What it tracks:
The Overall Star Rating is a composite score that combines three separate ratings: Health Inspections, Staffing, and Quality Measures. It gives each nursing home a single score from 1 star (much below average) to 5 stars (much above average).

How CMS calculates it:
CMS starts with the Health Inspection rating as the baseline. If the Staffing rating is 4 or 5 stars (and higher than the Health Inspection rating), CMS adds one star. If the Staffing rating is 1 star, CMS subtracts one star. Then the same logic applies to Quality Measures: a 5-star QM rating adds a star, a 1-star QM rating subtracts a star. The final score is capped between 1 and 5.

What the numbers mean in plain language:
Health Inspections carry the most weight. A facility with a strong inspection record starts with a higher baseline. Staffing and Quality Measures push it up or pull it down by one star each. A 5-star facility performed well across all three areas. A 1-star facility performed poorly in at least one area and was not rescued by the others.

Red flags for families:
A facility with a 5-star overall rating but a 1- or 2-star Health Inspection rating got its score boosted by staffing or quality data. That means it passed the paperwork but had problems during the actual on-site inspection. Look at the individual ratings, not the overall number. A high overall score can mask a serious inspection failure.

What it tracks:
The Health Inspection rating measures how well a facility met federal health and safety requirements during its most recent on-site surveys. These include standard annual inspections, complaint investigations, and infection control inspections.

How CMS collects the data:
State survey agencies conduct unannounced inspections on a 9-to-15-month cycle. Surveyors observe staff-resident interactions, review medical records, inspect kitchens, evaluate medication administration, interview residents and families, and check fire safety compliance. Each violation is called a “deficiency” or “citation.” Citations are scored based on their scope (how many residents were affected) and severity (how serious the harm was). More severe and widespread deficiencies generate more penalty points. As of July 2025, CMS uses only the two most recent standard surveys (instead of three) to calculate this rating, with the most recent survey weighted at 75% and the previous one at 25%. Complaint and infection control inspections still use a three-year lookback.

What the numbers mean in plain language:
Lower deficiency counts are better. Facilities are ranked against other nursing homes in the same state. The top 10% earn 5 stars. The bottom 20% earn 1 star. The remaining 70% split evenly into 2, 3, and 4 stars. Because rankings are state-based, a 3-star facility in one state might have more citations than a 3-star facility in another state with stricter survey teams. A citation count well above the state average signals a pattern, not a one-time problem.

Red flags for families:
Watch for citations labeled “Immediate Jeopardy,” which means surveyors found a situation that caused or was likely to cause serious injury or death. Any facility with repeated complaint investigations in a short period deserves extra scrutiny. If a facility required multiple revisits to correct major deficiencies, that means the problems were not fixed on the first attempt. Also compare the facility’s citation count to the state and national averages listed on Care Compare. A facility with 38 citations against a state average of 4.8 is not having a bad year. It is a facility with systemic problems.

What it tracks:
The Staffing rating measures how many nursing hours each resident receives per day. CMS tracks three staffing categories: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs). It also reports total nursing staff turnover, RN turnover, and the number of administrators who left the facility in the past year.

How CMS collects the data:
Nursing homes submit staffing data through CMS’s Payroll-Based Journal (PBJ) system, which pulls directly from the facility’s payroll records. CMS adjusts the staffing numbers based on the facility’s case mix, meaning a facility with sicker or more complex residents is expected to provide more hours of care. To earn a 5-star Staffing rating, a facility must meet CMS thresholds for both RN hours and total nursing hours per resident per day.

What the numbers mean in plain language:
More hours per resident per day means more hands available to provide care. The national average for total nursing hours is about 3 hours and 53 minutes per resident per day. RN hours average about 41 minutes per resident per day nationally. Turnover percentage tells you how stable the workforce is. A turnover rate of 50% means half the nursing staff left in a single year. When staff constantly change, residents lose continuity of care, and new employees are less familiar with each resident’s needs and routines.

Red flags for families:
If a facility reports “Not available” for staffing data, that is a concern on its own. It means the facility either did not submit reliable data or the numbers were so extreme that CMS flagged them as implausible. RN turnover above 50% means the most clinically trained nurses are leaving at alarming rates. If the facility has had more than one administrator leave in a year, leadership is unstable. Total nursing hours well below the national average of 3 hours 53 minutes means residents are competing for attention. Physical therapist hours at zero means residents are receiving no rehabilitation support. A facility with low staffing and high turnover will struggle to provide consistent, safe care regardless of what any other rating says.

What it tracks:
Quality Measures track 15 clinical outcomes for residents, split into two groups: Long-Stay (residents expected to remain in the facility) and Short-Stay (residents there temporarily for rehab). These measures cover conditions like pressure ulcers (bed sores), antipsychotic medication use, emergency room visits, hospitalizations, falls with injuries, catheter use, urinary tract infections, ability to walk or care for oneself, and bowel or bladder incontinence.

How CMS collects the data:
Most quality measures come from the Minimum Data Set (MDS), a standardized health assessment that nursing homes are required to complete for every resident and submit to CMS quarterly. Some measures (hospitalizations, ER visits, and successful discharge rates) come from Medicare claims data. CMS uses the four most recent quarters of data and requires a minimum of 20 eligible residents per measure to produce a score. If a facility does not have enough data, CMS fills in the gap using the state average.

What the numbers mean in plain language:

Red flags for families:
Any single measure that is double the national average signals a systemic failure, not a statistical blip. If multiple measures are above average at the same time, the facility has compounding problems. Pay close attention to the antipsychotic rate. A high rate combined with low staffing hours often means the facility is sedating residents because it does not have enough staff to provide proper care. If pneumonia or flu vaccination rates are far below average, the facility is failing at basic preventive care. When data says “Not available,” the facility either had too few residents to measure or did not submit data. Neither of those is reassuring.

What it tracks:
The Special Focus Facility designation identifies nursing homes with a history of serious, repeated quality failures. CMS marks these facilities with a red hand icon on Medicare Care Compare. An SFF designation is not triggered by a single bad inspection. It reflects a documented pattern of harm over time.

How CMS assigns the designation:
CMS uses a scoring formula that weighs the number, scope, and severity of deficiencies over the facility’s most recent inspection cycles. Facilities in the bottom tier nationally are placed on the SFF candidate list. From that list, each state selects facilities for the SFF program based on the worst records. Once designated, the facility faces inspections every six months (instead of annually) and must demonstrate measurable improvement. If the facility fails to improve, CMS can impose fines, deny Medicare payments, or terminate the facility from Medicare and Medicaid entirely.

What the designation means in plain language:
An SFF facility is one that the federal government has identified as consistently dangerous. It is under enhanced oversight because standard oversight was not enough to prevent ongoing harm. These facilities had multiple opportunities to fix their problems and did not. The designation is public, and it should be treated as a serious warning signal.

Red flags for families:
If your loved one is in an SFF facility, request the full inspection report from Medicare Care Compare immediately. Contact your state’s Long-Term Care Ombudsman to ask about the facility’s current status and any open investigations. Document everything you observe during visits: condition of your loved one, staffing levels, cleanliness, response times when you press the call button. Do not wait for the next inspection cycle to raise concerns. File a complaint with your state survey agency if you see anything that worries you. You do not need proof. You need to report it.