Understanding Nursing Home Inspection Reports

The Centers for Medicare & Medicaid Services (CMS) requires every Medicare and Medicaid-certified nursing home in the United States to undergo regular health inspection surveys. These inspections are unannounced—facilities receive no advance notice—and occur approximately every 12 to 15 months, with a national average of about 12.9 months between surveys.

The inspections are conducted by state survey agencies (often the state's Department of Health) acting on behalf of CMS. Survey teams typically include registered nurses, dietitians, social workers, sanitarians, and other specialists who spend several days on-site evaluating the facility.

There are three types of surveys a nursing home may receive:

• Standard surveys — the routine, comprehensive inspection covering all major regulatory areas
• Complaint investigations — triggered by reports from residents, families, staff, or other sources about potential problems
• Extended surveys — conducted when a standard survey finds substandard quality of care (deficiencies at severity level G or higher in certain categories)

Inspectors evaluate nursing homes against federal requirements defined in the 42 CFR Part 483 regulations. These cover virtually every aspect of nursing home operations:

Surveyors observe resident care, review medical records, interview residents and staff, and examine facility policies. They are looking for evidence that the facility meets—or fails to meet—each regulatory requirement.

When inspectors find a violation, they cite it using an F-tag (Federal tag code). Each F-tag is a unique identifier that maps to a specific federal regulation. The F-tag system was significantly revised in November 2017 as part of CMS's Phase 2 requirements update, reorganizing tags into a more logical structure.

F-tags are numbered sequentially (e.g., F550, F684, F689) and grouped into regulatory categories. Some commonly cited F-tags include:

Each F-tag citation includes a statement of the deficiency, the evidence found, and a severity/scope rating indicating how serious the problem is and how many residents are affected.

Every deficiency is rated on two dimensions: severity (how serious the harm or potential for harm) and scope (how many residents are affected). These two dimensions combine into a single letter grade from A through L.

Severity Levels

CMS defines four severity levels, from least to most serious:

Scope Levels

Scope describes how many residents are affected by the deficiency:

• Isolated — affects one or a very limited number of residents
• Pattern — affects more than a limited number of residents but is not pervasive throughout the facility
• Widespread — pervasive throughout the facility or represents a systemic failure that affects or has the potential to affect a large portion or all residents

The Complete A-L Matrix

Severity and scope combine into 12 possible ratings. Here is the complete matrix:

Deficiencies rated A through C are the least serious. Deficiencies rated J through L represent the highest level of concern—immediate jeopardy to resident health or safety.

After the survey team completes their inspection, the facility receives a Statement of Deficiencies (Form CMS-2567) listing every cited violation. The facility is then required to:

1. Submit a Plan of Correction (PoC) within 10 calendar days. The PoC must describe how each deficiency will be corrected, how residents affected will be identified and protected, what systemic changes will prevent recurrence, and the completion date.
2. Implement corrections within the timeframes specified in the PoC. The state survey agency may conduct a follow-up visit to verify corrections were made.

For more serious deficiencies (severity levels G through L), CMS has a range of enforcement remedies available:

• Civil monetary penalties (CMPs) — fines ranging from $71 to $25,048 per day depending on severity, or per-instance fines of $1,141 to $71,785
• Denial of payment — CMS stops reimbursing the facility for new Medicare/Medicaid admissions
• State monitoring — a state-appointed monitor oversees facility operations
• Directed plan of correction — CMS or the state dictates specific corrective actions
• Temporary management — an outside manager is appointed to run the facility
• Termination — the facility loses its Medicare/Medicaid certification

Facilities with a pattern of serious deficiencies may be designated as a Special Focus Facility (SFF) by CMS, subjecting them to inspections every six months and heightened enforcement.

In addition to routine inspections, state survey agencies investigate complaints filed about nursing homes. Anyone can file a complaint—residents, family members, staff, ombudsmen, or anonymous tipsters.

Complaints are prioritized based on the alleged severity:

• Immediate jeopardy complaints must be investigated within 2 business days
• Non-immediate jeopardy, high priority complaints must be investigated within 10 business days
• Other complaints may be addressed during the next scheduled survey or within a defined timeframe

Complaint investigation results appear on CMS reports alongside standard survey results. A facility with frequent substantiated complaints may see this reflected in their CareGrader grade through both the health inspection and penalty history components.

Health inspections account for 35% of the CareGrader grade—the single largest component. Our algorithm analyzes inspection data from the three most recent survey cycles and evaluates:

• Total number of deficiencies cited per survey cycle
• The severity/scope rating (A through L) of each deficiency
• Whether any immediate jeopardy citations (J, K, L) were issued
• Findings of abuse, neglect, or exploitation
• Results from complaint investigations
• Performance relative to state and national averages

Facilities with immediate jeopardy citations, abuse findings, or widespread deficiencies (scope levels C, F, I, or L) receive significant score reductions. The remaining 65% of the grade comes from staffing, quality measures, and penalty history.

You can search nursing homes on CareGrader to see each facility's grade, including a detailed breakdown of their inspection history, number of deficiencies, and severity distribution.

When reviewing a facility's inspection history, these findings should raise concern:

• Any immediate jeopardy citation (J, K, L) — the most serious finding possible, indicating residents were or could be in immediate danger
• Abuse, neglect, or exploitation findings — regardless of severity level, these indicate a fundamental failure in resident protection
• Widespread deficiencies (C, F, I, L) — problems affecting the entire facility suggest systemic issues rather than isolated incidents
• Recurring deficiencies — the same F-tag cited across multiple surveys indicates the facility is not fixing underlying problems
• Special Focus Facility (SFF) status — CMS has designated this facility as one of the worst-performing nursing homes in the state
• Large or frequent fines — civil monetary penalties indicate CMS considered the deficiencies serious enough to warrant financial enforcement
• Denial of payment orders — CMS has stopped paying for new admissions, one of the strongest enforcement actions short of termination