Being Successful With the Nursing Home State Survey

Surviving With Your Sanity and Staff Intact

Medical meeting during state survey
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"State is in the building! State is here!" If you've worked in a skilled nursing facility for more than a year, chances are that you've heard this panicked statement at least once.

These unannounced annual stated surveys and complaint investigation surveys significantly increase the stress of caring for residents, whether they're in the facility for short-term subacute rehab, dementia care, or long-term care.

So, how do you survive? What can you do to have a successful survey? Try some of these tips from those who've been there and lived to tell about it.

Strategies Prior to Survey

Prepare a Survey Notebook

When state surveyors arrive, they will ask you for page after page of information. Gather all of this ahead of time. If you follow the Entrance Conference Worksheet and have everything gathered and updated weekly, you will save yourself a lot of time, stress, and headaches by eliminating the task of trying to find it when the surveyors are waiting on you. 

Do Rounds and Practice

Nervousness can make some staff members' minds go blank, but if there are regular opportunities to practice answering the basics—such as infection control policies, like handwashing and gloving protocols—it often becomes easier to answer correctly when a surveyor poses the question.

Issue Written Reminders

Some facilities hand out cards to their staff that contains important reminders, including the different types of abuse, how to file a complaint with the facility or the state agency, and fire drill procedures. These cards can be attached to the back of a name badge and flipped through to help remind staff of the information. This is information that staff must be trained on annually, but sometimes it can still be helpful to have it available for a reminder when a surveyor asks.

Do It Right All Year Long

With the amount and extent of the regulations, this is easier said than done. However, it's generally going to be easier to learn the right way and practice it all year long, instead of frantically trying to remind staff of the right way to do a task. As you're able, identify if a less-than-ideal short cut is being taken and re-educate staff on the correct procedure.

Interview Residents and Families

The questions and tasks that surveyors perform have been clearly identified and shared with providers, so ask these interview questions regularly to see how residents and families think you're doing. Spend time monthly speaking with residents about their food, activities, nursing care and response time.

The survey process was updated in 2017, and far more of the surveyors' time is spend directly talking with residents. If you're able to identify and respond to any concerns that residents might have as they occur, you'll have happier residents and better survey outcomes.

Gather Knowledge

Review the most common deficiencies being issued. You can search online and fairly easily identify key issues. Also, based on your quality indicators, you will often know what surveyors will be looking at ahead of time. It's worth spending time to review your policies that are related to the flagged quality indicators, since these areas will very likely be reviewed.

Use the QAPI Process

The Quality Assurance and Performance Improvement process should be used when you identify an issue that needs improvement. If your facility struggles with a high percentile of falls, for example, the QAPI process can target falls as an area to improve. This will likely have the benefit of improved resident results, as well as help you explain to surveyors that you are working systematically at improvement in reducing resident falls.

Strategies During Survey


Take a moment and just take a deep breath. Inhale and exhale. Take another moment to remind your coworkers to breathe. Having surveyors in the building can make things pretty hectic and it's important to slow down, just for a minute.

Remind Yourself Why You're All Here

A survey can be stressful and difficult, certainly for the nursing home providers, but also for the surveyors. In the middle of that stress, remind each other that providers and surveyors alike are all here for the same reason—the residents—and that they are what matter. Chances are, you're committed to the quality of life and excellence in care for your residents. Hold onto that thought throughout the process and let it shape your responses and actions.

Ask Clarifying Questions

Don't guess or assume if you're not sure what the surveyor is really asking. State the question back to them in your own words and ask them if that's what they mean if you're unsure. This can be an important strategy to make sure you have a clear understanding of what they need and it can also give you a few seconds to think through your answer before you speak.

Less Is More

Be mindful of what you say. Surveyors are trained to write down what you say in answer to their questions and asking for a moment to think to format an answer will not hurt you. However, rambling on and providing extraneous information beyond what answers their questions often will.

Being nervous can have different effects of people and, for many, talking too much can be a result. Answer the question that was asked and resist the temptation to provide additional information unless you've thought it through and believe it will help explain your rationale for a decision or defend your facility's course of action.

Get Help From a Coworker

Sometimes, conversations with surveyors can feel pretty intimidating, almost as if you're being interrogated. If you're in the middle of a difficult conversation, say, "Excuse me a moment," and then come right back with a coworker to help you respond to the surveyors' questions.

This strategy isn't appropriate when a basic question is asked, such as, "What do you do if you suspect abuse?" That's a question that every staff member should be able to answer. But if you're in a detailed conversation about a pressure ulcer and trying to defend and explain the facility's actions, it can be very helpful to have more than one person listen and respond to questions.

Always Check the Care Plan

Always. If you're asked how someone transfers, check the care plan before you answer, even if you care for them every day and know this resident's care backward and forwards. The care plan could have just been changed and your protocol for transferring someone should always contain the first step of checking the care plan.

Tell the Truth

Don't ever lie or stretch the truth. Having surveyors in the building pressing you on an issue may tempt you to do almost anything to "get out of trouble." Don't ever give in to that temptation. Look for more information. Provide more records. Think about how you can defend their allegations. Bring someone with you to talk to the surveyors. But, don't ever falsify records or be untruthful. It's not worth risking your job, your license, your residents, or your integrity.

Remain Professional

Take the high road when you're interacting with the surveyors. You will likely not agree with everything that is said and done. But, you'll feel better at the end of the day if you are able to maintain your professional demeanor, despite the circumstance. Help your teammates out by checking in with them and debriefing after difficult conversations.

Know When to Say "Uncle"

This can be difficult, especially if the situation feels unjust or wrong to you. Emotions can run high and there may be times when you strongly disagree with a surveyor. It's okay to defend your position or debate your point with the surveyors. In fact, that's often an important part of the survey process. But, when you sense you're hitting that brick wall, it's probably not going to be helpful to continue to pursue the issue.

Own the Obvious Mistake

Admit that you're wrong when a clear deficiency is pointed out to you. Doing so can lower defenses on both sides. For example, there are times when an issue is debatable, but there are also other times when you or your facility have clearly made a mistake and it's time to own it. Keep the attitude of a learner. We are never perfect and we can always improve our practices. We can always learn more and it's appropriate and professional to shift from a defensive position to a learning position.

Provide Information Before They Exit

Respectfully present information before the surveyors leave the facility in order to defend the allegations and questions being asked. After they exit the facility, they will not accept additional information that you try to provide to them.

Re-Frame the Experience as Education

Re-framing an experience means that you change how you look at it. Viewing and experiencing the survey process as an educational experience can be very helpful. Try to remember that although you, as a provider, may be looking at the situation from the opposing view as compared to that of a surveyor, you can always learn from the experience.

For example, having to explain why a specific intervention was chosen to address a resident's need can help you refine your thought process and perhaps improve the choice the next time. Having something pointed out can help you research innovative and best practices in that area, too.

A Word From Verywell

Remember that in the end, it's still all about the residents. The survey process, while flawed, may at times be able to help us identify better practices and facilitate change as we strive for continual improvement in the quality of life and excellent care for our residents.

State and federal surveys can, at times, be discouraging and disheartening experiences, unfortunately. Our hope is that these practical strategies can help provide support and encouragement to those of us who, day in and day out, are faithfully working to care for those who have been entrusted to us.

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