CMS Five-Star Quality Rating System: How It Works
The CMS Five-Star Quality Rating System scores every Medicare- and Medicaid-certified nursing home from 1 to 5 stars across three domains — Health Inspections, Staffing, and Quality Measures — then combines them into an Overall Rating using a fixed CMS formula, not a simple average. Health Inspections is the foundation and the only domain based directly on survey findings, which means every deficiency your facility is cited for has a direct, lasting line to your public star rating.
Quick answer
The CMS Overall Rating for a nursing home starts with the Health Inspection star rating, then adds or subtracts one star each for Staffing and Quality Measures at the extremes. It is a step-by-step formula, not a weighted average.
Health Inspections use state-relative cut points that CMS recalibrates monthly; Staffing and Quality Measures use national point thresholds. A 1-star Health Inspection rating limits the Overall to 2 stars, and an active Special Focus Facility receives no star ratings at all.
This page covers nursing home (SNF) ratings on Medicare Care Compare, not Medicare Advantage, Part D, or hospital star ratings. Below: how each domain is scored, how the overall number is built, and where survey outcomes do the most damage.
The Three Domains
The CMS Five-Star Quality Rating System scores each nursing home on three domains: Health Inspections, Staffing, and Quality Measures. Each domain gets its own 1-to-5-star rating, and the three combine into the Overall Rating.
| Domain | Based on | Threshold type |
|---|---|---|
| Health Inspections | Two most recent standard surveys, plus 36 months of complaint and infection-control findings | State-relative, recalibrated monthly |
| Staffing | PBJ hours per resident day plus turnover data | National point thresholds, updates quarterly |
| Quality Measures | 15 MDS and claims-based clinical measures | National point thresholds, updates quarterly |
1. Health Inspections
The Health Inspection rating is built from points CMS assigns to deficiencies on a nursing home's two most recent standard surveys, weighted 75% for the most recent and 25% for the one before. This two-survey method has applied since the July 2025 refresh (CMS memo QSO-25-20-NH, June 18, 2025, revised September 10, 2025); it previously used three surveys. See the dated change log for 2024-2026.
Complaint and focused infection-control findings count for 36 months: at 3/4 weight for the first 12 months, then 1/4. Second, third, and fourth revisits add 50%, 70%, and 85% of the cycle's score. More points mean worse performance.
Facilities are ranked within their state: the top 10% get 5 stars, the bottom 20% get 1 star, and the middle 70% split evenly across 2, 3, and 4 stars. CMS recalibrates these cut points every month, but a facility's rating holds until its own score changes.
2. Staffing
The Staffing rating combines six measures from Payroll-Based Journal (PBJ) data: case-mix adjusted RN, total nurse, and weekend nurse hours per resident day, plus RN, total nurse, and administrator turnover. Since July 2024, hours are case-mix adjusted using the 25 PDPM nursing categories.
Points across the six measures total up to 380. A score of 320 or more earns 5 stars, and below 155 earns 1 star. Missing a PBJ deadline, or four or more days in a quarter with no RN hours, means an automatic 1-star Staffing rating for that quarter.
3. Quality Measures (QM)
The Quality Measure rating is calculated from 15 measures, 9 for long-stay and 6 for short-stay residents, built from MDS assessments and Medicare claims. Examples include pressure ulcers, falls with major injury, antipsychotic use, hospitalizations, and successful return to the community.
MDS-based measures use the four most recent quarters of data; claims-based measures use a full year, and community discharge uses two years. CMS raises the QM rating thresholds periodically, most recently at the July 2026 refresh.
How the Overall Rating Is Built
The CMS Overall Rating is not an average of the three domains. It is a formula that starts with the Health Inspection rating, adjusts for Staffing and Quality Measures, and then applies two special rules:
Start with the Health Inspection rating
This is the baseline for the Overall Rating — everything else only adjusts it up or down from here.
Adjust for Staffing
Add one star if the Staffing rating is 5 stars. Subtract one star if the Staffing rating is 1 star. Staffing ratings of 2 to 4 stars leave the result unchanged.
Adjust for Quality Measures
Add one star to the running total if the Quality Measure rating is 5 stars. Subtract one star if the Quality Measure rating is 1 star.
Apply the Health Inspection ceiling
If the Health Inspection rating is 1 star, the Overall Rating cannot be upgraded by more than one star total, no matter how strong Staffing and Quality Measures are.
