CMS Raises Quality Measure Thresholds in the July 2026 Five-Star Refresh: What Nursing Homes Need to Know

The Centers for Medicare & Medicaid Services (CMS) has updated the Nursing Home Five-Star Quality Rating System Technical User’s Guide for the July 2026 refresh. The primary change affects the point thresholds used to assign Quality Measure (QM) star ratings.

CMS increased the QM rating thresholds based on national improvement in quality measure scores between January 2025 and April 2026. The individual scoring thresholds for specific quality measures did not change. Instead, nursing homes may now need a higher combined QM score to earn or maintain the same long-stay, short-stay, or overall QM star rating.

For nursing home leaders, this update reinforces an important reality: maintaining current performance may not always be enough to maintain a current star rating as national quality performance continues to improve.

What Changed in the July 2026 Five-Star Refresh?

CMS periodically raises QM rating thresholds to encourage continued quality improvement and prevent rating standards from remaining static as provider performance improves nationally.

Under the methodology established by CMS, QM rating thresholds may be increased every six months by an amount equal to 50% of the average improvement in QM scores. For example, if national QM performance improves by 2%, CMS may raise the applicable rating threshold by approximately 1%.

For the July 2026 refresh, CMS calculated average improvement using data from January 2025 through April 2026. The resulting thresholds apply to long-stay, short-stay, and overall QM ratings.

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July 2026 QM Rating Point Ranges

CMS calculates separate long-stay and short-stay QM ratings and combines these results when determining the overall QM rating. Because fewer points are available through the short-stay measures, CMS applies an adjustment factor so long-stay and short-stay performance contribute equally to the overall QM calculation.

What Does This Mean for Nursing Homes?

The updated thresholds do not mean that CMS changed the performance requirements for each individual quality measure. Facilities will continue to receive QM points using the existing individual measure scoring methodology.

The difference is that more total points may now be required to reach certain star-rating levels.

A nursing home could maintain relatively stable QM results yet experience a change in its QM star rating because the national rating thresholds increased. CMS has previously acknowledged that a rating change caused by an updated methodology does not necessarily indicate an immediate change in care quality or facility operations.

At the same time, the revised thresholds are intended to continually raise expectations as quality performance improves across the nursing home sector.

Facilities that are close to the lower boundary of their current star rating may face the greatest risk. A small change in one or more measures could result in movement to a lower rating category, while facilities seeking to improve their rating may need additional QM gains to reach the next threshold.

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Why QM Performance Matters Beyond the QM Rating

Quality measures are only one component of the Five-Star Quality Rating System, but the QM rating can influence a nursing home’s overall star rating.

CMS begins the overall Five-Star calculation with the health inspection rating. The staffing and QM ratings may then increase or decrease the overall rating under specific conditions. A five-star QM rating may increase the overall rating by one star, while a one-star QM rating may decrease it by one star.

Five-Star ratings may also influence:

• Consumer and family perceptions
• Referral relationships
• Hospital and health system partnerships
• Managed care contracting discussions
• Organizational reputation
• Quality improvement priorities
• Market positioning and occupancy strategies

Because Care Compare provides publicly accessible information, changes in star ratings may generate questions from residents, families, referral partners, governing bodies, and other stakeholders.

Facilities should be prepared to explain both their current quality performance and any rating changes associated with updated CMS thresholds.

What Nursing Home Leaders Should Review

The July update presents an opportunity for leadership teams to move beyond reviewing the star rating alone and examine the performance contributing to the facility’s overall QM score.

Begin by reviewing current long-stay and short-stay QM scores against the updated thresholds. Determine whether the facility remains comfortably within its current rating category or is approaching a threshold that could affect future performance.

Leadership and interdisciplinary teams should also review measure-level trends. Look for changes over multiple reporting periods rather than reacting to a single data point. Areas showing gradual decline may indicate opportunities related to clinical practices, assessment accuracy, documentation, care planning, staff education, or interdisciplinary communication.

Quality measure results should also be evaluated alongside internal clinical and operational data. A measure may identify a potential concern, but additional investigation is often needed to understand the systems and processes contributing to the result.

Questions for leadership teams may include:

• Which QMs are contributing the most and least points to our current rating?
• Are performance trends improving, remaining stable, or declining?
• Are quality measure reports consistent with internal clinical data?
• Are MDS assessments complete, accurate, and supported by documentation?
• Have resident characteristics or clinical needs changed?
• Are identified improvement opportunities incorporated into QAPI activities?
• Do frontline staff understand how daily care practices influence resident outcomes and quality measures?

Avoid Focusing Only on the Threshold

The new rating thresholds are important, but facilities should avoid treating the change as only a scoring issue.

Quality measures reflect resident outcomes and care processes across areas such as function, mobility, falls, pressure injuries, hospital use, emergency department visits, medication use, and other aspects of care.

Improvement efforts are most effective when they focus on the underlying resident experience rather than simply attempting to gain enough points to reach the next star level.

For example, an unfavorable trend may require the interdisciplinary team to examine:

• Changes in resident acuity
• Assessment and documentation practices
• Care plan implementation
• Staff competency
• Communication during changes in condition
• Medication review processes
• Root causes contributing to repeat outcomes
• Whether improvement interventions are being implemented consistently

A sustained approach to quality improvement may support both stronger resident outcomes and improved Five-Star performance.

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Five-Star Ratings Will Continue to Evolve

CMS designed the recurring threshold adjustment process to encourage ongoing improvement and reduce the need for larger, less frequent changes to the rating system. As national performance improves, rating expectations may continue to increase.

For nursing homes, this creates a moving performance environment. A facility that remains at the same level over time may eventually lose ground as national benchmarks advance.

Regular monitoring, accurate assessments, strong interdisciplinary communication, and meaningful QAPI processes can help facilities identify emerging concerns before they significantly affect quality outcomes or public ratings.

The July 2026 update should serve as a reminder that Five-Star performance is not a one-time achievement. It requires sustained attention to the systems, processes, and clinical practices that support quality care every day.