If you’re evaluating nursing homes in Houston, the Centers for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System is one of the most useful publicly available data sources — but it’s also widely misunderstood. A facility with 5 stars is not always better than a facility with 3 stars on every dimension, and a 1-star health inspection rating can reflect a single bad survey year.
This guide explains how CMS Five-Star ratings are calculated, what each component measures, and how to use the data intelligently when choosing a nursing home in Houston.
How the Rating System Works
CMS assigns each certified nursing home four separate ratings:
- Overall rating (1–5 stars) — a composite of the three component ratings below
- Health inspection rating — based on state survey findings (inspections and complaint investigations)
- Staffing rating — based on hours of nursing care per resident per day, adjusted for case mix
- Quality measures rating — based on clinical outcomes data from resident assessments
CMS recalculates ratings monthly and publishes them on Medicare.gov’s Care Compare tool. This site syncs CMS ratings for Houston-area nursing homes monthly.
Health Inspection Rating (Most Important Component)
The health inspection rating is the most consequential component. It is based on:
- Standard surveys: Annual unannounced surveys conducted by HHSC inspectors covering 17 care areas (including resident rights, quality of care, infection control, and environment)
- Complaint investigations: Surveys triggered by complaints filed by residents, families, or staff
- Focused infection control surveys (added during and after the COVID-19 pandemic)
Each deficiency is classified by:
- Scope: Isolated (1 resident affected), pattern (multiple residents), or widespread
- Severity: A through L, where A–C are no harm, D–F are minimal harm, G–I are actual harm, and J–L are immediate jeopardy to resident health or safety
CMS uses a weighted point system: high-severity citations (G–L) carry exponentially more weight than low-severity ones. A single “Immediate Jeopardy” (J–L) citation can collapse a 5-star rating to 1 star overnight.
What to Look For
- Any “G” or higher severity citation in the past three years — these represent actual harm to residents
- Repeat deficiencies in the same category across multiple survey years — indicates a systemic problem, not an isolated incident
- Recent complaint investigations and their outcomes
- Compare the facility’s deficiency count to the Texas state and national averages (CMS publishes these on Care Compare)
Staffing Rating
The staffing rating measures two things:
- Total nurse staffing: Combined hours per resident per day from RNs, LVNs/LPNs, and CNAs
- RN hours specifically: Registered nurse hours per resident per day (RNs provide higher-acuity care than CNAs)
CMS uses MDS-based staffing data (self-reported) and compares facilities to state and national averages, adjusted for the facility’s case mix (i.e., how complex the residents’ care needs are). A facility serving post-acute rehabilitation patients needs different staffing than one serving stable long-term care residents.
What to Look For
- Compare RN hours to the state average — facilities below average on RN hours specifically may have inadequate clinical coverage
- A 5-star staffing rating with a 1-star health inspection should give pause — it may mean adequate staff levels but poor care practices
- Ask the facility directly for their current census and staffing ratios during day, evening, and night shifts — surveys measure past data, not current conditions
Quality Measures Rating
The quality measures (QM) rating is based on clinical outcomes drawn from the Minimum Data Set (MDS) — standardized assessments completed by facilities for every Medicare/Medicaid resident. Quality measures include:
- Percentage of residents experiencing pressure ulcers (bedsores)
- Percentage using physical restraints
- Percentage with urinary tract infections
- Percentage experiencing pain
- Percentage with falls resulting in major injury
- Vaccination rates (flu, pneumococcal)
- Short-stay measures: successful return to community, re-hospitalization rates
Quality measures are split into long-stay (residents living in the facility for 90+ days) and short-stay (post-acute rehabilitation) populations.
What to Look For
- Pressure ulcer rates are a strong signal of care quality — preventable in most cases with good positioning and skin care protocols
- Re-hospitalization rates for short-stay residents signal whether the facility is managing post-acute patients effectively or sending them back to the ER prematurely
- Compare to the Texas state average — a facility performing worse than average on multiple QMs warrants questions during the tour
Limitations of CMS Five-Star Ratings
CMS Five-Star ratings are a useful starting point but have well-documented limitations:
- Survey timing: Annual surveys are predictable — some facilities “stage” for surveys and allow standards to slip between them
- Self-reported staffing data: Until 2023, staffing data was self-reported. CMS now uses payroll-based data, which is more reliable, but historical ratings may be inaccurate
- Quality measure gaming: Some facilities code MDS data strategically to minimize quality measure deficiencies
- No direct care quality measurement: Five-Star does not directly measure resident experience, dignity, responsiveness, or actual quality of daily care interactions
How to Use CMS Ratings in Houston
- Use Five-Star as a filter to eliminate clear outliers (consistent 1–2 star facilities across multiple categories)
- Read the full inspection reports for any facility in your final list — available free on Medicare.gov Care Compare
- Compare health inspection deficiencies to the Texas state average (displayed on Care Compare)
- Ask the facility administrator about any G+ severity deficiency from the past three years — a good administrator will explain the corrective action taken
- Combine CMS data with an in-person tour using the 25-question tour guide
Browse Houston nursing homes with CMS Five-Star ratings displayed on every facility page. CMS data is synced monthly.