What Are CMS Star Ratings?
The Centers for Medicare and Medicaid Services (CMS) publishes a star rating system for every Medicare and Medicaid certified nursing home in the country. The ratings range from one star (much below average) to five stars (much above average) and are available on the Medicare Care Compare website.
The overall star rating is based on three separate components: health inspections, staffing levels, and quality measures. Each of these components has its own star rating, and the overall rating is a weighted combination of the three.
This system was designed to give families a quick way to compare nursing homes. And for a starting point, it works reasonably well. But there are important limitations that every family should understand.
What Each Component Measures
Health Inspections
This is the most heavily weighted component. Every nursing home is inspected by state surveyors, typically once every 12 to 15 months. The inspectors look for deficiencies in areas like infection control, medication management, resident rights, quality of care, and safety.
The inspection rating is based on the number, scope, and severity of deficiencies found, as well as how the facility compares to others in its state. Complaints that trigger additional inspections are also factored in.
Staffing
The staffing rating measures the number of nursing staff hours per resident per day. This includes registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). Higher staffing levels generally correlate with better care.
CMS uses data reported by the facilities themselves, verified against payroll records. The rating considers both the total staffing level and the RN staffing level specifically, since RNs provide the most skilled level of nursing care.
Quality Measures
This component tracks specific outcomes and care practices, such as the percentage of residents with pressure ulcers, the rate of falls, use of physical restraints, antipsychotic medication use, and whether residents are receiving appropriate vaccinations.
These measures are drawn from clinical data that facilities report regularly. They provide a snapshot of the outcomes residents are experiencing.
What the Ratings Miss
Star ratings are useful, but they have real blind spots.
First, the inspection process is a snapshot in time. A facility might perform well during an inspection but have ongoing issues the rest of the year. Some facilities are known to increase staffing and improve conditions right before an expected inspection.
Second, staffing data is self-reported. While CMS does verify against payroll, the numbers represent averages and may not reflect daily fluctuations. A facility might have adequate staffing most days but be dangerously understaffed on weekends or holidays.
Third, quality measures rely on data that facilities submit themselves. There is always a risk of inaccurate or incomplete reporting. Additionally, some quality measures may not capture the things that matter most to your family, like the warmth of the staff or the quality of the food.
Finally, the ratings do not account for the culture of a facility, the sense of community among residents, the responsiveness of management to family concerns, or the overall "feel" of the place. These intangible qualities often matter more than anything a rating can capture.
What to Look for Beyond Ratings
Use star ratings as a starting point, but do not stop there. Here are other things to research and observe.
Check the facility's inspection reports in detail on the Medicare Care Compare website. Read the specific deficiencies rather than just looking at the star count. A facility with a few minor deficiencies is very different from one with a serious care violation.
Look at online reviews, but read them critically. A single negative review may reflect one bad experience, while a pattern of similar complaints is more concerning.
Ask people in your community. Talk to local doctors, social workers, hospital discharge planners, and other families. Word of mouth is still one of the best ways to find a good facility.
Questions to Ask on a Tour
When you visit a facility, go beyond the polished tour and ask specific questions.
What is the staff-to-resident ratio on each shift, including nights and weekends? What is the staff turnover rate? How are care plans developed and how often are they updated? What happens when a resident's needs change? How does the facility handle medical emergencies? What activities and social programs are available? Can residents personalize their rooms? What is the process for filing a complaint or concern?
Pay attention to how staff interact with residents. Are they patient and kind, or do they seem rushed and disengaged? Do residents seem engaged and comfortable, or are they mostly sitting alone in front of a television?
Red Flags to Watch For
Certain things should raise immediate concerns. Strong or persistent odors can indicate poor hygiene practices. Staff who seem annoyed by your questions may signal a culture that is not family-friendly. Residents who appear unkempt or distressed warrant serious attention. High staff turnover, which you can sometimes learn about by talking to current staff, is one of the strongest predictors of poor care quality.
Also be cautious of facilities that pressure you to make a quick decision or that are unwilling to provide detailed information about costs, staffing, or inspection results.
Use Our Facility Finder
Our facility search tool lets you compare nursing homes, assisted living communities, and memory care facilities in your area. You can see star ratings, inspection results, staffing data, and cost information all in one place, without the referral fees that most placement services charge.