Washington, D.C. — Families searching for a nursing home often turn to Medicare’s star ratings as a starting point. But a new academic study says those ratings are far less reliable than most people assume — and the problems run deeper than a single bad score.
The research, published recently and covered by financial analysts, found that nursing home star ratings are highly volatile. Very few facilities held the same rating from one year to the next. Roughly half of nursing homes with one-star ratings gained at least one star within six months. About half of five-star facilities lost one or more stars in the same window.
The researchers don’t think that reflects real swings in care quality. They believe the volatility is largely a product of how the ratings are calculated — not what’s actually happening inside the building.
Two kinds of instability
The study identified two distinct sources of volatility. The first is facility-specific: over the long run, rating changes do tend to track genuine shifts in care quality. That part works as intended.
The second is more troubling. The ratings also experience what the researchers call “general volatility” — abrupt, system-wide shifts caused by changes in the methodology used to compile them. These changes can move ratings dramatically from one month to the next, with no connection to what’s happening on the floor.
That’s a problem for families trying to compare facilities over time. A nursing home that held a three-star rating for three years might have been above average in some of those years and below average in others — depending entirely on how the system was recalibrated.
The “average” problem
The government officially describes a three-star rating as “average.” The study found that’s not consistently true. Because of how the distribution shifts, a three-star rating can be above or below average depending on the year — and the definition of average varies significantly from state to state.
A facility that looks middle-of-the-pack nationally might be a standout in one state and a laggard in another.
What actually predicts quality
Despite the noise, the study found one consistent signal: staffing. Each additional hour of direct care per resident per day was associated with a higher star rating. That relationship held up across time and geography.
Ownership type also mattered. In 2025, only 14% of one-star nursing homes were operated by non-profits, while 47% of five-star facilities were. That gap has grown stronger over time, according to the researchers.
For families navigating the system, those two factors — actual staffing hours and non-profit status — appear to be more stable predictors of quality than the overall star rating itself.
The study also found that state minimum staffing laws had little effect on ratings. Most nursing homes already exceeded state-mandated minimums, so the mandates weren’t the binding constraint.
What it means for the industry
The findings add to a growing body of criticism around how quality is measured in long-term care. Operators have long complained that star rating cuts tied to staffing data audits can devastate a facility’s reputation without reflecting actual care failures — a concern that recently landed in federal court.
The researchers concluded the ratings system needs reform to reduce volatility and improve comparability. Until that happens, they say, users should treat the ratings as a rough guide — not a definitive verdict.
