With growing needs for senior skilled care, the Centers for Medicare and Medicaid Services (CMS) implemented the Five Star Quality Rating System in 2008 “to help consumers, their families, and caregivers compare nursing homes more easily and to help identify areas about which you may want to ask questions.” It’s a helpful starting point, but even CMS cautions families to evaluate a broader set of considerations when choosing care.
Feeling empowered and confident in your decisions for skilled care starts with understanding the Five Star Quality Rating System, its benefits and limitations, and the questions to ask all facilities. Here you’ll find the basics of the rating system, critical information families should know, questions to ask, and a step-by-step approach bringing it all together so you can confidently make the best decisions for your loved one.
What are nursing home star ratings?
Think of nursing home star ratings as a report card that helps you start your search, much like you might use online reviews when choosing any service provider. Launched in 2008, the CMS Five-Star Quality Rating System uses a scale of 1-5 stars (1=much below average, 5=much above average). Updated quarterly on the Medicare Care Compare website, the star ratings are available for all skilled care facilities and nursing homes certified for Medicare and Medicaid payments.
The rating system includes four components that work together to give you a picture of each facility:
- Overall Rating – summary of the three main areas
- Health Inspections – based on state survey results
- Staffing – nursing hours per resident and staff turnover
- Quality Measures – 15 specific care indicators
Understanding how these ratings work can help you feel more confident as you navigate what often feels like an overwhelming decision. Remember, you’re not just choosing a building, you’re choosing where your loved one will receive care, build relationships, and spend their days.
How star ratings are calculated
The rating system might seem complex at first, but breaking it down helps you understand what you’re actually looking at when you see those stars.
Health Inspections (Most Heavily Weighted)
Health inspections form the foundation of the overall rating because they represent what government inspectors actually observed during unannounced visits. Here’s what goes into this crucial component:
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- Unannounced annual state surveys conducted by trained inspectors
- Deficiencies found during these visits, ranked by severity and scope
- Follow-up visits and complaint investigations
- A ranking system that places facilities within their state (the top 10% earn 5 stars, while the bottom 20% receive 1 star)
This state-by-state approach means a 3-star facility in one state might perform quite differently than a 3-star facility in another state, which is important to keep in mind as you compare options.
Staffing Ratings
Adequate staffing is absolutely critical for quality care. Research consistently shows that higher staffing levels and lower turnover lead to better outcomes for residents. The staffing component measures:
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- Nursing hours per resident per day
- Staff turnover rates for nurses and administrators
- Weekend staffing levels (because quality care doesn’t take weekends off)
- Payroll-based data that facilities must submit regularly
If a facility doesn’t submit this required staffing data, they automatically receive a 1-star rating in this category. This is actually a red flag worth noting, as it suggests potential transparency issues.
Quality Measures
These 15 specific indicators focus on actual resident outcomes and experiences. They’re divided between short-stay residents (typically recovering from surgery or illness) and long-stay residents (those who call the facility home long-term). Examples include:
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- Hospitalization rates (fewer unexpected hospital visits often indicate better preventive care)
- Pressure ulcer rates (well-cared-for residents shouldn’t develop bedsores)
- Antipsychotic medication use (overuse of these medications is a serious concern in nursing home care)
- Functional improvement measures (good care should help people maintain or regain abilities when possible)
This data comes from detailed assessments called the Minimum Data Set (MDS) that facilities complete for each resident, combined with Medicare claims information.
Overall Rating Calculation
The overall rating isn’t simply an average of the three components. Instead, the health inspection rating serves as the foundation, with the possibility of earning bonus stars for excellent staffing and quality measures, or receiving penalty stars for poor performance. Special focus facilities—those with persistent quality problems—may have their ratings capped regardless of other measures.
Critical things families need to know.
While star ratings provide valuable information, there are several crucial points that can significantly impact your decision-making process.
Ratings Follow the Building, Not the Management
This is perhaps the most important thing to understand: when a nursing home changes ownership, the new company inherits the existing star rating. It can take several years of new inspections and data collection before the rating reflects the new management’s approach to care.
Recent research involving nearly 16,000 nursing homes found that one in five facilities changed ownership between 2016 and 2022. The study revealed that ratings often remained unchanged immediately after ownership transitions, even when the quality of care was shifting under new management.
This means that excellent new management might be working with a poor rating from previous ownership, while concerning new management might still benefit from a previous owner’s good rating. Always ask directly: “Has this facility changed ownership recently? If so, when and what changes have you implemented?”
