Quality Update: CMS Raises Quality Measure Thresholds in July Five-Star Refresh 

CMS recently released an updated Five-Star Quality Rating System Users Guide and implemented changes as part of the July 2026 Care Compare refresh.  

The most significant change for providers was not the addition of new quality measures or a redesign of the Five-Star system, but rather a recalibration of the thresholds used to determine Quality Measure (QM) star ratings. As nursing home performance improved nationally between January 2025 and April 2026, CMS increased the QM thresholds required to achieve each star level. The updated thresholds reflect one-half of the average national improvement observed during that period. 

Importantly, the underlying quality measures themselves did not change. CMS did not add new measures, remove existing ones, or alter the point values assigned to individual measures. 

As a result, facilities with the same performance in areas such as rehospitalizations, emergency department visits, pressure injuries, antipsychotic use, and falls with major injury may nonetheless see their Quality Measure star rating decline. 

A drop from four QM stars to three stars—or from three stars to two stars—does not necessarily indicate worsening quality or poorer resident outcomes. In many cases, it simply reflects higher national benchmarks and increased competition among providers. 

For operators and owners, the key takeaway is to look beyond the star rating itself and evaluate the underlying measures driving performance. Before concluding that quality has deteriorated, determine whether the facility’s actual outcomes changed or whether it simply fell on the wrong side of a higher national cutoff. 

This type of recalibration is not new. CMS periodically adjusts Five-Star methodologies to reflect changes in provider performance and policy priorities. Many providers will remember the significant Staffing Five-Star changes implemented in 2022, which dramatically altered staffing ratings nationwide despite little change in actual staffing performance. 

Compared with those changes, the July 2026 Quality Measure recalibration is relatively modest. However, facilities should be prepared to explain QM star changes to owners, boards, lenders, referral partners, and families who may assume that a lower star rating automatically reflects poorer care. 

The broader lesson remains the same: Five-Star ratings are relative measures, not absolute ones. They remain useful screening tools, but they do not tell the entire story. As CMS continues to refine the Five-Star system, providers should remember that a change in stars does not always represent a change in quality—it may simply reflect a change in how CMS chooses to measure it.