How to Read CMS Star Ratings for Nursing Homes

What Is the CMS Five-Star Rating System?

The Centers for Medicare & Medicaid Services (CMS) rates every Medicare- and Medicaid-certified nursing home in the United States on a scale of one to five stars. The program — called the Nursing Home Compare Five-Star Quality Rating System — was introduced in 2008 to help families compare facilities quickly and transparently.

Texas has 1,176 certified nursing homes in the CMS database. Nearly half are rated one or two stars, making it especially important for Texas families to understand what these ratings mean — and what they don't.

The Four Components of the Overall Rating

The overall star rating is not a simple average. It is calculated from three separate domain ratings, each carrying different weight:

1. Health Inspections (most heavily weighted)

This rating is based on the results of standard health inspections conducted by your state survey agency, typically once every 9–15 months. Inspectors look at dozens of areas including resident care, medication management, infection control, resident rights, and staffing adequacy.

The health inspection score accounts for three inspection cycles, with the most recent cycle carrying the most weight. Facilities with recent complaints or complaint investigations may score lower even if their routine inspections were acceptable.

2. Staffing (weighted second)

Staffing ratings reflect the number of hours per day that nursing staff — registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) — spend with each resident. Since 2023, CMS has also incorporated weekend staffing data and staff turnover rates, which are critical indicators of care continuity.

3. Quality Measures (weighted third)

Quality measures (QMs) are drawn from two sources: clinical assessments submitted by facilities (MDS data) and Medicare claims. They track outcomes such as the percentage of residents who experienced falls with major injury, pressure ulcers, hospitalizations, and use of antipsychotic medications.

CMS calculates separate QM ratings for long-stay residents (those in the facility 100+ days) and short-stay residents (typically post-acute rehabilitation patients).

How the Overall Rating Is Calculated

The overall star rating starts with the health inspection rating, then adjusts up or down based on staffing and quality measure ratings. Specifically:

• A facility with a 1-star health inspection rating cannot receive more than 2 stars overall, regardless of staffing or QM scores
• A facility with a 5-star staffing rating gets one star added to its health inspection-based score
• A facility with a 5-star quality measure rating gets one additional star added
• The maximum possible overall rating is 5 stars

Special Designations and Red Flags

Beyond the star rating, CMS applies several additional designations that families should pay close attention to:

• Special Focus Facility (SFF): A facility with a long history of serious quality problems, subject to enhanced oversight. Texas has 36 SFF or SFF Candidate facilities.
• Abuse Icon: The facility has had a substantiated complaint or citation related to abuse, neglect, or exploitation of residents within the past year.
• Most Recent Inspection More Than 2 Years Ago: A flag indicating the facility may not have been inspected on the standard cycle — a potential gap in oversight.
• Payment Denial: CMS has denied Medicare/Medicaid payments to the facility as a penalty for serious deficiencies.

What Star Ratings Don't Tell You

As useful as CMS ratings are, they have real limitations that families must understand:

• Ratings are retrospective. A facility's rating reflects past performance. A 4-star facility may have recently changed ownership or lost key staff.
• Inspection cycles are infrequent. Standard inspections happen roughly once per year. A lot can change between visits.
• Self-reported data can be gamed. Quality measure scores rely partly on data submitted by the facility itself.
• Ratings don't capture culture. A 3-star facility with compassionate, stable staff may provide better day-to-day care than a 4-star facility with high turnover.

How to Use Ratings Effectively

Think of the star rating as a starting point for investigation, not a final verdict. Here is how to use them well:

1. Filter out the worst. Eliminate any facility with a 1-star rating, an abuse icon, or SFF status unless there are compelling geographic or financial reasons.
2. Dig into health inspection citations. Visit Medicare's Care Compare and read the actual citation details, not just the count.
3. Check staffing trends. Look at RN hours per resident per day. The CMS minimum is 0.55 hours — good facilities typically provide 0.8 or more.
4. Visit in person. No data substitutes for a facility tour. Visit unannounced if possible.
5. Speak to current residents and families. Their experience is the most direct signal of day-to-day quality.

Frequently Asked Questions