Hearing a staff member say, “State just walked in the door,” shouldn’t ignite survey panic mode in the director of nursing services (DNS) and other department leaders in the nursing home, says Michelle Synakowski, RN, LNHA, RAC-CT, RAC-CTA, RAC-MT, RAC-MTA, president and CEO of ProSynk Healthcare Compliance Services.
Survey does not always have to be a devastating whirlwind, says Synakowski, who will present the April 24 session “Navigating the Survey Process and Avoiding Rough Seas” at the April 22 – 25 AAPACN 2025 Conference in Louisville, KY. “To avoid that feeling of being battered by the survey team, you can learn how to manage the process. You can take steps to empower yourself to have more control over what happens during survey. You may not always end up deficiency-free, but you definitely can reduce the negative impacts of the survey process.”
Highlights of effective survey management techniques that Synakowski will cover in detail at the conference session to help nurse leaders create an actionable plan include the following:
Do record reviews before survey to identify QM-triggering residents
To guide their initial on-site approach, surveyors review certain information, including the facility’s previous survey history, as well as its performance on the Nursing Home Quality Initiative (NHQI) quality measures (QMs), says Synakowski. “The surveyors examine trends, and they pick a sample of residents who trigger multiple QMs. This allows them to look at one resident and review, for example, five QMs vs. needing five separate residents (and five separate medical charts) to review those five QMs.”
The bottom line is that residents who trigger multiple QMs are more likely to be targeted during survey, says Synakowski. “A few months before your survey window opens up, you and your nursing management team should start doing chart reviews on a regular basis (e.g., once a week after morning report). You want to look for the QMs that are triggering and determine, for example, if you can identify any trends and whether all the necessary documentation is in place.”
Keep common IJ-level citations active in QAPI
“Surveyors consistently cite a number of the same F-tags at the immediate jeopardy (IJ) level year after year,” says Synakowski. “Your ongoing QAPI [quality assurance and performance improvement] program should always address the most frequent IJ-level citations.” Note: See the AAPACN chart “Top 10 IJ-Level Citations in the Past Few Years” at the end of this article.
No matter how well a facility performs, putting those critical F-tags through QAPI all the time will help the DNS limit IJ-level deficiencies, explains Synakowski. “When surveyors identify a problem during survey, they will always say, ‘Let me see your QAPI.’ If you don’t have any QAPI project on it at all, then you start moving down a different road. However, if you do have a QAPI project, the survey team often will cite you at a G, H, or I level (Actual Harm That Is Not Immediate) instead of at the IJ level.”
Train staff for surveyor interviews
Providers need a defined process for communicating with surveyors when the survey team is on-site, says Synakowski. “Everyone, including the DNS and other department leaders, should learn some ‘interview survival skills.’ For example, two of the many skills that we will discuss at the conference session are that (1) you should only answer the question that is being asked, and (2) you shouldn’t ever agree with a surveyor when they say, ‘Wouldn’t you agree that …?’”
Knowing and practicing these and other communication skills in advance will help promote better outcomes with the survey team interviews no matter what type of leading question a surveyor may ask, says Synakowski. “The goal is to avoid a negative interaction that will end up in black-and-white print on your Statement of Deficiencies (form CMS-2567).”
Plan a citation-reducing “surveyor arrival” strategy for staff
“To use a sports metaphor, survey should be your big game day—your Super Bowl where you would never hit the field without a strategy,” says Synakowski. “Facility staff in every department, including but not limited to nursing, should be prepared to begin implementing a ‘surveyor arrival’ strategy the minute that the survey team shows up in the building.”
This strategy should include a focus on common citations that are easily addressed, suggests Synakowski. “Some citations are easy fixes if staff across all departments understand their role and take prompt action. Everyone should have the mindset of ‘When I know that the surveyors have entered the building, it’s my job to go do X, Y, and Z.’”
Synakowski offers two examples, one involving kitchen staff and one for nursing staff, of how implementing a staff “surveyor arrival” strategy can serve as a last-minute double-check of simpler ongoing survey preparations:
* F-tag 812 (Food Procurement, Store/Prepare/Serve – Sanitary) is a frequent citation, says Synakowski. “Surveyors often cite F812 at a scope-and-severity level of F (Widespread/No Actual Harm With Potential for More Than Minimal Harm That Is Not Immediate Jeopardy). Implementing a strategy to minimize these citations should include, for example, having specific kitchen staff—as soon as the surveyors arrive—make sure that the dishwasher logs and refrigerator temperature logs are current and available and that nothing in the refrigerator is unlabeled, undated, or past its useable date.”
