Every Medicare- or Medicaid-certified nursing home has a public record on Medicare's Care Compare: an overall star rating, three sub-ratings, inspection citations, federal fines and staffing numbers. The stars are a quick filter; the inspection details tell you what went wrong and whether it was fixed.
How the star ratings work
Care Compare gives each nursing home an overall rating from one to five stars, built from three separate ratings: health inspections, staffing and quality measures. CMS explains the method in its Five-Star Technical Users' Guide (September 2026 edition), which is the source for the details below.
Health inspections
State inspectors make an unannounced "standard" inspection of each nursing home about once a year on average, spending several days on site. They also investigate complaints and run focused infection control inspections.
The health inspection rating is based on:
- The two most recent standard inspections, with the newest counting for three quarters of the score and the older one a quarter
- Citations from complaint and infection control inspections over the past three years, with the most recent 12 months weighted more heavily
- Extra points when inspectors had to come back more than once to confirm problems were fixed
Each citation earns points based on how serious and how widespread it is. More points means a worse score. Homes are then ranked against other homes in the same state: the best 10 percent get five stars, the worst 20 percent get one star, and the middle 70 percent are split evenly across two, three and four stars. So a three-star home in one state is not directly comparable to a three-star home in another.
Staffing
The staffing rating uses six measures, taken from payroll data that nursing homes submit to CMS each quarter:
- Registered nurse (RN) hours per resident per day
- Total nurse hours per resident per day (RNs, licensed practical or vocational nurses, and nurse aides)
- Total nurse hours per resident per day on weekends
- Nurse staff turnover over a year
- RN turnover over a year
- How many administrators left in a year
Hours are adjusted for how sick the residents are. A home gets an automatic one-star staffing rating if it fails to submit data, if its data can't be verified in an audit, or if it reports four or more days in a quarter with no RN hours while residents were there.
Quality measures
The quality measures rating draws on 15 measures: nine for long-stay residents and six for short-stay residents. Medicare defines short-stay as 100 days or less (often people recovering after a hospital stay) and long-stay as 101 days or more. The measures include things like falls with major injury, pressure ulcers, antipsychotic use, rehospitalization and how many short-stay residents successfully return home. Care Compare also shows separate short-stay and long-stay ratings, since a home can be strong at rehab and weaker at long-term care.
How the overall rating is built
The overall rating is not an average. CMS builds it in three steps:
- Start with the health inspection rating.
- Add one star if the staffing rating is five stars; subtract one if it is one star.
- Add one star if the quality measures rating is five stars; subtract one if it is one star.
The result can't go above five or below one, and a home with a one-star health inspection rating can't be raised by more than one star overall. In practice, the inspection rating drives the overall score, and staffing and quality can move it up or down by up to two stars.
A home with only one standard inspection is too new to rate and shows "Not Available."
What citations and scope/severity mean
When inspectors find that a home doesn't meet a federal standard, they issue a citation (also called a deficiency). Each one gets a letter from A to L that combines two things.
Severity, from least to most serious:
- A, B, C: no actual harm, potential for minimal harm
- D, E, F: no actual harm, but potential for more than minimal harm
- G, H, I: actual harm to a resident
- J, K, L: immediate jeopardy to resident health or safety
Scope is the position within each group: the first letter means isolated, the second a pattern, and the third widespread. So a D is an isolated problem with potential for harm, while an L is a widespread situation putting residents in immediate danger.
Don't stop at the count. Several D-level citations are a different story from one G-level citation where a resident was hurt. Read the inspector's narrative for anything at G or above, and look for the same problem on more than one inspection.
A few other things to know:
- Citations a home is disputing through the informal dispute process are shown on Care Compare but don't count in the rating until the dispute ends.
- The third most recent standard inspection is displayed but not used in the rating, so it's still worth reading for patterns.
- Fire safety (life safety) citations are not part of the star rating.
