Understanding CMS Nursing Home Star Ratings: What Texas Families Need to Know
The CMS Five-Star Quality Rating System is the most important tool for evaluating nursing homes in Texas. Created by the Centers for Medicare & Medicaid Services, this system rates every Medicare/Medicaid-certified nursing home on a 1-to-5 star scale.
How the Star Rating System Works
Each nursing home receives ratings in three categories plus an overall rating:
1. Health Inspection Rating (Weighted Most)
Based on the 3 most recent annual inspections and complaint investigations. This category carries the most weight in the overall rating because it reflects actual on-site findings by state surveyors.
- Scope and severity of deficiencies found
- Number of repeat deficiencies
- Correction of identified problems
2. Staffing Rating
Based on two measures of nursing staff hours per resident per day:
- Registered Nurse (RN) staffing — Higher RN hours correlate with better outcomes
- Total nursing staffing — Includes RNs, LPNs, and CNAs
Staffing data is self-reported by facilities and audited by CMS. The national minimum standard is 4.0 total nursing hours per resident per day (effective 2026).
3. Quality Measures Rating
Based on 15+ quality measures in three domains:
- Short-stay measures — ER visits, falls with injury, pressure sores
- Long-stay measures — Catheter use, UTIs, weight loss, antipsychotic medication use
- Process measures — Staff vaccination rates, functional assessments
What Each Star Rating Means
- 5 Stars — Much Above Average: Top-performing facilities. Excellent care quality, strong staffing, clean inspection records.
- 4 Stars — Above Average: Good quality with minor areas for improvement.
- 3 Stars — Average: Meets minimum standards. Some areas of concern to monitor.
- 2 Stars — Below Average: Notable quality concerns. Requires careful evaluation before choosing.
- 1 Star — Much Below Average: Significant quality problems. Generally not recommended unless no alternatives exist.
Texas Nursing Home Ratings Overview
Texas has approximately 1,200 Medicare/Medicaid-certified nursing homes. The distribution:
- 5-Star: ~15% of facilities
- 4-Star: ~20% of facilities
- 3-Star: ~25% of facilities
- 2-Star: ~22% of facilities
- 1-Star: ~18% of facilities
Texas’s average rating is slightly below the national average, making it especially important to research individual facilities.
Limitations of the Star Rating System
While the CMS rating system is valuable, it has limitations:
- Self-reported staffing data can be inflated (new federal staffing requirements aim to address this)
- Lag time — Ratings may not reflect the most recent inspection results
- Doesn’t capture everything — Resident satisfaction, food quality, and activities aren’t measured
- One bad inspection can disproportionately lower a facility’s rating
Tips for Using Star Ratings Effectively
- Always visit in person — A 5-star facility with a cold, institutional feel may not be the best fit
- Check recent inspection reports at medicare.gov/care-compare
- Compare all three sub-ratings — A facility with 5 stars overall but 2 stars in staffing is a red flag
- Talk to current residents’ families for real-world perspectives
- Use our directory to compare CMS-rated nursing homes in your Texas city