State-by-State Variations Matter
Because health inspection ratings rank facilities within their state, a 3-star facility in a state with generally high-quality nursing homes might actually provide better care than a 4-star facility in a state with more systemic challenges. Research shows significant variations between states, with some having much higher percentages of low-rated facilities.
What Ratings Don’t Tell You
Star ratings, while helpful, can’t capture everything that matters for your loved one’s quality of life:
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- Specialized services like memory care programs, rehabilitation therapy, or specific medical expertise
- Cultural competency and language services that might be crucial for your family
- Family engagement policies and how welcoming the facility is to visitors and family involvement
- Location convenience that allows frequent family visits (which can significantly improve both care quality and resident wellbeing)
- Staff personality and facility culture (the intangibles that make a place feel like home versus just a medical facility)
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Timing Considerations
Remember that ratings reflect past performance, not necessarily current conditions. Recent management changes, staffing improvements, or quality initiatives may not yet be captured in the quarterly updates. Similarly, the impacts of COVID-19 may still be affecting some facilities’ data, as the pandemic significantly disrupted normal operations.
Pros and cons of the Star-Rating System.
Understanding both the strengths and limitations of the rating system helps you use it more effectively in your decision-making.
Advantages
The star rating system offers several valuable benefits for families:
- Easy-to-understand comparison tool that doesn’t require medical expertise to interpret
- Standardized metrics that allow fair comparisons across facilities in each state
- Quality improvement incentive for facilities to address deficiencies and enhance care
- Public accessibility with regular updates and free access through Medicare’s website
- Comprehensive data collection backed by government oversight and professional inspections
Limitations
However, the system has important limitations to keep in mind:
- Missing intangible factors like warmth of staff interactions or sense of community
- Delayed reflection of changes due to the time lag between improvements and rating updates
- Potential confusion during ownership transitions when ratings don’t match current management
- Limited scope regarding specialized care needs or unique family preferences
- Possible system manipulation as some facilities may focus narrowly on rating metrics rather than overall care quality
Beyond the Numbers
As CMS noted, “no rating system can address all of the important considerations that go into a decision about which nursing home may be best for a particular person.” Star ratings are your starting point, not your final answer. The “best” facility is ultimately the one that feels right for your loved one and meets their specific needs, preferences, and circumstances.
Questions to ask about star ratings.
When you visit potential facilities, coming prepared with specific questions can help you understand both the ratings and the reality behind them.
During Your Facility Research
- “Has this facility changed ownership recently? If so, when and why?” This helps you understand whether current management is responsible for the existing rating.
- “What specific improvements have you made to address any low ratings?” Look for concrete examples and timelines, not vague promises.
- “Can you walk me through your most recent inspection results?” A good facility will be transparent about both strengths and areas for improvement.
- “How do you ensure adequate staffing, especially on weekends and holidays?” Staffing challenges are widespread, but good facilities have specific strategies to maintain care quality.
- “What quality improvement initiatives are currently underway?” This shows whether the facility is actively working to enhance care or just maintaining the status quo.
Understanding the Context
These questions help you interpret ratings within the broader picture:
- “How do your ratings compare to other facilities in our area?” This helps you understand the local landscape and realistic expectations.
- “Are there any citations or deficiencies currently under dispute?” CMS now displays disputed citations on Care Compare for greater transparency.
- “What specialized services do you offer that might not be reflected in ratings?” This is where you learn about programs that matter specifically to your loved one.
- “How has your performance trended over the past few years?” Look for consistent improvement or concerning declines.
- “What would you say are your facility’s greatest strengths beyond what ratings show?” This gives staff a chance to share what makes them proud of their work.
Additional Questions Based on Your Visit
Pay attention to your experience during the visit and ask follow-up questions:
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- “I noticed [specific observation]. Can you explain how you handle this situation?”
- “What activities and engagement opportunities do you provide for residents with [your loved one’s interests or needs]?”
- “How do you communicate with families about their loved one’s care and any changes?”
- “What’s your policy on family involvement in care planning?”
Using ratings effectively.
Now that you understand the system, here’s a practical approach to using star ratings as part of your decision-making process.
Step-by-Step Approach
Now that you understand the system, here’s a practical approach to using star ratings as part of your decision-making process.
- Start with ratings as your initial filter. Use Medicare’s Care Compare website to identify facilities with 3+ stars in your area. While 1 and 2-star facilities shouldn’t be automatically dismissed, higher-rated facilities give you a better starting point.
