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?
The Centers for Medicare & Medicaid Services (CMS) rates every Medicare-certified nursing home on a scale of 1 to 5 stars, with 5 stars being the highest quality. This rating system, launched in 2008 and continuously refined, helps families compare facilities using standardized, objective criteria.
But what do these stars really mean? To find out, we analyzed data from all 14,751 Medicare-certified nursing homes in the United States. Here's what the numbers reveal.
The Rating Distribution: How Rare Are 5 Stars?
Many people assume most nursing homes are "average" (3 stars), but the reality is more complex. Here's the actual distribution across all 14,751 facilities:
💡 Key Insight
The distribution is surprisingly even, with a slight skew toward lower ratings. 42.3% of facilities earn 1 or 2 stars, while 37.3% earn 4 or 5 stars. This means quality varies dramatically - choosing the right facility truly matters.
How Star Ratings Are Calculated
The overall star rating is not a simple average. CMS uses a complex algorithm that combines five components:
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.
⚠️ Important Limitation
Star ratings have a critical flaw: they use a "snapshot" of staffing data rather than continuous monitoring. Some facilities have been caught artificially inflating staffing levels during the 2-week measurement period.
This is why our composite quality score uses additional factors like nurse turnover rates and compliance history to provide a more complete picture.
What Separates 5-Star from 1-Star Facilities?
We analyzed the characteristics of the 2,781 facilities with 5 stars versus the 3,156 facilities with 1 star. The differences are stark:
| 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 Means
The data clearly shows that staffing levels and staff stability matter enormously. 5-star facilities don't just have more staff - they also retain their nurses better, creating continuity of care. And perhaps most importantly, 100% of 5-star facilities are free from abuse violations.
Geographic Variations: Best and Worst States
Star ratings aren't evenly distributed across the country. Some states have consistently higher-quality facilities:
🏆 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
The difference between the best state (Alaska, 3.60 average) and worst state (Louisiana, 2.34 average) is more than a full star - equivalent to the gap between a typical 3-star and 2-star facility.
How to Use Star Ratings When Choosing a Facility
DO: Use ratings as a starting point
Star ratings are objective and standardized, making them perfect for initial screening. Start by filtering for 4+ star facilities when possible. This immediately eliminates facilities with serious quality issues.
DO: Look at component ratings
Two facilities can have the same overall rating but very different profiles:
- Facility A: 3 stars overall (5 staffing, 2 health, 3 QM)
- Facility B: 3 stars overall (2 staffing, 5 health, 3 QM)
If high staffing is your priority, choose Facility A despite identical overall ratings.
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: Rely solely on star ratings
Ratings are backward-looking (based on past performance) and don't capture everything that matters:
- Culture and staff attitudes
- Food quality and variety
- Activities and social engagement
- Specialized care for specific conditions (dementia, Parkinson's, etc.)
- Proximity to family members
DON'T: Automatically eliminate 3-star facilities
Remember, 19.4% of all facilities earn 3 stars - that's nearly 1 in 5. Some 3-star facilities may be excellent fits, especially if they:
- Have strong component ratings in areas you care about most
- Recently improved (check the trend on our facility pages)
- Are significantly closer to family, allowing 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.
Ready to Find the Right Facility?
Now that you understand what star ratings really mean, use our comprehensive search tool to find high-quality facilities in your area.
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.