigned inside each state. Staffing and quality-measure stars use national thresholds. Because the overall rating starts from the in-state health inspection rating, two homes in different states can show the same overall stars for different underlying records.
A star rating is a summary of the data CMS had when it calculated the file. It is not a recommendation, a license grade, or a promise about the week a family visits. Homes with a missing rating are still in the file. On a facility page, a CMS footnote explains the blank when the dictionary has a code for it.
The three domains
The overall rating is built from three ratings. Each one is also one to five stars.
- Health inspections. State surveyors, overseen by CMS, inspect homes for the federal Medicare and Medicaid requirements. A standard survey is due about once a year. Complaint investigations, facility-reported incidents, and focused infection control surveys can add citations during the year. Each citation has a tag, such as F689, and a scope and severity letter from A to L.
- Staffing. Homes report payroll hours through the Payroll-Based Journal. CMS turns those hours into hours per resident per day, adjusts them for resident case mix, and combines them with turnover. The staffing guide walks through the measures.
- Quality measures. These come from resident assessment data and Medicare claims. The rating uses a subset of the measures shown on Care Compare, split into long-stay residents (more than 100 days) and short-stay residents. The September 2026 guide uses 10 assessment-based measures and five claims-based measures for the stars.
How the health inspection score is built
A lower health inspection score is a stronger record. CMS assigns points to each citation from its scope and severity. Letters A, B, and C, which are findings with the potential for no more than minimal harm, are worth zero points in Table 1 of the guide. Immediate jeopardy (J, K, and L) is worth the most. Some severity cells add points when the deficiency is substandard quality of care. If a deficiency is past non-compliance and the severity was immediate jeopardy, the guide assigns the points used for a G-level deficiency. The full grid is Table 1 of the September 2026 Technical Users' Guide.
Revisits add points when noncompliance continues. The first revisit adds none. The second adds 50 percent of the cycle's health inspection score, the third adds 70 percent, and the fourth adds 85 percent.
CMS then weights recent surveys more heavily. The most recent standard survey, rating cycle 1, has a weight of three-quarters. The previous standard survey, rating cycle 2, has a weight of one-quarter. Complaint and focused infection control surveys from the most recent 12 months also take the three-quarter weight. Those from 13 to 36 months ago take the one-quarter weight. The two weighted cycle scores are added to make the total weighted health inspection score printed in the Provider Information file.
Stars are percentiles inside the state, not a national cut. In the guide's method, the 10 percent of homes in a state with the lowest weighted scores receive five stars. The middle 70 percent are split as evenly as the distribution allows across four, three, and two stars. The 20 percent with the highest scores receive one star. Cut points are recalibrated so that the state distribution stays close to those shares, but an individual home keeps its rating until its own weighted score changes. If a state has fewer than five homes to set cut points, CMS uses the national distribution. This site prints the cut-point ranges from the State-Level Health Inspection Cut Point file on each state page when that file includes the state.
Citations that are still in informal dispute resolution or independent informal dispute resolution are public, and they stay out of the star calculation until the dispute is resolved. A risk-based survey, flagged with footnote 29 in the data dictionary, is a shorter visit used for higher-performing homes. It is still an inspection, and its findings still enter the record.
How staffing and quality measures become stars
Staffing points come from six measures: case-mix adjusted total nurse hours, case-mix adjusted registered-nurse hours, case-mix adjusted weekend total nurse hours, total nurse turnover, registered-nurse turnover, and the number of administrators who left. The first two can contribute up to 100 points each, weekend hours and each turnover rate up to 50, and administrator turnover up to 30. The maximum is 380 points. Table 3 of the September 2026 guide assigns one star below 155 points, two stars from 155 to 204, three stars from 205 to 254, four stars from 255 to 319, and five stars from 320 to 380, after any rescaling when a turnover measure is unavailable for a reason that the guide treats as missing rather than failed.