Fines and payment denials
Medicare may penalize a nursing home for a serious health or fire safety citation, or for leaving a citation uncorrected for a long time. Care Compare lists two kinds:
- Fines, charged once per citation or for each day until the problem is corrected
- Payment denials, where Medicare and Medicaid stop paying for new residents until the home corrects the problem
If a home still doesn't fix the problems, Medicare can end its agreement, and residents on Medicare or Medicaid are moved to another certified home. States can impose their own penalties too, which may appear on state websites rather than Care Compare.
Warning signs: the abuse icon and Special Focus Facilities
The abuse icon
Care Compare shows an abuse icon next to homes recently cited for abuse or neglect. Under the September 2026 guide, a home gets the icon if it was cited for abuse where a resident was harmed (level G or higher) on its latest standard inspection or a complaint or infection control inspection in the past 12 months, or if it was cited for abuse at level D or higher in both of the last two inspection periods.
A home with the icon has its health inspection rating capped at two stars, so its best possible overall rating is four stars. The icon comes off at the first monthly update after the home no longer meets the criteria.
Special Focus Facilities
CMS runs the Special Focus Facility (SFF) program for nursing homes with a persistent record of serious problems. CMS describes these as homes with about twice the average number of citations and a "yo-yo" history of fixing problems only temporarily.
- A home currently in the program shows a yellow warning sign instead of an overall rating, and no ratings in any area.
- SFFs are inspected about twice as often as other homes, at least once every six months.
- A home graduates after two consecutive standard inspections with 12 or fewer citations, none above level E.
- CMS also publishes a monthly list of SFF candidates: homes in each state with the worst inspection scores that are eligible for the program. Being on the candidate list is a warning sign on its own.
CMS posts the current SFF and candidate lists on CMS.gov. On the positive side, starting in September 2026, Care Compare adds a trophy icon to high-performing five-star homes.
Reading the staffing and turnover numbers
Beyond the star, compare the actual staffing numbers across your shortlist.
- Hours per resident per day are averages across a quarter. They don't tell you how many staff are on the floor at a given moment or how much care any one resident gets.
- Weekend hours are scored as their own measure, so you can see whether staffing holds up on Saturdays and Sundays.
- Turnover shows how many nurses and aides left within a year. Lower is better: staff who stay longer know the residents and their routines.
- Administrator turnover: CMS gives its lowest score on this measure to homes where two or more administrators left in a year.
For context, federal rules require an RN on site for at least eight straight hours a day, seven days a week, and an RN or licensed practical nurse on duty around the clock. There is no federal standard for ideal overall staffing levels.
Using the record alongside a visit
Medicare and the National Institute on Aging both recommend visiting before you decide.
- Bring the record with you. Note the most serious recent citations and ask the administrator what changed. Medicare's checklist suggests asking whether every citation from the last inspection was corrected.
- Ask to see the latest inspection report on site. Nursing homes must keep their most recent survey available in a public place.
- Visit twice. Make a second visit without calling ahead, on a different day or time, and stop by at a meal.
- Watch staff with residents. Are interactions warm and respectful? Are residents clean and dressed?
- Ask about staffing: aides per resident on each shift, and how long the director of nursing has been there.
Take our touring checklist so you compare homes on the same points. If a home was cited for something specific, such as falls, ask how they handle it now. You can also contact your area's long-term care ombudsman, an advocate for residents who can answer questions about residents' rights and help resolve problems.
Practical next steps
- Search nursing homes near your parent on Pairlo's senior living search, or browse by state. Every nursing home page on Pairlo links to its CMS inspection record.
- For each home on your shortlist, check the overall rating, then open the health inspection details and read any citation at level G or above.
- Check for the abuse icon, any fines or payment denials in the past three years, and whether the home is on the SFF or SFF candidate list.
- Compare RN hours, weekend staffing and turnover across your shortlist.
- Visit at least twice, with your questions written down, and ask about anything in the record that worried you.
- Get paperwork in order before admission, including health care proxy and power of attorney. Our documents checklist lists what families usually need.
If you live far away, an aging life care manager can visit homes for you and give you an independent read.