Special Focus Facilities are not rated
Nursing homes currently in the Special Focus Facility program are not assigned an Overall Rating or any domain rating. Care Compare shows an SFF warning icon in place of the stars until the facility leaves the program.
The Overall Rating can never exceed 5 stars or fall below 1. CMS assigns no fixed weights to the domains; depending on Staffing and Quality Measures, the Overall can move up or down by as much as two stars from the Health Inspection rating.
The abuse icon shows the formula in action. A harm-level abuse citation (F600, F602, or F603) on the latest standard survey or a complaint survey in the past 12 months, or repeat abuse citations, caps the Health Inspection rating at 2 stars. That limits the best possible Overall to 4 stars.
Why Survey Deficiencies Have Outsized Weight
Survey deficiencies have outsized weight because the Health Inspection rating is the base of the Overall Rating, and a bad standard survey keeps counting until two newer standard surveys replace it. After one newer survey it still carries 1/4 of the inspection score.
Immediate Jeopardy findings hit hardest: a single isolated Immediate Jeopardy citation is worth 50 points, against 4 points for an isolated D-level citation.
That is why the speed and quality of Plan of Correction work matters beyond avoiding a CMP. A POC that holds up at the first revisit avoids revisit points entirely. See our full guide to writing a Plan of Correction and the full post-survey timeline. For an improvement plan built on these rules, see how to improve your nursing home CMS star rating.
Which Domains Change Fastest
Staffing and Quality Measure ratings change fastest, because CMS recalculates both every quarter. Health Inspection gains are slower, because they depend on the timing of the next standard survey, which happens about annually and no later than 15 months after the last.
A facility that improves staffing this quarter can see it at the next quarterly refresh. A facility recovering from a poor survey has to wait for newer surveys to replace it in the two-survey window.
PoC360 Helps You Protect the Domain That Matters Most
Since Health Inspections is the ceiling on your entire Overall Rating, closing out citations fast and correctly is the highest-leverage thing you can do for your public score. PoC360 generates a structured first-draft POC the moment your survey is imported, so your team spends its 10 days reviewing and approving instead of starting from a blank page.
Start Free Trial →Frequently Asked Questions
How often is the CMS Five-Star Rating updated?+
Care Compare refreshes monthly. Health Inspection cut points are recalibrated every month, but a facility's inspection rating changes only when its own weighted score changes, such as after a new survey, a complaint deficiency, or a later revisit. Staffing ratings are recalculated quarterly from PBJ data, and Quality Measure ratings update quarterly using the four most recent quarters of available data.
Which domain matters most for the Overall Rating?+
Health Inspections matter most, because the Health Inspection rating is the starting point for the Overall Rating formula. Staffing and Quality Measures can each add one star at 5 stars or subtract one at 1 star, but they cannot override a poor inspection rating: a 1-star inspection rating limits the Overall to 2 stars, and CMS assigns no fixed percentage weights to the domains.
Can a nursing home have a 5-star Overall Rating with a low Health Inspection score?+
Not with a 1-star or 2-star Health Inspection rating. The Overall Rating starts from the inspection rating and moves at most one star for Staffing and one for Quality Measures, so a 2-star inspection rating tops out at 4 stars overall. A 1-star inspection rating tops out at 2 stars, because CMS limits the upgrade to one star. A 3-star rating can reach 5 only with 5-star Staffing and Quality Measures.
Does an Immediate Jeopardy citation affect the star rating?+
Yes, significantly. IJ findings sit at the top of the severity scale used to calculate Health Inspection points and can depress that domain — and therefore the Overall Rating — for as long as the finding remains within the lookback window CMS uses for that domain.
Does Special Focus Facility status cap the Overall Rating?+
It does more than cap it. Under the current CMS Technical Users' Guide, nursing homes in the Special Focus Facility program are not assigned an Overall Rating or any domain rating at all. Care Compare shows an SFF warning icon in place of the stars, and ratings are displayed again only once the facility is no longer a current participant in the program.
Sources: CMS Design for Care Compare Nursing Home Five-Star Quality Rating System: Technical Users' Guide, September 2026; CMS memo QSO-23-01-NH (revised January 28, 2026). Last reviewed 2026-10-06. We review this article as CMS regulations and enforcement guidance change.
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