Medicare.gov compresses a facility's entire regulatory record into one number between 1 and 5. Here's the machine that does the compressing — and the four things it quietly leaves out.
The overall star is built from three component ratings, per CMS's Five-Star Technical Users' Guide:
| Component | Where the data comes from | Who generates it |
|---|---|---|
| Health inspections | Citations from standard and complaint surveys | State inspectors (independent of the facility) |
| Staffing | Nurse hours and turnover from payroll submissions | Facility payroll, audited format |
| Quality measures | Clinical assessments (MDS) and some claims data | Mostly the facility, about itself |
The composite starts from the health inspection star, and the other two components can each move it up or down — generally by at most one star each, with guardrails that keep a poor inspection rating from being fully papered over. The health inspection rating is the backbone; the other two are adjustments.
The backbone component is a within-state percentile ranking, not a national grade — roughly the top 10% of facilities in each state get 5 stars and the bottom 20% get 1, per CMS's state cut-point tables. Identical records can earn different stars in different states. This one gets its own guide.
Since July 2025, the health inspection rating counts only the two most recent standard survey cycles — weighted toward the newest, plus complaint surveys from the last 12 months — per CMS memo QSO-25-20-NH. But the public citation file still carries roughly three cycles of history. CareCheck's ledgers show everything CMS publishes, which is why a facility's ledger can be longer than its star implies.
The window also assumes inspections are happening on schedule. In the current CMS release, 1,065 of 14,695 facilities (7.2%) had their most recent standard health inspection more than two years ago — CMS's own staleness flag, which CareCheck displays with the survey date on every affected facility page.
Most quality measures are built from MDS assessments that facilities submit about their own residents. Federal auditors have documented what you'd expect: a 2025 OIG audit found nursing homes failed to report 43% of falls with major injury that showed up in Medicare hospital claims. CMS has started blending independent claims data into some measures, but the self-reported core remains — which is why CareCheck's ledgers lead with inspections, penalties, and payroll staffing, the three streams a facility doesn't write about itself.
While a facility carries CMS's abuse icon, its health inspection rating is capped — so part of a flagged facility's low star is mechanical, not incremental new information. And Special Focus Facilities have their ratings withheld entirely: 86 facilities in the current release show no stars by design, which is not the same as "not rated" (that story here).
None of this makes the stars worthless. Within one state, they're a reasonable first sort — CareCheck's own DC table uses them that way. But they are a summary with editorial choices inside, and CMS publishes the ledger they summarize: every citation with a severity letter, every fine with a date, every payroll staffing report. That record is what CareCheck lays out, facility by facility, with its methodology in the open.