Key Findings
- •Only 18.9% of nursing homes achieve 5 stars - it's truly an elite designation
- •5-star facilities have 50% more RN staffing than 1-star facilities (0.77 vs 0.51 hours/day)
- •100% of 5-star facilities are abuse-free, vs 26.4% of 1-star facilities with violations
- •Ratings are fairly evenly distributed, with 21.4% earning 1 star and 18.9% earning 5 stars
What Are CMS Star Ratings?
Every Medicare-certified nursing home gets rated on a 1-to-5 star scale by the Centers for Medicare & Medicaid Services. Five stars means top quality. One star means serious problems.
The system launched in 2008, and families rely on it every day to compare facilities. But here's the thing: most people don't know what those stars actually measure.
To find out what the ratings really mean, we analyzed data from all 14,751 Medicare-certified nursing homes in the United States. What we found might surprise you.
How Rare Are 5 Stars? (More Than You'd Think)
Most people assume nursing homes cluster around "average"—that 3 stars would be the most common rating. They're wrong.
The distribution is surprisingly even across all rating levels. Here's what we found when we looked at all 14,751 facilities:
What This Actually Means
42.3% of facilities earn 1 or 2 stars. Another 37.3% earn 4 or 5 stars. The rest fall in the middle.
Bottom line: Quality varies wildly. The facility you choose matters more than most people realize.
How Star Ratings Are Calculated
Here's where it gets complicated. The overall rating isn't a simple average of three scores. CMS uses a weighted algorithm that looks at multiple factors.
Think of it like this: health inspections are the foundation, then staffing and quality measures adjust the rating up or down.
1. Health Inspections
Based on annual state surveys examining quality of care, resident rights, safety, and sanitation. This is the most heavily weighted component.
2. Staffing Levels
Measures total nursing hours per resident per day and RN hours specifically. Adjusted for resident acuity (sicker residents need more care).
3. Quality Measures
17 clinical quality indicators including falls, pressure ulcers, antipsychotic medication use, and resident mobility/function.
4. Overall Rating
Starts with health inspection rating, then adjusted up or down based on staffing and quality measures. A facility can't get 5 stars without strong performance across all areas.
The Gaming Problem Nobody Talks About
Star ratings have a critical flaw: staffing data is based on a 2-week snapshot, not continuous monitoring.
Some facilities game the system. They staff up during the measurement period, then cut back afterward. It happens more often than you'd think.
That's why we built our composite quality score to include nurse turnover rates and compliance history—factors that are harder to fake.
What Separates 5-Star from 1-Star Facilities?
We compared 2,781 facilities with 5 stars to 3,156 facilities with 1 star.
The differences? Not subtle.
| Metric | 5-Star Average | 1-Star Average | Difference |
|---|---|---|---|
| RN Hours/Resident/Day | 0.77 hours | 0.51 hours | +51% more RN time |
| Total Nurse Hours/Day | 4.30 hours | 3.65 hours | +18% more staffing |
| Nurse Turnover Rate | 38.6% | 53.4% | 38% lower turnover |
| Abuse Violations | 0% | 26.4% | Zero tolerance |
What This Tells You
Staffing matters. A lot. 5-star facilities don't just have more nurses—they keep them around longer. That means continuity of care. Familiar faces. People who know your loved one's preferences.
And here's the number that matters most: 100% of 5-star facilities are abuse-free. Not 99%. One hundred percent.
The Geography Problem: Where You Live Matters More Than It Should
Star ratings aren't evenly distributed across the country. If you're in Alaska, you're looking at facilities that average 3.60 stars. In Louisiana? Just 2.34 stars.
That's more than a full star difference—equivalent to the gap between a typical 3-star and 2-star facility.
