What Happens During a CMS Survey? A Behind-the-Scenes Guide for SNF Staff

For many skilled nursing facility staff members, the annual CMS survey is the most stressful event of the work year. Surveyors arrive unannounced, spend several days observing every aspect of care delivery, and produce a document that can affect the facility's reputation, finances, and ability to operate. But the survey process itself is well-defined, and understanding what happens at each stage can transform it from an anxiety-inducing mystery into something your team can prepare for and navigate with confidence.

The Annual Recertification Survey

Every Medicare- and Medicaid-certified skilled nursing facility undergoes a recertification survey approximately every 9 to 15 months. The survey is conducted by state survey agency staff on behalf of CMS. Its purpose is to determine whether the facility meets the federal requirements for participation in Medicare and Medicaid, as outlined in 42 CFR Part 483. The survey is unannounced — the facility receives no advance notice of the date or time the survey team will arrive.

Survey teams typically consist of two to five surveyors, depending on the size of the facility. The team usually includes registered nurses, a life safety code specialist, and may include a dietitian, social worker, or pharmacist consultant. The lead surveyor is called the Team Coordinator and is responsible for managing the overall survey process.

Offsite Preparation

Before the survey team ever arrives at your facility, they have already done significant preparation. Surveyors review your facility's history, including prior survey results, complaint investigations, and any enforcement actions. They review data from the CMS Quality Measures system, staffing data from the Payroll-Based Journal, and any recent incidents reported through the state's event reporting system. This offsite prep helps surveyors identify potential areas of concern before they walk through the door.

The Entrance Conference

The survey begins with an entrance conference, typically held with the Administrator and Director of Nursing. During this meeting, the Team Coordinator introduces the survey team, explains the survey process, and requests specific documents and information. The facility is usually asked to provide a current census list with room numbers, a list of residents with specific conditions or care needs, staffing schedules, meal times, and access to the medical records system.

The entrance conference is brief — usually 15 to 30 minutes. Surveyors want to get on the floor and begin observations as quickly as possible. Your team should have a survey readiness binder or checklist prepared in advance so you can provide the requested materials promptly. Delays in producing documents can create a negative first impression and may even be cited as a deficiency if they suggest poor organization.

Resident Sample Selection

After the entrance conference, the survey team selects a sample of residents to review in depth. The sample typically includes residents selected based on quality measure triggers, complaints received by the state agency, observations during the initial tour, and a random component to ensure broad coverage. The sample size varies but usually ranges from 15 to 30 residents in a medium-sized facility.

For each sampled resident, surveyors review the medical record, observe care delivery, interview the resident (if able), interview responsible family members, and interview direct care staff. This is where the majority of deficiencies are identified — through the gap between what the care plan says should be happening and what surveyors actually observe.

Key Survey Pathways

The CMS survey process uses a structured set of pathways to guide the investigation. Each pathway focuses on a specific area of care or regulatory requirement. Common pathways include unnecessary medications, where the surveyor reviews medication regimens for appropriateness; quality of life, which covers dignity, self-determination, and accommodation of needs; nutrition, which examines meal service, dietary assessments, and weight management; and infection control, which evaluates the facility's infection prevention program and staff practices.

Surveyors are trained to follow the evidence. If an observation or record review reveals a potential problem, the surveyor investigates further to determine whether a regulatory requirement was not met. This investigative approach means that a single observation — like a staff member not performing hand hygiene — can lead the surveyor down a pathway that results in a citation if the investigation reveals a systemic problem.

Staff Interviews

Staff interviews are a significant component of the survey. Surveyors interview CNAs, licensed nurses, department heads, and other personnel to assess their knowledge of facility policies, individual resident care needs, and regulatory requirements. Common interview questions include asking a CNA to describe a specific resident's care plan and preferences, asking nurses about fall prevention interventions for a high-risk resident, asking dietary staff about therapeutic diet modifications, and asking any staff member about abuse reporting procedures and timelines.

Staff who cannot articulate the care needs and interventions for their assigned residents raise red flags for surveyors. This is why ongoing education and competency verification are so important — not just for the survey, but for quality care delivery every day.

The Exit Conference

At the conclusion of the survey, the Team Coordinator holds an exit conference with the facility's leadership team. During this meeting, the surveyors share their preliminary findings, though they are careful to note that findings are subject to change during the final review process. The exit conference is not the time to argue about citations. Listen carefully, ask clarifying questions to make sure you understand the findings, and take detailed notes.

Within a few days to a few weeks after the survey, the facility receives the official Form 2567 — the Statement of Deficiencies and Plan of Correction. This document lists every deficiency cited during the survey, organized by F-Tag number, with the surveyor's findings and scope and severity rating for each. The facility then has a defined period, typically 10 calendar days, to submit a Plan of Correction addressing every cited deficiency.

What Comes Next

After submitting your Plan of Correction, the state survey agency reviews it for acceptability. If the POC is accepted, the facility must implement all corrective actions by the dates specified. The survey agency may conduct a revisit to verify compliance, particularly for citations with higher scope and severity ratings. Facilities with serious deficiencies may face enforcement actions including civil monetary penalties, denial of payment for new admissions, or in extreme cases, termination from the Medicare and Medicaid programs.

The best approach to the survey process is ongoing preparation. Facilities that maintain strong systems year-round — complete care plans, active QAPI programs, regular staff education, and robust documentation — consistently perform better during surveys than facilities that scramble to prepare when they hear the surveyors are in the lobby.

Paul Richards, RN, MSHI

Founder, EasyPOC

Paul Richards is a registered nurse and Chief of Informatics & Quality at The Allure Group, where he oversees healthcare informatics and quality improvement across a network of six skilled nursing facilities in New York City. He holds a Master of Science in Health Informatics and built EasyPOC to solve the compliance documentation challenges he witnessed firsthand every day.