SNF Star Ratings: Improving Your Quality Rankings

A hospital discharge planner pulls up your facility’s profile. Before they talk to your staff, before they review your care capabilities, they see your star rating.

That score influences how quickly you get referrals, how families perceive your care, and whether hospitals trust you with their patients.

If you’re leading admissions, managing operations, or trying to keep your census up, you need to understand how the CMS Five Star Quality Rating System works — because your rating affects every part of your facility’s performance.

In this article, we’ll cover:

• What SNF star ratings are and how CMS calculates them

• The three components of the CMS Five Star Rating System

• Why ratings matter for families and facility operators

• Tips for improving and maintaining a strong SNF rating

What are SNF star ratings?

SNF star ratings are part of the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System, a national framework used to evaluate and compare the performance of skilled nursing facilities (SNFs). Each facility is assigned a rating from one to five stars, with five indicating above-average quality.

These ratings are designed to bring more transparency and consistency to a highly complex industry. They provide a snapshot of how well a facility is performing across three critical areas: health inspections, staffing, and quality measures.

For SNF leaders, this rating system directly impacts how your facility is perceived by families, hospitals, and referral partners. CMS updates these ratings monthly and makes them available to the public through its Care Compare website.

It’s where most families and hospital discharge planners go when evaluating their options.

What do the ratings measure?

Medicare star ratings for skilled nursing facilities play a key role in how families, hospitals, and referral partners evaluate care quality and decide where to send patients.

Ratings are based on three specific categories, each reflecting a different part of your facility’s performance:

• Health inspections

• Staffing levels

• Quality measures

Each category gets its own star rating, and together, they determine your overall score.

Health inspections carry the most weight. These come from standard CMS surveys, as well as any complaint investigations or follow-ups over the past three years. Deficiencies are scored based on severity, scope, and recency. A major citation can drag your rating down for years, even if you’ve made real improvements since then.

Staffing focuses on registered nurse (RN) hours and total nurse staffing per resident, adjusted for case mix. While the data is self-reported, CMS now verifies it against payroll-based journal (PBJ) submissions. This means staffing reports need to be both accurate and consistent. Even small drops in coverage can reflect poorly when compared nationally.

Quality measures (QMs) are drawn from MDS assessments and track specific clinical outcomes, things like fall rates, rehospitalizations, and pressure ulcers. Some QMs are long-stay focused, others short-stay, and CMS weights them accordingly.

Each component gives a snapshot of how your facility performs clinically and operationally. Together, they build the foundation of your public-facing rating.

How to interpret the stars

CMS star ratings for Skilled Nursing Facilities (SNFs) range from 1 to 5, with 5 stars representing the highest quality. These ratings are not based on a fixed national standard but are comparative within each state, meaning your facility is ranked against others in your region.

For the health inspections domain, the system uses a percentile-based approach. The top 10% of facilities in a state earn a five-star rating for health inspections, while the bottom 20% receive one star. The remaining facilities in the middle 70% are assigned two, three, or four stars. 

However, the overall star rating isn’t directly tied to these percentiles alone. Instead, it’s a composite score that starts with the health inspections rating and is adjusted based on two additional domains: staffing and quality measures. 

For instance, strong performance in staffing or quality measures might boost your overall rating, while weaker results could lower it.

This system means that even if your facility’s internal metrics stay the same, your rating can shift if other facilities in your state improve their performance. Here’s what else can influence your score:

• Recent surveys or complaints: These directly affect the health inspections rating, which serves as the foundation of the overall score.  

• Changes in reported staffing or MDS submissions: Accurate and timely reporting is critical, as staffing and quality measures play a significant role in adjusting the overall rating.  

• State-level adjustments based on historical performance: CMS periodically recalibrates the rating system, which can lead to changes in how facilities are scored.

Because CMS updates the data monthly and recalculates ratings with new information, your facility’s score might change even if nothing inside your building seems different. This makes it essential to monitor both your internal metrics (like survey results and staffing levels) and how they stack up externally against other SNFs in your state.

