Each violation found during an inspection is called a deficiency. Deficiencies are assigned a Scope and Severity letter grade from A to L. The more serious and widespread the harm, the more points the deficiency adds to the facility’s score. A lower score means fewer and less severe deficiencies, which translates to a higher star rating.

As of July 2025, CMS uses the two most recent standard surveys to calculate this rating. The most recent survey carries 75% of the weight and the previous one carries 25%. Complaint investigations and infection control surveys still use a three-year lookback.

Revisit penalties apply when a facility fails to correct deficiencies promptly. A second revisit adds 50% of the health inspection score. A third revisit adds 70%. A fourth revisit adds 85%.

Health Inspection ratings are ranked relative to other facilities within the same state, not nationally. The top 10% in each state earn 5 stars. The bottom 20% earn 1 star. The middle 70% split evenly into 2, 3, and 4 stars. This means a 3-star facility in a state with strict surveyors may actually outperform a 4-star facility in a state with lenient oversight.

The Staffing domain scores six measures: case-mix adjusted total nurse staffing, case-mix adjusted RN staffing, case-mix adjusted total nurse staffing on weekends specifically, total nurse turnover, RN turnover, and administrator turnover. The maximum possible score is 380 points.

The weekend staffing measure was added specifically to address the documented pattern of facilities reducing staff on Saturdays and Sundays when oversight is lower.

Total nursing hours nationally average about 3 hours 53 minutes per resident per day. RN hours average about 41 minutes per resident per day. A turnover rate of 50% means half the nursing staff left in a single year. Administrator turnover above 1 per year signals leadership instability.

Nine measures track chronic care residents: increased need for help with daily activities, worsened ability to walk, pressure ulcers among high-risk residents, catheter use, urinary tract infections, falls with major injury, antipsychotic medication use, hospitalizations per 1,000 resident days, and ER visits per 1,000 resident days.

Six measures track rehab residents: discharge function score (whether the resident met expected recovery goals), new or worsened pressure ulcers, new antipsychotic medication initiation, re-hospitalization rates, ER visits, and successful return to home or community within 31 days of discharge.

Pressure ulcers in long-stay residents: national average 5.1%. Antipsychotic use in long-stay residents: national average 16.7% (updated January 2026 with claims data integration). ER visits per 1,000 long-stay days: national average 1.80. Hospital transfers per 1,000 long-stay days: national average 1.89. Short-stay re-hospitalization: national average 23.9%. Catheter use: national average 1%.

CMS places facilities on the SFF list when they score in the bottom tier nationally across repeated inspection cycles. Once designated, the facility faces inspections every six months instead of annually and must demonstrate measurable improvement. If they do not improve, CMS can impose fines, deny Medicare payments, or terminate the facility from the program entirely.

When a facility is on the active SFF list, all star ratings are suppressed on Care Compare. The profile shows a yellow warning icon instead of stars. As of 2026, CMS also lists active SFF facilities on a publicly available candidate list updated monthly.

Separate from SFF status, CMS places a red hand icon on facilities with documented abuse citations. The icon triggers when a facility has a harm-level abuse citation (Scope/Severity G or higher) on the most recent survey or within the past 12 months, or repeat abuse citations (D or higher) on both the most recent and the prior survey. A facility with the abuse icon has its Health Inspection rating hard-capped at 2 stars and its overall rating capped at 4 stars.

As of July 2025, Medicare Care Compare now aggregates performance data for entire corporate chains. Families can see how many facilities within a chain have triggered the abuse icon and what the chain’s average ratings are across all domains. This allows identification of whether poor performance is a single facility’s problem or a pattern across a corporate operator’s entire portfolio.

Quality Measures are largely self-reported through the Minimum Data Set. A 2014 investigation found that nearly two-thirds of facilities on the federal Special Focus Facility watch list were simultaneously achieving 4- and 5-star ratings on their self-reported Quality Measures. Abt Associates, the firm that designed the rating system, confirmed that upward movement in national star ratings was almost entirely driven by improvements in self-reported data, not by improvements in objective state inspection results.

Because antipsychotic medication use penalizes a facility’s Quality Measures score, facilities discovered they could attach a schizophrenia diagnosis to residents’ medical records and exclude those residents from the reported drugging rate entirely. The schizophrenia diagnosis rate in nursing homes nearly tripled between 2012 and 2024. The January 2026 antipsychotic respecification now cross-validates these diagnoses against claims data to catch this fraud, but families should still request medication administration records directly if they observe unexplained sedation.

OIG audits found that up to 43% of severe falls resulting in major injury were never reported in facilities’ self-submitted MDS assessments. Falls are a key Quality Measures indicator. A facility reporting a very low fall rate may simply be failing to document them.

A longitudinal study spanning 2009 to 2024 found that facility ratings fluctuate significantly from month to month and very few facilities maintain a consistent rating over time. A 3-star facility in a state with highly punitive surveyors may objectively provide better care than a 4-star facility in a state with lenient oversight, because Health Inspection ratings are relative to each state, not nationally comparable.