How to Read CMS Star Ratings and Nursing Home Inspections

What Care Compare rates — and what it leaves out

Care Compare is Medicare's public rating tool for the roughly 15,000 nursing homes certified to bill Medicare or Medicaid — 14,695 of them as of CMS's June 2026 data refresh. Each facility carries an overall rating of one to five stars built from three component ratings — health inspections, staffing, and quality measures — drawn from state surveys, payroll records, and clinical data. CareScout's 2024 provider survey reports a $9,277 national monthly median for a semi-private room; use the source-and-vintage table for planning context, then verify the facility's current rate and payer terms.

Two limits up front. First, stars only cover skilled nursing — assisted living, memory care, and independent living have no federal ratings, a gap covered below. Second, the health-inspection star grades facilities against other facilities in the same state, not against a national bar: the top 10 percent of homes in each state get five stars and the bottom 20 percent get one. Staffing and quality-measure stars, by contrast, use national cut points. So a 4-star health-inspection home in a leniently surveyed state may not equal a 4-star home in a strict one. Treat stars as a screen, never a verdict.

The overall star is a formula, not an average

CMS starts with the health-inspection rating and adjusts from there in two steps. A five-star staffing rating adds one star; a one-star staffing rating subtracts one. Then a five-star quality-measure rating adds one star; a one-star quality-measure rating subtracts one. Nothing in between moves the needle — a 4-star staffing rating adds nothing at all. The overall rating can therefore sit at most two stars above or below the inspection star, and if the inspection rating is one star, CMS caps any upgrade at a single star no matter how good the other two domains look.

Two consequences worth holding onto. A home with middling inspections reaches five stars only by hitting five stars on both staffing and quality measures — quality data alone can never lift it more than one notch. And because a single one-star domain drags the whole rating down, a 3-star overall can mean three mediocre components or one genuinely alarming one. Always open all four ratings before judging a facility.

Health inspections: the rating to trust most

Health-inspection stars are the only component based entirely on independent, on-site observation. State surveyors working under federal rules arrive unannounced at least every 15 months — about every 12 on average — and deficiencies from complaint investigations and focused infection-control surveys over the past three years count too. Since the July 2025 refresh, CMS scores the two most recent standard surveys rather than three: the most recent carries three-quarters of the weight and the prior one a quarter. Complaint and infection-control findings follow the same split, with the last 12 months weighted three-quarters and months 13 through 36 weighted a quarter. The practical upshot is that the newest survey dominates — one clean cycle can lift a rating quickly, and one bad recent cycle will sink it just as fast.

Don't stop at the star. Care Compare posts the full inspection reports — the Statement of Deficiencies, Form CMS-2567 — for the three most recent inspection cycles, though only the two most recent are scored. Federal rules go further: a facility must post the results of its most recent survey where residents and families can see them, and must make three years of surveys, certifications, and complaint investigations available for anyone to review on request. Watch for two flags on a facility's page. An abuse icon — a red hand — marks homes recently cited for abuse, and it is not merely cosmetic: it caps the health-inspection rating at two stars, which means the best overall rating such a home can display is four. Separately, a yellow warning sign in place of the stars means the home is a current Special Focus Facility, the program reserved for the country's persistently worst performers; those homes get a full onsite survey at least every six months, roughly twice the normal rate, and CMS publishes no star ratings for them at all while they are enrolled. As of September 2026, CMS also plans to flag its highest-performing homes with a new risk-based-survey icon, so expect the page layout to shift.

Scope and severity: decoding the A–L citation letters

Every deficiency in an inspection report carries a letter from A to L that combines severity — how much harm occurred or could have — with scope: whether the problem was isolated, a pattern, or widespread. Higher letters are worse, and within each severity band the letters step from isolated to pattern to widespread. Most families skim right past these codes, but they are the most information-dense detail in any inspection report. The four bands, and one decision rule:

• A–C: no actual harm, with potential for only minimal harm. Mostly procedural findings — and CMS assigns them zero points, so they do not move a facility's score at all.
• D–F: no actual harm, but potential for more than minimal harm. D alone accounts for roughly 63 percent of every health citation in the country, so a few scattered Ds are normal, not alarming.
• G–I: actual harm to at least one resident. Fewer than 4 percent of citations reach this band. Ask the administrator directly what happened and what changed afterward.
• J–L: immediate jeopardy — the violation caused, or was likely to cause, serious injury or death. The jeopardy must be removed immediately, and enforcement action, often a civil money penalty, typically follows.
• Decision rule: count citations lettered G or higher across the two survey cycles CMS actually scores. Zero is what you want. A J, K, or L within two years — or any abuse citation — should push a community to the bottom of your list unless leadership can walk you through exactly what changed.

