LSM 417 Week 3 Survey, Certification and Responding to Citations Example

Nine Deficiencies, One at Level G: How a Nursing Home Survey Works, What the Scope and Severity Letters Mean and How the Home Answered Within Ten Days

[Student Name]

University of Phoenix

LSM/417: Regulations in Lifespan Management

Week 3 Assignment

[Instructor Name]

[Date]

The nursing home, its survey and its citations are composites written for a model paper; survey and enforcement rules come from the sources listed.

At 7 a.m. on a Monday, three state surveyors arrived at a composite 120-bed nursing home for its annual standard survey. They stayed three days. On Wednesday afternoon, the exit conference previewed findings, and ten days later the home received a statement of deficiencies listing nine citations. This paper explains how the survey worked, what the citations meant and how the home responded.

The Survey

Surveys are unannounced and follow federal procedures. The team held a brief entrance conference, requested lists of residents and key records and began touring. Over three days, surveyors interviewed residents and families privately, observed meals, care and a medication pass, reviewed a sample of residents' records, examined staffing and infection control and checked the kitchen and environment. The surveyor guidance they used interprets each federal requirement and gives surveyors probes and procedures (Centers for Medicare & Medicaid Services, 2024).

The Scope and Severity Grid

Each deficiency is rated on two dimensions. Severity has four levels: no actual harm with potential for minimal harm; no actual harm with potential for more than minimal harm; actual harm that is not immediate jeopardy; and immediate jeopardy to resident health or safety. Scope has three levels: isolated, pattern and widespread. The combinations produce letters from A, the least serious, to L, immediate jeopardy that is widespread.

The Home's Nine Citations

Six citations were at levels D and E, potential for more than minimal harm, isolated or in a pattern: care plans not updated after falls, a medication stored past its expiration date, an incomplete residents' trust fund reconciliation and three infection control lapses, including staff not performing hand hygiene between residents during a meal. Two were at level B. One was at level G.

The Level G Citation

A resident admitted with a small pressure injury on her heel had not been repositioned on the schedule in her care plan, and the wound was not reassessed for eight days, during which it worsened to a deeper wound. The surveyors found actual harm to one resident, isolated in scope: level G. A level G citation says the home did not just risk harm; a resident was actually hurt.

The Plan of Correction

The home had ten calendar days after receiving the statement of deficiencies to submit a plan of correction. For the level G citation, the plan addressed four elements. For the affected resident: wound specialist consultation, a pressure-redistributing mattress and repositioning every two hours with documentation. For others at risk: skin assessments of all residents within 72 hours, identifying three more who needed changes. For the system: weekly wound rounds by a designated nurse, an electronic alert when a wound assessment is overdue and retraining on repositioning. For monitoring: the director of nursing audits wound documentation weekly for three months and reports to the quality committee. Each element had a completion date.

The Other Citations

The home treated the lower-level citations with the same discipline. For the hand hygiene lapses, it placed sanitizer at every dining table, assigned a staff member to prompt hand hygiene at meals for a month and audited meals twice a week. For the expired medication, pharmacy began monthly checks of every medication cart. For the trust fund reconciliation, the business office adopted a monthly signed checklist. None of these citations caused harm, but each was a signal that a routine process had drifted.

Informal Dispute Resolution

The home disagreed with one level D citation, believing the surveyor had misread a care plan revision date. It requested informal dispute resolution with the state within the same ten-day period, submitting the dated care plan. The state removed the citation.

Enforcement

Because of the level G citation, the federal Medicare agency imposed a civil money penalty. Federal enforcement procedures set out a range of remedies, from directed plans of correction and required in-service training up through fines, a halt on payment for newly admitted residents and, at the extreme, termination, and require denial of payment for new admissions if a facility remains out of substantial compliance three months after the survey and termination of its provider agreement if noncompliance continues six months (Centers for Medicare & Medicaid Services, 2026).

The Revisit

Surveyors returned unannounced 38 days later and verified the corrections for the level G and other citations. The home was found back in substantial compliance, avoiding escalating remedies.

Public Consequences

Survey results are posted publicly and feed the health inspection portion of the federal star rating. Research on two decades of public reporting has found that ratings prompt some real improvement, but also that some score gains do not reflect better care and that important aspects of quality go unmeasured (Konetzka et al., 2021). The home's inspection rating fell by one star.

The Cost of the Citation

The level G citation had costs beyond the penalty. Staff time spent on the plan of correction, audits and retraining totaled more than 120 hours in the first month. The home's inspection rating fell, and the admissions director reported that two hospital case managers asked about the citation when considering referrals. The administrator answered openly, describing what had happened and what had changed, and both hospitals continued to refer. The experience persuaded the board to fund a part-time wound care nurse, a cost it had deferred for two years.

Learning From the Survey

The administrator treated the survey as feedback. The quality committee added wound care and hand hygiene to its monthly audits, and the home began quarterly mock surveys using the same surveyor guidance.

Conclusion

A standard survey ended with nine deficiencies, one at level G for actual harm from a worsening pressure injury. Understanding the scope and severity grid, submitting a complete plan of correction within ten days, disputing one citation with evidence and correcting problems before escalating remedies applied brought the home back into compliance. The lasting value came from turning findings into system changes that protect all residents.

References

Centers for Medicare & Medicaid Services. (2024). State operations manual, Appendix PP: Guidance to surveyors for long term care facilities. https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf

Centers for Medicare & Medicaid Services. (2026). State operations manual, Chapter 7: Survey and enforcement process for skilled nursing facilities and nursing facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107c07pdf.pdf

Konetzka, R. T., Yan, K., & Werner, R. M. (2021). Two decades of nursing home compare: What have we learned? Medical Care Research and Review, 78(4), 295-310. https://doi.org/10.1177/1077558720931652