Methodology · CMS Five-Star
The CMS Overall rating is the most-cited number in nursing home oversight, and the most misunderstood. Here is how it is composed, what it captures, and the cases where it can mislead.
CMS computes three independent component ratings, each on a 1–5 star scale, then combines them into an Overall rating using a fixed adjustment rule.
1. Health Inspection (1–5 stars)
Based on the three most recent annual surveys plus complaint and infection-control surveys. CMS weights deficiencies by severity (A–L scale) and scope (isolated / pattern / widespread). The weighted score is binned into quintiles within each state, so 5 stars represents the top 10% of a state’s inspection performance. Recent year weighted 50%, year-2 33%, year-3 17%.
2. Staffing (1–5 stars)
Drawn from auditable Payroll-Based Journal data. Combines RN hours per resident day, total nursing hours per resident day, and weekend RN staffing — each case-mix adjusted using the resident acuity (RUG-IV) profile. Reporting non-compliance or implausibly low weekend staffing automatically caps the Staffing rating at 1 star.
3. Quality Measures (1–5 stars)
A composite of 10 long-stay and 5 short-stay clinical measures (antipsychotic use, falls with major injury, pressure ulcers, weight loss, depression, UTI, restraints, catheters, ER visits, rehospitalization). Risk-adjusted from MDS resident assessments. Note that MDS data is reported by facility staff, so QM accuracy is only as good as the facility’s assessment discipline.
The Overall rating starts at the Health Inspection rating, then:
The Overall rating cannot go below 1 star or above 5 stars. CMS publishes the adjustment rules in the official Five-Star Technical Users’ Guide.
Every facility profile on Placet displays the Overall rating prominently and breaks out the three component ratings as separate cards so visitors can see whether the headline number is being propped up by a strong staffing or QM result despite weak inspection performance. We also surface the abuse icon flag, SFF / SFF Candidate status, and the underlying deficiency list independently, because those signals often arrive before the next monthly star rating refresh reflects them.
What is the CMS Five-Star Rating?
The CMS Five-Star Rating is the overall quality score (1–5 stars) the federal government assigns to every Medicare- and Medicaid-certified nursing home. It is published on Care Compare and updated monthly. The Overall rating is a composite of three component ratings: Health Inspection, Staffing, and Quality Measures.
How is the Overall rating calculated?
The Overall rating starts with the Health Inspection rating. CMS then adjusts it: it goes up by one star if Staffing is 4 or 5 stars and Quality Measures is 5 stars, and goes down by one star if Staffing is 1 star. Facilities cited for abuse, neglect, or harm in the past 12 months cannot have an Overall rating above 2 stars.
Can a 5-star facility still have serious problems?
Yes. The Five-Star system is a relative comparison and a heavily smoothed signal. A 5-star facility can still have an active immediate-jeopardy citation, an SFF Candidate flag, or a 12-month complaint surge that has not yet rolled into the rating cycle. Always read the deficiency list and complaint trend, not just the star count.
Why does the Health Inspection rating use rolling 36 months?
CMS weights the most recent annual survey at 50%, the prior year at 33%, and the year before at 17%. The intent is to smooth out a single bad inspection, but it also means a facility under new ownership inherits the prior owner's record for up to three years.
How does Placet display the Five-Star components?
Every Placet facility profile shows the Overall rating prominently and also breaks out the three component ratings (Health Inspection, Staffing, Quality Measures) so you can see whether the headline number is propped up by a strong staffing rating despite weak inspection results.