Methodology
How We Grade Senior Care Facilities
CareGrader assigns A-F grades to every Medicare/Medicaid-certified facility in the United States using official government data from the Centers for Medicare & Medicaid Services (CMS).
The A-F Scale
Each facility receives a composite score from 0 to 100, which maps to a letter grade:
Grading Components
The composite score is a weighted average of four component scores:
Health Inspections (35% weight)
Based on CMS health inspection survey results. We analyze the number, scope, and severity of deficiencies from the three most recent inspection cycles. Facilities with immediate jeopardy citations, abuse findings, or widespread deficiencies receive significant score reductions.
- Number of deficiencies per survey cycle
- Severity levels (A through L scale)
- Scope: isolated, pattern, or widespread
- Immediate jeopardy citations
- Abuse or neglect findings
- Complaint investigation results
Staffing (25% weight)
Evaluated using Payroll-Based Journal (PBJ) staffing data submitted directly to CMS. This measures actual staffing hours, not self-reported estimates. We focus on RN hours per resident per day, total nursing hours, weekend staffing, and turnover rates.
- RN hours per resident per day (PBJ verified)
- Total nursing hours per resident per day
- Weekend staffing levels
- RN turnover rate
- Total nurse turnover rate
- Comparison to state and national averages
Quality Measures (25% weight)
Derived from CMS quality measure data for both long-stay and short-stay residents. These metrics track health outcomes like falls, infections, pressure ulcers, and use of restraints or antipsychotics.
- Long-stay: falls, infections, catheter use, restraint use
- Long-stay: antipsychotic medication use
- Short-stay: rehospitalization rates
- Short-stay: emergency department visits
- Three-quarter rolling averages
- Performance vs. state and national benchmarks
Penalty History (15% weight)
Accounts for CMS enforcement actions including monetary fines, payment denials, and state monitoring. Facilities with larger, more recent, or more frequent penalties receive lower scores. Special Focus Facility (SFF) designation results in additional score reduction.
- Total fine amounts (last 3 years)
- Number of enforcement actions
- Recency of penalties
- Payment denial episodes
- Special Focus Facility (SFF) status
- SFF candidate status
Weight Distribution
Data Freshness
CMS updates its datasets monthly. We re-ingest all provider data, inspection results, staffing metrics, quality measures, and penalty records on a monthly cadence. Grades are recomputed after each data refresh, so our ratings always reflect the most current government data available.
Limitations
Our grading system relies on publicly available CMS data and has inherent limitations:
- Inspections occur periodically, not continuously. Conditions may change between surveys.
- Staffing data is based on payroll records and may not capture all staffing arrangements.
- Some facility types (assisted living, independent living) are state-regulated and may have less comprehensive CMS data.
- Quality measures are clinical metrics and may not capture all aspects of resident experience.
We recommend using CareGrader grades as one input in your decision, alongside in-person visits and conversations with staff and residents.