CMS assigns one staffing star for the quarter when a home submits no staffing data by the deadline, when the data show four or more days with residents in the building and no registered-nurse hours, or when an audit finds that the home did not respond or that reported hours and verified hours disagree in a way the guide treats as significant.
Quality-measure points are national as well. Long-stay and short-stay scores are totaled separately and then combined. CMS raised the rating thresholds in the July 2026 refresh by half of the average improvement in scores from January 2025 through April 2026. The thresholds for individual measures did not change in that refresh. The numeric bands are Table 5 of the Technical Users' Guide. This page does not reprint them, because the guide is the record CMS updates when the bands move.
How the overall star is set
The September 2026 guide assigns the overall rating in three steps. It does not apply a percentage weight to the three domains. The health inspection rating is the starting point, and staffing or quality measures can move the result.
- Start with the health inspection rating.
- Add one star if the staffing rating is five stars. Subtract one star if the staffing rating is one star. The result stays between one and five.
- Add one star if the quality-measure rating is five stars. Subtract one star if it is one star. The result stays between one and five.
If the health inspection rating is one star, staffing and quality measures together can raise the overall rating by no more than one star. A home with no health inspection rating receives no overall rating. A home too new to have two standard surveys has no ratings displayed in any domain. Depending on the other two domains, the overall rating can sit as many as two stars away from the health inspection rating, except for that one-star cap.
The Provider Data Catalog's technical-details page describes an extra condition on the staffing adjustment, that the five staffing stars must also exceed the health inspection rating. The September 2026 Technical Users' Guide does not include that condition. Facility pages on this site show the stars CMS published in the Provider Information file. They do not recalculate them.
Icons and homes that are not rated
Special Focus Facilities are homes CMS has selected because of a history of serious quality problems. The guide says current participants are not given an overall rating or domain ratings. The data dictionary uses footnote 18 for a home that is not rated for that reason. On a facility page, the special-focus field is the value CMS put in the Provider Information file.
The abuse icon is separate from the stars. The guide turns it on for deficiency tags F600, F602, or F603 when either of two patterns is met. The first is a harm-level citation, scope and severity G or higher, on the most recent standard survey or on a complaint or focused infection control survey in the past 12 months. The second is a repeat citation at D or higher: one in the recent window and one on the previous standard survey or on a complaint survey 13 to 24 months earlier. While the icon is on, the health inspection rating is capped at two stars, so the overall rating cannot rise above four.
The high-performing icon is a trophy mark in addition to the five-star rating. The guide describes it for homes with fewer citations, higher staffing, and other quality indicators, and points to CMS memorandum QSO-26-14-NH for the criteria.
What changes a rating
A new standard survey, a new complaint deficiency, a focused infection control deficiency, another revisit, or the end of a dispute can change the health inspection score. Complaint and infection-control citations also "age": when they move from the most recent 12 months into the older window, their weight drops from three-quarters to one-quarter. Staffing stars change when a new Payroll-Based Journal quarter replaces the previous one, when case mix changes, or when turnover is recalculated. An audit can set staffing to one star for a period the guide specifies. Quality-measure stars move when newer assessment or claims quarters enter the four-quarter window, and when CMS resets the thresholds.
State pages on this site sort homes by the overall rating in the file, then by the health inspection rating, then by the staffing rating, then by name. That order is a way to read the file. It is not a list CMS publishes under the title of best homes.
Sources
- CMS Five-Star Quality Rating System, which links the current Technical Users' Guide and the state cut-point tables.
- Nursing Home Five-Star Quality Rating System: Technical Users' Guide, September 2026.
- Provider Data Catalog technical details for nursing homes.
- Nursing Home Data Dictionary for footnote codes, including Special Focus status and risk-based surveys.
- Medicare Care Compare, where CMS displays the same rating system for the public.
- CMS Provider Data Catalog, nursing homes, processing date September 1, 2026, modified September 30, 2026, released October 8, 2026.