Why SNF star ratings matter

If your facility is trying to build stronger hospital partnerships, drive more referrals, or improve occupancy, your CMS rating matters a great deal in the way others see you and how much they trust your facility.

Hospitals and ACOs often rely on these ratings when choosing where to discharge patients. A lower star rating can slow your admissions pipeline or put you behind higher-rated competitors. In some regions, hospitals are even setting minimum star rating thresholds for their preferred provider networks.

Families use these ratings too, especially adult children searching online after a parent is hospitalized. Even if your clinical outcomes are strong, a poor rating can undercut the trust you’ve built locally.

There’s also a reputational layer. State surveyors pay closer attention to one- and two-star facilities. Your rating can influence how regulators approach future inspections — or how they interpret borderline deficiencies.

Bottom line: Your star rating affects how your facility is treated by hospitals, families, and regulators. It's not the only measure that matters, but it’s one you can’t afford to ignore.

Common criticisms of the five-star system

Most operators are familiar with the CMS rating process, but many question how accurately it reflects real-world performance. Some of the most common concerns include:

Inconsistent enforcement across states

Surveyors in one region may cite for issues that wouldn’t draw a deficiency elsewhere. Operators in multi-state groups often notice that what earns a four-star rating in one state might barely get three in another.

The lack of nationwide standardization adds uncertainty, especially when ratings influence referrals and regulatory scrutiny.

Heavy reliance on self-reported data

While CMS now cross-checks staffing levels with payroll-based journal data, much of the quality measures reporting still depends on what facilities enter through the MDS.

If one facility is extremely diligent about reporting falls or pressure ulcers and another is less thorough, the more transparent one may appear to have worse outcomes, even if it’s actually providing better care.

Risk of gaming the system

Some facilities have optimized their documentation practices to improve ratings without necessarily improving care. For example, keeping staff hours artificially inflated before PBJ submissions or selectively reporting quality events can temporarily bump a star rating.

These practices erode trust in the system and make it harder for high-performing facilities to stand out for the right reasons.

Lagging data timelines

Star ratings reflect data from the past, sometimes several months or more. That means recent improvements (like new leadership, training investments, or better staffing coverage) can take a long time to show up in your public score.

Limited reflection of specialty care or acuity

Facilities that take higher-acuity patients or accept short-notice discharges from hospitals may face unfair penalties on certain quality metrics. The system doesn’t fully adjust for the level of care complexity, which can discourage facilities from accepting high-need or high-risk patients.

How facilities can improve their rating

Improving your CMS star rating involves building systems that catch issues early and support staff consistently. One of the most effective strategies is running internal mock surveys.

Facilities that bring in former state surveyors or experienced consultants often uncover issues that would otherwise lead to citations, from outdated care plans to overlooked infection control procedures.

Treating mock findings like real tags, with assigned follow-ups and documentation, can help your team prepare with confidence.

Staffing data is another critical area. CMS verifies reported hours using PBJ data, so it’s essential to ensure that what’s submitted reflects reality on the floor.

Facilities making progress in this area are reviewing timekeeping systems to catch discrepancies in weekend, overnight, or agency hours. Even small errors can create staffing shortfalls on paper, dragging down your rating.

Turnover also plays a big role. Facilities focused on retention (not just recruitment) are seeing better outcomes. Peer mentorship programs, onboarding check-ins, and flexible scheduling can all reduce churn and help stabilize coverage, which improves both care and survey readiness.

Leading operators also keep a close watch on quality indicators before they show up in MDS reports. Daily or weekly tracking of metrics like falls, rehospitalizations, or new pressure injuries allows teams to act quickly and avoid long-term impact on their star rating. Some SNFs use internal alerts or simple dashboards to flag trends early.

Finally, when deficiencies happen, the most effective response is a structured one. Facilities that take the time to perform root cause analyses, retrain staff, and share learnings across locations are less likely to repeat the same issues.

