Medicare Star Ratings:

Physical inspections, staffing, and quality outcomes measures

Medicare Star Ratings are a way to compare the quality of nursing facilities based on measured facts not opinions. The federal Medicare agency rates nursing facilities with a 1 to 5-star rating system. It goes beyond just local reputation. The scoring is in half-star (1/2)  increments. Nursing facilities are graded on three areas and also receive a combined score. The stars provide a quick summary of quality. It’s like a movie reviewer or Consumer Reports rating system.

Nursing facilities can be stand-alone or attached to a Continuing Care Retirement Community (CCRC).  CCRCs are also called Life Plan or Life Care Communities. CCRCs offer a range of living stages. The first stage is from independent living. Independent living provides little to no assistance to residents. As more help is required, a CCRC may have assisted living or memory care.  Skilled nursing is typically the last stage in a CCRC. If attached to a CCRC, the nursing facility is the only part of the community scored by Medicare.

As of 2017, Assisted Living and Memory Care facilities are not rated by Medicare.

You can compare the results for all skilled nursing facilities in a city or ZIP code or for a particular facility through this Medicare Star Rating link.

medicare ratings uses a series of stars

Medicare rating for nursing facilities uses a familiar five-star rating system.

Health Inspections

Nursing facilities are periodically inspected by Medicare. Inspections are a condition of receiving Medicare reimbursements. Nursing facilities are also inspected in response to complaints. The rating looks back three years at both types of inspections. Medicare Star Ratings consider three things when problems are found. First, the severity of any deficiencies or errors cited. Second, the number of mistakes. And, third, how long or how many re-inspections it takes to get right with the standards. A Medicare 5-star rating means mistakes are minor and few and quickly redressed. Only 10% of facilities in any state are 5-star rated. The bottom 20% are 1-stars. The other three categories equally distribute the remaining facilities with about 23.3% in each of the 2, 3 and 4-star categories.


Nursing facilities track skilled-staff to patient ratios two ways. An overall skilled-staff to patient ratio and,  a subset, the registered nurses (RNs) to patient ratio. RNs are required for some patient care tasks so their presence in adequate numbers is important. Licensed Practical Nurses (LPNs) and Nurse Aides fill other roles. Ratings consider RN hours per resident day. And, separately, RN + LPN + nurse aide hours per resident day.

Clerical and housekeeping staff are not measured or rated by Medicare, but can and do matter to both residents and other staff.

There is also a so-called risk adjustment or case-mix adjustment performed. That is, facilities with high need residents require more staff to get the same rating.

The staffing requirements are stringent so the expected standard is high. The median or average falls in the 3-star range. Less than 30% of all facilities are 5-star rated. Staffing star ratings can roughly be read as 3-stars are average, 4-stars above average and 5-stars are substantially above average.

Note that a far larger share of nursing facilities rate 5-stars for staffing (30%) than for inspections (10%). Medicare Star Ratings for inspections are a larger share of the overall facility score.


Medicare ratings track 18 different quality measures (QMs) for nursing facilities. But current ratings only include 11 of the QMs, 8 long-stay measures and 3 short-stay measures.

Generally, the quality measures discourage use of restraints or antipsychotic drugs to manage patients and encourage effective pain management. The numbers of urinary tract infections, bed sores, and patient falls are metrics of inadequate care.

The top 25% of nursing homes by QMs are 5-star. The bottom 15% are 1-star. The remaining three categories contain 20% of the total distribution.

Again, note that the distribution for 5-stars is not the same category-to-category. Inspection scores are the toughest. Staffing is an easy A or 5-star. Results by QMs are in between.

If a nursing facility is underperforming on staffing, it’s a warning sign. The facility either has poor management. Or the facility is struggling with a shortage of skilled workers. Either reason is a warning to potential residents.

Overall Medicare Star Rating

The overall Medicare Star Ratings starts with and heavily weight the health inspection. A bad inspection record limits how well a facility can do even with excellent staffing and strong quality measures.

Special Focus Facilities

Medicare has a list of facilities with a long history of serious problems. These so-called “Special Focus Facilities” are targeted for improvement. They receive both added regulatory scrutiny and assistance to improve. However, if you’re shopping for nursing care you don’t want to choose a problem facility for yourself or your loved one. If it can be avoided. The current list to avoid is here at this link.

Comparisons are to other facilities within your State

One flaw with the Medicare Star Ratings? It is difficult to compare facilities across state lines. Rankings are relative to other facilities within the same state.

Also see: Is Self-Reported Provider Data Reliable? 

Sources. Summarized from two federal government sources (Medicare Star Ratings): (short version) (long version, 25 page users guide)

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