CMS is changing the nursing home survey process.

Beginning September 8, 2026, the Centers for Medicare & Medicaid Services will implement the Risk-Based Survey, or RBS, process nationwide for qualifying nursing homes.

For nursing home administrators, directors of nursing, regional leaders, and compliance professionals, this is more than a change in survey mechanics. It is another reason to take a hard look at survey readiness, staffing, quality performance, complaint activity, and the systems your organization has in place before surveyors arrive.

CMS estimates that only about 12% of nursing homes nationwide currently qualify for the Risk-Based Survey process.

So, what exactly is changing, who qualifies, and what should your facility be doing now?

What Is a Risk-Based Survey?

The Risk-Based Survey is a modified version of the traditional Long-Term Care Survey Process, or LTCSP, intended for higher-performing nursing homes.

CMS began testing the model in 2023 across 22 states and more than 100 facilities. According to CMS, the pilot was able to identify noncompliance and resident risk at levels comparable to the traditional survey process.

For qualifying facilities, the Risk-Based Survey may include:

• A more focused survey process

• Fewer survey activities

• A smaller resident sample

• Fewer surveyors onsite

• Approximately half the onsite survey time of the traditional LTCSP

That does not mean the standards are reduced.

Facilities are still expected to comply with federal requirements, and surveyors will continue evaluating resident safety, quality of care, regulatory compliance, and facility systems.

The major difference is that CMS is directing fewer survey resources toward facilities it considers lower risk while allowing states to direct more resources toward facilities where greater risk may exist.

Can a Nursing Home Request a Risk-Based Survey?

No.

A facility cannot simply request a Risk-Based Survey because it has a strong leadership team, recently performed well on survey, or believes it is low risk.

CMS establishes which facilities qualify based on specific performance criteria.

CMS plans to provide State Survey Agencies with lists of qualifying facilities quarterly. Eligibility can also change if certain events occur before the survey begins.

How Does a Facility Qualify for the Risk-Based Survey?

To qualify, CMS requires facilities to meet a number of quality, staffing, survey, and compliance-related criteria.

Among the requirements, a facility must have:

• A 5-Star Overall Rating

• At least a 3-Star Staffing Rating

• No Actual Harm citations during the applicable survey cycle

• No Immediate Jeopardy citations during the applicable survey cycle

• No Substandard Quality of Care citations during the applicable survey cycle

• No staffing waiver in effect

• No failed Payroll-Based Journal staffing data audit

• No failed Minimum Data Set audit

• A Health Inspection Score at or below the 50th percentile within the state

• No qualifying concern related to post-admission schizophrenia diagnoses under the CMS criteria

• No change of ownership since the last standard survey

• No Special Focus Facility candidate designation

• No period exceeding 18 months without a standard survey

CMS defines the applicable survey cycle to include the most recent standard survey and complaint investigations occurring during the previous year.

This means qualifying for RBS is not based on one good annual survey alone.

Staffing, complaints, audit performance, quality indicators, and other operational factors matter.

Qualifying Once Does Not Mean You Stay Qualified

Even if a facility appears on the Risk-Based Survey qualification list, eligibility can be lost before the survey begins.

CMS identifies several events that can disqualify a facility, including:

• Actual Harm citations

• Immediate Jeopardy citations

• Abuse citations

• Substandard Quality of Care citations

• Pending intake investigations triaged at Immediate Jeopardy

• More than three active non-IJ complaints or facility-reported incidents meeting certain risk thresholds

• CMS-approved nursing waivers

• A change in ownership

If one of the identified exclusion criteria is met, the State Agency must convert the survey to the traditional Long-Term Care Survey Process.

That is an important distinction.

Risk-Based Survey eligibility is not simply a status to achieve. It reflects an ongoing picture of facility performance.

Why Is CMS Making This Change?

CMS has acknowledged significant pressure on the nursing home survey system.

According to the agency, survey funding has not increased since 2015, while State Survey Agencies have experienced more than a 20% increase in their obligation to conduct complaint surveys.

