State surveys of nursing homes are comprehensive, unannounced inspections conducted by state-level agencies on behalf of the Centers for Medicare & Medicaid Services (CMS). The primary purpose of these surveys is to verify that facilities receiving Medicare or Medicaid funding are compliant with federal requirements for participation, ensuring residents receive a high level of care and safety. These inspections are an accountability measure designed to protect the vulnerable population residing in skilled nursing and long-term care facilities. Surveys are not scheduled in advance and can occur at any time, including weekends and after business hours, to capture a true picture of daily operations. Facilities that fail to meet these established federal standards are issued citations, which can lead to fines, corrective action plans, or loss of government funding.
Core Quality of Care Standards
Surveyors focus on measurable clinical outcomes to determine if a nursing home is maintaining or improving a resident’s highest practicable well-being. A major focus is the prevention of pressure ulcers, commonly known as bedsores. The team evaluates whether the facility consistently implements preventive measures, such as frequent repositioning, providing proper nutrition and hydration, and using specialized pressure-reducing mattresses.
Minimizing the risk of falls is another critical area, as about one-third of falls among residents result in a major injury. Surveyors look for evidence of individualized fall risk assessments, the use of targeted interventions, and staff training to prevent these incidents. They also investigate medication management practices, checking for errors in administration, dosage, and adverse drug interactions. This includes a specific review of the use of antipsychotic medications, ensuring behavior is managed without drugs when possible.
The inspection team assesses the adequacy of nutritional and hydration support, monitoring for unexplained weight loss or signs of dehydration. Comprehensive care planning is also reviewed to ensure the resident’s plan is person-centered, addresses their current medical and psycho-social needs, and is updated to prevent deterioration in function. For instance, incontinence must be promptly assessed and managed with appropriate treatments to attempt to restore continence and prevent related issues.
Protecting Resident Rights and Dignity
State surveyors dedicate significant time to ensuring residents are afforded their federal and state-protected rights, which guarantee a dignified existence and self-determination. A primary concern is freedom from all forms of mistreatment, including verbal, sexual, physical, and mental abuse, as well as neglect and the misappropriation of personal property. Surveyors interview residents and staff, and observe interactions to confirm a culture of respect and consideration.
The team investigates the facility’s adherence to the right to privacy, which includes confidentiality of medical records and private communication with visitors. Residents also have the right to exercise self-determination, meaning they can make choices about their daily schedule, activities, and medical care, including the right to refuse treatment. This autonomy is protected through the requirement that facilities seek reasonable accommodation for a resident’s preferences.
A major focus is the restriction of physical and chemical restraints. Surveyors verify that restraints are not used for staff convenience or as a substitute for supervision. Physical or chemical restraints are only permitted if they are medically necessary to treat a resident’s symptoms, must be authorized by a physician for a specific period, and require the resident’s consent. Residents must be able to voice grievances about their care or the facility without fear of reprisal or discrimination.
Facility Safety and Infection Control
The facility’s physical environment and its protocols for disease prevention are closely examined to maintain a safe and healthy living space. Surveyors verify the implementation of an infection prevention and control program, which includes proper hand hygiene, cleaning protocols for equipment, and surveillance for communicable diseases. This program is important in a congregate setting to prevent outbreaks of infections like norovirus or Clostridioides difficile.
Food service sanitation is a required check, as nursing home residents are considered a highly susceptible population for foodborne illnesses. Inspectors look for compliance with standards like the U.S. Food and Drug Administration’s Food Code, ensuring proper food handling, storage temperatures, and staff hygiene. This also includes verifying that high-risk foods, such as unpasteurized juices or raw animal products, are not served to immunocompromised individuals.
Emergency preparedness is another mandatory review, requiring facilities to have a comprehensive plan based on a thorough risk assessment. This plan must detail procedures for evacuation, communication with external authorities, and the provision of essential subsistence needs like food, water, and medical supplies during a disaster. The team checks for compliance with fire safety regulations, including functional sprinkler systems and clear evacuation routes.
Staffing and Operational Compliance
State surveyors assess the administrative foundation of the nursing home, ensuring adequate resources are in place to support quality care. A core requirement is that the facility maintains sufficient nursing staff, both in number and competency, to meet the needs of all residents twenty-four hours a day. Surveyors review staffing data, often through the Payroll-Based Journal (PBJ) system, and may interview staff to determine if they have enough time to complete their assigned duties.
The facility must also maintain detailed documentation of staff competency, training records, and performance reviews. Required training topics for all staff include resident rights, abuse prevention, and infection control, ensuring the team is equipped with the necessary skills to deliver safe care. Another major focus is the Quality Assurance and Performance Improvement (QAPI) program, which CMS mandates for all skilled nursing facilities. QAPI is a data-driven, systematic process that requires the facility to continuously monitor its care systems, identify areas for improvement, and implement corrective action plans.