Staffing: hours per resident day, and who actually shows up

Staffing ratings come from Payroll-Based Journal data — auditable payroll records every facility must submit quarterly — not from self-reported schedules. Six measures feed the rating: case-mix adjusted total nurse hours per resident day (RNs, LPNs, and aides combined), RN hours specifically, total nurse hours on weekends, plus total nurse turnover, RN turnover, and administrator departures. The hours are adjusted for how much care each facility's residents actually need. Landmark CMS-commissioned research from 2001 linked roughly 4.1 total hours per resident day with better outcomes; as of CMS's June 2026 figures the national average sits at about 3.9 hours, with RN hours at roughly 0.7 and weekend total nurse staffing dropping to about 3.4. Care Compare shows each facility's numbers beside its state and national averages, so the comparison takes seconds.

Since July 2022 the rating has folded in turnover and weekend coverage, and both deserve equal attention. Nationally, total nursing staff turnover averages about 46 percent a year and RN turnover about 43 percent — meaning nearly half the nursing staff at a typical home is gone within twelve months. As a rough screen, turnover comfortably below 40 percent beats the national average, while rates above 60 percent — or a parade of departed administrators — signal instability that residents feel directly. Staffing also dips on weekends nearly everywhere, so check the weekend figure, then verify with your own eyes: tour on a Saturday and count. Our tour questions guide covers what to ask.

Quality measures: useful, but graded largely on the honor system

The quality-measure rating tracks 15 clinical indicators — nine for long-stay residents and six for short-stay — covering pressure ulcers, falls with major injury, antipsychotic medication use, rehospitalizations, ER visits, and more. Five of the 15 come from Medicare claims, which are hard to game; the other 10 come from assessments the facility performs on its own residents. Treat this rating as a tiebreaker between homes with comparable inspections and staffing, not as an anchor. One measure deserves special attention if your parent has dementia: the share of long-stay residents receiving antipsychotic medication, which averages about 15 percent nationally but varies widely between facilities. CMS respecified that measure in January 2026 to draw on claims and encounter data alongside facility assessments, making it one of the more trustworthy numbers on the page — and one worth asking about whenever memory care needs are part of the picture.

Why assisted living has no federal stars — and what to check instead

There is no Care Compare for assisted living. Medicare neither certifies nor pays for assisted living room and board — it treats that as custodial long-term care and covers none of it — so the federal government has no rating authority over these communities. Regulation belongs entirely to the states. What gets inspected, how often, and whether reports are posted online varies by state: some publish full survey histories in searchable databases, while others release reports only through public-records requests. Memory care usually operates under the same state assisted-living license, often with an added dementia-care endorsement.

The absence of federal ratings does not leave you blind; it moves the homework to the state level. Every state licenses assisted living or residential care under some name and inspects communities on some cycle, many treat those reports as public records, and every state — plus DC, Puerto Rico, and Guam — runs a free Long-Term Care Ombudsman program that fields complaints about assisted living and board-and-care homes as well as nursing homes. Our guide to choosing assisted living builds these steps into a full process; the short version:

• Search your state licensing agency's website for the community's inspection history — try searching "assisted living inspection reports" plus your state's name. If nothing is posted online, request the reports; in many states they are public records.
• Ask the community for its most recent licensing survey and plan of correction. A confident operator hands both over; hesitation is itself an answer.
• Call your state's Long-Term Care Ombudsman — a free, federally mandated resident-advocate program that covers assisted living and knows local complaint histories. The Eldercare Locator can connect you.

A 20-minute pre-tour checklist

Run this sequence for every nursing home on your shortlist before you book a single tour. It takes about twenty minutes per facility and reliably surfaces the problems that brochures and lobby renovations are designed to bury. If you are still deciding whether your parent needs skilled nursing at all — or whether assisted living plus home health might serve — work through choosing between care levels first, then come back to this list.

For eligible nursing homes, Haven's CMS-backed comparisons use star ratings, inspection findings, and payroll-based staffing records — never paid placement. State-license records are labeled separately, and coverage varies by jurisdiction; see our methodology. If you would rather start from a shortlist matched to your parent's needs, our free assessment takes about three minutes. Either way, treat the checklist below as the floor for any community you plan to visit.

• Look up the facility on Medicare's Care Compare and note all four star ratings — never just the overall. A yellow warning sign instead of stars means the home is a current Special Focus Facility; "Not Available" usually means it is too new to have two standard surveys.
• Open the inspection reports for the two most recent survey cycles and count citations lettered G or higher; plan to ask about every one.
• Check the staffing tab: total and RN hours per resident day versus the state and national averages, plus weekend hours, nurse turnover, and administrator departures.
• Scan for the abuse icon — remember it caps the health-inspection star at two and the overall at four — and for Special Focus Facility status. Either is disqualifying for most families.
• Use quality measures as a tiebreaker, with a close look at antipsychotic medication use.
• Call the state Long-Term Care Ombudsman and ask about the facility's complaint history.