The single most useful fact about the five-star widget is printed nowhere near it: the health inspection rating — the backbone of the overall star — is graded on a curve, and the curve is drawn one state at a time.
CMS doesn't score facilities against a national yardstick. For the health inspection rating, it computes an inspection score from each facility's citations and then ranks that score against other facilities in the same state. The stars follow the ranking:
| Health inspection stars | Roughly which facilities get them |
|---|---|
| ★★★★★ | The top ~10% of facilities in that state |
| ★★ – ★★★★ | The middle ~70%, in bands |
| ★ | The bottom ~20% of facilities in that state |
CMS publishes the actual dollar-and-cents version of this — separate cut-point tables per state — in its state-level cut-point tables. Fifty-plus different grading curves, one per state, refreshed as the data changes.
It's not arbitrary. Inspections are carried out by state survey agencies on CMS's behalf, and states differ — in how aggressively they cite, how backed up they are, how they staff surveys. Ranking within a state controls for the strictness of that state's inspectors. As statistical engineering, it's defensible. As consumer labeling, it's a problem: nothing on the star widget tells you the grade is relative to in-state neighbors, not to nursing homes in general.
It means identical inspection records can produce very different stars depending on the state. A Scripps News analysis found 397 facilities rated 4 or 5 stars that would have scored 1 star under another state's curve, with the same inspection findings. The facility didn't change; the curve did.
One wrinkle that makes the overall star confusing rather than useless: only the health inspection component is curved by state. The staffing rating and the quality-measure rating use national thresholds. The overall star blends one state-relative number with two national ones — which is why we say it doesn't compare across state lines rather than saying it means nothing.
Families here shop across DC, Maryland, and Virginia in a single afternoon — three different curves. A 4-star facility in the District and a 3-star facility in Silver Spring have not taken the same test, and their stars can't settle the comparison.
That's why CareCheck's all-DC comparison table sorts by CMS stars — every facility in it is on the same curve — and why, as we add Maryland and Virginia suburbs, cross-state tables will rank by the raw record instead.
The record underneath the stars is not curved. These travel across state lines just fine:
Harm-level citations. A citation lettered G or worse
means inspectors found actual harm to a resident (G–I) or immediate jeopardy (J–L) — the letters
mean the same thing in every state.
Federal fines imposed. Dollar amounts and dates, straight from CMS's penalty file
(with the imposed-vs-paid caveat).
Payroll-based staffing hours. Nurse hours per resident per day come from audited
payroll submissions, not from ratings math.
Every CareCheck facility ledger leads with exactly these, and every facility page notes that its stars are within-state. For how the rest of the rating machine works, see how star ratings actually work and the methodology.