Note: In calendar year (CY) 2024, F812 was the third most frequent citation nationwide after holding steady in fourth place in both CY 2023 and CY 2022. However, among citations with a scope and severity of F or greater, F812 was the second most-commonly cited F-tag in CY 2024—the same position it has held since CY 2021, according to QCOR data accessed March 3, 2025.
* F761 (Label/Store Drugs and Biologicals) is another common citation that is often given for outdated medications, notes Synakowski. “The strategy to reduce these citations should include, for example, the nurse checking for outdated medications on the medication cart and in the refrigerator in the medication room as soon as possible when they learn that the survey team is on-site.”
Note: F761 was the seventh most frequent citation across the United States in CY 2024—the same as in CYs 2023 and 2022. However, among citations with a scope and severity of E (Pattern/No Actual Harm With Potential for More Than Minimal Harm That Is Not Immediate Jeopardy) or greater, it was the fifth most common F-tag in CY 2024, up from sixth place in CYs 2023 and 2022, according to QCOR data accessed March 3, 2025.
The following AAPACN graphic illustrates:
Create a communication command center
“A very strategic communication strategy has to take place when the state is in the building,” says Synakowski. “You should have a defined process of good practices.”
Two key components of this process are as follows:
* Active listening by all staff. “Everyone in the facility should be paying attention to which residents the surveyors are looking at and what questions they are asking,” suggests Synakowski. “Anyone who has any interactions with any surveyor needs to call in and report, ‘This is what just happened on my floor.’”
* A one-person command center. “You should designate one person as the facility’s command center, and staff must understand that they have to call the command center as soon as that interaction with the surveyor ends,” says Synakowski. “Your command center then needs to call every other unit so that they also know who and what the surveyors are looking for.”
The insights gained employing command center communication can help providers address issues and prepare staff in real time, says Synakowski. “For example, if you know that a specific resident is being targeted, your nurse manager can do a quick review of that resident’s care plan with the certified nursing assistant (CNA).”
The following AAPACN graphic illustrates that these on-site practices work in sync:
What to expect at the conference session
“Attendees should expect to come away with tangible tools that they can use to create a survey action plan,” says Synakowski. “You will learn how to better prepare for survey and then how to manage your staff all the way through the survey process.”
Top 10 IJ-Level Citations in the Past Few Years
| CY 2025 (data through Feb. 23) | CY 2024 | CY 2023 | CY 2022 |
| • F689 (Free of Accident Hazards/ Supervision/Devices) • F600 (Free From Abuse and Neglect) • F684 (Quality of Care) • F678 (CPR) • F580 (Notify of Changes (Injury/ Decline/Room, etc.)) • F880 (Infection Prevention and Control) • F726 (Competent Nursing Staff)* • F773 (Lab Services Physician Order/Notify of Results)* • F692 (Nutrition/ Hydration Status Maintenance)* • F714 (Physician Delegation of Tasks to NPP)* *Not in the top 10 in CY 2024, CY 2023, or CY 2022 | • F689 (Free of Accident Hazards/ Supervision/Devices) • F600 (Free From Abuse and Neglect) • F684 (Quality of Care) • F678 (CPR) • F580 (Notify of Changes (Injury/ Decline/Room, etc.)) • F760 (Residents Are Free of Significant Med Errors) • F835 (Administration) • F686 (Treatment/ Services to Prevent/ Heal Pressure Ulcer) • F610 (Investigate/ Prevent/Correct Alleged Violation) • F607 (Develop/ Implement Abuse/ Neglect Policies)** ** Not in the top 10 so far in CY 2025 or in CY 2023 or CY 2022 | • F689 (Free of Accident Hazards/ Supervision/Devices) • F600 (Free From Abuse and Neglect) • F684 (Quality of Care) • F835 (Administration) • F880 (Infection Prevention and Control) • F678 (CPR) • F760 (Residents Are Free of Significant Med Errors) • F580 (Notify of Changes (Injury/ Decline/Room, etc.)) • F686 (Treatment/ Services to Prevent/ Heal Pressure Ulcer) • F610 (Investigate/ Prevent/Correct Alleged Violation) | • F689 (Free of Accident Hazards/ Supervision/Devices) • F600 (Free From Abuse and Neglect) • F684 (Quality of Care) • F880 (Infection Prevention and Control) • F835 (Administration) • F678 (CPR) • F686 (Treatment/ Services to Prevent/ Heal Pressure Ulcer) • F610 (Investigate/ Prevent/Correct Alleged Violation) • F760 (Residents Are Free of Significant Med Errors) • F580 (Notify of Changes (Injury/ Decline/Room, etc.)) |
This AAPACN resource is copyright protected. AAPACN individual members may download or print one copy for use within their facility only. AAPACN facility organizational members have unlimited use only within facilities included in their organizational membership. Violation of AAPACN copyright may result in membership termination and loss of all AAPACN certification credentials. Learn more.