Medicare updates its 5-Star Nursing Home Quality Rating system


Medicare recently announced three updates to its Five Star Nursing Home Quality Rating System. If you see a lower quality measure rating for your facility, it’s because of these changes, even though the underlying QM data may not have changed.

Medicare outlines these three changes, which it describes as significant improvements, to its system:

  • Incorporated the two nursing home quality measures for antipsychotic use into the Quality Measure Rating.
  • Increased the number of points necessary to earn a Quality Measure Star Rating of two or more stars.
  • Changed the scoring method for the Staffing star rating. Nursing homes must earn a 4-star rating on either the RN or total Staffing rating to achieve an overall Staffing rating of 4-stars.

Because of these changes, Medicare cautions, it’s not appropriate to compare your facility's QM ratings that appeared in February with those that appeared in earlier months.

Here’s how the ratings are calculated:

Medicare creates the overall 5-star rating for nursing homes based on three parts:

  • Health inspections rating: The health inspection ratings are based on the three most recent comprehensive (annual) inspections, and inspections due to complaints in the last 3 years. More emphasis is placed on recent inspections.
  • Quality Measures (QM) rating: The values on eleven QMs (a subset of the 18 QMs listed on Nursing Home Compare) are combined to create the QM rating. QMs are derived from clinical data reported by the nursing home.
  • Staffing rating:

The staffing rating is based on two measures:

o 1) Registered Nurse (RN) hours per resident per day; and

o 2) total staffing hours per resident per day. Total staffing includes: RNs; Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs); and Certified Nurse Aides (CNAs). Staffing data are submitted by the facility and are adjusted for the needs of the nursing home residents.

Star ratings are given for each part and the overall rating ranges from 1 star to 5 stars, with more stars indicating better quality.

The overall 5-star rating is assigned in these steps:

1. Start with the health inspections rating.

2. Add 1 star if the staffing rating is 4 or 5 stars and greater than the health inspections rating. Subtract 1 star if the staffing rating is 1 star.

3. Add 1 star if the quality measures rating is 5 stars; subtract 1 star if the quality measures rating is 1 star.

4. If the health inspections rating is 1 star, then the overall rating cannot be upgraded by more than 1 star based on the staffing and quality measure ratings.

5. If a nursing home is a special focus facility, the maximum overall rating is 3 stars.

The 5-star rating system has strengths and limitations. Here are some things to consider as you study the ratings system:

Health inspection results


  • Comprehensive: The nursing home health inspection process looks at all major aspects of care – about 180 different items -- in a nursing home.
  • Onsite visits: This information comes from a team of objective inspectors who visit each nursing home to check on the quality of care, inspect medical records, and talk with residents about their care.
  • Federal quality checks: Federal inspectors check on the state inspectors' work to be sure the national process is being followed and that any differences between states stay within reasonable bounds.


  • Variation among states: There are some differences in how different states carry out the inspection process, even though the standards are the same across the country.
  • Medicaid program differences: There are also differences in state licensing requirements that affect quality, and in in-state Medicaid programs that pay for much of the care in nursing homes. Thus, it’s safe to assume best comparisons are made by looking at nursing homes within the same state.



  • Overall staffing: The quality ratings look at the overall number of staff compared to the number of residents and how many of the staff are trained nurses.
  •  Adjusted for the population: The ratings consider differences in how sick the nursing home residents are in each nursing home, since that will make a difference in how many staff persons are needed.


  • Self-reported: The staffing data are self-reported by the nursing home, rather than collected and reported by an independent agency.
  • ‘Snapshot’ data: Staffing data are reported just once a year and reflect staffing over only a two-week period of time.

Quality measures


  • In-depth look: The quality measures provide an important in-depth look at how well each nursing home performs on important aspects of care. For example, these measures show how well the nursing home helps people keep their ability to dress and eat, or how well the nursing home prevents and treats skin ulcers.
  • National measures: The quality measures used in the 5-star rating are used in all nursing homes.


  • Self-reported: Again, the quality measures are self-reported by the nursing home, rather than collected and reported by an independent agency.
  • Limited aspects: The quality measures represent only a few of the many aspects of care.

You can view the technical manual containing additional information on the 5-star quality rating system - Opens in a new window.

Other Resources:

Comparing nursing homes

The ratings system