CMS reports that these resource limitations have contributed to delays in complaint investigations and a backlog of nursing homes awaiting standard surveys.

The Risk-Based Survey model is designed to allow states to use fewer resources in higher-performing facilities and redirect those resources toward facilities and complaints where residents may face greater risk.

For operators, that means survey readiness remains important regardless of whether your facility qualifies for RBS.

If anything, facilities that do not meet the higher-performing criteria should be asking why.

The Most Common Citation Risks Have Not Gone Away

The survey process may be changing, but many of the compliance issues driving deficiencies remain familiar.

Based on 2026 national citation data, several of the most frequently cited areas include:

These are not obscure regulatory requirements.

They involve the everyday systems that nursing homes manage: infection control, falls, supervision, food safety, quality of care, medications, care planning, documentation, and activities of daily living.

The question for leadership is not whether your policies address these areas.

The better question is whether your actual practices match your policies when nobody knows a surveyor is watching.

What Should Nursing Home Leaders Do Now?

Start by reviewing CMS QSO-26-14-NH with your leadership and quality teams.

You can review or download the CMS memorandum here:

https://www.cms.gov/files/document/qso-26-14-nh-original-release-2026-07-16.pdf

Next, evaluate your organization through the same lens CMS is using.

Look beyond your most recent survey.

Review:

• Current Five-Star performance

• Staffing performance

• Recent complaints and facility-reported incidents

• Previous deficiency patterns

• Infection prevention practices

• Accident and supervision systems

• Care planning

• Medication management

• Documentation

• MDS accuracy

• PBJ reporting

• Quality assurance and performance improvement activity

Most importantly, do not wait until your survey window becomes urgent to begin preparing.

Survey readiness should be an operational process, not an annual event.

How SMK Medical Helps Facilities Prepare

At SMK Medical, we work with nursing homes, regional teams, and post-acute care organizations to identify compliance risk before surveyors walk through the door.

Our survey readiness support is not designed simply to generate a list of findings.

We work with leadership to understand why an issue exists, determine the level of risk, and develop practical next steps.

Our support may include:

• Comprehensive Mock Surveys

• Survey Readiness Assessments

• High-risk clinical and regulatory reviews

• Infection prevention reviews

• Accident prevention and supervision reviews

• Care planning and documentation review

• Pharmacy and medication management review

• Quality-of-care review

• Leadership coaching and survey preparation

• Identification of potential deficiencies before survey

• Practical recommendations for corrective action

Our goal is straightforward.

Find the risk before the surveyors do, then help your team do something about it.

Do Not Make Your Actual Survey Your Practice Survey

A mock survey provides leadership with an opportunity to see the building differently.

It can help determine whether policies have actually been implemented, whether staff understand expectations, whether documentation supports the care being delivered, and whether systems are working consistently across shifts and departments.

If your survey window is approaching, if your team has concerns about readiness, or if you simply want an experienced second set of eyes on your facility, we can help.

Call SMK Medical directly at 313-314-8267.

You can also schedule a free 30-minute healthcare consultation with our team:

https://tidycal.com/smkmedical/schedule-your-free-30-minute-health-care-consultation-now

Learn more about our Mock Survey and Survey Readiness services:

https://mocksurvey.com

Free Resource: Mock Survey Preparation eBook

We also created a free Mock Survey Preparation eBook that nursing home leaders can use with their teams as part of their survey readiness process.

Access the free eBook here:

https://flipbooklets.com/pdfflipbooklets/mocksurvey-prep-book

Need Ongoing Compliance Support?

Survey readiness should continue between mock surveys and annual surveys.

SurveyGuard is our compliance and quality management platform built specifically for post-acute care organizations.

SurveyGuard helps teams manage survey readiness, audits, plans of correction, QAPI, grievances, compliance monitoring, and other quality activities from one platform.

Learn more at:

https://surveyguard.com

SMK Medical
Your Post-Acute Care Compliance Experts
313-314-8267