Nursing Homes
Nursing Home Quality Measures: What the Star Ratings Mean
Nursing home star ratings run from one to five stars. See how CMS builds them from surveys, staffing, and quality scores, and what a star cannot tell you.
Key takeaways
- Each home gets an overall rating of one to five stars on Care Compare.
- The overall rating is built from three parts: health surveys, staffing, and quality measures.
- The survey rating is the base. Staffing and quality scores can move the overall mark up or down.
- Survey scores are ranked inside each state, not across the whole country.
- Staffing scores use the hours of care staff give each person each day, plus staff turnover.
- Quality scores use health facts the home reports and facts from Medicare claims.
- A star is a first screen. It is not a full picture of life in the home.
Each nursing home on Care Compare has a star rating. The rating runs from one star to five stars. More stars mean better scores on the checks CMS runs. Fewer stars mean weaker scores.
Many families start with the stars. That is a fair first step. But a star is a summary. It rolls three sets of checks into one mark. To use it well, you need to know what sits under it.
This guide shows how CMS builds the rating. It shows what each part checks. It also shows what a star cannot tell you about a home. Our guide to how much a nursing home costs per month covers the cost side of the same choice.
The three parts of the rating
CMS builds the overall rating from three parts. Each part also gets its own star mark. You can see all four marks on a home page in the provider directory.
The first part is health surveys. State teams visit each home and check it against federal rules. The second part is staffing. It looks at how much staff time each person gets. The third part is quality measures. It looks at health results for the people who live in the home.
No one part tells the whole story. A home can score well on one part and poorly on the next. That is why CMS shows each part on its own, not just the overall mark.
How the overall star is built
CMS starts with the survey rating. That mark is the base for the whole score.
Next, CMS looks at the staffing rating. If the staffing rating is five stars and higher than the survey rating, one star is added. If the staffing rating is one star, one star is taken away.
Next, CMS looks at the quality rating. If the quality rating is five stars, one star is added. If the quality rating is one star, one star is taken away.
One guard rule applies. If the survey rating is one star, the overall rating can rise by no more than one star from the other two parts. Strong staffing and quality scores cannot hide a weak survey base for long.
What the survey rating checks
State survey teams visit homes about once a year. The visits are not announced in advance. Teams also visit when a person files a complaint, and they run checks on infection control.
On a visit, the team checks if the home meets federal health and safety rules. If the team finds a gap, the home gets a citation. Each citation notes the rule that was missed and how much harm was found, or could have been found.
Points are set for each citation. The points turn on how wide the problem was and how grave it was. More points are added if the same problem was found on a past visit and was not fixed. Recent visits count more than older ones.
Homes are ranked inside their own state. The top ten homes in each hundred, with the fewest points, get five stars for this part. The bottom twenty in each hundred get one star. The homes in the middle get two, three, or four stars.
A home must write a plan to fix each citation. CMS can fine a home or deny payment if fixes do not come. You can read more in our guide to how to compare nursing homes using public records and a visit.
What the staffing rating checks
The staffing rating looks at the time care staff spend with the people who live in the home. Homes send their staffing facts to CMS in a set form. CMS adjusts the facts for how much care the people in that home need.
The rating uses these facts:
A home can get one star for this part if it has no licensed nurse on site each day. The same mark can apply if the home does not send its staffing facts, or if the facts cannot be checked.
Staffing facts matter in daily life. More staff time can mean faster help with meals, baths, and calls for aid. High turnover can mean new faces often, and less time for staff to learn each person well.
- Nurse hours for each person each day, with time from licensed nurses counted on its own.
- Total care hours for each person each day. This count adds licensed nurses, aides, and aides in training.
- Total care hours on weekends, counted the same way.
- How many care staff left the home in a year.
- How many licensed nurses left the home in a year.
- How many top managers left the home in a year.
What the quality rating checks
The quality rating looks at health results. CMS builds it from a set of quality measures. Some measures track short stays. These are stays of one hundred days or less, often for rehab after a hospital stay. Other measures track long stays, for people who live in the home.
The facts come from two places. Homes report health facts for each person who lives there. Medicare claims add facts about hospital use and other care.
CMS uses the four most recent quarters of facts. Each home earns points on each measure. Some measures count more than others. The points are added up, and the total sets the star mark for this part.
Facts this part can track include:
Lower rates are better on most of these measures. A home that keeps people safe and well tends to score well here. A home with weak results will show it in this part of the score.
- How many short stay patients went back to a hospital soon after they arrived.
- How many short stay patients went to an emergency room.
- How many people got a drug for psychosis for the first time.
- How many people have skin sores that are new or worse.
- How many long stay people fall and are hurt.
What a star cannot tell you
A star rating is built from facts CMS can count. Some key parts of life in a home cannot be counted that way.
Use the stars to cut a long list down to a short list. Then visit the homes on that list. Talk with staff. Talk with people who live there and with their families if you can. Check the survey reports for the same homes. The visit and the reports fill the gaps the star leaves.
- A star cannot tell you if staff know each person by name.
- A star cannot tell you how fast staff answer a call light at night.
- A star cannot tell you if the food tastes good or if meals feel calm.
- A star cannot tell you if the home fits a special need, such as care for a wound or for memory loss.
- A star is based on past facts. A home can change for better or worse after the facts were gathered.
Who pays for nursing home care
The star rating has no link to who pays. Payment turns on the type of care and on the rules of each program.
Ask each home how it bills for short rehab care and for long care. Keep the two apart in your own notes.
- Medicare pays for skilled care in a nursing home for a short time when the care rules are met, such as after a hospital stay. It does not pay for long stays that are just daily help and a place to live.
- Medicaid can pay for long nursing home care for people who qualify under their state tests. Each state runs its own program.
- Private pay means the person or the family pays from their own funds. Many long stays are paid this way, at least at first.
Sample situation
Dan is choosing a nursing home for his father, Paul. Paul needs rehab after a hip break. He may need long care after the rehab ends.
Dan looks up two homes on Care Compare. The first home has four stars overall. Its survey mark is four stars, its staffing mark is three stars, and its quality mark is four stars. The second home also has four stars overall. But its survey mark is two stars, and strong staffing and quality marks pulled the overall mark up.
Dan reads the survey reports for both homes. The second home has repeat citations for slow response to calls for aid. That fact matters a lot to Dan, since Paul will need help to get up at night. Dan visits both homes in the evening. He asks how many aides work at night and how calls are tracked.
The stars helped Dan make a short list. The reports and the visit helped him choose. He picked the first home, where the survey base was strong and the night staffing matched what Paul needs.
Steps to use the ratings well
- Start with the overall star mark to make a short list of homes near you.
- Open each home page and read the three part marks, not just the overall mark.
- Read the survey reports. Look for repeat problems and for problems that touch your family member's needs.
- Check the staffing facts. Look at weekend hours and at staff turnover.
- Check the quality facts that match your case: short stay facts for rehab, long stay facts for a long stay.
- Visit the homes that stay on your list. Visit at a busy time of day if you can.
- Ask staff how they handle the needs your family member has each day.
- Write down what you saw and heard, home by home, while the visit is fresh.