- Research recent changes and news. Look up each facility’s ownership history and any recent news coverage. The ProPublica Nursing Home Inspect database can help you find detailed inspection reports and ownership changes. This investigative tool compiles more than 90,000 inspection reports in a searchable format, making it easier to spot patterns or recent issues.
- Schedule visits at different times. Visit your top choices during different times of day and days of the week. A Tuesday morning visit might look very different from a Friday evening visit. Pay attention to staffing levels, resident engagement, and the general atmosphere. Weekend visits can be particularly revealing about staffing adequacy.
- Use your prepared questions. Bring your list of questions and don’t hesitate to ask for specific examples or clarification. A good facility will welcome your thoroughness and see it as a sign of a caring family member.
- Trust your instincts alongside the data. While ratings provide important objective information, your gut feelings about how your loved one might feel in each environment are equally valuable. Consider factors like natural lighting, noise levels, how staff interact with current residents, and whether the facility feels welcoming to families.
Red flags to watch for at skilled care facilities.
While touring facilities, be alert to these warning signs that might not be captured in star ratings:
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- Consistent 1-star ratings across multiple years with no clear improvement plan
- Recent significant drops in ratings without transparent explanations
- Evasive answers about rating-related issues or refusal to discuss inspection results
- High visible staff turnover or lots of unfamiliar faces across multiple visits
- Persistent odors in the facility, which may indicate inadequate housekeeping or care
- Staff who seem surprised or unprepared for unannounced family visits
- Residents who appear consistently unengaged, inappropriately sedated, or poorly groomed
- Lack of activities or social engagement visible during your visits
- Difficulty getting answers to basic questions about care approaches or policies
Getting Additional Support
Remember, you don’t have to navigate this process alone. Several resources can provide additional guidance:
- Long-Term Care Ombudsman Programs operate in every state to advocate for nursing home residents and can provide insights into local facilities. These trained advocates work to resolve complaints and can offer valuable perspective on facilities in your area.
- State health departments maintain additional inspection information and complaint records that might not be immediately visible in star ratings.
- Local Area Agencies on Aging often have staff who are familiar with facilities in your community and can provide additional guidance based on their experience with other families.
Your ongoing role after placement.
Choosing a facility is just the beginning of ensuring quality care for your loved one. Star ratings can change over time, and your active involvement remains crucial.
Stay Engaged and Vigilant
Regular visits at varying times help you monitor care quality and catch potential issues early. Many families find that their presence alone helps ensure better attention to their loved one’s needs. Pay attention to changes in your loved one’s condition, mood, or stories about their daily experiences.
Monitor Rating Changes
Check the facility’s star ratings quarterly when updates are released. Declining ratings might signal problems that warrant discussion with facility management. Similarly, improving ratings can validate your choice and the facility’s commitment to quality care.
Know Your Resources
Keep contact information for your state’s Long-Term Care Ombudsman program readily available. If concerns arise, they can help advocate for your loved one and investigate potential problems. You can find your local ombudsman through the Consumer Voice directory.
Use Available Tools for Ongoing Assessment
The official CMS nursing home checklist isn’t just for initial selection, it can guide ongoing evaluation during your visits. Organizations like CANHR (California Advocates for Nursing Home Reform) also provide detailed evaluation checklists that ask important questions like “How long has the facility been operating under the present management?”
Making the best decision for your family.
Choosing skilled care for someone you love is rarely easy, and it’s normal to feel overwhelmed by the weight of the decision. Star ratings provide valuable, objective information, but they’re just one tool in your decision-making toolkit.
The most important thing to remember is that the “best” facility isn’t necessarily the one with the highest star rating, it’s the one that best meets your loved one’s individual needs, preferences, and circumstances. A 3-star facility with specialized dementia care and a warm, engaging staff might be perfect for your family member, while a 5-star facility focused on post-surgical recovery might not be the right fit.
Trust the combination of objective data from star ratings, your observations during visits, answers to your questions, and your instincts about where your loved one will receive not just good medical care, but also experience dignity, engagement, and quality of life.
Remember that choosing skilled care is often a journey, not a one-time decision. Needs change, facilities evolve, and sometimes a move becomes necessary. By staying informed, engaged, and advocating for your loved one, you’re providing one of the most important gifts possible: ensuring they receive the respectful, quality care they deserve.
Your thoughtfulness in researching and asking questions shows how much you care. That same care and attention will serve you well as you support your loved one in whatever facility you choose, helping ensure they thrive in their new environment.
Ready to explore if The Restoracy is the right fit? Schedule a tour, bring your questions, and ask us about our star ratings and care philosophy.