🏆 Top 10 States
- 1. Alaska3.60 avg
- 2. Washington DC3.47 avg
- 3. Hawaii3.37 avg
- 4. Arizona3.35 avg
- 5. Puerto Rico3.33 avg
- 6. New Jersey3.26 avg
- 7. Utah3.25 avg
- 8. Delaware3.23 avg
- 9. Idaho3.20 avg
- 10. Washington3.18 avg
Bottom 10 States
- 1. Guam2.00 avg
- 2. Louisiana2.34 avg
- 3. Illinois2.44 avg
- 4. Missouri2.51 avg
- 5. Georgia2.58 avg
- 6. Oklahoma2.65 avg
- 7. Mississippi2.68 avg
- 8. Kentucky2.68 avg
- 9. Wyoming2.70 avg
- 10. West Virginia2.70 avg
Find High-Quality Facilities in Your State
Use what you've learned about star ratings to find the best nursing homes near you:
How to Use Star Ratings When Choosing a Facility
DO: Use ratings as your first filter
Star ratings are objective and standardized. That makes them perfect for screening out problematic facilities. Start by filtering for 4+ stars when possible—this immediately cuts facilities with serious quality issues.
DO: Dig into the component ratings
Two facilities with the same overall rating can be completely different:
- Facility A: 3 stars overall (5 staffing, 2 health, 3 QM)
- Facility B: 3 stars overall (2 staffing, 5 health, 3 QM)
If staffing is your priority? Choose Facility A. Same overall rating, totally different experience.
DO: Compare to our composite quality score
Our quality score incorporates additional factors like nurse turnover, deficiency severity, penalty amounts, and historical trends. A facility might have 4 stars but a mediocre composite score if they have high turnover or recent serious violations.
DON'T: Make this your only criterion
Ratings reflect past performance. They don't capture everything that makes a facility right for your loved one:
- Staff attitudes and culture
- Food quality (this matters more than people think)
- Social activities and engagement
- Specialized care for dementia, Parkinson's, or other conditions
- Distance from family (frequent visits improve outcomes)
DON'T: Write off 3-star facilities automatically
Nearly 1 in 5 facilities earns 3 stars (19.4%). Some might be perfect for your situation, especially if they:
- Excel in the specific areas you care about most
- Show improving trends over recent quarters
- Are 20 minutes away instead of 2 hours (this matters for frequent visits)
- Specialize in your loved one's specific condition
5 Common Misconceptions About Star Ratings
Myth 1: "Most facilities are 3 stars (average)"
Reality: Only 19.4% are 3 stars. The distribution is remarkably even from 1-5 stars, with slightly more low-rated facilities than high-rated ones.
Myth 2: "5-star facilities are too expensive for most families"
Reality: Star ratings don't directly correlate with price. Many non-profit 5-star facilities accept Medicaid. Quality depends more on management and staff culture than luxury amenities.
Myth 3: "The rating is just an average of the 3 component ratings"
Reality: CMS uses a complex weighted algorithm. Health inspection rating is the foundation, then adjusted based on staffing and quality measures. A facility with excellent staffing but poor health inspections won't get 5 stars.
Myth 4: "Ratings are updated in real-time"
Reality: Ratings are updated quarterly, but reflect surveys conducted months earlier. A facility could have changed significantly (better or worse) since their last rating. Always check the "last inspection date" on our facility pages.
Myth 5: "All 5-star facilities provide the same quality of care"
Reality: Even among 5-star facilities, there's variation. Some barely qualify for 5 stars, while others excel in every category. This is why our composite quality score (0-100 scale) provides more granularity.
Find Quality Care Near You
Now that you know what the stars actually measure, put that knowledge to work. Search facilities in your area, compare quality scores, and find the right fit for your family.
Methodology
This guide is based on analysis of data from all 14,751 Medicare-certified nursing homes in the United States, Puerto Rico, Guam, and U.S. Virgin Islands, current as of October 2024.
Data sources include:
- CMS Nursing Home Compare database (Provider Information)
- CMS Health Inspection surveys
- CMS Staffing data (Payroll-Based Journal)
- CMS Quality Measures (MDS 3.0 and Claims-based)
- CMS Deficiencies, Complaints, and Penalties data
All statistics in this guide were calculated directly from the raw CMS data. Averages exclude facilities without ratings or missing data for specific metrics.
Related Guides
Continue learning with these related articles:
State Quality Rankings
See which states have the highest-rated nursing homes and compare state averages
Health Inspection & Violations
Understanding deficiency citations and how they impact facility quality
Understanding Staffing Levels
Why nurse staffing ratios matter and how they affect care quality
Tour Checklist
Know what to look for when visiting a nursing home in person