Since CMS weighs repeat citations more heavily, addressing patterns proactively can make a measurable difference in your future score.

Frequently asked questions

What is considered a good SNF rating?

A rating of four or five stars is generally considered strong. These scores indicate above-average performance compared to other facilities in your state. Facilities with three stars are rated average, while one- and two-star ratings signal below-average outcomes and often face more scrutiny from hospitals and regulators.

Are staffing levels a big factor in ratings?

Yes, staffing is a key part of the CMS Five-Star Rating System. Ratings consider both RN coverage and total nurse staffing hours, adjusted for case mix. Inaccurate or inconsistent payroll reporting can negatively impact your staffing score, and low staffing levels may also raise concerns during inspections.

How often does CMS update ratings?

CMS updates star ratings monthly using the latest data from surveys, staffing reports, and quality metrics. However, some components are based on a rolling three-year window, so changes may not show up immediately after improvements are made.

Why do some highly rated SNFs still have complaints?

A strong star rating reflects performance across standardized CMS metrics, but it may not capture every individual experience. Complaints can still occur at high-rated facilities, especially if they take high-acuity patients or experience sudden staffing changes. CMS also weighs complaint investigations as part of health inspection scores.

What affects a facility’s quality measures?

Quality measures are based on MDS submissions and cover outcomes like falls, pressure ulcers, hospital readmissions, and antipsychotic use. These are risk-adjusted but still influenced by how consistently and accurately data is reported. Facilities accepting medically complex residents may need to monitor these metrics more closely.

How can SNFs prepare for better survey results?

Facilities that do well on surveys usually prepare year-round — not just before expected visits. Conducting mock surveys, tracking internal quality indicators, and training staff on common deficiency areas can help minimize surprises. Addressing prior citations and documenting corrective actions also shows a pattern of continuous improvement.

Turning strong SNF star ratings into real referral wins

Strong SNF star ratings can boost your visibility, build hospital trust, and help fill your beds, but they’re only part of the equation. The other part is operational readiness. When a referral comes in, can your team respond quickly and confidently?

Can you make fast, accurate decisions without scrambling across systems or second-guessing a patient’s financial fit?

That’s where many facilities run into friction. Despite best intentions, teams are still flipping between platforms, manually reviewing complex hospital packets, and racing against referral windows without full visibility. This puts hard-earned hospital relationships at risk.

ExaCare was built to solve this exact problem. Our AI-powered admissions software gives SNFs and post-acute providers the tools to process referrals faster, screen patients more accurately, and eliminate guesswork from the intake process.

How ExaCare supports your SNF rating goals

ExaCare helps with two of the biggest drivers behind your star rating: speed and accuracy in patient admissions.

Here’s how ExaCare supports your CMS goals behind the scenes:

• Fewer admission errors: ExaCare’s AI parses lengthy referral packets and highlights critical clinical and financial risks, reducing the chance of admitting a patient your facility isn’t prepared to care for.
  
  

• Smarter staffing planning: By surfacing high-acuity needs up front, the platform gives your team the information they need to plan staff assignments more effectively for new admits.
  
  

• Improved hospital trust: Facilities that respond quickly and accurately to referrals build stronger relationships with discharge planners, who often factor CMS star ratings into their decisions.
  
  

• Better census management: Low census can impact staffing ratios and hurt quality. ExaCare helps you capture more referrals by responding faster, keeping occupancy stable and your staffing model balanced.
  
  

• Data to drive improvement: Built-in analytics let you track response times, referral outcomes, and denial reasons, giving leadership teams the insight to optimize processes and reduce friction in admissions.

With all your referrals in one place (and key clinical and financial insights surfaced automatically) your team can focus on what matters: Making the right call, the first time.

If your facility is investing in marketing or trying to build stronger referral pipelines, make sure your admissions process can keep up. ExaCare helps you stay fast, accurate, and prepared so those hard-won referrals don’t slip away.

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